"If that's not labor, then what is?" Where is Japan's medical care? March 22, 19:43
That night, I couldn't let go.
"Doctor, please come, I can hear your mother's heartbeat..." Her
nurse called out to her, and she jumped up and ran as fast as she could.
Every minute and every second that I delay in making a decision could affect the future of the mother and child.
The days are tough, but it's rewarding.
But there is one thing that breaks my heart.
This time is not considered "working time."
[“Good Morning Japan” scheduled to be broadcast at 7:00 on Saturday, March 23rd]
“Something disorganized is happening.”
``It's a balance of accounts. It's become a loophole, a loophole,''
said Kawamura (pseudonym), a 30-year-old obstetrician and gynecologist in the Kanto region.
The interview was about the ``reform of the way doctors work'' that will begin this April.
Dr. Kawamura
: ``Something incoherent is happening. If that isn't labor, then what is?'' Far from being a 'reform', in the end, doctors as workers will be even less protected.''
What is happening?
Mr. Kawamura began talking about the reality of on-duty work for doctors.
(The following is Mr. Kawamura's story. *All images are for illustrative purposes only.)
I can't sleep on duty
I usually work in the obstetrics and gynecology department at a secondary emergency hospital.
In between, I am asked to work night shifts at an outside hospital about twice a week due to a lack of manpower. I will be on duty only after I finish my daytime medical treatment.
One day on duty.
On that day, as soon as I arrived at the place I was on duty at around 7 p.m., I received an emergency call saying that a pregnant woman was suffering from stomach pain.
It takes about 2 to 3 hours for each person to perform tests, draw blood, and explain things to the patient.
Around 9:00 p.m., a pregnant woman came in with a fever and was complaining of pain in her lower back and stomach, so I went to see her.
In the early morning hours after the date changed, I received a request saying, ``I am in preterm labor.Will you accept my request?'' I considered the possibility of a caesarean section, and prepared for the surgery at any time.
Since she was a pregnant woman from far away, she arrived at the hospital just before 2am. She wasn't in a position to give birth any time soon, so she checked the baby on a monitor, and by the time she finished explaining, it was around 3:30.
no one sees, no one knows
The most dangerous situation of the day came after this.
Early in the morning, a pregnant woman who was just 10 months pregnant came to me complaining, ``My heart is pounding and hurting.'' She had symptoms of arrhythmia and her heart rate was over 200 beats. This is extremely dangerous. Her heart is a pump, and if it continues like this, it will become exhausted. In some cases, it is not surprising that they may die.
Anyway, she thought, ``I have to stop it right away.'' There are drugs that slow the heart. But the problem is the fetus. There was a risk that the drug could have an adverse effect on the fetus.
When I carefully administered the drug while monitoring the electrocardiogram, the arrhythmia stopped after about an hour, but it returned two hours later. However, we decided to wait and see what happened as we decided that further use of the drug would be dangerous for the fetus.
The sun had already risen. I handed it over to the day shift doctor. She later heard that this mother was able to give birth safely. After this, she returned to her own hospital and worked until the evening, as usual. Naturally, with the condition she was in, she hadn't gotten any sleep.
However, the hospital where you are on duty has given you permission to stay overnight, so even though you may receive a certain amount of allowance for being on duty, it will not be counted as working hours. On-duty time is also treated as "rest" time between shifts during the day.
No one knows or knows how busy I have been.
(This is Dr. Kawamura's story)
“Special provisions” of the Labor Standards Act
What is the "permission to stay overnight" that the doctor mentioned?
This means that if the work is lighter than your usual work and allows you to get enough sleep, if you obtain permission from the Labor Standards Inspection Office and pay a certain amount of allowance, you can calculate the working hours during that time. , it is a system that can be considered as "zero".
For example, a typical example is a building security guard who patrols regularly at night and monitors crime prevention monitors, while being able to sleep during the rest of the time. It is assumed that there will be something called "sleep duty."
However, in recent years, there has been a rapid increase in the number of cases in which medical institutions have obtained this "stay overnight duty permit."
In 2020, the number of permits was 144, the following year it was 233, and the latest data for 2022 is 1,369.
When the ``Doctor Work Style Reform'' system begins in April this year, a cap will be placed on the number of hours that doctors who treat patients can work throughout the year.
Therefore, given the limited number of doctors available, medical institutions are trying to reduce working hours as much as possible.
A report requested one day
So, how is it possible to get permission in a hospital that is so busy that it is hard to sleep?
At the beginning, Dr. Kawamura was on duty at the hospital, and one day he was asked to give the following report.
"Collecting data to make it easier for the Labor Standards Office to issue permits"
"Please break down your work into smaller sections and record only the time you spent on your own work, such as examinations and treatment, in 5-minute increments."
