Geographic Distribution Of Physicians Research Articles

Geographic distribution of family physicians in Japan and the USA: a cross-sectional comparative study.

Solutions for geographic maldistribution of physicians is challenging around the world, but primary care specialists are expected to resolve this issue. This study compares the geographic distribution of family physicians in Japan and the USA, both of which are developed countries without a major system for physician allocation by the public sector; however, the two countries differ greatly in the maturity of family medicine (ie length of its history as part of the healthcare system and the population of qualified family medicine experts). This cross-sectional comparative study used publicly available online databases for Japan in 2018 and 2017 in the USA. The municipalities in Japan and counties in the USA were divided into quintile groups according to population density. The number of family physicians per unit population in each group of areas was calculated, and was evaluated with a residual analysis. The geographic distribution of all physicians in Japan was simulated assuming that the proportion of family physicians among all physicians in Japan (0.16%) was increased to match that in the USA (11.8%). Of 320 084 physicians in Japan and 899 244 in the USA, 519 (77.2%) family physicians in Japan and 105 999 (100%) in the USA were included. The distribution of family physicians in Japan was noticeably shifted to areas with the lowest population density. In contrast, family physicians in the USA were distributed equally across areas. The distribution of physicians of other specialties (general internists, pediatricians, surgeons and obstetricians/gynecologists) was shifted heavily to areas with the highest population densities in both countries. The simulation analysis showed the geographic maldistribution of the total number of physicians improved substantially if the proportion of family physicians in Japan is increased to match that in the USA. The distribution of family physicians is more equitable than that of other medical specialists; however, an immature family medicine system can lead to an aggregation of family physicians in rural areas. This aggregation supports equity due to the broader scope of practice required by family physicians in rural areas. In countries where family medicine has not yet matured as a specialty, provided that the equitable aggregation of family physicians in rural areas can be maintained, increasing the number of family physicians as a proportion of the total number of physicians may improve the geographic maldistribution of the total number of physicians.

Concentration and inequality in the geographic distribution of physicians in the European Union, 2006-2018

Concentration and inequality in the geographic distribution of physicians in the European Union, 2006-2018

Education in the Mais Médicos program: the gap between proposals and implementation

Abstract: Introduction: The scarcity and inequalities in the geographical distribution of physicians challenge the consolidation of the right to health and create migratory flows that increase health inequities. Due to their complex and multidimensional characteristics, they demand multisectoral political approaches, considering several factors related to the availability and area of practice of medical doctors, as well as the social vulnerability of local populations. Objective: This study aimed at analysing results of the “Mais Médicos” (More Doctors) Program Educational Axis in Brazil. Methodology: A documental research was conducted, highlighting the location and the public or private nature of new undergraduate medical school vacancies between the years 2013 until 2017, which were then compared to the goals and strategies outlined in the official Program documents. Results: The Educational Axis reached important milestones despite the resistance of some institutional actors. The Program extended its undergraduate vacancies by 7696 places, 22.48% of that in public institutions and 77.52% in private ones. Vacancy distribution prioritized cities in rural areas of Brazil, at the same instance bringing forward significant regulatory changes for undergraduate medical courses. However, political disputes with representatives of medical societies and stakeholders interested in favouring the private educational and healthcare sectors surface in the official discourses and documents. These factors weakened the program normative body, creating a hiatus between its core objectives and respective implementation. Evidence related to the concentration of vacancies in the Southeast regions allow the maintenance of a known unequal workforce distribution, despite a proportionally bigger increase in the Midwest, North and Northeast regions. Conclusion: The predominance of vacancies in private institutions and the weakening of the new undergraduate courses monitoring instruments can compromise changes in the graduate students’ profiles, which are necessary for the fixation of physicians in strategic geographic areas to promote Primary Healthcare.

