エビデンスに基づく地域医療教育 文献レビューと政策への適用
医師の都市部集中とへき地・地方での医師不足は積年の社会問題となっている。医師の地理的偏在是正のために政策の果たす役割は大きく，特に医学教育への政策介入について，過去に多くの実証研究が行われた。本稿では過去の研究成果をレビューし，効果的に地方やへき地で働く医師を増やすためのエビデンスに基づく方策を考察する。医師のへき地就労を促進する因子として，医師自身がへき地出身であること，プライマリ・ケアに関連する総合性の高い診療科を標榜していること，へき地医師養成プログラム出身であること，卒後早期のへき地診療経験などがある。その他，卒前の地域医療実習，へき地勤務を条件とした奨学金貸与，医学部キャンパスをへき...
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| Published in | 医療と社会 Vol. 22; no. 1; pp. 103 - 112 |
|---|---|
| Main Authors | , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
公益財団法人 医療科学研究所
2012
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0916-9202 1883-4477 |
| DOI | 10.4091/iken.22.103 |
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| Abstract | 医師の都市部集中とへき地・地方での医師不足は積年の社会問題となっている。医師の地理的偏在是正のために政策の果たす役割は大きく，特に医学教育への政策介入について，過去に多くの実証研究が行われた。本稿では過去の研究成果をレビューし，効果的に地方やへき地で働く医師を増やすためのエビデンスに基づく方策を考察する。医師のへき地就労を促進する因子として，医師自身がへき地出身であること，プライマリ・ケアに関連する総合性の高い診療科を標榜していること，へき地医師養成プログラム出身であること，卒後早期のへき地診療経験などがある。その他，卒前の地域医療実習，へき地勤務を条件とした奨学金貸与，医学部キャンパスをへき地に設置することなども有効性が示唆されている。わが国における政策としては昭和47年設立の自治医科大学，および平成20年以降急速に拡大し入学定員が1,000名を超えた医学部地域枠がある。さらに近年，卒前医学教育における地域医療実習，卒後臨床研修における地域医療研修が必修化された。これら政策はある程度上記のエビデンスを踏まえたものになっている。しかしながら地域枠の制度設計は都道府県によってばらつきが大きく，また地域枠の入試制度，卒前の地域医療実習，卒後の地域医療研修にはまだ改善の余地が大きい。今後これらの政策が有効に働くために，科学的根拠に基づくさらなる改革が求められる。 |
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| AbstractList | 医師の都市部集中とへき地・地方での医師不足は積年の社会問題となっている。医師の地理的偏在是正のために政策の果たす役割は大きく，特に医学教育への政策介入について，過去に多くの実証研究が行われた。本稿では過去の研究成果をレビューし，効果的に地方やへき地で働く医師を増やすためのエビデンスに基づく方策を考察する。医師のへき地就労を促進する因子として，医師自身がへき地出身であること，プライマリ・ケアに関連する総合性の高い診療科を標榜していること，へき地医師養成プログラム出身であること，卒後早期のへき地診療経験などがある。その他，卒前の地域医療実習，へき地勤務を条件とした奨学金貸与，医学部キャンパスをへき地に設置することなども有効性が示唆されている。わが国における政策としては昭和47年設立の自治医科大学，および平成20年以降急速に拡大し入学定員が1,000名を超えた医学部地域枠がある。さらに近年，卒前医学教育における地域医療実習，卒後臨床研修における地域医療研修が必修化された。これら政策はある程度上記のエビデンスを踏まえたものになっている。しかしながら地域枠の制度設計は都道府県によってばらつきが大きく，また地域枠の入試制度，卒前の地域医療実習，卒後の地域医療研修にはまだ改善の余地が大きい。今後これらの政策が有効に働くために，科学的根拠に基づくさらなる改革が求められる。 |
| Author | 松本, 正俊 竹内, 啓祐 井上, 和男 |
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| Copyright | 2012 公益財団法人 医療科学研究所 |
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| DOI | 10.4091/iken.22.103 |
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(2000) “State Scholarship, Loan Forgiveness, and Related Programs : The Unheralded Safety Net,” Journal of American Medical Association. 284 (16) : 2084-2092. Wiwanitkit V (2011) “Mandatory Rural Service for Health Care Workers in Thailand,” Rural and Remote Health. 11 : 1583. Ranmuthugala G, Humphreys J, Solarsh B, Walters L, Worley P, Wakerman J et al. (2007) “Where is the Evidence that Rural Exposure Increases Uptake of Rural Medical Practice?” Australian Journal of Rural Health. 15 (5) : 285-288. Barnighausen T and Bloom DE (2009a) “Designing Financial-incentive Programmes for Return of Medical Service in Underserved Areas : Seven Management Functions,” Human Resources for Health. 7 : 52. Koike S, Ide H, Yasunaga H, Kodama T, Matsumoto S and Imamura T (2010) “Postgraduate Training and Career Choices : An Analysis of the National Physicians Survey in Japan,” Medical Education. 