Medical Specialties Selected by Graduates of Juntendo University

Objective : We conducted a survey to investigate the specialties selected by graduates of Juntendo University following the completion of clinical training, and compared the results obtained before and after the introduction of the mandatory clinical training system. Materials : Subjects were 1,115 graduates (male: 743, female: 372) who participated in the new clinical training system between 2004 and 2015. Controls were 1,068 graduates (male: 786, female: 282) who participated in the old clinical training system between 1992 and 2003. Methods : The specialties selected were classified into“internal medicine”,“surgery”,“required specialties (emergency medicine, pediatrics, obstetrics and gynecology, and psychiatry, which are compulsory for the clinical training system)”,other specialties, so-called“minor specialties”,and“basic medicine”.The percentage of graduates in each specialty was compared before and after the introduction of the mandatory clinical training system. Results : The percentage of graduates increased in internal medicine (from 32.8 to 34.1%), required specialties (from 18.0 to 20.7%), and basic medicine (from 0.6 to 1.5%, p=0.0276), but decreased in surgery (from 14.9 to 11.0%, p=0.0071) and minor specialties (from 33.7 to 32.7%). When surgery was included as a required specialty, the ratio of graduates who selected internal medicine, required specialties, and minor specialties was approximately the same (one third for each), with no significant differences being observed from before the introduction of the mandatory system. Conclusions : Our University graduates who selected internal medicine, required specialties (including surgery), and minor specialties accounted for approximately one third each, with the remainder selecting basic medicine.


Introduction
The history of the clinical training system in Japan began with an internship program in 1946. In 1968, a clinical training system was implemented, and since 2004, the introduction of a new system has mandated physicians to undergo clinical training 1) 2) . Under the former system, the majority of new physicians chose to work at a university medical office immediately after graduation because the system was not mandatory. However, the introduction of a national matching system, which began at the same time as a new training system in 2004 allowed for clinical training at hospitals other than university hospitals, and thereby expanded future career options. Residents are concentrated in urban areas and mostly remain in hospitals in these areas after training. Furthermore, departments with a busy schedule or those that require emergency responses have become less popular, resulting in the geographical and specialty maldistribution of physicians 3) . University education and clinical training experiences are considered to influence the specialty selected by graduates; however, the distribution of physicians who graduated from university in different specialties currently remains unclear.
Therefore, we herein conducted a survey to investigate the specialties selected by graduates of Juntendo University following the completion of clinical training.

Subjects and Methods
Subjects were 1,115 graduates (male: 743, female: 372) who participated in the new clinical training system between 2004 and 2015, excluding those who were registered in the new certification system for medical specialists, which was initiated in 2018.
Controls were 1,068 graduates (male: 786, female: 282) who participated in the old clinical training system between 1992 and 2003. Although no significant differences were observed in the total number of graduates before and after the introduction of the mandatory clinical training system (approximately 1,100 graduates in both groups), the number of males decreased by 43, whereas that of females increased by 90.
We initially classified medical specialties into 5 groups:"internal medicine" ,"surgery" ,"required specialties (emergency medicine, pediatrics, obstetrics and gynecology, and psychiatry, which are compulsory for the clinical training system)" , other specialties, so-called"minor specialties" , and"basic medicine" . The percentage of graduates in each specialty was compared before and after the introduction of the mandatory clinical training system. A subgroup analysis was also conducted to examine changes in the number of physicians according to the specialty selected.
Physicians who complete 2 years of clinical training are often called a"senior resident" ,"specialist trainee" , or"new medical staff"depending on the institution. Not all graduates targeted in this study qualified as a medical specialist; however, physicians who pursued a career in a specialty were referred to as an"attending doctor"in this study 4) .
Statistical analyses were performed using the chisquared test with JMP ® 9.0 (SAS Institute Inc., Cary, NC, USA). The significance of differences was set to p < 0.05 in all settings.
The present study was conducted with the approval of the Ethics Committee of Juntendo University (Approval number: 2019187).

Specialties selected by graduates
The percentage of attending doctors in each specialty was compared before and after the introduction of the mandatory clinical training system. The percentage of attending doctors increased in internal medicine (from 32.8 to 34.1%), required specialties (from 18.0 to 20.7%), and basic medicine (from 0.6 to 1.5%, p = 0.0276), but decreased in surgery (from 14.9 to 11.0%, p = 0.0071) and minor specialties (from 33.7 to 32.7%).
In the present study, surgery was regarded as an independent specialty, but is practiced as part of the required specialties in the clinical training system. When surgery was included as a required specialty, the ratio of graduates who selected internal medicine, required specialties, and minor specialties was approximately the same (one third for each), with no significant differences being observed from before the introduction of the mandatory clinical training system ( Figure-1). A similar distribution was also observed in the results obtained by sex ( Figure-2).

Changes in the number of attending doctors by specialty
Figure-3 to 7 shows a comparison of the number of attending doctors by specialty before and after the introduction of the mandatory clinical training system.

1) Internal medicine
The number of attending doctors increased in cardiology, pneumology, gastroenterology, hematology, oncology, and general medicine after the introduction of the mandatory clinical training system (Figure-3).

2) Surgery
The number of attending doctors in digestive surgery decreased by one third (from 120 to 76). Regarding subspecialties, the number of attending doctors increased in breast surgery, thoracic surgery, and cardiovascular surgery, but not pediatric surgery (Figure-4).