Education in the Mais Médicos program: the gap between proposals and implementation

Abstract: Introduction: The scarcity and inequalities in the geographical distribution of physicians challenge the consolidation of the right to health and create migratory flows that increase health inequities. Due to their complex and multidimensional characteristics, they demand multisectoral political approaches, considering several factors related to the availability and area of practice of medical doctors, as well as the social vulnerability of local populations. Objective: This study aimed at analysing results of the “Mais Médicos” (More Doctors) Program Educational Axis in Brazil. Methodology: A documental research was conducted, highlighting the location and the public or private nature of new undergraduate medical school vacancies between the years 2013 until 2017, which were then compared to the goals and strategies outlined in the official Program documents. Results: The Educational Axis reached important milestones despite the resistance of some institutional actors. The Program extended its undergraduate vacancies by 7696 places, 22.48% of that in public institutions and 77.52% in private ones. Vacancy distribution prioritized cities in rural areas of Brazil, at the same instance bringing forward significant regulatory changes for undergraduate medical courses. However, political disputes with representatives of medical societies and stakeholders interested in favouring the private educational and healthcare sectors surface in the official discourses and documents. These factors weakened the program normative body, creating a hiatus between its core objectives and respective implementation. Evidence related to the concentration of vacancies in the Southeast regions allow the maintenance of a known unequal workforce distribution, despite a proportionally bigger increase in the Midwest, North and Northeast regions. Conclusion: The predominance of vacancies in private institutions and the weakening of the new undergraduate courses monitoring instruments can compromise changes in the graduate students’ profiles, which are necessary for the fixation of physicians in strategic geographic areas to promote Primary Healthcare.

Temporal trends of physician geographical distribution and high and intermediate physician density areas and factors related to physicians' movement to low physician density areas in Japan: a longitudinal study (1996-2016).

ObjectivesA major issue in Japan’s health policy is the geographical maldistribution of physicians. This study aimed to analyse temporal trends in the geographical distribution of physicians and analyse physicians in high and intermediate physician density areas and factors related to their movement to low physician density areas in Japan.DesignA longitudinal study.SettingAll physicians in 344 secondary medical districts.ParticipantsI analysed data from the biennial national census, conducted by the Ministry of Health, Labour and Welfare between 1996 and 2016 and and divided it into two cohorts of 10 years each: 1996–2006 and 2006–2016.Primary and secondary outcome measuresI estimated the temporal trends in the number and percentages of physicians, and used logistic regression to analyse physicians in high and intermediate physician density areas and the factors related to their movement to low physician density areas.ResultsThe overall number of Japanese doctors increased by 31% between 1996 and 2016. The number of physicians per population in the physician high-density areas increased by 29%, while those in low-density areas increased by 32%, suggesting that the gap between areas marginally decreased. The multivariable logistic regression analyses revealed that academic hospital experience had the highest OR for predicting physician movement to low physician density areas after 10 years, both in the 1996 and 2006 cohorts. Other factors that positively correlated with physician movement were being male, being younger than 40 years, being qualified after the age of 30, urban area, intermediate physician density area and practice in a non-academic hospital.ConclusionsAs less-experienced physicians demonstrate high mobility among geographic categories, and retention rates are low in low physician density areas, especially for less-experienced physicians, a new system that considers these factors would create opportunities for younger physicians to work in low-density areas.

Time trends in the geographical distribution of physicians, nurses and midwives in Europe

