Introduction: Jichi Medical University (JMU) is an experimental medical school established in 1972 by the Japanese Ministry of Home Affairs and all 47 prefectures in Japan (equivalent to the states of Australia) with a special mission to produce rural doctors and distribute them nationwide. The JMU has adopted a contract-based 'home prefecture recruiting scheme' in which students recruited evenly from all the 47 prefectures of Japan are required to work in their home prefectures for 9 years (including 6 years of rural service) after graduation in exchange for having their 6 years of undergraduate medical education tuition fees waived. Although the JMU system is now being partially adopted by an increasing number of other medical schools in Japan, the effectiveness of this equal distribution scheme is largely unknown.
Methods: A retrospective cohort study of 1255 graduates who had completed their contract by 2000 was conducted. Baseline data were collected at matriculation and graduation between 1972 and 1991. Workplace addresses were followed up in 2000, 2004, and 2006. Follow-up rates were 98.7% in 2000, 98.2% in 2004, and 98.0% in 2006. Data excerpted from the 2004 National Population Census including various demographic indicators (eg population, population density, and physicians/population ratio) for each of the 47 prefectures were merged, through prefectural identification codes, with the baseline and follow-up addresses of the subjects.
Results: Of all JMU graduates after contract, 69.8% settled in their home prefectures. The rates varied from 45.5% to 93.3% among the prefectures (p<0.001). The settlement rate tended to be higher in prefectures with a lower population density or physician : population ratio. Among prefectural demographics, the physician : population ratio and medical institution : population ratio were negatively correlated with settlement rate in the prefecture (correlation coefficient -0.34 [p=0.020]; and -0.35 [p=0.017], respectively). In short, prefectures with a relative shortage of physicians had higher settlement rates. In multivariable analysis of personal factors, female sex and physician : population ratio of home prefecture were negatively associated with settlement (OR 0.25 [95%CI 0.10-0.58] and OR for 1 SD increase 0.82 [0.71-0.94], respectively). Primary care specialty was positively associated with settlement (1.80 [1.35-2.39]). Mother's higher academic background was negatively associated with settlement (OR for university vs junior high school graduate 0.54 [95%CI 0.34-0.88]).
Conclusions: The home prefecture recruiting scheme has attained its goal, particularly in medically underserved prefectures. The high retention rates indicate that the scheme would be beneficial for other medical schools in Japan, which are now beginning to implement programs similar to JMU, and also medical educators and policy makers in countries searching for effective political interventions to maldistribution of physicians.