3) Required specialties
The number of attending doctors increased the most in the emergency department, followed by obstetrics and gynecology. When surgery was included as a required specialty, the total number of attending doctors in required specialties was 350 and 349 in the old and new clinical training systems, respectively ( Figure-

4) Minor specialties
The number of attending doctors increased in anesthesiology, radiology, plastic surgery, urology, and neurosurgery (Figure-6).

5) Basic medicine
The number of attending doctors increased in pathology and public health (Figure-7).

Discussion
In Japan, physicians are free to select the course of their career after obtaining a medical license. Therefore, the maldistribution of physicians occurs both geographically and in practice areas 5) . Since 2008, the government has undertaken various measures, such as expanding the admission quota of medical schools, in order to gradually increase the number of physicians in many departments. However, this maldistribution has not yet been eliminated 6) .
Prior to the introduction of the mandatory clinical training system, the majority of physicians worked at a university medical office immediately after graduating from medical school, and followed the advice of their superior in terms of their career choices, such as work location and training programs. However, with the aim of reducing the gap in the competence of physicians before advancing to specialties, a mandatory 2-year clinical training period was introduced that placed an importance on nurturing physicians with a wide range of knowledge and medical skills focused on primary care. Specifically, it requires physicians to undergo training in internal, emergency, and community medicine regardless of their specialty preference, and also requires them to experience a clinical rotation in various fields, such as surgery, pediatrics, obstetrics and gynecology, and psychiatry. In addition, the new system stipulates the right amount of payment to residents, and prohibits them from engaging in other part-time work during clinical training. Therefore, a reality that was not possible to foresee in clinical exercise during university has become visible, thereby impacting on the selection of future specialties. Medical departments that involve a busy schedule and hard work started to be avoided. The majority of residents choose the course of their career during the period of training, with more than 40% of residents changing their career course after clinical training. The experience of clinical training influences their career path as much as the education they receive at university 7) 8) .
Based on this background, we conducted a survey to investigate the specialties elected by our graduates, and compared the results obtained before and after the introduction of the mandatory clinical training system. University graduates who selected internal medicine, required specialties (including surgery), and minor specialties accounted for approximately one third each, with the remainder selecting basic medicine. No significant differences were observed in this ratio before and after the introduction of the mandatory clinical training system. A similar distribution was also found in the results obtained by sex; however, the number of female attending doctors selecting basic medicine has increased. It currently remains unclear whether a difference exists in the specialties selected by the graduates of our university and those in other universities; however, the present results were of significance because they clarified the career distribution of our medical graduates.
By specialty, the number of physicians selecting general internal medicine and oncology increased in the area of internal medicine, and this may be attributed to both of these being relatively new fields in addition to the concept of"generalist"being popularized.
Surgery, particularly digestive surgery, was once a department with many physicians in the university; however, the number of physicians who select this specialty has decreased nationwide 3) . This may be due to the categorization of surgical specialties according to specific organ systems (rather than numbering them, such as first or second surgery), which was adopted when the new clinical training system was about to be introduced. At around this time point, breast surgery was also established as an independent specialty. Regarding required specialties including surgery, there was no difference in the total number of attending doctors before and after the clinical training system, and it was considered appropriate to configure surgery, pediatrics, obstetrics and gynecology, and psychiatry as required specialties of the clinical training. The number of attending doctors increased the most in the emergency department, followed by obstetrics and gynecology. After-hour emergency patients were previously admitted directly to each department. The emergency department was established after the introduction of the mandatory clinical training system in order to respond to the increasing number of physicians who selected to practice as a"generalist" , similar to those selecting general medicine as their specialty. Furthermore, the increase observed in the number of medical students who apply for the Chiiki-Waku quota (Chiiki-Waku: medical students in medically underserved areas) may be another reason for the increase in the number of physicians selecting the required specialties excluding surgery. Although the Chiiki-Waku program aims to nurture physicians who engage in rural medical practice, the specialties available for selection after clinical training are limited to the emergency department, pediatrics, and obstetrics and gynecology.
Regarding minor specialties, the number of physicians increased in anesthesiology, radiology, plastic surgery, urology, and neurology. Anesthesiologists who work freelance also appeared after the introduction of the mandatory clinical training system. The number of female attending doctors increased in basic medicine, and this may be due to their consideration of the parenting/work balance. "The new certification system for medical specialists"was initiated in 2018 and certifies physicians with sufficient experience and training in a specific specialty as a"medical specialist" 9) .
Although this system was established by academic societies, not the government, the majority of residents are registered during clinical training. To prevent the concentration of physicians in urban areas and certain specialties, some regions and hospital departments set an upper limit in the number of physicians they recruit. Nevertheless, it remains unclear whether this will minimize the maldistribution of physicians.
One limitation of the present study is that the percentage of our graduates in each specialty cannot be compared with that of the graduates of other universities. This information is important for reviewing undergraduate and postgraduate education, and, thus, warrants further study. Another limitation is that we were unable to follow-up physicians who changed their specialty due to the opening of clinics and those who took temporary leave from their medical practice.
Our university graduates who selected internal medicine, required specialties (including surgery), and minor specialties accounted for approximately one third each, with the remainder selecting basic medicine. The impact of the new clinical training system initiated in 2018 on the future career course of our graduates needs to be monitored.

Authorsʼ contributions
YT conceived of this study, and participated in its design and coordination and helped to draft the manuscript. TS participated in the design of this study and MW and MS collected the data. HW performed the statistical analysis. TO was major contributor in writing the manuscript.
All authors read and approved the final manuscript.

Conflicting interest statement
The Authors declare that there is no conflict of interest.