Gender Inequality Improvement in Medical School Admissions in Japan

Abstract

Purpose:

To investigate the effects of gender discrimination in Japan's medical school admission process and to assess whether the situation has improved since the disclosure of such discrimination in 2018.

Materials and Methods:

A cross-sectional study was conducted using secondary data from the Ministry of Education, Culture, Sports, Science, and Technology. The proportions of male and female applicants vis-à-vis all successful candidates admitted from 2016 to 2021 were analyzed; four medical schools were found to be systematically guilty of discriminatory admission practices. Acceptance rate ratios (ARRs) were estimated, and difference-in-differences (DID) analysis was used to examine the differences in ARRs between the two groups—the 4 and 75 medical schools that were and were not reported, respectively—in the predisclosure (2016–2018) and postdisclosure (2019–2021) periods.

Results:

Female applicants were subjected to discriminatory admission practices at the four reported medical schools in the predisclosure period. However, postdisclosure, those four medical schools had higher female than male acceptance rates in all 3 years. DID analysis revealed a statistically significant estimated average treatment effect on the treated of 0.25148 (95% confidence interval [0.00455–0.49840]), indicating a 0.25-point increase in ARRs relative to the other 75 medical schools.

Conclusions:

Discriminatory practices against female applicants have decreased since the disclosure in 2018, with the acceptance rate of female students exceeding that of male students for the first time in 2021. In response to these findings, we propose recommendations to further promote gender equality in medicine.

Introduction

Throughout recent decades, there has been a substantial increase in the number of women pursuing a medical education.¹ Nevertheless, the pervasive existence of gender discrimination within the sphere of medicine, specifically regarding remuneration, advancement opportunities, and progress in academic trajectories, constitutes a universally acknowledged obstacle.^2

–5 Despite the substantial evidence suggesting that female physicians frequently achieve superior patient satisfaction, demonstrate enhanced adherence to medical guidelines,^6,7 and facilitate improved clinical outcomes such as decreased hospital mortality and readmission rates⁸ compared with their male colleagues, their static career advancement has become a concern.^2

–5 Specifically, discrimination in entrance examinations could potentially undermine the quest for equality in the field of medicine, leading to a diminished presence of women in clinical practice and disadvantaging female patients.⁹

Within the Japanese context, in 2018, it was revealed that four medical educational institutions had persistently exercised systematic discrimination against women during the admission process.¹⁰ By universally applying deductions to the scores of female applicants, the representation of women was deliberately curtailed, thereby favoring male applicants, who were perceived as probable long-term contributors to the workforce.^11
–13 However, there remains an information gap concerning the comparative difficulty faced by female candidates in passing the entrance examination before the 2018 revelation, and the subsequent question of whether there has been a shift toward more equitable practices following the exposure of this discriminatory trend. Consequently, we explore how the disclosure of discriminatory practices by the Ministry of Education, Culture, Sports, Science and Technology (MEXT) and associated institutions ameliorated the gender discrimination in the acceptance rates of female applicants at these four medical schools.

Materials and Methods

We conducted a cross-sectional study based on secondary data obtained from the MEXT.¹⁴ For the four medical schools reported by the MEXT to discriminate against female applicants—Juntendo University (JU), Tokyo Medical University (TMU), Kitasato University, and St. Marianna University School of Medicine—we analyzed the ratio of male and female applicants to the total accepted students admitted from 2016 to 2021. This ratio was compared with that of the 75 medical schools that were not reported. Acceptance rate ratios (ARRs) were calculated by obtaining ratios of the acceptance proportions of female examinees and subsequent successful applicants, compared to male counterparts. Academic years between 2016 and 2018 were considered predisclosure, and those between 2019 and 2021 were considered postdisclosure. Difference-in-differences (DID) analysis was used to examine the difference in ARRs between the two groups of schools in these two periods.

