A standardized graduate medical training for specialist certification is essential to providing high-quality medical care, but it may not be sufficient to tackle the needs of aging populations, in which demands for medical services are not only growing, but also vary substantially. This is becoming critical in rural areas, where shortages in the health care workforce are most acute.1 Japan, the most rapidly aging society on the planet, currently is implementing a program of integrated community-based comprehensive services on the one hand, and a new certification mechanism of graduate medical education for specialists on the other.
In Japan, each academic specialty association has provided a specialist certification without any standardized guidelines. To reform the system, a comprehensive, independent institution called the Japan Medical Specialty Board was launched with government assistance in 2014.2 However, a regulation was proposed that stated that only large hospitals would be eligible to provide training programs; this evoked a wide range of social disputes among stakeholders. The proposed scheme would pull young physicians away from small- and medium-sized hospitals, causing a significant shortage of physician providers, especially in rural areas. Furthermore, academic associations insisted on joining the board as staff members, thus jeopardizing the principle of an independent review.
After the triple disaster hit Fukushima, the authors have been working in the city of Minamisōma, which is located 23 km from the Fukushima Daiichi reactors. It is 1 of the most medically underserved and rapidly aging areas of Japan, where approximately 30% of the population is age 65 and older. Surprisingly, there have been quite a few young physicians who are enrolled in the local residency program. As the new certification system would deprive these young physicians of specialist training, we sent an open letter of opposition to the Ministry of Health, Labour and Welfare.3 The Japan Medical Association, the Japan Hospital Association, and some local governments declared their opposition as well.4 Eventually, the board postponed the implementation of the new program until 2018.
The major elements of medical services in aging populations include the shift from cure to care, and from fragmentation to integration.5 Young physicians need to understand how to manage chronic conditions, such as dementia. As the percentage of older individuals generally is larger in rural areas than in cities, these locations provide suitable training not only for general practitioners but also for future specialists. It is time to rethink the approach for certifying specialists, and promote diverse options while maintaining the quality standard of training.