Abstract Background Data on the supply of health professionals show large variations in the health workforce density among European countries based on national-level data. However, little attention has been paid to the comparison of health professional density at the regional level. This study aimed to analyse the density of physicians, nurses and midwives at regional level, using a cross-country comparative design and examine time trends. Methods Descriptive analysis of Eurostat data on the rate of health professionals per population at national and regional levels (NUTS 2 regions) for 2017 and time trends (2005-2017) and comparison to population density. To improve the cross-country comparability of data a set of criteria was applied, resulting in 15 European countries covered on physicians and eight for nurses and midwives. Changes over time in the regional distribution were analysed, using percentage change and compound annual growth rate (CAGR). Results We found a 2.4-fold difference in the physician density between the highest and lowest density countries (Austria: 513, Poland 241.6 per 100.000) and a 3.5-fold difference among nurses (Denmark: 1702.5, Bulgaria: 483). Differences by regions across Europe were higher and varied up to 4.5-fold both for physicians and nurses/midwives and did not improve over time. Results show that in all countries physician density levels are highest in densely populated regions, with capitals and/or major cities, while density of nurses and midwives tends to be higher in less populated areas. Overall, physician rates grew at a faster rate than the density levels of nurses and midwives. Conclusions International data should not only cover supply indicators at national level, but routinely collect regional data on the number of health professionals to demonstrate regional differences in workforce supply and to improve monitoring and workforce planning at regional levels. Key messages Despite increases in the density levels of physicians, nurses and midwives, time trends over a ten-year period showed no improvement in the geographical distribution within countries. The study is the first of its kind to descriptively analyse geographical density levels and time trends among health professionals across a selection of European countries using Eurostat data.

Physician Distribution by Specialty and Practice Setting: Findings in Japan in 2000, 2010 and 2016.

As the medical demand is projected to increase along with the population aging in Japan, the geographical distribution of physicians is a significant concern for society and policymakers. To implement effective measures on geographical physician distribution, this study aimed to describe and compare the distribution of physicians by specialty in 2000, 2010 and 2016 in Japan, and examine whether practice setting was associated with distribution. To quantify the geographical physician distribution by specialty, we calculated the Gini coefficients of physicians working at clinics or hospitals in 2000, 2010, and 2016. We used the basic geographic unit for medical care planning in Japan, a secondary medical area, as the study unit. To show the association between the geographical distribution of physicians in each specialty and their practice setting, we categorized specialties into two groups by the proportion of physicians in that specialty working in hospitals, and showed aggregated Lorenz curves for each category. The overall geographical distribution of physicians appeared to improve during the study period, but varied by specialty. Those in specialties, where at least 90% of physicians work in hospitals such as anesthesiologists and radiologists, were more clustered, as shown by the Lorenz curves and the Gini coefficients. Similar distributional differences were also found even when we excluded physicians working in clinics, meaning that the distributional variation could be explained by other factors than the distribution of hospitals. These results suggest that the nature of practice in each specialty strongly affects the geographical distribution of specialists.

Time changes in the geographical distribution of physicians and factors associated with starting rural practice in Japan.

The geographical maldistribution of physicians is an important issue for health policy. This study aimed to evaluate recent trends in Japan and identify the factors associated with starting a rural practice. A longitudinal study was conducted using secondary analysis of national census data. The number of physicians in each region was described in 1996, 2006, and 2016 and, for two cohorts, 1996 to 2006 and 2006 to 2016; a logistic regression analysis was used to identify factors related to starting a rural practice after 10 years. Between 1996 and 2016, the number of physicians in rural areas increased by 4%. Results of the logistic regression analysis showed that, in both cohorts, the factor with the highest odds ratio for starting a rural practice after 10 years was initial academic hospital experience. Other factors showing positive correlations were additional hospital practice and being qualified and over 30 years old, whereas female sex and aged at least 40 years had negative correlations. From 1996 to 2016, despite the increase in the total number of physicians, geographical maldistribution increased. Some findings support the policy that some physicians should work in rural areas in return for scholarships.

