Why the Ministry of Health, Labour and Welfare’s Regulations on Opening “Aesthetic Clinics” Will Not Help Solve the Maldistribution of Doctors

Masahiro Kami, M.D., Ph.D. President, Medical Governance Research Institute, Tokyo, Japan

Keywords: #Ministry of Health, Labour and Welfare, #National Medical Licensing Examination, #Doctor Shortage, #Aesthetic Clinics, #Doctor Maldistribution, #Cosmetic Surgery

As the maldistribution of doctors exacerbates shortages in rural areas and certain specialties, the government has proposed measures to regulate the outflow of doctors to aesthetic clinics, which has been cited as one of the causes. The proposed regulations include requiring doctors to work for at least five years in publicly insured medical services before allowing their clinics to provide insurance-covered treatments. Additionally, local governments may request that doctors opening clinics in areas with a high concentration of private practitioners provide home healthcare or emergency care, with possible recommendations issued for those who do not comply.

While substantial public funds are invested in training medical students, an increasing number of doctors are bypassing specialty training and joining aesthetic clinics immediately after completing their initial medical training. This trend has been recognized as a concern within the medical community. However, will these government measures effectively address the issue of doctor maldistribution? This article explores expert opinions on the matter.

Typically, after passing the National Medical Licensing Examination, doctors undergo two years of clinical training as residents, followed by three to five years as specialists (formerly known as senior residents) before obtaining their specialty certification. About 9,000 individuals obtain medical licenses annually, but in recent years, approximately 200 doctors—just a few percent of the total—have been choosing to work in aesthetic clinics immediately after completing their initial clinical training without pursuing further specialization.

This shift has led to worsening doctor shortages in specialties such as general surgery, obstetrics and gynecology, and pediatrics. Meanwhile, the number of cosmetic surgery clinics increased by 44% from 2020 to 2023, reaching 2,016 facilities. Additionally, the number of doctors working in cosmetic surgery clinics more than doubled from 2016 to 2022, reaching approximately 1,200 (according to a survey by the Ministry of Health, Labour and Welfare).

In response to this trend, the government is considering the aforementioned regulatory measures. However, one of the key reasons more doctors are choosing aesthetic clinics is the grueling working conditions and low wages associated with specialty training. In contrast, salaries at major aesthetic surgery clinics are significantly higher. For example, job listings indicate that Shonan Beauty Clinic offers an annual salary of 22 million yen, with applications open to first-year residents and those without prior experience. Similarly, Tokyo Central Beauty Clinic (TCB) advertises salaries starting at 30 million yen per year on its dedicated recruitment website.

A physician working at a university hospital commented:

“Although there is a fundamental legal principle of freedom in choosing one’s profession, the fact that healthcare is funded by public insurance—essentially taxpayers’ money—justifies imposing regulations on doctors and medical institutions providing insurance-covered treatments. If doctors who do not meet certain conditions are restricted from offering insurance-covered services, it is a rational policy. Notably, many aesthetic clinics that perform elective procedures also provide insurance-covered dermatological treatments, so being unable to offer such services would be a financial blow to them.”

Another factor contributing to doctor maldistribution is the concentration of physicians in urban areas, leading to shortages in rural regions. To address this, the Ministry of Health, Labour and Welfare is considering measures such as increasing allowances for doctors working in designated doctor-shortage areas, securing substitute doctors for holiday shifts, and using insurance funds to support major hospitals that dispatch doctors to surrounding areas. Additionally, there is a proposal to withhold subsidies from doctors who open clinics in areas with an excess of private practitioners unless they also provide home healthcare or emergency services.

Will these measures effectively resolve the maldistribution of doctors? To gain insight, we spoke with Masahiro Kami, M.D., Chairman of the Medical Governance Research Institute, who provided an analysis.

Japan’s Low Number of Medical Graduates Compared to Global Standards

The Ministry of Health, Labour and Welfare’s approach—tightening regulations on aesthetic clinics and strengthening support for rural doctors—will not solve the problem of doctor maldistribution. The ministry believes young doctors are choosing aesthetic surgery because it offers better working conditions and higher salaries compared to conventional specialties. An estimated 200 doctors per year move directly into aesthetic surgery after completing their initial training, a group sometimes referred to as “Chokubi” (direct beauty) doctors. This, in turn, has led to a decline in the number of doctors entering core specialties such as internal medicine and general surgery.

However, this argument is flawed. The fundamental issue is the overall shortage of doctors, and restricting “Chokubi” doctors will not solve the problem. The root cause is that Japan produces far fewer doctors than other developed countries.

