Abstract
Background: Sustainability of the 24/7 acute coronary syndrome response system is at risk due to the Work Style Reform for physicians.
Methods and Results: A survey of 93 facilities in Chugoku-Shikoku region found that 30% of facilities expected acute coronary syndrome services to be restricted due to the Work Style Reform. Approximately 35% had implemented task shifting, which reduced physicians’ workload by 30% and improved team care.
Conclusions: Task shifting improved the working environment. However, various barriers to implementation were also identified. Further investigation is needed to achieve a balance between the Work Style Reform and sustainability of the acute coronary syndrome response system.
The ‘Work Style Reform’ is a policy introduced in Japan to prevent workers from overworking and to improve their working conditions. This reform, which is set to be implemented in 2024 in the medical field, mandates strict management of physicians’ working hours. It aims to reduce long working hours, ensure appropriate rest periods, and revise work practices to protect physicians’ health and enhance the quality of medical care. This law is an enforceable regulation that imposes penalties on healthcare facilities in case of violations.1
Percutaneous coronary intervention (PCI) is an essential treatment for acute coronary syndrome (ACS), requiring an extremely urgent response that must be performed with a 24/7 operational capability.2 In Japan, it has traditionally been common practice for physicians to serve not only as the first PCI operator but also as the second operator, performing sterile procedures. However, the declining proportion of young cardiologists3 and the stringent regulation of working hours introduced by the Work Style Reform for physicians may pose challenges to maintaining the ACS treatment system. In other words, ACS response systems in Japan, which have been sustained by excessive overtime work by cardiologists, are now at risk of collapse. As a potential solution, the government has also advocated for ‘task shifting’ where medical duties are delegated to other healthcare professionals. However, the extent to which this has been implemented in real-world settings remains unclear. In light of this, the Diversity Committee of the Chugoku-Shikoku Branch of the Japanese Circulation Society conducted a survey to clarify the current state of ACS management, as well as the progress of task shifting in the region.
Methods
In March 2024, a questionnaire was distributed to facilities in the Chugoku-Shikoku region of Japan that manage ACS (Supplementary Table). The first half of the questionnaire aimed to assess the current status of the ACS facilities, including the number of full-time cardiologists, catheterization procedures, physicians responsible for catheterization, first operators for PCI, physicians on standby at home for emergency catheterization per day, on-call days per week per physician, and whether the facility is considered sustainable as an ACS treatment center after implementation of the Work Style Reform for physicians.
The second half of the questionnaire focused on the status of task shifting for second operator roles in cardiac catheterization by medical staff. This section included questions about the timing of task shift implementation, the types of healthcare professionals involved in task shifting, the degree of workload reduction for physicians following implementation, and the factors that hinder the adoption of task shifting. This protocol received approval from the Ethics Committee of Yamaguchi Prefectural Grand Medical Center (Approval no. 2023-012), and conformed to the provisions of the Declaration of Helsinki.
Statistical Analysis
Continuous variables are presented as mean ± standard deviation of the mean, or as median values. Categorical variables were analyzed using χ2
or Fisher exact test analysis. All statistical tests were 2 sided and P values <0.05 were considered statistically significant. Statistical analyses were performed using SPSS v27.0 (SPSS).
Results
The questionnaires were distributed to 93 facilities and 81 responses were received (87.1% response rate).
Background of Respondent Facilities
The characteristics of the 81 facilities that provided valid responses are presented in Table 1. The average number of cardiologists per facility was 7.68±4.60, while the average number of physicians responsible for catheterization procedures was 6.70±3.47 with a median of 6. The average number of PCI first operators was 4.51±2.30, with a median of 4, a maximum of 13, and a minimum of 1.
Table 1.
