寺裏 寛之

BACKGROUND: In Japan, local governments have rural clinics designated for areas without physicians (RCDA) to secure physicians for rural medical care. Moreover, a medical policy of dispatching physicians between the RCDA and core hospitals for rural areas (CHRA) exists. This study aimed to assess the actual situation of physician migration from RCDAs and those who migrated, and examine the factors associated with their migration. METHODS: This retrospective cohort study used biennial national physicians' survey data from 2012 to 2018. It targeted physicians who worked at RCDAs in 2012 and participated in all four surveys (n = 510). The physicians were divided into two groups. One group consisted of physicians who worked continuously at the RCDA over the four study periods (retained physicians, n = 278), and the other included physicians who migrated to other institutions midway through the study period (migrated physicians, n = 232). We tracked the types of facilities where RCDA physicians worked from 2012 to 2018, also examined the factors associated with their migration. RESULTS: Among physicians from RCDAs who migrated to other institutions (n = 151) between 2012 and 2014, many migrated to hospitals (n = 87/151, 57.6%), and some migrated to CHRA (n = 35/87, 40.2%). Physicians in their 40s (Hazard ratio 0.32 [95% CI 0.19-0.55]), 50s (0.20 [0.11-0.35]), and over 60 years (0.33 [0.20-0.56]) were more likely to remain at RCDAs. Changes in their area of practice (1.82 [1.34-2.45]) and an increase in the number of board certifications held by physicians between 2012 and 2018 (1.50 [1.09-2.06]) were associated with migration. CONCLUSIONS: Many migrating physicians choose to work at hospitals after migrating from RCDAs. It was seemed that the physician dispatch system between RCDA and CHRA has been a measure to secure physicians in rural areas. Young age, obtaining board certification, and changes in areas of practice were associated with physician migration from RCDAs.

病院勤務医は,診療支援の目的で主たる従事先(主従事先)とは別に従たる従事先(従従事先)を有する場合がある。働き方改革の労働時間の規制は,従従事先の診療に影響することを危惧する声がある。そこで,その影響を推測するために地域医療支援病院の医師の従従事先の実態の把握を目的とした。調査は2018年の医師・歯科医師・薬剤師統計を用い,対象は病院の常勤医師(n=144383)とした。従従事先を有する医師の割合は,地域医療支援病院群(11.8%)がそれ以外の病院群(22.4%)と比較して有意に低かった。地域医療支援病院群の医師で従従事先が医師少数区域である割合は,医師少数県(17.9%)で医師多数県(10.6%)や医師中程度県(8.8%)よりも有意に高かった。地域医療支援病院群の医師の従従事先は,割合は大きくはないものの医師少数区域への医療支援を担っており働き方改革の影響を注視する必要がある。(著者抄録)

In Japan, there are rural clinics designated for areas without physicians to ensure the availability of medical care for rural area residents. The purpose of this study was to clarify the attributes of physicians working in the rural clinics. Using the 2018 Ministry of Health, Labour and Welfare data in Japan, we compared the attributes and board certifications of physicians in rural clinics with those of physicians in other clinics. The age group with the highest percentage of physicians was the over 70 group (16%) and the early 30s group (15%) at rural clinics; however, the highest percentage of physicians at other clinics was the 70 over group (20%) and the early 60s group (16%). The number of physicians working in the internal medicine field at rural clinics was 550 (89%). There were 147 (27%) board-certified physicians in that field. Among them, the number of board certifications in internal medicine, surgery, and other than internal medicine or surgery were 79 (54%), 17 (12%), and 51 (35%), respectively. The proportion of board-certified surgery physicians within the internal medicine field in rural clinics was significantly higher than in other clinics (5%). In rural clinics, the age distribution of physicians was different from that in other clinics, and many of the physicians worked in the internal medicine field, but some of them seemed to have a mismatch between their board-certifications and their fields of practice. Further studies are necessary to clarify what the mismatches mean in rural practice.

Objective: Despite the high prevalence of mental disorders in rural areas, mental health services are lacking because of shortages of resources and difficulty in accessing such services. Telemental health services can be beneficial for these patients. This study summarizes the efficacy of telemental health in managing mental disorders in rural areas. Materials and Methods: The MEDLINE and Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials on telemental health for mental disorders in rural areas until June 2022. The reviewers independently screened, extracted, and assessed study quality using the Risk of Bias 2 tool. Results: Six eligible studies were identified on mental health symptoms, insomnia, depression, and schizophrenia. The quality of all the studies was moderate, and they all reported that telemental health effectively improved the symptoms of mental disorders. One study reported a reduction in relapse and rehospitalization rates in young individuals. Another study reported that it was effective in improving the symptoms of depression and anxiety in older individuals. Conclusions: Although further studies are warranted, telemental health services could effectively improve the symptoms of mental disorders in rural areas.