The multi-tiered medical education system and its influence on the health care market\u2014China\u2019s Flexner Report

BackgroundMedical education is critical and the first step to foster the competence of a physician. Unlike developed countries, China has been adopting a system of multi-tiered medical education to training physicians, which is featured by the provision of an alternative lower level of medical practitioners, or known as a feldsher system since the 1950s. This study aimed to illustrate the impact of multi-tiered medical education on both the equity in the delivery of health care services and the efficiency of the health care market.MethodsBased on both theoretical reasoning and empirical analysis, this paper documented evidence upon those impacts of the medical education system.ResultsFirst, the geographic distribution of physicians in China is not uniform across physicians with different educational training. Second, we also find the evidence that high-educated doctors are more likely to be hired by larger hospitals, which in turn add the fuel to foster the hospital-center health care system in China as patients choose large hospitals to chase good doctors. Third, through the channels of adverse selection and moral hazard, the heterogeneity in medical education also imposes costs to the health care market in China.DiscussionOverall, the three-tiered medical education system in China is a standard policy trade-off between quantity and quality in training health care professionals. On the one hand, China gains the benefit of increasing the supply of health care professionals at lower costs. On the other hand, China pays the price for keeping a multi-tiered medical education in terms of increasing inequality and efficiency loss in the health care sector. Finally, we discuss the potential policy options for China to mitigate the negative impact of keeping a multi-tiered medical education on the performance of health care market.

The distance and chance of lifetime geographical movement of physicians in Japan: an analysis using the age-period-cohort model

BackgroundThe uneven geographical distribution of physicians in Japan is a result of those physicians electing to work in certain locations. In order to understand this phenomenon, it is necessary to analyze the geographic movement of physicians across the Japanese landscape.MethodsWe obtained individual data on physicians from 1978 to 2012 detailing their attributes, work institutions, and locations. The data are from Japanese governmental sources (the Survey of Physicians, Dentists, and Pharmacists). The total sample size was 122 150 physicians, with 77.5% being male and 22.5% female. After obtaining the data, we calculated the geographical distance of each physician’s movement by using geographic information systems software (GIS; ArcGIS, ESRI, Inc., CA, USA). Geographical distance was then converted into time distance. We compared the resulting median values through nonparametric testing and then conducted a multivariate analysis. Our next step involved the use of an age-period-cohort (APC) model to measure the degree of impact three points of data, experience (experience years), the historical and environmental context of the data (survey year), and physician cohort (registration year) had on the movement of each physician.ResultsThe ratio of female physicians who selected an urban area as their first working location was higher than that of male physicians. However, the selection of an urban area was becoming more popular as a first working location for both males and females as the year of data increased. The overall distance of geographical movement for female physicians was less than it was for male physicians. Physicians moved the greatest distance between their second and fourth years following license acquisition, at which point the time distance became shorter. The median time distance was 46 min in 2000 and 22 min in 2008. The physicians in our study did not move far from their first working location, and the overall distance of movement lessened in the more recent years of study. The median distance of movement after 20 years was 25.9 km for male physicians, and 19.1 km for female physicians. The results of the APC model indicated that the effects of experience years (age) gradually declined, that the survey year (period) effects increased, and that the registration year (cohort) effects increased initially before leveling off.ConclusionsThe trends following the introduction of the new mandatory training system in 2004 may imply that the concentration of physicians in Japan’s urban areas is expected to increase. After 2000, the effect of that period on physicians explains their geographical movements more so than the factor of their age.

Geographic Distribution of Hand Surgeons Throughout the United States.

The purpose of this study was to evaluate the geographic distribution of hand surgeons in the United States. We assessed the states and congressional districts (CDs) for optimal numbers of surgeons, determined whether there is an even distribution, and identified factors influencing practice location. Hand surgeon practice location data from the American Association for Hand Surgery and American Society for Surgery of the Hand (2015) and both state and CD population data from the US Census (2014) were assessed. CDs each contain approximately the same population. Furthermore, select hand surgeons were asked to fill out a survey to identify how 6 factors influence practice location. A total of 2,707 American Association for Hand Surgery active and American Society for Surgery of the Hand active and candidate US members were included. The mean number of hand surgeons per state was 53 (range: 3-298). The most hand surgeons were in California, Texas, New York, and Florida and least were in Wyoming and Alaska. There were 16, 11, and 24 states with suboptimal, optimal, and greater-than-optimal density, respectively. There were 436 CDs. We found 231, 30, and 175 CDs with suboptimal, optimal, and greater-than-optimal density, respectively. There were weak correlations between hand surgeons and CD populations and between CD population densities and CD hand surgeons per capita. Twenty hand surgeons were included in the survey resulting in no difference of any 1 factor compared with the other 5 factors. There was a difference in the factor "population size" between hand surgeons from greater-than-optimal and suboptimal CDs. The findings of our study indicate that hand surgeon proportions do not correlate with population proportions, and distribution is not skewed toward areas of higher population density. Many areas are not optimally served, and hand surgeons may be choosing where to practice based on a combination of factors beyond population need.