Characteristics of Respondent Facilities
| |
No. facilities |
| No. hospital beds |
| n<400 |
33 |
| 400≤n<600 |
35 |
| 600≤n<800 |
11 |
| 800≤n<1,000 |
2 |
| No. cardiac catheterizations (total) |
| n<200 |
10 |
| 200≤n<400 |
27 |
| 400≤n<600 |
19 |
| 600≤n<800 |
10 |
| 800≤n<1,000 |
9 |
| n≥1,000 |
6 |
| No. cardiac catheterizations (emergency) |
| n<50 |
24 |
| 50≤n<100 |
30 |
| 100≤n<200 |
24 |
| 200≤n |
3 |
| No. PCIs |
| n<100 |
13 |
| 100≤n<200 |
33 |
| 200≤n<300 |
17 |
| n≥300 |
18 |
| ACS response system |
| 24/7 response |
75 |
| Rotation system with other hospitals |
6 |
| No. cardiologists |
7.68±4.60 |
| No. catheterization operators |
6.70±3.47 |
| No. PCI first operators |
4.51±2.30 |
Continuous variables are presented as mean±standard deviation of the mean. ACS, acute coronary syndrome; PCI, percutaneous coronary intervention.
Current Status and Sustainability of Physicians and Facilities Involved in ACS Management
The average on-call duty for each physician performing cardiac catheterization was 3.83±1.79 days per week, with 12 (14.8%) facilities reporting that physicians were on call every day (Figure 1A). If the facility strictly complies with the rules of the Work Style Reform for physicians, 31 (38.3%) facilities indicated that they would have to reduce ACS management. Among these, 3 (3.7%) facilities reported that they would be forced to completely halt ACS management, while 28 (34.6%) facilities stated that they would need to impose partial restrictions. Even among the 50 (59.3%) facilities that indicated they could continue to manage ACS as before, 42 (51.9%) facilities acknowledged that they would have to keep the burden on each physician in order to maintain the current system (Figure 1B).
Current Status of Task Shifting Implementation
As of March 2024, 30 (37%) facilities had already implemented task shifting for the second operator role (Figure 2A). The adoption rate was significantly higher in facilities with ≤3 PCI first operators compared with those with ≥4 (66.7% vs. 22.2%; P<0.001; Figure 2B). Additionally, among the facilities that had implemented task shifting, 19 (63.3%) facilities reported that medical staff were involved in both scheduled and emergency catheterizations, while 11 (36.7%) facilities limited task shifting to scheduled catheterizations during daytime hours, with emergency procedures still being handled exclusively by physicians. Regarding the timing of task shift implementation, 3 (10%) facilities introduced it before 2005, 5 (17%) facilities between 2006 and 2010, 8 (27%) facilities between 2011 and 2015, 3 (10%) facilities between 2016 and 2020, and 11 (37%) facilities after 2021. The majority of participating medical staff were clinical engineers (88%), followed by nurses (6%), and radiologic technologists (6%; Figure 2C).
Benefits and Concerns After the Implementation of Task Shifting
In facilities that have implemented task shifting, the time burden on physicians related to cardiac catheterization was reduced by 30.7±18.8% (Figure 2D). Additionally, in facilities where task shifting was applied to emergency catheterizations, the on-call burden was reduced by 21.3±18.1% (Figure 2E). Positive aspects of task shifting included increased engagement from medical staff, who became more interested and actively involved in catheterization procedures and conferences, as well as improved operational speed. Many physicians reported that although their total working hours did not change, they were able to use the time saved through task shifting to complete other tasks. Specifically, in response to the question, ‘Is this task shifting necessary to maintain the function of your hospital as an ACS response center in the future?’, all facilities that implemented task shifting answered ‘Yes’. Some concerns were also identified, such as the difficulty for medical staff to take over roles uniquely suited to physicians as second operators, including consulting on treatment plans, substituting for the first operator, and giving instructions to the surrounding staff, even though the technical aspects of catheterization assistance could be shifted (Table 2).
Table 2.
Opinions on Feedback After Task Shifting, Factors Hindering Task Shifting, and Justification for Not Implementing Task Shifting
| |
No. facilities |
| Feedback on the implementation of task shifting |
| Increased engagement of medical staff |
11 |
| Increased efficiency of catheter laboratory operations |
10 |
| Improved proficiency in catheterization tasks |
9 |
| Tasks beyond the capabilities of medical staff* |
7 |
| Unclear allocation of responsibility |
4 |
| Factors preventing task shifting |
| Shortage of manpower among medical staff |
13 |
| Ambiguity regarding the legal scope of the procedures that medical staff are permitted to perform |
11 |
| Lack of motivation among medical staff |
6 |
| Reasons for not requiring task shifting |
| The second operator role should be a training opportunity for beginner cardiologists |
8 |
| The second operator should be a physician for safety reasons |
7 |
*Tasks include discussing treatment plans during procedures, substituting for the first operator, and providing rapid instructions when the patient’s condition becomes unstable.
