Learning Challenges and Motivations of Medical Students in Japan's Regional Quota System: A Qualitative Study From Okinawa Prefecture

Introduction Japan's Regional Quota System (Chiiki-Waku) aims to mitigate physician shortages in medically underserved areas by enrolling medical students who are committed to providing regional service. However, students in this system face distinct academic and emotional challenges, particularly in geographically and culturally unique regions like Okinawa Prefecture. Despite the system's importance, there is limited research exploring these students' educational experiences. Methods This qualitative study examined the motivations, challenges, and learning experiences of 12 Chiiki-Waku medical students at the University of the Ryukyus. Semi-structured interviews were conducted and analyzed using a thematic analysis approach. Researchers engaged in iterative coding and theme development, ensuring credibility through reflexive discussion and peer debriefing. Results Three overarching themes and 11 related concepts were identified from the interviews. Theme 1 was "Motivation stemming from a sense of obligation and inferiority", including pre-admission academic anxiety, efforts to overcome feelings of inferiority, fear of repeating a year, and commitment reinforced by loan obligations. Theme 2 was "Uncertainty and narrow perspectives resulting from changes in the Regional Quota System", covering inadequate information, feelings of confinement, emotional strain, and conflict between duty and personal aspirations. Theme 3 was "Motivation and learning fostered by interpersonal connections", highlighting inspiration from diverse activities, supportive relationships, and shared peer-learning systems. Together, these themes illustrate how quota-based students navigate tension between institutional constraints and personal growth through obligation, uncertainty, and connection. Conclusion Chiiki-Waku students in Okinawa demonstrate strong commitment and adaptability despite systemic and psychosocial challenges. Tailored support systems, transparent policy communication, and structured mentorship should be strengthened to enhance educational outcomes and retention in underserved areas. These findings inform educational reforms that can better support regional medical workforce development across Japan.