The Determinants of Physicians’ Location Choice: Understanding the Rural Shortage

A long-standing challenge in the US health care system is the provision of medical services to rural areas. This paper develops a structural spatial equilibrium model with heterogeneous physicians and uses it to explore the impact of policies, namely loan forgiveness and salary incentives, on the geographical distribution of physicians. I collect micro data from physicians’ directories on their medical school, residency, and first-job choices and use this new dataset to both allow for physicians’ preference to remain close to their residency location and to implement an instrumental-variable approach to overcome endogeneity issues caused by the correlation between wages and unobserved amenities. I find that residents strongly prefer remaining close to their residency location. The combination of loan forgiveness and salary incentives has led to 1.2 percent more physicians choosing rural areas. Using the government spending currently allocated to loan forgiveness to further increase salary incentives would lead to 6 times more primary care physicians choosing rural areas and a higher average quality of rural physicians compared to the impact of current policies.

Factors Affecting the Service Delivery Locations of Newly Graduated Iranian General Practitioners

Background: Many factors affect physicians’ dispersion across various locations in Iran. Identifying these factors can be effective in planning for a fair distribution of physicians throughout geographical areas. Objectives: This study aims to identify the key factors affecting newly graduated general practitioners’ (GPs’) choice of service delivery in Iran in regard to location. Methods: This was a mixed-method, applied study using a descriptive survey. A questionnaire was designed based on key variables extracted from relevant literature and analyzed from interviews with experts in the field. We used expert opinions to assess the questionnaire’s validity, and Cronbach’s coefficient alpha was calculated (0.925) to confirm its reliability. The questionnaire was randomly distributed among 400 participants (GPs) applying for their mandatory service in Iran during four periods in 2015 (100 participants were surveyed in each period). The data was analyzed using the 8th edition of SPSS and AMOS, and both exploratory and confirmatory factor analysis methods were applied. Results: Forty key factors were identified loading on five main factors during EFA, which explained 77.90% of the total variance. We used the following designations for the five factors: 1) socioeconomic developmental status, 2) geographical conditions, 3) personal reasons, 4) district health services, and 5) demographics. In CFA, the third factor has the highest weight with 0.97, and the first factor has the lowest weight with 0.89. But the slight differences among factor load show the importance of all factors. The highest weighted factor relates to a number of health center variables, such as the type of roads in the district, social development and liberation, physician efficiency in the region, and distance from the provincial capital. Conclusions: To resolve the unequal geographic distribution of physicians, it is necessary to consider the key factors affecting the attractiveness of a district for GPs and the existing demand for health services. Attempting to resolve the developmental inequalities among different districts, as well as implementing motivational policies to encourage physicians to work in less developed districts, is recommended.