The average treatment effect on the treated (ATET) was estimated in DID analysis by comparing the change in outcomes (ARRs) for the four schools before and after the disclosure with the change in outcomes for the control group over the same time period. The unmatched difference between these two changes was the ATET. The significance level was set at 5%. All analyses were performed using Stata statistical software version 17.0 (StataCorp., College Station, TX). To compare the four medical schools' characteristics and admission procedures, we examined each school's application guidelines for 2021 and the Obunsha Passnavi website (https://passnavi.evidus.com). This research project did not require ethical approval as it utilized pre-existing data.

Results

Regarding the admission practices of the four medical schools, male applicants were found to be more likely to clear entrance examinations in the predisclosure period. Table 1 provides the admission characteristics and procedures of the four targeted schools and the ARRs of male and female applicants at the four medical schools. Acceptance rates for women were lower than for men in JU during all 3 years of the predisclosure period. The lowest ARR for women was 0.32 in 2018, observed in TMU, compared to the ARRs of the other 75 medical schools as a control (0.89 in 2016, 0.99 in 2017, 0.89 in 2018, 1.04 in 2019, 0.93 in 2020, 1.01 in 2021).

Table 1.

Summary of the Admission Procedures of the Four Schools

	JU	TMU	KU	SMUSM
Type	Private
Subjects in the entrance examination
Mathematics, Science, English language
Interview	Yes
Essay	Yes
Aptitude test	No			Yes
Additional points based on the application document and the report from the graduating high school	No			Yes
Admission capacity	136	119	109	115
Discriminatory practices pointed out by the MEXT^a	Yes			Likely
Percentages of enrolled male and female students	65.5% vs. 34.5%	63.1% vs. 36.9%	58.2% vs. 41.7%	58.5% vs. 41.4%
Acceptance rate ratios for accepted admissions by gender in universities
2016	0.62	0.79	0.79	1.2
2017	0.65	1.07	1.12	0.97
2018	0.52	0.32	1.17	0.68
2019	1.06	1.02	1.28	1.27
2020	0.84	0.92	0.88	1.64
2021	0.97	0.98	1.1	1.85

Gender discrimination, that is, the uniform reduction of the scores of female applicants in the medical school admission process and intentional suppression of the number of female examinees accepted.

JU, Juntendo University; KU, Kitasato University; MEXT, Ministry of Education, Culture, Sports, Science and Technology; SMUSM, St. Marianna University School of Medicine; TMU, Tokyo Medical University.

In 2019, right after the disclosure, none of the four medical schools had lower acceptance rates for women than for men in any year. DID analysis (Fig. 1) revealed that the estimated ATET was statistically significant at 0.25148 (95% confidence interval [0.00455–0.49840]), indicating a 0.25-point increase in the ratio relative to the other 75 medical schools.

FIG. 1.

Effect of intervention on the outcome: Difference-in-differences analysis. This figure shows the time trend in the acceptance rate ratios for female students in the 4 accused medical schools (black) and the other 75 medical schools (gray).

Discussion

The present study disclosed that female contenders were subject to prejudiced admission protocols at four medical academies. However, the DID analysis unveiled, unprecedentedly, that in the triennium subsequent to the MEXT's revelation concerning discriminatory actions against female aspirants by the aforementioned medical schools, the acceptance rates for women were higher than for men. In this section, we discuss why these challenges emerge, and what steps should be taken to mitigate gender-based discrimination against women in the future.

