2020 Volume 2 Issue 1
Workstyle reform for Japanese doctors is a priority of Japanese labor policy. Factors influencing this include the low birthrate and longevity of the population and the long working hours experienced by Japanese workers. Long working hours imperil the health of doctors and create discord between their work and other life roles. The Japanese government enacted measures to promote workstyle reform for doctors, including a provision that capped legal overtime work. The limit was set to sustain healthcare services in the community. However, the allowed level of overtime is substantially higher than the so-called “line of karoshi” at which point worker compensation for work-related medical disorders is approved. Despite limited research, several measures can be considered to reduce health risks of overworked doctors, such as recommending psychological detachment from clinical work and maintaining work-life balance. Doctors should realize that self-care is a professional imperative. Organizational efforts from public administration entities or hospitals are required to secure the health of doctors. The number of surgeons and obstetricians has not recently increased. Gender role stereotyping has encouraged male Japanese doctors to work long hours and makes it difficult for female doctors to continue their professional life after childbirth. Without reforming the workstyle and protecting the health of doctors, younger workers, particularly women, are liable to avoid entering medical professions. To ensure the provision of good healthcare, it is necessary to change traditional values and improve the work environment. Academics in occupational fields should produce evidence that will help improve Japanese labor policies.
During the 10 years from 2015 to 2025, the Japanese population will decrease by 4.6 million. The population aged 65 years and older will increase by 2.9 million, whereas the productive-age population will decrease by 5.6 million1). As the Japanese social insurance system depends on the transfer of money from the working generation to those who are retired, the increasing aged population and the decreasing working population has caused financial difficulty2). Serious matters must be addressed to maintain the workforce, such as improving the work environment for older people and women and a greater acceptance of foreign workers. Another aspect is particularly related to medical professionals. The elderly population will reach 36 million in 2020, and additional medical professionals are needed to manage a high-mortality-rate society.
Another related issue is the presence of long working hours and overwork. Overall, there is a declining trend in actual working hours per year for Japanese workers. However, the proportion of part-time workers has been increasing, comprising 30 percent of the total Japanese workforce. Assessing the trend of total actual working hours per year separately for general workers and part-time workers shows that the total actual working hours of general workers has remained high (on average 2,010 hours per year in 2018)3). In addition, Japanese workers tend to not use their annual paid vacation entitlement.
A total of 1,732 claims were submitted requesting worker compensation for work-related mental disorders in 2017, of which 506 claims for mental disorders were approved for compensation, and 98 cases were for suicide4). The number of claims for mental disorders increased more than tenfold during the last two decades. Long working hours and overwork are believed to be behind this phenomenon. The Japanese government has instituted several measures to address this situation. In 2006, the government amended the industrial safety and health law and introduced the system of the Doctor’s Interview of Workers with Long Working Hours. A law regarding preventive measures against karoshi (death due to overwork) was enacted in 2014. An assessment of the number of claims requesting compensation does not reveal any effect of the introduction so far.
In 2018, the government instituted a set of measures to promote Japanese workstyle reform, which included an amendment to the Labor Standards Act. The amended act includes new regulations on working hours and the introduction of a work-interval system (minimum daily rest periods). Prior to this change, there was no official limit on overtime work in Japan. The amendments to the Japan Labor Standards Act included provisions that capped legal overtime at 45 hours per month and 360 hours per year for full-time workers. The provisions permitted an extension of up to 100 hours per month and 720 hours per year for busy periods for a maximum of 6 months per year. This regulation has been in effect since April 2019 for large enterprises. There are some exceptions, including a 1-year delay in implementation for small- and medium-sized enterprises, and a 5-year delay for occupations for which it is difficult to implement the regulation immediately, such as drivers, construction workers, and medical doctors.
Japanese doctors work very long hours. Over 40 percent of Japanese hospital doctors work more than 60 hours per week5). Various factors contribute to the long working hours of doctors, such as doctor shortages and an uneven distribution of doctors between regions6) and specialties7,8), and a lack of task sharing9). There are health risks for doctors because of overwork (karoshi and burnout)10), contributing to the issue of medical care security11).
A recent meta-analysis based on pooled data from European cohort studies, which included unpublished research, provided robust evidence related to this topic10). The analysis showed elevated risks for cardiovascular diseases among those who worked long hours (55 or more hours per week) compared with those working standard hours (35–40 hours per week). The authors found an increased risk of incident coronary heart disease (relative risk [RR] 1.13; 95% confidence interval [CI], 1.02–1.26) and incident stroke (RR 1.33; 95% CI, 1.11–1.61). As the prevalence of long working hours is high among Japanese doctors, the impact of long working hours on cardiovascular diseases (e.g., coronary heart disease and stroke) cannot be negligible. Given that the prevalence of Japanese doctors with long working hours (60 or more hours per week) was 40%, more than 15% of cardiovascular disease cases are estimated to be attributable to long working hours. Burnout is another considerable health issue among doctors12). Long working hours are closely related with physician burnout13), and physician burnout may jeopardize patient care14). Furthermore, the cost related to clinical and organizational outcomes is enormous15).