A Ministry of Health, Labor and Welfare official explains, ``Even in medical departments that are said to be busy, such as emergency departments and obstetrics and gynecology, we can obtain permission if we put some effort into it.'' This means that you can obtain permission flexibly, such as narrowing down the time slot.
On its website, the Ministry of Health, Labor and Welfare is encouraging medical institutions to obtain permission by showing 20 cases in which it was granted permission.
On the other hand, the data that Dr. Kawamura was asked to report to the hospital did not include the time spent preparing for accepting pregnant women or giving instructions to nurses.
Dr. Kawamura
: ``For example, even if you actually strained yourself for three hours, only that one hour will be counted in your report.''I want to be able to respond responsibly when receiving patients. It's a little heartbreaking that even though we've been preparing for this, we can't fit that part into the application time, or rather, they think it's our working hours.''
“If you operate it strictly, you will go bankrupt.”
Why is the acquisition of "overnight duty permit" being promoted in the medical field?
There is a phrase that I was often asked during interviews.
``This is to protect local medical care.''
Compared to large urban hospitals, which have a large number of doctors, local medical institutions have no choice but to rely on outside personnel. In particular, many doctors from university hospitals are dispatched to various locations.
If a cap is placed on doctors' working hours, university hospitals will no longer be able to dispatch doctors who work long hours.
Hospitals across the country would be in trouble if their dispatch services were discontinued, so they scrambled to acquire them.
The director of a university hospital reveals his true feelings, saying, ``If we strictly enforce overnight duty permits, local medical care could collapse.''
On the other hand, we hear the following voices from doctors in the field.
``Even though I had permission to stay overnight, I was told not to turn down an ambulance at any time.'' ``
I couldn't sleep because I was treating three or four patients at the same time. 36-hour work days were the norm.''
"Even though the actual situation has not changed, there have been cases where the apparent hours have been reduced and the salary has been reduced. I was disappointed and felt like I was wasting my time."
Husband collapsed while working
The influence of the ``stay overnight duty'' system also reached unexpected places.
“My family's life changed completely after I received a sudden phone call from work saying that my husband had collapsed.Although my husband's life was saved, he was bedridden, and I was left wondering what the future would hold for my children, who were still in kindergarten and elementary school at the time. There were days when I felt at a loss as to how to survive, and I felt overwhelmed with anxiety."
Six years ago, a male doctor in his 40s who worked at a university hospital in Tokyo collapsed while working. His diagnosis revealed that he had developed a subarachnoid hemorrhage.
A male doctor once said that he "couldn't sleep" on the day after his shift. His wife believed that the accident was caused by overwork, and filed an application for certification as a work-related accident with the Labor Standards Inspection Office.
One of the points of focus in the examination for workers' compensation certification was the length of "working hours." Of particular interest was the handling of on-duty hours.
"Black box"
On this point, evaluations were divided depending on the administrative agency.
The Labor Standards Inspection Office, which conducted the initial review, excluded six hours of on-duty time as nap time, but included the remaining time in working hours.
However, the national examination board, which conducts higher-level examinations, issued a decision in January that ``as a general rule, on-duty work hours should not be included in working hours.''
The basis for this was the ``permission to stay overnight.''
Out of a total of 18 overnight shifts, 660 minutes = 11 hours were recognized as working hours, which were clearly considered to be work hours based on access records of electronic medical records examined by lawyers. limited to "time".
Kitaro Kanie, a lawyer who is familiar with labor issues and was involved in the workers' compensation application in this case, points out the effects of permission to work overnight.
Attorney Kitaro Kanie
: ``When I wanted to investigate a doctor's actions during the night, I had to piece together medical records one by one.Even then, it was difficult to prove working hours. I think there is a strong possibility that if a direct permit is issued, there will be a trend towards not recognizing it as working hours. Unless there is a dispute, such as applying for workers' compensation or going to court, doctors' working hours could become a 'black box.'
The claim for workers' compensation was not approved, and the male doctor's wife plans to fight the case in court.
Entered the Labor Standards Office...Confession of the Director
On the other hand, there are cases in which the Labor Standards Inspection Office enters medical institutions and makes recommendations regarding the operation of the "day shift permit."
St. Luke's International Hospital is located in Chuo Ward, Tokyo.
The number of emergency patients accepted is one of the highest in Tokyo. It is one of the hospitals that focuses on emergency medical care, but in 2016 it was raided by the Labor Standards Inspection Office and received a "recommendation for correction."
``What hospital doctors are doing is not ``on-duty'' but regular night shifts, and they must be paid an allowance for overtime work.'' It
pointed out the ``illegal status.''
The hospital's permission to provide overnight care was obtained in 1966.