First, this quandary serves as a mere superficial manifestation of a much more extensive dilemma in Japan. A study posits that the prevalence of gender discrimination in medical school admissions is an unfortunate, yet, integral facet of the Japanese health care system.^11,15 Indeed, reports from the Organisation for Economic Co-operation and Development indicate that Japan boasts 2.6 physicians per 1000 inhabitants, an average that aligns closely with that of the United States.¹⁶ However, Japan also claims one of the highest global positions regarding bed-to-population ratio (12.6 beds/1000 inhabitants), a figure that is 4.85 times higher than that of the United States.¹⁷ The consequent burden of ward management and on-duty labor is substantial.^17,18

In addition, the gravest issue for Japanese physicians lies in the fact that not all duty work is acknowledged as constituting working hours.¹⁹ To eschew such a workload, female medical residents tend to gravitate toward career trajectories that do not involve extra on-duty or emergency department commitments.²⁰ This deficiency of physician human resources in Japan, coupled with the skewed allocation of physician specialties, may have been perpetuated over a considerable duration, thereby inadvertently favoring the recruitment of male physicians.^15,21

Gender-related factors influencing the admission process were presented in the First Emergency Report of the Third-Party Committee on Admissions to JU as well as the Report of the Internal Investigation Committee of TMU.^11
–13 The reports showed that JU scores favored male candidates and emphasized that it is reasonable to reduce the admission scores for female applicants owing to their strong communication skills. However, these skills are critical because most human errors in the intensive care unit are caused by communication problems between doctors and nurses.²²

Second, patriarchy is deeply rooted in Japanese society.²³ The stereotypical thinking prevalent in Japan that “men work outside, and women do the housework” has been reported even among women.²⁴ One study has found that female students were ready to continue working despite expected changes in their lifestyle over time but felt a need to adjust their work schedule after having a baby.²⁴ In the same study, while male medical students were generally accepting of men taking leave for childcare, more of them expected their female partners to stay at home. Moreover, male medical students were typically less aware than their female counterparts of men being favored in the current clinical setting.²⁴ This patriarchal social and cultural background and gender bias is hard to notice even among women and will be challenging to change in a short period of time.

Third, the working environment and lack of women leaders in medicine are major challenges.^4,5,25,26 Inadequate childcare facilities and maternity leave provisions, coupled with the absence of a fair work atmosphere, significantly hinder the inclusion of female physicians in Japan—recorded to have the minimum proportion of female doctors among Organisation for Economic Co-operation and Development nations.^4,27 Undeniably, there is an urgent need for the Japanese medical sector to acknowledge the insufficiency of career support for its female physicians.⁴ A Japanese study has reported a notable decrease in the employment rate of female physicians during their late 20s and 30s, a trend not observed among male physicians.²⁸

Further, a survey of the graduates of two private medical schools has revealed that only one-third of women who took a break from their careers returned to full-time work owing to challenges in balancing work with childbirth and childcare.²⁹ This absence of an environment that allows female physicians—who have striven hard in their careers—to continue their contributions to medicine is largely attributed to the lack of female leadership. For instance, despite the substantial increase in female physicians' total population in Japan—about 22% currently—the representation of female academics, particularly professors (a mere 8%),^4,25 deans of all medical schools (nonexistent, 0%), and university hospital directors (also nonexistent, 0%), has shown negligible progress over the last decade.²⁶ In addition, only 6.9% of women serve as governing board members of the 19 basic medical societies, a reality that potentially aggravates the prevalent barriers for women in leadership positions.⁵

Three years following the exposure of gender discrimination, all four medical schools involved have yet to officially announce any concrete remedial actions. However, score manipulations that formerly placed female contenders at a disadvantage have been abolished. The measures adopted by JU provide an example of potential solutions.¹¹ Their third-party committee on entrance examinations recommended enhancing the system and subjecting it to governance for increased transparency and objectivity, alongside conducting regular inspections and evaluations to ensure fair admission processes.¹¹ Furthermore, JU offered refunds for examination fees to female students.³⁰ Improvements were observed from 2019 to 2021, with a statistically significant difference in the acceptance rates between male and female applicants postdisclosure. Unexpectedly, the acceptance rate for female applicants surpassed that of male applicants in the nationwide medical school statistics for the first time in 2021.¹²

Female doctors often adopt a patient-centered approach,³¹ and the lack of gender diversity in medicine is a significant disadvantage for patients,^32
–34 necessitating correction. We question the passive acceptance of gender disparity as an unavoidable part of medical school admissions, highlighting significant progress made by government agencies in revealing discriminatory practices. We believe that this issue is relevant for medical institutions worldwide that deal with similar historical contexts and challenges. Therefore, we propose the following recommendations to promote a more balanced representation of genders in medicine.