44 (3) : 289-297. Strasser R and Neusy AJ (2010) “Context Counts : Training Health Workers in and for Rural and Remote Areas,” Bulletin of World Health Organization. 88 (10) : 777-782. 長崎県福祉保健部（2010）「長崎県医学修学資金貸与制度」<http://www.pref.nagasaki.jp/izin/isi/isinoyousei/igakusyugakusikin/isi_sikin_taiyo/> 2011年4月26日アクセス Matsumoto M, Inoue K, Farmer J, Inada H and Kajii E (2010c) “Geographic Distribution of Primary Care Physicians in Japan and Britain,” Health & Place. 16 (1) : 164-166. Barnighausen T and Bloom DE (2009b) “Financial Incentives for Return of Service in Underserved Areas : A Systematic Review,” BMC Health Services Research. 9 : 86. 島根大学医学部「地域枠推薦入試について（出願要件）」<http://www.med.shimane-u.ac.jp/chiikiwaku/outline.html.> 2011年4月15日アクセス Matsumoto M, Inoue K, Bowman R, Noguchi S and Kajii E (2010a) “Physician Scarcity is a Predictor of Further Scarcity in US, and a Predictor of Concentration in Japan,” Health Policy. 95 (2-3) : 129-136. 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Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH and Hart LG (1996) “Beyond Retention : National Health Service Corps Participation and Subsequent Practice Locations of a Cohort of Rural Family Physicians,” Journal of American Board of Family Practice. 9 (1) : 23-30. Bowman RC and Penrod JD (1998) “Family Practice Residency Programs and the Graduation of Rural Family Physicians,” Family Medicine. 30 (4) : 288-292. Dunbabin JS and Levitt L (2003) “Rural Origin and Rural Medical Exposure : Their Impact on the Rural and Remote Medical Workforce in Australia,” Rural and Remote Health. 3 (1) : 212. Ricketts TC (1999) Rural Health in the United States. New York : Oxford University Press. 鹿児島大学離島へき地医療人育成センター（2010）『地域推薦枠医学生の卒前・卒後教育をどうするか？』（会議録） Ban N and Fetters MD (2011) “Education for Health Professionals in Japan-- Time to Change,” Lancet. 378 (9798) : 1206-1207. Kobayashi Y and Takaki H (1992) “Geographic Distribution of Physicians in Japan,” Lancet. 340 (8832) : 1391-1393. Weaver DL (1990) “The National Health Service Corps : A Partner in Rural Medical Education,” Academic Medicine. 65 (12 Suppl) : S43-44. Cullen TJ, Hart LG, Whitcomb ME and Rosenblatt RA (1997) “The National Health Service Corps : Rural Physician Service and Retention,” Journal of American Board of Family Practice. 10 (4) : 272-279. Matsumoto M, Inoue K and Kajii E (2008a) “Characteristics of Medical Students with Rural Origin : Implications for Selective Admission Policies,” Health Policy. 87 (2) : 194-202. |
| References_xml | – reference: 島根大学医学部「地域枠推薦入試について（出願要件）」<http://www.med.shimane-u.ac.jp/chiikiwaku/outline.html.> 2011年4月15日アクセス – reference: Kobayashi Y and Takaki H (1992) “Geographic Distribution of Physicians in Japan,” Lancet. 340 (8832) : 1391-1393. – reference: Weaver DL (1990) “The National Health Service Corps : A Partner in Rural Medical Education,” Academic Medicine. 65 (12 Suppl) : S43-44. – reference: Ban N and Fetters MD (2011) “Education for Health Professionals in Japan-- Time to Change,” Lancet. 