Once a night shift permit has been granted, there is no need for the operator to regularly report on how the business operates.
The hospital director (head of the emergency department at the time), who has been involved in emergency medicine for many years, looks back on the time he received the correction recommendation as follows.
"Until then, I hadn't really paid much attention to the difference between overnight shifts and night shifts. It wasn't until the Labor Standards Office pointed out to me that I realized that overnight shifts only involve light labor."
Why was he not aware of the difference even though he was in a position to manage doctors?
He says that the reason for this was his ``feeling as a doctor'' that had been ingrained in him over many years.
Director Shinichi Ishimatsu
: ``I was taught that it was natural for doctors to work 24 hours a day, 365 days a year.There was even an atmosphere where I felt guilty for not being at the hospital. The fact that he wasn't there made me think that there was something missing as a doctor.I had only ever worked as a doctor, so I thought this was normal.''
"There's no such magic."
St. Luke's International Hospital was forced to make a fundamental review of the way doctors work and the medical system. for example.
・Outpatient treatment on Saturdays: reduced from 34 departments to 6
・Due to a review of the system for emergency outpatient clinics (from 4 to 2) late at night and early in the morning
, there has been an increase in the number of cases in which we have had to temporarily refuse to accept emergency patients. .
Norio Otani, head of the emergency department, describes his shock at the time:
Norio Otani, Director of the Emergency Department
: ``Everyone was shocked to see that the number of ambulances received decreased.``Even if there are fewer people, we have no choice but to protect the ambulances, even if it's just one person.'' That's what I thought. However, it's quite difficult to make on-site medical treatment efficient, and it often ends up cutting corners."
We have also stopped face-to-face conferences, where doctors gather to discuss cases.
We also switched to sharing materials online, leaving as much time as possible for medical treatment.
Across the hospital, physician overtime has significantly decreased from an average of nearly 100 hours to less than 40 hours.
However, it is said that there are still difficulties.
Emergency Department Director Norio Otani
: ``The number of emergency calls is increasing, and society's needs for emergency services are increasing rapidly.Is manpower increasing in proportion to this? That's not the case.It would be easy to say, ``Just turn away the ambulances and patients that come,'' but I don't think that's the case.In that case, the best thing to do is to decide where to make the decision, but at this point. And the answer is honestly no.”
At the end of the interview, Director Otani murmured something that still rings in my ears.
“There is no magic that will make everything go well with just one move.”
Beyond “self-sacrifice”
It is said that today's medical care in Japan is based on the so-called "self-sacrifice" of working doctors.
Experts have pointed out that if this situation continues, there is a risk that there will be no one left in the harsh medical field.
Professor Soichi Koike of Jichi Medical University
: ``If we continue as we have been doing until now, there may come a time when everything suddenly stops working.What is the best way to use limited medical resources?'' I think this is an issue that patients and society as a whole need to consider."
I don't see an easy solution.
However, if you only try to make ends meet, distortions will inevitably appear at some point.
I believe that what is needed now is to keep this in mind, not to seek easy answers, but to fundamentally reexamine the state of medicine and society and come up with concrete measures to make them sustainable.
When the reality does not match
One last thing. What should doctors do in the future if they are faced with a situation where the ``overnight shift permit'' does not match the reality of the workplace?
The standards for permission to work overnight shifts stipulate that if an employee performs "normal work" during overnight shifts, that time must be treated as working hours and be paid an appropriate premium.
According to a Ministry of Health, Labor and Welfare official, if there is any inappropriate operation or illegal response, please contact the nearest Labor Standards Inspection Office for consultation. Other methods include consulting with a lawyer who is knowledgeable about labor issues, and in the past there have been cases in which overtime work during overnight shifts has been approved by courts.
In addition, the Ministry of Health, Labor and Welfare also has a ``Labor Standards-related Information Email Desk'' on the Ministry of Health, Labor and Welfare's website to report situations where ``normal work'' has become a norm at night or on holidays.
"Labor Standards Related Information Email Desk" submission form (Ministry of Health, Labor and Welfare website)
Leaving the NHK site
The information collected here will be used by Labor Standards Inspection Offices and prefectural labor bureaus to select targets for on-site inspections.
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Network Reporting Department Reporter
Soraya Sugimoto Joined the station in
2015
After working at the Kumamoto bureau, he is currently at his current post.
Covers a wide range of issues related to labor issues and the difficulty of living
. While reporting on ``Doctors' work style reform,'' he is thinking about the meaning of work.
Social Affairs Department Reporter
Shiori Sugimoto Joined
the agency in 2013
After working at the Kagoshima and Osaka bureaus, she is currently at her current post
Covering a wide range of issues related to medical care and children.When
my son was hospitalized, I witnessed the harsh working style of doctors.