Work-life balance has come under the spotlight in a special context of Japanese workstyle reform. Japan has the lowest proportion of female doctors among the Organisation for Economic Cooperation and Development (OECD) countries. The average proportion of female doctors in OECD countries was 46.5% in 2015. The proportion was the lowest in Japan, at 20.3%16). The trend of female doctors’ participation in the labor force by age group shows an M-curve, as many female doctors quit their jobs upon marriage or childbirth. This pattern is hardly seen in the other OECD countries.
Hard work is a virtue in Japan, and the male-breadwinner model deeply permeated 20th-century Japanese society. Such gender role stereotyping has pressured male Japanese doctors to devote themselves full time to their practice and work long hours, leaving all other family life roles to their female partners and sacrificing their private lives. Stereotyping forces female doctors to do household chores in addition to their professional tasks, making it difficult to continue with professional life17). Importantly, these circumstances have forced many female doctors to quit their jobs; thus, they cannot utilize their professional ability.
Excessive work demands not only affect doctors’ health, but they also impact the outcomes of patients who should benefit from the doctors’ expertise. Working limits for doctors have been regulated based on a discussion regarding medical care security in Western societies. In Japan, the regulation was enacted by placing importance on securing medical services.
In the United States, inhumane working conditions of residents gained prominent attention during an inspection of a medical accident where an 18-year-old girl died because of a lethal drug interaction. In the early 2000s, accumulating data showed increased risks of accidents and/or medical errors due to extended work shifts or extended-duration shifts18). Accordingly, in 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented rules limiting residents to an 80-hour workweek. In 2011, ACGME implemented additional rules, including one stating that intern shifts were not to exceed 16 hours. After the implementation of the resident working hour restrictions, there was a report that burnout indices were lowered among internal medicine residents of a university health center, though residents reported attending fewer educational conferences and less satisfaction19). Recently, however, a nation-wide, cluster-randomized trial involving 117 general surgery residency programs in the United States revealed that compared with the ACGME standard working hour policies, there were no inferior patient outcomes for flexible and less-restrictive working hour policies for surgical residents. There were no significant differences in resident satisfaction regarding overall well-being and education quality between the two policies11). The same type of randomized controlled trial among internal medicine residency programs found no difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard working hour policies and programs with more flexible policies20). ACGME has since eased their regulations to allow resident shift lengths of 24 hours.
The European Union (EU) has set a different level of regulation. The European Working Time Directive requires a maximum working week of 48 hours and establishes rest periods; this regulation is applicable to all occupations across the EU (however, it is not strictly enforced, and junior doctors may opt-out in the United Kingdom). A systematic review of 11 studies of high or intermediate quality found that long working hours per day or very long hours per week were associated with percutaneous injuries and road traffic accidents21). Doctors were surveyed 10 years after the directive was introduced. Generally, senior doctors agreed the directive was good for doctors’ work-life balance, while they thought it had a negative impact on managing patient care and on junior doctors’ training opportunities22).
In the amendments to Japan’s Labor Standards Act, three levels have been set to cap the overtime hours of doctors working in medical institutions. For doctors in general, the total overtime hours have been set at 960 hours per year and less than 100 hours per month. The total working hours include hours worked on off-duty days. For doctors working at certain medical institutions that provide crucial medical services to the local community, such as emergency treatment, perinatal care, and advanced cancer treatment, the overtime regulation permits an extension of up to 1,860 hours per year and 100 hours per month. The figures were set on the grounds that such levels of working hours are required to sustain the services provided at these medical institutions. The same level of overtime has been set for residents who are focusing on their basic skills and abilities within a residency program and for trainees who practice at specified medical institutions and who are training in specialized knowledge and skills. This regulation will be enacted in 2024 and will be in place through 2035.
Although overtime work is limited, the upper limit is immensely above the so-called “line of karoshi” where worker compensation for work-related medical disorders will be approved (more than 80 hours of overtime per month). The government has formed a panel of experts to discuss how to protect doctors’ health. Doctors who are predicted to work overtime beyond the above limit must see a doctor for a medical check. Although there is no evidence of the effectiveness of these medical interviews, the following points should be considered.
First, the focus of these measurements should not only consider restrictions in working time — they should also comprise medical advice and a health assessment. Regarding the assessment, stressors other than long working hours should be assessed (Table 1). There is robust evidence showing that job characteristics assessed by occupational stress models, such as the job demand–control model and the effort–reward imbalance model, predict cardiovascular diseases23,24) and mental illness, including depression25) and suicide26). An assessment of such job characteristics will provide hints for measures to take to reduce stressful work conditions.
Doctors with severe or unusual symptoms (Table 2) may be advised to discuss restrictions on work with the hospital administrators or be referred to the appropriate professional medical organization. Burnout should be assessed among stressed doctors because the risk of burnout among doctors is high and the consequent outcome is significant12). Furthermore, the suicide rate among doctors is high. Interviewers should be cognizant of the onset of work-related diseases, such as cardiovascular disease, mental illness (especially depression), sleep disorders, and suicidal ideation. Several easy-to-use instruments to screen depression at occupational fields have been introduced (e.g., the Brief Structured Interview for Depression)27). Any subsequent measures, such as referral to a specialist or follow-up observation, must be carried out after screening28).