Countermeasure 1: fair and transparent entrance examinations

Transparency in test administration and scoring can reduce bias and discrimination in examination processes. Transparency should be accomplished by having a third-party review and grade the examinations, which would eliminate any subjective bias from internal reviewers. To further enhance transparency, the university could release the examination results to all applicants, regardless of whether they passed or failed. This would allow students to compare their scores and see where they ranked among their peers, thereby ensuring a level playing field. This practice also promotes a culture of accountability and fairness, as institutions would need to uphold consistent, unbiased grading procedures to avoid potential scrutiny.¹¹

Countermeasure 2: addressing patriarchal values in the education system

According to UN Women, changing social norms and values that perpetuate gender discrimination is key to achieving gender equality.³⁵ In the context of medical education, it is essential to tackle patriarchal values that might favor men over women. For instance, universities could integrate gender equality and antidiscrimination topics into their curricula, which would help the students, staff, and faculty understand the value and importance of gender equality in the medical profession.⁴ Furthermore, universities could develop policies and regulations that penalize discriminatory behaviors. In addition, support systems should be implemented to allow female medical professionals to continue their careers for longer, such as implementing family-friendly policies like longer maternity leaves and flexible work hours.^4,28,35

Countermeasure 3: creation of supportive and adequate working environments

The World Health Organization states that supportive work environments can significantly enhance the longevity and satisfaction of medical careers for both men and women.³⁶ It is critical to address factors, such as pregnancy and childbirth, that might cause women to leave their medical careers prematurely. For instance, creating policies that support maternity leave, providing childcare services, and allowing flexible working hours can help alleviate these challenges. These policies could be supplemented with career development programs and mentorship opportunities specifically designed for women, which would further contribute to a more supportive and inclusive work environment.^4,28,36

Limitations

There are several limitations to this study. First, although it would have been desirable to directly compare the scores that were originally used as criteria for passing the examinations, it was not possible to obtain and compare the scores and other information for men and women at the four medical schools. Second, it was not possible to analyze the effects of gender differences in the selection process. Each university should publish the number of students who cleared the first and second rounds of admission. Furthermore, an evaluation of how interviews and essays affect the selection process should be undertaken.

Finally, future research should examine whether there are any gender differences in the setting of subjects by examining the correlation between the score rates of the subjects and the pass rates of men and women. Despite the noted limitations, it is positive to see that the MEXT has responded promptly and transparently to past scandals, showing attempts to improve the present situation.

Conclusions

This study showed how female applicants were subjected to discriminatory admission practices at four medical universities in the predisclosure period, which changed postdisclosure. Notably, the acceptance rate of female medical students exceeded that of male students for the first time in 2021, revealing a change in medical schools' attitude toward female candidates. Ultimately, our study counteracts the presumption that gender differences are inevitable in the entrance examination selection process in the medical field. In response to these findings, we propose the following to promote gender equality: (1) impartial and transparent admission assessments, (2) an educational mechanism tackling the entrenched patriarchal ethos that preferentially privileges men over women, and (3) the establishment of professional environments conducive to women.

Footnotes

Authors' Contributions

T.W., K.M., and Y.To. designed the study, the main conceptual ideas, and the proof outline. K.M., K.S., Y.S., Y.Ta.,Y.N., and K.K. worked out all the data details. K.M., Y.S., Y.Ta., Y.N., K.K., and K.S. collected the data on entrance admission of medical schools. T.W. and Y.To. aided in interpreting the results and worked on the article. Y.To. and T.W. supervised the project. T.W. and K.M. wrote the article with support from Y.Ta. and K.S. All authors discussed the results and commented on the article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article

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