378 (9798) : 1206-1207. – reference: Frehywot S, Mullan F, Payne PW and Ross H (2010) “Compulsory Service Programmes for Recruiting Health Workers in Remote and Rural Areas : Do They Work?” Bulletin of World Health Organization. 88 (5) : 364-370. – reference: Strasser R and Neusy AJ (2010) “Context Counts : Training Health Workers in and for Rural and Remote Areas,” Bulletin of World Health Organization. 88 (10) : 777-782. – reference: Matsumoto M, Inoue K, Bowman R, Noguchi S and Kajii E (2010a) “Physician Scarcity is a Predictor of Further Scarcity in US, and a Predictor of Concentration in Japan,” Health Policy. 95 (2-3) : 129-136. – reference: 鹿児島大学離島へき地医療人育成センター（2010）『地域推薦枠医学生の卒前・卒後教育をどうするか？』（会議録） – reference: Pathman DE, Taylor DHJ, Konrad TR, King TS, Harris T, Henderson TM et al. (2000) “State Scholarship, Loan Forgiveness, and Related Programs : The Unheralded Safety Net,” Journal of American Medical Association. 284 (16) : 2084-2092. – reference: Bowman RC and Penrod JD (1998) “Family Practice Residency Programs and the Graduation of Rural Family Physicians,” Family Medicine. 30 (4) : 288-292. – reference: Department of Health and Ageing, Australian Government (2011b) “Rural Clinical Schools.” <http://www.health.gov.au/internet/main/publishing.nsf/Content/work-st-rcs> Accessed August 4, 2011. – reference: Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH and Hart LG (1996) “Beyond Retention : National Health Service Corps Participation and Subsequent Practice Locations of a Cohort of Rural Family Physicians,” Journal of American Board of Family Practice. 9 (1) : 23-30. – reference: 文部科学省（2010）「鈴木寛文部科学副大臣記者会見録（平成22年12月16日）」<http://www.mext.go.jp/b_menu/daijin/detail/1300330.htm> 2011年8月3日アクセス – reference: Pathman DE, Konrad TR, King TS, Taylor DHJ and Koch GG (2004) “Outcomes of States' Scholarship, Loan Repayment, and Related Programs for Physicians,” Medical Care. 42 (6) : 560-568. – reference: 岡山雅信, 梶井英治（2004）「地域医療実習への標準プログラム導入の効果」『医学教育』35（3）：197-202 – reference: Matsumoto M, Inoue K, Kajii E and Takeuchi K (2010e) “Retention of Physicians in Rural Japan : Concerted Efforts of the Government, Prefectures, Municipalities and Medical Schools,” Rural and Remote Health. 10 (2) : 1432. – reference: Shibuya K, Hashimoto H, Ikegami N, Nishi A, Tanimoto T, Miyata H, Takemi K, Reich MR (2011) Future of Japan's System of Good Health at Low Cost with Equity : Beyond Universal Coverage. Lancet 378 (9796) : 1265-1273. – reference: Matsumoto M, Inoue K, Farmer J, Inada H and Kajii E (2010c) “Geographic Distribution of Primary Care Physicians in Japan and Britain,” Health & Place. 16 (1) : 164-166. – reference: Magnus JH and Tollan A (1993) “Rural Doctor Recruitment : Does Medical Education in Rural Districts Recruit Doctors to Rural Areas?” Medical Education. 27 (3) : 250-253. – reference: Matsumoto M, Inoue K, Bowman R, Noguchi S, Toyokawa S and Kajii E (2010b) “Geographical Distributions of Physicians in Japan and US : Impact of Healthcare System on Physician Dispersal Pattern,” Health Policy. 96 : 255-261. – reference: Wiwanitkit V (2011) “Mandatory Rural Service for Health Care Workers in Thailand,” Rural and Remote Health. 