Looking at Figure 1, Japan has one of the lowest numbers of medical graduates per capita among OECD countries, ranking just above Israel and South Korea. In response, South Korea has taken government-led steps to significantly increase medical school enrollment.

This issue is rarely reported in Japan. The Ministry of Health, Labour and Welfare (MHLW) has consistently claimed that “there will be a surplus of doctors.” In a 2006 report on the supply and demand of doctors, the MHLW predicted that by 2022, the number of doctors engaged in clinical practice would exceed the required number and eventually become excessive. However, given that Japan produces an extremely low number of doctors by international standards, such a claim is simply unrealistic.

The MHLW remains steadfast in its position, insisting that “there are enough doctors, and the real issue is maldistribution.” This is why they argue that doctors must be forcibly reassigned. However, if the absolute number of doctors is insufficient, maldistribution is inevitable. It is true that doctors tend to be concentrated in urban areas while rural regions face shortages. However, in a country like Japan, where population decline is accelerating, the decline of regional cities is inevitable. The issue of doctor shortages in rural areas should be discussed within this broader context. This is a global problem, and other countries have responded by expanding telemedicine, relaxing doctors’ exclusive authority, and granting greater responsibilities to nurses.

Moreover, since the establishment of Jichi Medical University and the introduction of regional quotas for medical school admissions, the MHLW has pursued rural healthcare policies by investing enormous amounts of taxpayer money—at the cost of infringing upon young people’s constitutionally guaranteed rights to choose their profession and place of residence. Before introducing new regulatory measures, the government should first evaluate the effectiveness of these existing policies. Clearly, they have not produced sufficient results.

One issue that the MHLW does not address as a policy concern is the significant geographical disparity in doctor distribution, characterized by a west-high, east-low pattern (Figure 2). The number of doctors in each prefecture correlates with the number of doctors trained locally (Figure 3). This uneven distribution stems from the fact that most medical schools are concentrated in western Japan.

This situation is influenced by Japan’s modern history. The current governance system was established between the Meiji Restoration and the pre-war period, primarily led by the western domains of Satsuma and Chōshū. As a result, higher education institutions were preferentially established in western Japan. Many of these institutions evolved directly from the domain schools (hankō) of the late Edo period into national universities. In contrast, in eastern Japan, many domain schools were dismantled, and the establishment of higher education institutions was delayed.

Before World War II, Kyushu had three national universities—Kyushu Imperial University, Kumamoto Medical College, and Nagasaki Medical College—whereas the Kantō, Kōetsu, and Tōhoku regions had only four: Tokyo Imperial University, Tohoku Imperial University, Niigata Medical College, and Chiba Medical College. The one medical school per prefecture policy implemented during Japan’s period of rapid economic growth further widened this disparity. For instance, in 1980, three new national medical schools were established in Shikoku, which had a population of 4.42 million at the time. However, Chiba Prefecture, with a population of 5.37 million, was denied a new medical school simply because Chiba University already existed.

This gap widened because prefectures in western Japan are smaller, whereas those in eastern Japan are larger. This can be traced back to the Meiji Restoration when the victorious western domains were able to maintain their administrative independence, while the eastern domains were forced to merge. Consequently, when budgets were allocated on a per-prefecture basis, western Japan received disproportionately larger allocations than eastern Japan. This historical context underlies the maldistribution of doctors today.

The level of secondary and high school education improves in regions with access to higher education institutions, creating a self-reinforcing cycle of regional disparities in human resources. This explains why Nobel Prize winners and even prime ministers have predominantly come from western Japan. Addressing Japan’s doctor shortage requires a historical perspective. One effective solution would be to establish new medical schools in eastern Japan. Strengthening regulations on young doctors will not solve the problem—it is a discussion that should be approached more rationally.

By Business Journal Editorial Department, in collaboration with Masahiro Kami, M.D., President of the Specific Nonprofit Organization Medical Governance Research Institute

About Masahiro Kami

Masahiro Kami graduated from the University of Tokyo Faculty of Medicine in 1993 and earned his doctorate from the university’s graduate school in 1999. A medical doctor specializing in hematologic malignancies, he conducted clinical and research work at Toranomon Hospital and the National Cancer Center. In 2005, he founded the Translational Research Human Network System (now the Advanced Medical and Social Communication System) at the University of Tokyo Institute of Medical Science, focusing on medical governance. Since 2016, he has served as the president of the Specific Nonprofit Organization Medical Governance Research Institute.

This article was originally published in Japanese in Business Journal on Dec 13, 2024.