Ethical Basis of Recognizing Generalist Physicians in Japan

In Japan there are currently two types of nationwide distribution issues concerning physicians. One is the skewed distribution of physician specialty towards subspecialists with few generalists. Another is the geographical distribution with the low number of physicians in rural or municipal areas compared to those in urban areas. The first issue, in fact, has caused the second issue since subspecialist physicians are not likely to serve clinical practice in rural or municipal areas due to the spectrum of their practicing capacity. Regarding the distribution issue of physician specialty, most people agree that we should produce a greater number of generalist physicians that can effectively care for patients with a broad range of medical problems in this extremely aged society. However, generalist physicians have not been recognized by the Ministry of Health, Welfare and Labour, Japanese government, as a formal physician specialty being able to show it on their clinic signboards or their official documentation to a local public health center. Thus, some generalist physicians in Japan continue to have serious identity crisis or anxiety over career development. Almost 30 years have passed since the first attempt to obtain formal recognition of generalist physicians in Japan, but this idea was rejected for multiple reasons including the resistance of Japanese Medical Association to bureaucratic control. There was a well known hypothesis that the government might try to use this opportunity of formally recognizing a generalist physician as producing a gatekeeper for controlling healthcare costs and restricting physicians’ freedom of utilizing the signboard of any specialties. Until now multiple attempts for introducing generalist physicians formally into Japanese clinical scenes have been rejected. In 2014 the Japanese Medical Specialty Board was established for developing the certification processes of all clinical specialties in Japanese physicians. It was also supposed to promote the formal recognition of generalist physicians in Japan with professional autonomy. In the last two years, however, this organization actually had weak governance and only a small percentage of stakeholders enjoyed the control over setting the requirements for curriculum, learning environment and hospital program qualifications. Because the board set strict accreditation requirements for training hospitals with the need to have a large number of beds and teachers for a major teaching program, many smalland middle-sized hospitals are at risk of a massive shortage of young physicians who are likely to move to large hospitals with major programs for their certifications. Only large urban hospitals and university hospitals can afford to have major programs for almost all specialties except for generalist specialty. Thus the board was criticized for causing an unintended threat to community healthcare by inducing the massive shift of young physicians from rural and municipal small-sized hospitals to large-sized hospitals