Sustaining Home Medical Care in a Mountainous Rural Region: A Qualitative Study of Physician Motivation, Burden, and Nighttime Care Systems

INTRODUCTION: As population aging accelerates, demand for home medical care is increasing, particularly in rural and mountainous regions where access to hospital-based services is limited. However, sustaining home care, especially nighttime and out-of-hours coverage, remains challenging due to workforce constraints and the accumulated burden on physicians. This study examined how the perceived "attractiveness" and "burdens" of home medical care are linked to the sustainability of nighttime care systems in a rural Japanese context. METHODS: This qualitative study integrated autoethnography describing the first author's experience with urban home medical care and semi-structured interviews with physicians practicing home care in Unnan City, a mountainous rural area in Japan. Interview transcripts and field notes were analyzed using inductive qualitative content analysis, with triangulation across data sources to identify recurring themes related to motivation, burden, and system sustainability. RESULTS: Five interrelated themes were identified: a sense of mission to deliver care to patients unable to access hospitals; substantial nighttime and out-of-hours burden experienced as geographical strain, emotional labor, and persistent tension; intrinsic enjoyment derived from engaging with patients' everyday lives; professional fulfillment associated with providing seamless care across emergency, inpatient, outpatient, and home settings; and educational value for younger physicians. Importantly, participants described that the nighttime burden could be mitigated through sufficient staffing and rotation-based duty distribution, and that continuity of care enhanced both job satisfaction and training opportunities. CONCLUSIONS: The interaction between professional meaning, workload distribution, and system design shapes the sustainability of rural home medical care. Beyond a narrative of sacrifice, rural home care can be sustained when meaningful clinical work, fair allocation of nighttime duties, and educational opportunities are aligned to support workforce retention and continuity of care.