Medical Students' Views on Family Medicine in Japan: Insights From an International Comparison

The issue of medical students' attitudes toward pursuing a career in family medicine (FM) is critical in addressing current and future health care challenges such as aging populations, complex health care needs, and the shortage of health care professionals.¹ Previous research has identified several factors influencing medical students' specialty choices, including rural background, interest in underserved care, lower income expectations, and exposure to FM clerkships.² Conversely, aspirations for higher income, prestige, and a research-oriented career have been negatively associated with interest in FM.² In Japan, factors such as interest in clinical reasoning, community-oriented practice, and involvement in preventive care have been linked to a preference for FM.³ However, there is limited research on Japanese medical students' views on FM careers and the barriers to choosing FM as a career. This study aims to fill this gap by identifying Japanese medical students' perspectives on FM and comparing them with those of medical students in China where FM has successfully been promoted by major primary health care reform. We believe that comparing two countries with similar cultures and circumstances yet demonstrating different outcomes regarding the promotion of FM could provide insights that are applicable to the promotion of FM on an international scale.

In Japan, primary care has traditionally been provided by hospital-trained physicians.⁴ FM was recently recognized as an independent discipline, with the Japan Primary Care Association introducing the first family medicine board certification in 2009. As of December 31, 2022, there were 1,126 board-certified family physicians (FPs), representing 0.3% of all registered medical doctors (339,623) in Japan.^5,6 In contrast, the Chinese government implemented extensive primary health care reforms, rapidly increasing the number of FPs from 32,400 to 309,800 between 2009 and 2018. These reforms included the establishment of 559 hospital-based and 1,660 community-based training programs, the creation of multiple pathways to becoming an FP, and the integration of FM curricula into medical education.⁷

We conducted a cross-sectional, self-administered, online survey from November 2020 to February 2021. The survey aimed to elucidate the characteristics of Japanese medical students by comparing results with an identical study conducted in China in 2016.⁸ The study received approval from the research ethics committee of Teine Keijinkai Hospital (ID 4-019182-00), and all participants provided online consent before starting the survey.

The study sample consisted of 438 medical students, ranging from first to sixth year, from 28 medical schools across Japan. The survey was distributed via the mailing lists of each medical school, making it impossible to accurately calculate the response rate. In the online survey, all mandatory questions, except for the optional question regarding preferred specialties, were required to be answered prior to submission. Consequently, all submitted responses were included in the analysis without the application of any exclusion criteria. By contrast, the identical online survey conducted in China by the senior authors (Q.C. and M.D.F.) in 2016 (during the “Introduction to Medicine” lecture for 347 first-year students at Peking University Health Science Center), required all questions including the one regarding preferred specialties, to be answered prior to submission. A total of 335 students completed the Chinese survey.

We used a survey instrument initially administered to medical students in China in 2016,⁸ developed based on Wright et al's research.⁹ Our survey included one question about preferred specialty and 45 items with 5-point Likert-scale responses, covering career decision factors, FPs’ lifestyle and career, and attitudes toward FM. To improve response quality by reducing completion time, we excluded 14 questions related to preferred medical settings and patient age groups from the Japanese survey. Additionally, we removed two lifestyle-related questions that could suggest gender role stereotypes. Both the Chinese and the Japanese surveys were administered online, using Google Forms in Japan and the university's original online application in China. Participation was voluntary and anonymous in both studies.

The original English-language survey was translated into Japanese by bilingual investigators, with translation difficulties resolved through discussions among the translators and two other bilingual family physicians. The same method was used for translation from English to Chinese in the identical study. The instrument was pilot tested with three medical students.

Using Easy R software (EZR V. 1.55), we conducted a Mann-Whitney U test for scores on the 5-point Likert scale to compare the Japanese and Chinese groups. In the identical survey, we used SPSS 21.0 software (IBM Corp, Armonk, NY) for independent-sample t test between the scores of Chinese and international students. However, given that the Likert scale data in this study were ordinal and their distribution was unknown, we chose the Mann-Whitney U test as the method of analysis.

We received responses from 438 Japanese medical students and compared them with responses from 335 first-year medical students who participated in the identical survey conducted in China in 2016.⁸ The demographics of participants are shown in Table 1.

Among the 363 Japanese medical students who indicated their preferred specialty, 73 (19.8%) chose FM as their first choice, making it the second most popular specialty. In contrast, FM ranked third in popularity among medical students in China (Table 2).

Both Japanese and Chinese students valued "social commitment," "acceptable hours of practice," "stable/secure future," "flexibility outside medicine," "keeping all options open," and "long-term relationship with patients." Japanese students also valued "acceptable on-call schedule," "wide variety of patients' problems," and "patient population is interesting/stimulating." Chinese students valued "interest in research," "high-income potential," and "flexibility within medicine" (Table 3).

Students in both countries agreed on the need for FPs in rural areas and the necessity of government support for FPs. Chinese students perceived FPs as more respected by society, nurses, and other specialists compared to Japanese students. Japanese students viewed FPs as specialists in primary care, valuing them equally to specialists in other fields, but they assigned lower scores to the level of respect FPs receive from other specialists (Table 4).

Both groups rated FM career highly in terms of requiring broad knowledge and providing continuous and comprehensive care. However, they were less positive about FPs’ careers offering good income and personal time. Japanese students were more likely to disagree with the statement "FM career has too much simple and repetitive work" (Table 5).

Our study provides valuable insights into the attitudes of Japanese medical students toward FM compared to medical students in China. While FM is a relatively popular specialty among Japanese students, they might be hesitant to choose FM due to negative perceptions, such as low respect for FPs from others and poor work-life balance. This lack of respect for FPs was particularly pronounced in Japan compared to China. Therefore, increasing the prestige of FM and improving work-life balance through flexible working arrangements and enhanced support systems might be effective strategies to attract more medical students to FM. Additionally, we should emphasize the significant contributions of FPs to society, including their broad knowledge and continuous, comprehensive care, as these factors align with the career attributes valued by medical students.

Our study found some students hold the misconception that FM career is too simple and repetitive; however, it is, in fact, highly complex due to the variety of issues addressed during patient visits.¹⁰ This complexity may also appeal to students who prioritize factors such as a "wide variety of patients' problems," and an "interesting/stimulating patient population," both of which rank among the top 10 factors influencing career decision-making in Japan.  

The promotion of FM is a common challenge faced by many countries. Insights derived from the comparison of two countries with similar cultures and circumstances, but differing outcomes might potentially be applied to enhance the promotion of FM in other countries.

This study has limitations. The voluntary nature of the survey and the inability to accurately calculate the response rate may introduce response bias. Additionally, cultural and systemic differences between Japan and China may influence the generalizability of the findings. It is also noteworthy that the Chinese study only included responses from first-year students, whereas our study collected responses from Japanese medical students across all 6 years of their education. The two studies were conducted 5 years apart, specifically comparing the pre-COVID-19 and post-COVID-19 pandemic periods, which limits the ability to make meaningful comparisons. Future research should address these limitations by employing more robust sampling methods and exploring the cultural nuances that affect medical students' career choices.