``We have no choice but to get by somehow.'' ``


This is an issue that has been imposed on us on the ground.''



April 1st. Starting today, legal upper limit regulations on working hours will apply to doctors who treat patients.



This ``reform of the way doctors work'' is beginning to have an impact on the medical care we receive, including the reduction of medical treatment systems.



On the other hand, some people in the field have pointed out that this is a loophole in the reform.



What will change in Japanese medical care?

"Go home, go home, go home."

6am.



Hiroyuki Kasashima (54), head of the gastrointestinal surgery department, has come to work at Hakodate City Hospital, which is responsible for emergency medical care in southern Hokkaido.



I always go to work around the time the sun rises in the morning.



The reason he comes to work early in the morning is to check in detail the working status of his 10 or so subordinate doctors.

The word “go home” appears on the surgery schedule.

The words ``Go home'' written on a surgical schedule are a sign for doctors who perform emergency surgery at night, urging them to go home.

Hiroyuki Kasashima, chief of gastrointestinal surgery at Hakodate Municipal Hospital, said


, ``If someone who is not asleep is performing routine or originally scheduled surgery, they will not be able to demonstrate their true potential to patients.I ask that those who have worked all night should go home.''

On the other hand, Mr. Kasashima himself is having a hard time even on weekends.



It's 10am on Friday after finishing work early in the morning.



From here, I will spend 2 nights and 3 days going to another hospital to provide support.

The destination is Okushiri Island, which takes more than four hours by car and ferry.



Immediately after arrival, you will begin outpatient treatment.

The biggest goal is to have the only full-time doctor who has been protecting the island rest.



We support local hospitals multiple times a month, including on Okushiri Island on weekends.

Hiroyuki Kasashima, chief of gastrointestinal surgery,


says, ``For the doctors who protect the town in small groups, we give them time to do a little family service or take some time to rest.That's what we do.That mission is more important.''

However, this year, this dispatch has been reduced.



Approximately three people, including Mr. Kasashima, were dispatched to Okushiri Island every month, but the dispatch of orthopedic surgeons was discontinued and the number was reduced to about two per month.

The background is ``reform of the way doctors work''

The background to this decision is an increase in emergency medical care and reforms to the way doctors work.

Last year, Hakodate Municipal Hospital responded to more than 6,600 emergency transport cases, the highest number ever.



Moreover, in the southern Hokkaido region, where 90% of doctors are concentrated in Hakodate, they have to travel far to provide support, which can be a burden on the time they spend traveling and staying there.

Kiyofumi Morishita, Director of Hakodate Municipal Hospital,


says, ``Southern Hokkaido is about three times the size of Tokyo, but if you go from there to support medical treatment, you'll have to travel a considerable distance.(As a result of work style reforms, )To be honest, I'm still not sure how much energy I'll have left to support others."

Termination of dispatch of doctors

Under these circumstances, there are other areas besides Okushiri Island where the dispatch of doctors has been discontinued.



In Matsumae Town, Hokkaido, the weekly dispatch of pediatricians has been discontinued.



As a result, it is no longer possible to see a pediatrician in the town.

Mother


: ``I had to have my child examined quite often, so it would be reassuring for me as a parent if the pediatrician could come even once a week.''

The town says the only way to survive for the time being is through medical examinations by a general practitioner.

Mayor Hideo Ishiyama of Matsumae Town, Hokkaido


: ``It's very disappointing, but we want to get through this with the current doctor system.I think creating an environment where doctors can easily come to visit us is a difficult administrative task.''

Kiyofumi Morishita, Director of Hakodate Municipal Hospital


: ``Work style reform will reduce supply capacity and create a gap (with medical needs).I am concerned about how we can fill that gap.What will happen in the future? I think the challenge that has been imposed on the field is whether to close the gap.”

What is “Doctor Work Style Reform”?

Behind this impact is the reform of the way doctors work.



From April 1st, upper limits on holidays and overtime working hours have been applied based on the Labor Standards Act.



Work style reform based on the law began five years ago for many occupations, and upper limits have been put in place.However, until now there has been no upper limit for working doctors, as there has been a grace period due to the impact on local medical care. did.

The upper limit set is ``960 hours a year,'' which is the so-called ``karoshi line.''



This translates to an average of 80 hours per month, which is almost the same regulation as general workers.



On the other hand, as an exception, a special standard of ``1,860 hours a year on a provisional basis'' will be set, assuming that employees are forced to work long hours in order to secure the local medical system, such as in some emergency hospitals.



In addition, measures to ensure health include limiting continuous working hours and ensuring rest time.

First of all, what are the actual working hours of working doctors?

