In high-incidence areas of COVID-19 in Japan where physician shortage is a serious issue, community teaching hospitals with a greater resident physician workforce are significantly associated with a higher number of patient admissions. There was no such relationship among university hospitals. The number of staff physicians is also not related to admissions among both community and university hospitals. Community hospitals received more admissions per 100 beds compared to university hospitals, which was consistent with our prior hypothesis that university hospitals have roles as research institutions and highly-specialized tertiary care.
Our results, at least for resident physicians, are in line with previous studies which link improvement in physician shortage with acceptance of more patient admissions [11,12,13]. Since Japan has the lowest number of hospital physicians by population as well as by hospital beds in OECD countries [6, 14], increasing the volume of physicians, especially resident physicians, in community hospitals should be recommended. In Japan, doctors who are 1–5 years post-graduation are classified as resident physicians. Due to their lack of experience, junior residents (1–2 years post-graduation) do not bear sole responsibility for clinical decision-making but are important members of the physician team and are expected to contribute to patient care through daily interaction with patients, medication prescription and play a substantial role in the decision-making process. Additional responsibility is given to senior residents (3–5 years post-graduation). Thus, it can be said that resident physicians play a pivotal role in the hospital setting. Although the total number of physicians has been increasing recently [15], the number of internal medicine physicians has decreased [16]. Thus, the number of internal medicine residents should be increased to meet the demands of internal medicine admissions, including COVID-19 cases with a high risk for mortality. In the long term, medical schools should accept applications from more students so as to be better prepared not only for pandemic resilience of the healthcare system but also for the increasing needs of a hyper-aging society and medical service expansion. Recent trends also show that medical schools in Japan have become increasingly popular amongst high school students, and it is difficult to enter due to the limited availability of only a small number of total slots [17]. Thus, the demand for becoming future physicians remains high for high school students in Japan and it is not difficult to recruit talented applicants.
In the short term, several strategies could be considered to enhance manpower in community hospitals. First, resident physicians’ training slots at university hospitals and other non-COVID-19 care hospitals could be transferred to community hospitals so as to be better prepared for emergencies, despite this measure being opposed to the prioritized education for medical residency. This transfer could be done as a temporary flexible measure to shift the physician workforce in midst of a pandemic wave. Second, weekend or nighttime work in community hospitals could be supported by clinic doctors during the pandemic waves if these clinic doctors have the willingness to work in community hospitals on a part-time basis. These two measures could be employed in the current health system of Japan, but investment is needed from the central and local governments to pay cooperating hospitals and clinic doctors. Third, in Japan there are nurse practitioners and medical students who are well educated to assist physicians and they may be assembled in community hospitals as temporary physician assistants in the highest incidence areas of COVID-19 in Japan. This measure calls for the development and enforcement of a new law that includes the introduction of new medical professionals such as physician assistants. Forth, introducing and enhancing telemedicine using information technology would reduce workload during the surges.
Physician workforce included staff and resident physicians, but our results revealed the significance of the number of resident physicians for accepting patient admissions. In Japan, doctors who are 1–5 years post-graduation are classified as resident physicians. Due to their lack of experience, junior residents (1–2 years post-graduation) do not bear sole responsibility for clinical decision-making and the clinical level of staff physicians is higher in knowledge and skill. However, contemporary hospital care is provided to patients by a team that includes resident physicians, and they are expected to contribute to patient care through daily interaction with patients, medication prescription and playing a substantial role in the clinical decision-making process. Additional responsibility is given to senior residents (3–5 years post-graduation). Staff physicians have roles as conductors in team care but the actual workload for admitting patients through the emergency department is mostly provided by many resident physicians based on the command of their senior physicians. Thus, it can be said that resident physicians play a pivotal role in the hospital setting.
There are several limitations in the current study. First, patients in our study included all admissions to the department of internal medicine and thus non-COVID-19 patients were also included. We could not determine the disease classifications of admitted patients since our database of the Japanese Society of Internal Medicine did not include these data. However, at the time of the pandemic waves and especially during the healthcare collapse, not only COVID-19 but also non-COVID-19 patients were at risk of refusal of admission in the highest incidence areas. Thus, it may be prudent to count admissions of internal medicine patients as a health system capacity measure. Second, this research could not evaluate the following factors associated with the work contents of individual physicians; the severity of patients; research work related to COVID-19 care and the increase in efforts to teach medical students. This study was motivated to improve the Japanese healthcare system to decrease the number of refusals of necessary admissions by reconsidering the distribution of physicians who can provide care for internal medicine patients. Physicians in Japan have been noted as hard workers regardless of hospital owner organizations; we admire all the works they have done and would like to provide information which can help construct a more efficient and protective environment for them to save patients [18]. The recent enactment of The Work Style Reform Bill point towards recognition from the central government to deal with the increased workload that physicians are subjected to, and these reforms will hopefully lead to reducing the burden on these doctors hence improving the general well-being of physicians and an improved health care system. Third, the analyzed data is of one-year duration and thus cannot be compared with data from continuing years. However, if associations suggested from our results would sustain over years, we must focus on this issue with deeper concern and urgency. Forth, the cost and effect of these pandemic surge workloads among medical professionals including physicians, nurses and other co-medical staff were not assessed, besides the medical costs for COVID-19 inpatients that have been paid by national expenditure as of January 2022. Fifth, data was not available for nursing staff and other healthcare workers in the current study. These occupations are indispensable for an inpatient care team. In addition, there is no assessment of interactive or affiliated relationships between community hospitals and university hospitals in terms of dispatching workforce. Future studies are needed to examine the role of interactions of these professionals during the pandemic.
In conclusion, during the COVID-19 pandemic in Japan, improving resident physician shortage may enhance patient admissions to the department of internal medicine at least in community teaching hospitals. Several measures are recommended as urgent short-term policies, including temporary flexible transfer of physician workforce to community teaching hospitals from university hospitals, non-COVID-19 care hospitals, or clinics. Nurse practitioners could become temporary physician assistants. Long-term policy change should also be considered to increase slots in medical schools.