Factors Preventing the Introduction of Task Shifting
Fifty-one (63%) facilities have not implemented task shifting for the second operator role, and of these, 28 facilities are not currently considering its implementation. This trend was significantly stronger in facilities with ≥6 catheterization physicians (50.0% vs. 16.2%; P<0.002). The reasons cited include the view that the second operator role is an important training opportunity for beginner physicians and that, for safety reasons, the second operator should be a physician.
In the remaining half of the facilities, there is a recognized need for task shifting, but implementation has not been achieved. The reasons for not being able to implement task shifting include a lack of manpower (25%), an absence of medical staff willing to take part (12%), and ambiguity regarding the legal scope of procedures that medical staff are permitted to perform (22%; Table 2).
Discussion
This is the first survey to shed light on the current status of the ACS system and the task shifting of cardiac catheterization procedures in Japan. The survey revealed that ACS management in this region has been sustained by the sacrificial contributions of physicians striving to meet the expectations of local residents. To maintain a 24/7 operational capability, the average on-call standby for cardiologists, particularly catheterization operators, was found to be as high as 3.88 days per week. Reports indicate that not only does excessive overtime take a toll, but merely being on standby, even without being called in, can also result in significant physical and mental fatigue.4 Moreover, some facilities continue to operate as ACS response centers despite having only one PCI-performing physician.
The Work Style Reform for physicians was originally implemented to protect doctors from physical and mental illness, burnout, and even suicide, all of which can result from being overworked.5 However, in some facilities at least, a trade-off has emerged between ‘protecting physicians’ and ‘maintaining ACS response capabilities’. The Japanese Circulation Society and the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) have recognized that this situation can no longer be resolved solely through facility consolidation or the promotion of rotating schedules. As a solution, they have proposed the promotion of task shifting for sterile procedures in cardiac catheterization.
The demand for task shifting in sterile procedures during cardiac catheterization was previously unclear; this survey revealed that task shifting has already been implemented in 30 (37%) facilities. It was prevalent in facilities with fewer PCI first operators. Clinical engineers are mainly involved in task shifting, most likely due to their familiarity with the equipment and understanding of the procedures.
Task shifting has resulted in a reduction of approximately 30% in the time physicians spend on cardiac catheterization, and in some facilities, it has significantly reduced the standby time for emergency catheterizations as well. This indicates that task shifting has effectively alleviated the burden on physicians. Beyond reducing physician workload, task shifting has also had positive effects on team-based healthcare. It has increased the engagement of medical staff, who have become more interested and actively involved in catheterization procedures, and increased the efficiency of operations in the catheterization laboratory.
In facilities that have implemented task shifting, the majority expressed positive opinions about the decision. However, several issues were also pointed out. Specifically, while the technical aspects of catheterization can be shifted to medical staff, there were frequent concerns that tasks such as consulting on treatment plans during procedures, substituting for the first operator, and providing rapid instructions when the patient’s condition becomes unstable, cannot be adequately handled by medical staff.
While some facilities have successfully advanced task shifting, 63% of facilities had not implemented it as of 2024. Approximately half of these facilities reported that the physicians did not feel the need for task shifting. On average, these facilities had 8 physicians performing catheterizations, which is higher than the overall average. Naturally, in hospitals with a larger number of catheterization physicians, it is reasonable to reserve the second operator position as a training opportunity for younger doctors rather than assigning it to medical staff.