Recruitment and retention of physicians in rural Alberta: the spousal perspective

The overall geographic distribution of physicians in Canada, including Alberta, is misaligned with the population distribution. Some strategies, such as debt repayment, are currently in practice to increase recruitment and retention of physicians in rural locations. Of the factors influencing choice of practice location, 'spousal influence' is considered to play a significant role in recruitment and retention of physicians in literature. Most studies have focused on the physicians' perspective of their spouses' influence on staying in a rural location. This study is unique as it approaches rural recruitment and retention from the perspective of the physician spouse. The physician population for this study consisted of doctors practicing in rural southern Alberta. Participants were recruited via an email invitation and were invited to complete an online survey. The survey collected information regarding physician demographics and some relationship characteristics. The email invitation also contained a link to a second survey specific to the physician spouse or partner, asking a similar panel of questions. Physicians were asked to request their spouse or partner to complete this survey. Semi-structured interviews were conducted for those who consented to be contacted for interviews. Descriptive statistical analysis of the survey data was carried out. Thematic analysis of the qualitative interview data was conducted and was organized into three sections. The first and second sections present the personal experiences of rural recruitment and rural retention. The third section presents recommendations made by physicians and spouses to improve these processes. Specific interview quotes led the authors to derive themes under each section. The results of this study raise the voice and profile of the spouse in the process of rural recruitment and retention. In this study, the spouses of Canadian medical graduates were a positive influence in rural recruitment and retention, while the spouses of international medical graduates were generally less supportive of a rural lifestyle. Considerations to accommodate the educational, professional and cultural needs of the physician spouse must be incorporated into policy if large areas of underserved rural communities will continue to rely on international recruitment.

Interventions for increasing the proportion of health professionals practising in rural and other underserved areas.

The inequitable distribution of health professionals, within countries, poses an important obstacle to the optimal functioning of health services. To assess the effectiveness of interventions aimed at increasing the proportion of health professionals working in rural and other underserved areas. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, including specialised register of the Cochrane Effective Practice and Organisation of Care Group; March 2014), MEDLINE (1966 to March 2014), EMBASE (1988 to March 2014), CINAHL (1982 to March 2014), LILACS (February 2014), Science Citation Index and Social Sciences Citation Index (up to April 2014), Global Health (March 2014) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (June 2013). We also searched reference lists of all papers and relevant reviews identified, and contacted authors of relevant papers regarding any further published or unpublished work. Randomised trials, non-randomised trials, controlled before-and-after studies and interrupted time series studies evaluating the effects of various interventions (e.g. educational, financial, regulatory or support strategies) on the recruitment or retention, or both, of health professionals in underserved areas. Two review authors independently screened titles and abstracts and assessed full texts of potentially relevant studies for eligibility. Two review authors independently extracted data from eligible studies. For this first update of the original review, we screened 8945 records for eligibility. We retrieved and assessed the full text of 125 studies. Only one study met the inclusion criteria of the review. This interrupted time series study, conducted in Taiwan, found that the implementation of a National Health Insurance scheme in 1995 was associated with improved equity in the geographic distribution of physicians and dentists. We judged the certainty of the evidence provided by this one study very low. There is currently limited reliable evidence regarding the effects of interventions aimed at addressing the inequitable distribution of health professionals. Well-designed studies are needed to confirm or refute findings of observational studies of educational, financial, regulatory and supportive interventions that might influence healthcare professionals' decisions to practice in underserved areas. Governments and medical schools should ensure that when interventions are implemented, their impacts are evaluated using scientifically rigorous methods to establish the true effects of these measures on healthcare professional recruitment and retention in rural and other underserved settings.

Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002-11.

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver program's impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing.

States Can Transform Their Health Care Workforce.

The United States faces the simultaneous challenges of improving health care access and balancing the specialty and geographic distribution of physicians. A 2014 Institute of Medicine report recommended significant changes in Medicare graduate medical education (GME) funding, to incentivize innovation and increase accountability for meeting national physician workforce needs. Annually, nearly $4 billion of Medicaid funds support GME, with limited accountability for outcomes. Directing these funds toward states' greatest health care workforce needs could address health care access and physician maldistribution issues and make the funding for resident education more accountable. Under the proposed approach, states would use Medicaid funds, in conjunction with Medicare GME funds, to expand existing GME programs and establish new primary care and specialty programs that focus on their population's unmet health care needs.

