We first quantified the regional disparity in hospital characteristics on physicians’ workload, wages of residents, and popularity among medical students by population size in Japan. Contrary to our hypothesis, hospitals in most populated cities had a significantly lower workload per physician (fewer than the total average by 21.9 patients), paid fewer wages (than the average by 43,524.2 Japanese yen), and were more popular among students (than the average by 40.8%). Medical doctors and students were not likely to prioritize the number of cases they might actually experience and not the wages paid. Our findings meant a disadvantage for physicians working in non-populated areas, and that could lead to lower medical services there. Therefore, these regional disparities might be a political issue.
Workload
In our study, we clarified that physicians working in non-populated areas cared for more patients than those in the populated ones. Physicians working in the city of ≥2,000,000 cared for fewer patients annually by 21.9 patients than the overall average; for fewer by 37.5 patients than physicians working in the city of < 300,000. Although there have been several reports describing the regional disparities in the number of doctors [9, 18] in Japan, the discrepancy in workload has not been explored thus far. To the best of our knowledge, this is the first study to quantify the regional disparity in physicians’ workload in Japan. Excessive workload was reported to be a health hazard [5], burnout [19], and important demotivators for physicians [20, 21]. This problem may cause a public health crisis as well as negative impacts on individual physicians, patients, and healthcare systems [22]. Therefore, physicians working in non-populated areas (particularly de-populated areas) are at a higher risk of developing health problems [9]. It appears difficult to completely resolve these regional workload disparities for each hospital.
The Japanese Medical Specialty Board started a ceiling system [23], restricting the number of senior residents (doctors trained for > 2 years) working in Tokyo, Kanagawa, Aichi, Osaka, and Fukuoka Prefectures from 2018. However, their concentration in these prefectures remained unresolved by the end of 2019; therefore, a stricter ceiling system that can address regional disparity in the number of young doctors as well as the disparity of their workload is needed in Japan.
Wages
We demonstrated that the average monthly wage of junior residents in the most populated cities was significantly lower than in the others (< 100,000, < 200,000, < 300,000, < 400,000, and < 600,000).
Yamaguchi et al. reported that hospitals in small populated areas in Yamagata prefecture tended to pay doctors more on average than those in the large ones [24]. According to another report in Australia, general practitioners who worked in rural areas had higher earnings [25]. Our results are in line with these findings, showing that residents working in smaller population sizes had a tendency to earn higher wages than those in the larger ones. Wage was ranked as the third important factor in the questionnaire for medical students choosing hospital [12]; however, in fact, residents working in populated cities were paid lower wages than those in other areas. This discrepancy showed that most medical students did not prioritize wages during the resident term, despite hoping for higher salaries.
Popularity
We also found that there was a significant difference in medical students’ popularity (Fig. 3). The hospitals in the two populated areas were more popular than the average (112.1% in < 2,000,000 and 140.8% in ≥2,000,000). Our results are in line with those of other reports. A survey of medical residents in Japan showed that about 30% of them emphasized the location of hospitals when they decided to choose hospitals for work [12]. Similarly, location was rated as the most important factor for residency selection among American medical students [26]. There were three plausible reasons why medical students wanted to work in urban regions. First, the number of medical students born and raised in populated cities was large; hence, most of them would have returned there. Second, they might think that they could witness a wide range of diseases, including extremely rare ones, through conferences such as clinico-pathological conferences without directly being in charge of these cases at hospitals in populated cities. Finally, the number of famous doctors, surgical operations, and the latest treatments may be accumulated in populated cities. In addition to the ceiling system, others that attract not only young physicians, but also mature ones to work in less populated areas may be needed, such as remote learning, experiencing the latest medicines, or improving working conditions by introducing the Internet of Things.
Limitations
This study has some limitations. First, we analyzed workload at each hospital; thus, we did not know the actual workload of individual physicians and its disparities within a hospital. We speculated that younger physicians were more in charge of inpatients than older ones. Second, we did not include other factors, such as the existence of famous or teaching doctors and the hospital’s specialty, such as the number of coronary angiography and endoscopy, which may attract medical students. Future studies should include these factors. Third, this study targeted only physicians and doctors specializing in internal medicine. Thus, our findings may not apply to other departments, such as pediatrics or surgery.