The concern is that a substantial number of facilities want to implement task shifting but have been unable to do so. The reasons for this include not only a shortage of manpower and lack of motivation among medical staff, but also, notably, legal uncertainties. It remains unclear which procedures medical staff are legally permitted to perform. Although there are guidelines in Japan for the medical procedures that clinical engineers, nurses, radiologic technologists, and clinical laboratory technicians can perform, detailed descriptions specific to cardiac catheterization are lacking.6 As a result, many aspects are left to individual facilities to interpret, which creates hesitation in implementing task shifting.
In order for these facilities to move forward, in parallel with expanding task shifting for other non-sterile duties, it would be beneficial to promote interactions with facilities that have already implemented task shifting to help administrators, physicians and medical staff deepen their understanding of sterile task shifting. Most importantly, it is essential to legally clarify what each profession can perform under sterile conditions. A joint petition from multiple societies, including the Japanese Circulation Society and CVIT, has been submitted to the Ministry of Health, Labor and Welfare, advocating for a more proactive stance on promoting task shifting.7,8
Study Limitations
This survey was conducted within a local branch, involving a limited number of facilities. The results may also have been influenced by regional specificity. Details about task shifting, such as the number of medical staff involved in task shifting at each facility, the proficiency level of each medical staff member, and specific procedures being shifted, were not included in the questionnaire items for this study.
Conclusions
In the Chugoku-Shikoku region, many hospitals have maintained their ACS systems through the excessive overtime of physicians. Additionally, in hospitals where task shifting has been implemented, various parameters indicate a reduction in the burden on physicians. The Work Style Reform for physicians should ultimately achieve a balance between creating a better work environment and maintaining the ACS systems of facilities, rather than presenting a trade-off between the two. As this issue is relevant across Japan, a nationwide survey is necessary to gain further insights into the current situation.
Acknowledgments
The authors thank Junko Otsubo and the Japanese Circulation Society Chugoku regional office for their help in preparing and distributing the questionnaire.
Disclosures
K.T. is a member of Circulation Reports’ Editorial Team. The other authors declare no conflicts of interest associated with this manuscript.
IRB Information
Ethics Committee of Yamaguchi Prefectural Grand Medical Center (Approval no. 2023-012).
Data Availability
The deidentified participant data will not be shared.
Supplementary Files
Please find supplementary file(s);
https://doi.org/10.1253/circrep.CR-24-0100
References
- 1.
Ministry of Health, Labour and Welfare, Japan. Workstyle reform for physicians [in Japanese]. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iryou/ishi-hatarakikata_34355.html (accessed July 25, 2024).
- 2.
Matsuzawa Y, Tsujita K. Standing together with the general public against acute myocardial infarction: Japan’s efforts and future perspectives. Circ J 2024; 88: 1235–1236.
- 3.
Nishizaki F, Shimbo M, Fukue N, Matsumoto C, Noma S, Ohno-Urabe S, et al. National survey identifying the factors affecting the career development of cardiologists in Japan. Circ J 2023; 87: 1219–1228.
- 4.
Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006; 81: 82–85.
- 5.
Tokuda Y, Hayano K, Ozaki M, Bito S, Yanai H, Koizumi S. The interrelationships between working conditions, job satisfaction, burnout and mental health among hospital physicians in Japan: A path analysis. Ind Health 2009; 47: 166–172.
- 6.
Ministry of Health, Labour and Welfare. Promotion of operations that are implementable under the current system [in Japanese]. 2022. https://www.mhlw.go.jp/content/10800000/000597166.pdf (accessed July 25, 2024).
- 7.
The Japanese Circulation Society, Japanese Association of Cardiovascular Intervention and Therapeutics, Japanese Association of Medical Technologists, Japan Association for Clinical Engineers. Inquiries to Ministry of Health, Labour and Welfare regarding difficulties in performing work in cardiac catheterization laboratories due to the implementation of the ‘workstyle reform for physicians’ [in Japanese]. 2024. https://www.jamt.or.jp/data/asset/docs/1ed5cc83246198eb5fb45175dea257969eb10697.pdf (accessed July 25, 2024).
- 8.
Japanese Association of Cardiovascular Intervention and Therapeutics. Letter to Ministry of Health, Labor and Welfare regarding task shift [in Japanese]. 2022. https://www.cvit.jp/_assets/documents/news/2022/0512.pdf (accessed July 25, 2024).
