Professional identity and rural workforce commitment among regional quota medical students in Japan: a qualitative study

Abstract

INTRODUCTION: Many countries use rural admission pathways and bonded scholarship programs to address persistent shortages of physicians in underserved areas. In Japan, the Chiiki-Waku (regional quota) system was established to recruit and train medical students who are expected to contribute to rural and remote health care. However, variations in educational support and limited understanding of students' lived experiences may weaken the effectiveness of such programs in fostering long-term professional commitment. This study aimed to explore the learning experiences and educational needs of Chiiki-Waku medical students, with particular attention to how these experiences shape professional identity formation and future commitment to rural practice. METHODS: We conducted a qualitative study at the University of the Ryukyus in Okinawa, Japan, a setting characterized by geographically remote islands and challenges in healthcare access. Semi-structured interviews were undertaken with medical students admitted through the Chiiki-Waku system across different academic years. Purposive sampling was used to ensure variation in gender, year of study, and rural background. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically through an iterative coding process involving multiple researchers to enhance credibility. The analysis focused on identifying factors that facilitated or hindered students' professional identity formation and their anticipated commitment to rural practice. RESULTS: Four interrelated themes were identified: increased exposure to rural health care, addressing the loss of identity, enhancing communication between educators and students, and balancing the appeal and obligation of rural health care. Students highlighted the importance of repeated and meaningful rural clinical exposure, educational opportunities that reinforced their role as future rural physicians, proactive communication with faculty, and access to mentors. Participants also described tension between contractual obligation and intrinsic motivation, suggesting that professional commitment to rural practice may be strengthened when educational experiences foster both a sense of purpose and personal aspiration. DISCUSSION: These findings suggest that rural workforce commitment among Chiiki-Waku students is not simply a direct outcome of admission status or contractual obligation but is shaped through an ongoing process of professional identity formation. Repeated rural exposure, recognition of students' distinct roles, communication with educators and peers, and opportunities for reflection interacted to help students negotiate the tension between externally imposed service obligations and intrinsic motivation. CONCLUSION: Strengthening support for Chiiki-Waku medical students may be important for sustaining their commitment to rural health care. Educational strategies that provide repeated rural exposure, mentorship, recognition of students' distinct roles, and opportunities for reflection may help students negotiate the tension between obligation and aspiration and contribute to long-term rural workforce sustainability.