The characteristics of teaching hospitals, educational opportunities, and working conditions under the new PGME program differed significantly between university and non-university hospitals. These factors may determine the difference in resident characteristics and satisfaction with university and non-university hospitals. Residents at university hospitals were more likely female or wanting a DMSc degree. Residents at non-university hospitals were more likely to be satisfied with income, the residency system, and clinical skills training.
In September 2006, the Emergency Statement issued by the Association of Japanese Medical Colleges (AJMC) announced that the shift of residents from university hospitals was causing the collapse of medical services in certain communities, as well as stagnation in academic research, because of the shortage of physicians at university hospitals9
. To increase the number of university residents, the AJMC emphasized the importance of improvements in teaching conditions, including teaching resources, at university hospitals. However, our results indicate that better education resources do not overcome the other characteristics of university hospitals that lead to resident dissatisfaction. Similarly, Levine et al.10
investigated resident research and scholarly activity and found that non-university hospitals had greater barriers to this kind of activity, but that the residents still completed a variety of scholarly projects. Therefore, merely improving the teaching conditions at university hospitals may not increase the levels of resident satisfaction or resident clinical achievement.
Although the number of hospital beds was not statistically assessed in relation to resident satisfaction, it may influence the residency conditions that affect the level of resident satisfaction. Because there were fewer teaching staff at non-university than university hospitals, residents might have the opportunity to see patients with various health problems on their own, which would increase the clinical experience of the non-university residents. Moreover, the majority of non-university residents reported that they were satisfied with the good coordination with nurses and paramedical staff, which may prevent the residents from having to perform a high amount of extraneous work that university residents might have to perform.
The observed preference of females for university hospitals may not help to alleviate the disparity of physicians in rural areas because female physicians tend to switch from full-time to part-time employment due to family constraints12
. In Japan, only 14% of all physicians are female11
, and this issue needs to be monitored carefully in future investigations.
Only universities can grant a DMSc degree. Therefore, residents who want this degree are more likely to choose a university hospital, as confirmed by our survey. In addition, this finding had a statistical interaction with the satisfaction of residents with their salary. Residents at university hospitals were generally not satisfied with their incomes; however, if they were interested in the DMSc degree, they were less dissatisfied than those who were not interested. Under the traditional department system at university hospitals in Japan, residents and young physicians are required to perform hard work and are compensated minimally13
. This unrewarding work system has been regarded by physicians as a necessary sacrifice before obtaining the DMSc degree from a university. However, the DMSc title does not guarantee a high-wage job or an increased chance of employment. Consequently, the popularity of this degree has gradually been replaced by that for the title of specialist, certified by an academic society for each specialty, for which physicians can be candidates regardless of university or non-university affiliation. A report from Canada14
indicated that the interest of trainees in pursuing academic medicine wanes as they progress through their residency. In addition, a formal teaching curriculum for the DMSc degree is seldom provided in medical schools in Japan.
Several limitations of our study need to be discussed. First, our results might have been influenced by sampling bias. The response rate was relatively high for hospitals, but was low for resident. This was mainly due to technical reasons, including the fact that residents go for clinical training outside their own hospitals (i.e., visits to public health centers or to affiliated small local hospitals). In addition, because the number of residents per program director is larger at university hospitals, the directors may have been too busy to publicize the survey widely. Second, our survey only investigated the resident perception of “satisfaction,” and not clinical or educational outcomes. Therefore, we cannot estimate the direct difference in educational outcome between university and non-university hospitals. Finally, because of the cross-sectional nature of the survey, we cannot determine causality. Therefore, our results require careful interpretation.
In conclusion, despite the limited evidence, we found that the differences in the characteristics of teaching hospitals and residents and the levels of resident satisfaction may explain the major shift of residents from university to non-university hospitals. Hospital size and the teaching resources of university hospitals did not overcome the other characteristics that led to resident dissatisfaction. Thus, to attract residents, university hospitals need to improve the conditions of their residency programs.