11 : 1583. – reference: Barnighausen T and Bloom DE (2009a) “Designing Financial-incentive Programmes for Return of Medical Service in Underserved Areas : Seven Management Functions,” Human Resources for Health. 7 : 52. – reference: Rabinowitz HK (1993) “Recruitment, Retention, and Follow-up of Graduates of a Program to Increase the Number of Family Physicians in Rural and Underserved Areas,” New England Journal of Medicine. 328 (13) : 934-939. – reference: Cullen TJ, Hart LG, Whitcomb ME and Rosenblatt RA (1997) “The National Health Service Corps : Rural Physician Service and Retention,” Journal of American Board of Family Practice. 10 (4) : 272-279. – reference: Ranmuthugala G, Humphreys J, Solarsh B, Walters L, Worley P, Wakerman J et al. (2007) “Where is the Evidence that Rural Exposure Increases Uptake of Rural Medical Practice?” Australian Journal of Rural Health. 15 (5) : 285-288. – reference: Brooks RG, Walsh M, Mardon RE, Lewis M and Clawson A (2002) “The Roles of Nature and Nurture in the Recruitment and Retention of Primary Care Physicians in Rural Areas : A Review of the Literature,” Academic Medicine. 77 (8) : 790-798. – reference: Matsumoto M, Inoue K and Kajii E (2008b) “Contract-based Training System for Rural Physicians : Follow-up of Jichi Medical University Graduates (1978-2006),” Journal of Rural Health. 24 (4) : 360-368. – reference: World Health Organization (2010) “Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention : Global Policy Recommendations.” Geneva : WHO. – reference: Rabinowitz HK (1988) “Evaluation of a Selective Medical School Admissions Policy to Increase the Number of Family Physicians in Rural and Underserved Areas,” New England Journal of Medicine. 319 (8) : 480-486. – reference: Seifer SD, Vranizan K and Grumbach K (1995) Graduate Medical Education and Physician Practice Location. Implications for Physician Workforce Policy,” Journal of American Medical Association. 274 (9) : 685-691. – reference: Anderson M and Rosenberg MW (1990) “Ontario's Underserviced Area Program Revisited : an Indirect Analysis,” Social Science & Medicine. 30 (1) : 35-44. – reference: Koike S, Ide H, Yasunaga H, Kodama T, Matsumoto S and Imamura T (2010) “Postgraduate Training and Career Choices : An Analysis of the National Physicians Survey in Japan,” Medical Education. 44 (3) : 289-297. – reference: Inoue K, Matsumoto M, Toyokawa S and Kobayashi Y (2009) “Transition of Physician Distribution (1980-2002) in Japan and Factors Predicting Future Rural Practice,” Rural and Remote Health. 9 (2) : 1070. – reference: Hancock C, Steinbach A, Nesbitt TS, Adler SR and Auerswald CL (2009) “Why Doctors Choose Small Towns : A Developmental Model of Rural Physician Recruitment and Retention?” Social Science & Medicine. 69 (9) : 1368-1376. – reference: Ricketts TC (1999) Rural Health in the United States. 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| SubjectTerms | へき地医療 医学教育 医師偏在 医療政策 地域医療 |
| Subtitle | 文献レビューと政策への適用 |
| Title | エビデンスに基づく地域医療教育 |
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