On the other hand, problems caused by long working hours continued to be pointed out at the workplace.



According to a survey conducted by the Ministry of Health, Labor and Welfare in 2017 (R4) on the working conditions of doctors, the percentage of doctors whose annual working hours exceed the upper limit of 960 hours, the so-called ``karoshi line'', was 21.2%, which is still a high number. It has become.

What about in medical settings that are undergoing revisions?

Medical institutions that are promoting work style reform are also faced with the difficulty of how to balance this with meeting patient needs.



Eight years ago, St. Luke's International Hospital in Chuo Ward, Tokyo, began reviewing its work style after receiving a ``recommendation for correction'' from the Labor Standards Inspection Office regarding issues such as long working hours by doctors.



In order to reduce doctors' overtime work hours, we have proceeded with the following system review.



▼ Significantly reduced outpatient consultations on Saturdays


▼ Reduced the number of doctors who provide night consultations



As a result, overtime hours worked by doctors per month decreased from an average of nearly 100 hours to less than 40 hours across the entire hospital. .

On the other hand, the emergency department of this hospital is one of the top in Tokyo in terms of the number of patients it accepts.



The number of doctors working from night to early morning has been reduced by half, and the number of cases in which they have had to refuse to accept emergency patients has increased, and they are said to be working on this despite some conflict.

Shinichi Ishimatsu, Director of St. Luke's International Hospital


: ``The most difficult thing was to change the mindset of the doctors themselves.It was quite a shock to be forced to turn down emergency patients, but I was able to change the way I worked before.'' I also felt that it wouldn't last forever.Even now, I'm moving forward with this work style, feeling that it's difficult rather than completely fine."

Applications for “special exceptions” under the Labor Standards Act are rapidly increasing

Under these circumstances, medical institutions across the country have been working to obtain ``overnight duty permission.''

This is approved by the Labor Standards Inspection Office, and if you work at night or on a holiday, if you are able to get enough sleep, although it is light compared to your normal work hours, you will be able to work longer hours during those hours if you pay a certain allowance. This is a system that can be excluded from calculations.



For example, if you work on duty from 7:00 pm to 7:00 am the next morning, if you work a normal night shift, it will be 12 hours of overtime work, but if you obtain a "day shift permit", this will be overtime. It is considered "zero".



It may also be treated as "rest" time between shifts.

According to the Ministry of Health, Labor and Welfare, the number of cases in which medical institutions across the country approved ``overnight shift permission'' was 144 in 2020, four years ago, and 233 in the following year. The number of cases is 1,369, about six times that of last year, and is rapidly increasing ahead of the introduction of upper limits on working hours.

It has been pointed out that "working hours have become a black box"

The "overnight duty permit" also has an impact on doctors' claims for workers' compensation.



Six years ago, a male doctor in his 40s who was working at a university hospital in Tokyo collapsed during work and developed subarachnoid hemorrhage.One of the focuses of the review was on the handling of on-duty work.



Initially, the Labor Standards Inspection Office, which carried out the review, counted the on-duty hours, excluding nap time, as working hours.



However, in January this year, the national examination board, which conducts higher-level examinations, ruled that on-duty hours are ``in principle not included in working hours,'' based on the fact that the person has obtained a ``permit for night shift.'' I made the decision to do so.



In the end, the worker's compensation claim was not approved, and the male doctor's wife plans to fight the case in court.

Attorney Kitaro Kanie, who was involved in the workers' compensation application, said, ``


It is extremely difficult to prove whether or not a doctor's actions during the night constitute working hours, as we have to look at each medical record one by one



. If they do not allow this, unless there is a dispute such as applying for workers' compensation or going to court, doctors' working hours could become even more of a ``black box.''

"If we don't take action now, it will get worse."

How can we achieve both ``reducing the burden on doctors'' and ``maintaining the local medical system''?



We asked experts who are familiar with how doctors work and issues in local medical care.

Professor Soichi Koike of Jichi Medical University


: ``Of course it is important to adhere to the maximum working hours, but the most important thing is how to change the way doctors work in order to maintain a sustainable medical care delivery system.'' .If we don't take action now, there is a risk that all the stress that has accumulated will suddenly come out and the situation will get even worse in 5 or 10 years.How should we use our limited medical resources? We need to think about this together with patients and society as a whole."

``The government should carefully collect and analyze information on what issues and good practices exist regarding the new system, and provide feedback to the field, as well as provide the necessary institutional and financial support to resolve issues. I would like you to proceed with the consideration.”

(Physician work style reform reporting team, Shiori Sugimoto, Saki Onishi, Soraya Sugimoto, Ryohei Takahashi)