Geographical Disparities in the Distribution of Physicians in Turkey

AIM: In this study, it was aimed to demonstrate the geographic imbalances of human resources for health of Turkey, in the case of physicians by using some inequality indicators emphasizing the generally neglected concept; equity. METHOD: Inequality in geographic distribution of physicians and equity was evaluated by using Lorenz and concentration curves and Gini and Gini based indices. Under-five mortality per population was used as a proxy indicator for the health care need of the population. Geographic units were the provinces of Turkey. RESULTS: Gini Index for the physician distribution among the provinces in 2010 was calculated as 0.14. Ranking the population from the lowest through the highest physician density, the first quintile of the population had 13.6% of the total physicians; in contrast they had 32.9% of under-five deaths. The fifth quintile had 28.0% of physicians but they had only 13.8% of under-five deaths. Kakwani Progressivity Index for under-five deaths was -0.34. CONCLUSION: This study showed that the geographic distributional disparities can be quantified by using Kakwani Progressivity Index on an equitable basis. Not only the health manpower density but also the different health care need indicators should be taken into account in the planning of human resources for health and the achievements should be monitored by the methods used in this study

Geographic Distribution of Physicians: An International Comparison

本研究は医師の地理的分布について日米英の国際比較を行った。まず日英比較では，日本の診療所医師は英国の診療所医師に比べて地理的偏在度が高い傾向が認められた。英国の診療所医師は原則として総合医（GP）であり，またGPの定員は医療圏ごとに決まっている。日本における開業医の専門分化および自由開業制が地理的偏在に影響を及ぼしている可能性がある。続いて医師の地理的偏在度の推移を日米で比較した。1980年から2005年にかけて両国ともに医師数は一貫して増加していたが，医師の地理的偏在度はほとんど変化していなかった。米国では医師が所得の地理的分布に従って分布してゆく傾向があるのに対して，日本ではそのような傾向はなかった。公的医療保険の有無がこの差に影響を及ぼしている可能性がある。さらに米国では地域が医療過疎であるほど医師数は減っていく傾向があるのに対して，日本では医療過疎であるほど医師数が増えていく傾向があった。米国では医療過疎地に医師を誘導する政策が効果を挙げていない可能性がある。最後に医師の診療科目ごとの数と地理的分布を日米で比較した。2006年時点で日本の単位人口あたりの麻酔科医，放射線科医，救急医，病理医数は米国の半分以下であった。また日本では開業率の低い科ほど医師数が少なく地理的偏在度は高くなる傾向が見られた。日本においては開業の困難さがその科の医師数と医師分布に影響を及ぼしている可能性がある。本研究の結果より，わが国固有の医療制度が医師の地理的偏在に影響を与えていることが示唆された。

Retention of physicians in rural Japan: concerted efforts of the government, prefectures, municipalities and medical schools

In post-war Japan, a number of factors lead to a general shortage of physicians by the 1950s, which became acute in rural areas and has continued until recent times. Teamwork among national, prefectural, municipal governments and public medical schools has addressed this shortage of physicians. The national government doubled the number of medical schools in the 1960s and 1970s; each of the country's 47 prefectures, whether rural or not, has at least one medical school. In rural areas where private hospitals are not profitable, municipal governments have funded public hospitals and physician recruitment from their own budgets. A cooperative project among Japan's 47 prefectural governments and the national government established Jichi Medical University (JMU), which conducts a bound medical education program followed by obligatory rural service. As a result, the number of 'non-physician communities' (muichiku) nationwide has decreased by 73%; however, the gap between physician concentrations in urban and rural areas has not changed. Therefore, the government has recently implemented a JMU-like contractual program as a form of 'rural quota' at other medical schools in all 47 prefectures. If all the replicated programs work as successfully as JMU, the impact on the geographic distribution of physicians will be substantial. The Japanese public-sector-led rural physician securing system could also be effective in countries where rural healthcare provision is the responsibility of the public sector and close cooperation among levels of government is possible.