The health assessment may take into account individual demographic factors, including age and sex, because health problems induced by overwork can be increased or decreased according to the demographic characteristics of doctors. Regarding the gender differences of psychiatric diseases and suicide, for which there is a high risk among doctors, these conditions show a particularly high incident level among female doctors29). Regarding cardiovascular diseases, it is recommended to assess health risks among doctors using the assessment of the Framingham risk score30). A risk assessment chart that incorporates long working hours and work stress in addition to individual factors is available as a reference31).
There is no specific medical advice for doctors who work long hours. Not only time restriction but also comprehensive risk reduction is needed. It is well-known that doctors are reluctant to recognize that they are ill32). Doctors must realize that from a professional perspective, their health risks impact their individual issues, as well as the care they give to patients; therefore, they must get sufficient rest and stay healthy. Regarding sleep duration, it is recommended to get at least 6 hours of sleep per night33). General recommendations for good quality sleep can be given, such as avoiding caffeine and smoking, engaging in adequate physical exercise, and avoiding screen-time before going to bed. Consuming alcohol before bed should also be avoided because this habit is associated with an increased risk of cerebral bleeding death related to fewer sleeping hours34).
Complete disconnection from work (psychological detachment) is associated with good recovery35). Concrete advice may include coping behaviors that clear out one’s mind by engaging in physical fitness and/or hobbies. Although this coping strategy may not be effective for some workers, it may be a good coping strategy for medical professionals who are experiencing a substantial emotional load.
Satisfaction with vacations, hobby activities, and family get-togethers were found to be related to lower levels of fatigue among administrative workers and home business owners who reported long working hours that were comparable to those reported by doctors36). An unfavorable work–life balance was reported to be a risk factor for mental illness among doctors.
There is much evidence showing that favorable health behaviors can increase one’s stress tolerance help to prevent cardiovascular diseases. In addition to addressing sleep and rest, the medical advice should encourage doctors to eat fruits and vegetables, engage in physical fitness37,38), and properly manage their blood pressure and body weight. It should be recommended that they quit smoking and rest when tired.
It has been suggested that shorter intervals away from work lead to shorter sleeping times and poor sleep quality39). One report showed that staying home while ill reduced the risk of serious coronary events40). Necessary work restrictions, including compensated rest times, should be put into effect.
Prolonging the time away from work each day was shown to be effective for reducing the health risks of doctors39), and there was a high recovery effect as a result of doing activities unrelated to work35). Enabling doctors to disconnect from work includes freeing them from on-call jobs and strict shift controls. Regulations, such as standardized absences from work, are not necessarily required, as the degree of fatigue differs among doctors. However, a viable healthcare system requires that doctors can refrain from work for a time if the need arises. A backup system that enables restrictions on work and allows doctors to stay home when they are ill (i.e., doctor pools) is necessary. Otherwise, the public administration must ask citizens to understand the limited medical services.
The Japanese government has capped the legal overtime of doctors, but evidence shows that this level still poses risks to doctors’ health. The virtue of working hard has sustained Japanese healthcare, which is threatened by a shrinking workforce and an aging population. There is also a generation gap in attitudes surrounding work and work preferences. Veteran doctors are more willing to work long hours, whereas younger doctors are not, which appears to reflect the uneven distribution of doctors between specialties7,8) (young doctors tend to avoid selecting surgical specialties). Gender role stereotyping has pressured male Japanese doctors to work long hours and makes it very difficult for female doctors to continue their professional life after having children, resulting in the lowest proportion of female doctors among OECD countries. It is necessary to improve the work environment to ensure doctors’ health and to harmonize the work and life roles of both male and female doctors. Otherwise, the younger labor force, and particularly women, will not enter the medical profession. It is necessary to change traditional values to sustain the provision of good healthcare. Academics in the occupational health fields should present factual evidence to support the implementation or modification of regulations.
This work was supported by the Work‐related Diseases Clinical Research Grant 2017 (170401‐02) and 2020 (200401-01), the Health, Labour and Welfare Sciences Research Grants (H30-meneki-ippan-001), and the Exploratory Committee on Ensuring Doctors’ Health from the Ministry of Health, Labour and Welfare, Japan. A summary of this article was presented on November 2, 2019, at the 7th International Congress of Person-Centered Medicine—Promotion of Well-being: Challenges and Solutions. I thank Katherine Thieltges from Edanz Group (https://en-author-services.edanzgroup.com/) for editing a draft of this manuscript.
The Work‐related Diseases Clinical Research Grant 2017 (170401‐02) and 2020 (200401-01), the Health, Labour and Welfare Sciences Research Grants (H30-meneki-ippan-001), and the Exploratory Committee on Ensuring Doctors’ Health from the Ministry of Health, Labour and Welfare, Japan.