The Japanese government is currently aiming to adjust the doctor/population ratios to 3.0/1000. Our experience in various medical institutes in Japan allows us to recognize that this target is reasonable. However, whether or not this target level is optimal depends on two elements: the first is future technological breakthroughs in the medical field, and the second is whether or not the Japanese healthcare system, which is based on the medical doctors' monopoly over medical/healthcare treatments, will change.
In many countries, the medical doctors' monopoly over medical treatments has been reviewed, and the functions of paramedical workers have been expanded accordingly . In Japan, however, expanding the functions of paramedical workers in some fields is not as well appreciated as it is in other developed countries because of structural differences . We anticipate that expanding the paramedical functions will not resolve the doctor shortage problem in the near future. This is because the completion of the three essential procedures to expanding paramedical functions will take some time. These three procedures are: 1) reaching consensus regarding this problem, 2) modifying the relevant laws, and 3) educating new paramedical workers in regard to the new functions. We recognize the long-term possibility that some paramedical workers will provide a portion of the medical treatment that doctors currently monopolize. We predict that this possibility will result in a worsening of the doctor surplus in the long run.
Regarding eventual surplus/shortage of other kinds of health workforce, especially nurses, we do not expect a significant change. Some studies have reported a shortage of nurses today [18, 19]. However, just as for doctors, demand for them will decrease with a declining population in long term. At present, we did not make predictions for the nurse workforce with our model, as predictions concerning the nurse workforce are difficult using our simple model that predicts workforce supply only from the number of persons acquiring a license. In this way, predictions of nurse workforce numbers are difficult for two reasons: 1) many nurses are not working as nurses even though they possess a license license; 2) the ratio of working nurses to all nurse license holders is strongly influenced by economic conditions . These two reasons cause a gap between number of working nurses and nurse license holders.
The Japanese government is facing a dilemma. The doctor shortage in Japan is currently a serious problem that is hard to solve in the short term, even if the medical student quota is increased. On the other hand, the decreasing population of Japan guarantees that we will eventually face a doctor surplus problem in the long term, even if the medical student quota is not increased.
This means that it is difficult to decide on a medical school quota that would be most appropriate for matching supply and demand of doctors. Moreover, even if we adjust a medical student quota in future to respond to the decreasing population, it can cause an aging problem in the medical workforce: a shortage of young doctors who are generally more adept at coping with new technologies.
Increasing the medical school quota as proposed by the DPJ may diminish the academic performance of the average medical student. Although admission to medical school requires exceptional academic achievement in high school, in the future, more and more students will be able to pass the examination for admission to medical school, because the birthrate in Japan is decreasing. If the medical student quota is maintained at its current level, the percentage of all high school students that qualify for medical school will increase as the population decreases; if the quota is increased, the percentage of qualified students will be even greater. Such a reduction in the level of academic achievement required to become a medical student may reduce the quality of doctors and that of medical treatment.
Furthermore, an increase in the medical student quota may reduce the number of science and engineering students or their average academic performance. Many students who wish to enter medical school are accomplished in science and mathematics; those who do not qualify for medical school often choose to become scientists or engineers instead. If more of the students who are drawn to science and mathematics are able to become doctors, Japan may find itself with fewer or less-qualified scientists and engineers as a result. Therefore the DPJ's proposed increase may be detrimental to the economic potential of Japan in the long term.
Some countries have solved their doctor shortage problems by licensing other types of health practitioners, such as advanced practice nurses, who can fulfill some of the roles of doctors in certain situations. Japan does not offer such licenses, and the political influence of existing professional organizations is so strong that it is impractical and unrealistic to speak of licensing other types of health practitioners.
It will be difficult to resolve this dilemma without the help of foreign countries. In general, a national shortage or surplus of specialists is corrected through international exchange: when a particular specialty is in short supply, specialists are invited into the home country from abroad; in the event of a surplus, the home country's specialists seek work elsewhere. The international exchange of specialists is motivated not by government action but by individual specialists' own desire for better employment.
Most developed countries resolve shortages of health professionals by actively recruiting doctors from other countries. In the 1990s, for example, when the United Kingdom was facing a shortage of doctors, the National Health Service (NHS) actively recruited large numbers of health professionals from abroad, particularly from sub-Saharan Africa, to fill workforce gaps [21, 22]. The resulting flow of medical practitioners into the United Kingdom was so large that the recruitment policy was criticized for causing shortages of medical professionals in developing countries . In response to this criticism, the Commonwealth has since introduced guidelines for the recruitment of health workers from abroad .
In Japan, however, it is currently more difficult to recruit medical practitioners from abroad because the recognition of foreign licenses is tightly limited, and the number of graduates of foreign schools who are permitted to acquire Japanese licenses is also strictly controlled. We propose that loosening these regulations may reduce the current severe doctor shortage without creating a problematic surplus in the future.