Hospital doctors feeling the strain

Punishing workload, threat of litigation and little reward

by Akemi Nakamura

Whenever Naoshi Tamura is on a night shift at Ota Hospital in Tokyo, the surgeon works 36 consecutive hours with little sleep, seeing patients during the daytime and treating those transported to the emergency room at night.

“I work the night shift two to three times a month,” said Tamura, 49, who also serves as the director of the 211-bed hospital. “It makes me exhausted physically and psychologically.”

His current workload is extremely heavy. On weekdays, he works 12 hours a day, carrying out roughly 15 major and minor surgeries a month. On weekends, he attends business meetings or checks up on his patients who have just had operations. He can take only two days off work a month.

Tamura also feels growing pressure that the hospital may be sued by patients or their families who are dissatisfied with their treatment.

“Doctors who can’t endure this situation quit working at hospitals,” Tamura said.

He is a typical example of a hospital doctor working in tough conditions.

According to a Japan Hospital Association survey conducted in July 2006 of its 2,681 member institutions nationwide, 71.6 percent of 5,636 doctors at 536 hospitals said they worked night shifts. Of them, about 90 percent said they continued to work after the shift was over. In addition, 44 percent of the total said they worked more than 56 hours a week.

Despite their hard work, they are not adequately rewarded compared with doctors working at clinics, who usually do not have to work long shifts and who handle less serious cases. Medical institutions that have 20 beds or more are categorized as hospitals.

According to the Health, Labor and Welfare Ministry, the average annual salary of a hospital doctor in June 2007 came to ¥14.1 million, while that of a doctor who ran a clinic stood at ¥25.3 million and that of a doctor who worked at a clinic stood at ¥14.0 million.

Doctors can qualify to run a clinic provided they have finished a two-year mandatory medical internship in a hospital. But many young doctors opt to work in hospitals for years to improve their skills and also because it takes a multimillion-yen investment to open a clinic.

To improve the current situation, some hospital doctors plan to form a new lobby, Zenkoku Ishi Renmei (Japan Doctors League), in June.

“Hospital doctors have been so busy that they haven’t had time to think about working conditions,” said Takayuki Miwa, a psychiatrist at a hospital in Nagoya and one of the executives of the preparatory committee for the planned group.

The Japan Medical Association, a long-standing group with some 165,000 members, is well-known as a powerful lobby but observers say it has mainly worked for the betterment of practitioners.

So it’s time for hospital doctors to raise their voices and work to change their work conditions, Miwa said. About 650 doctors, mostly hospital doctors, have already become members of the preparatory committee.

Poor working conditions have been caused partly by the reduction in government-set medical fees paid to medical institutions, said Koichi Kawabuchi, a professor of health-care economics at Tokyo Medical and Dental University.

The fees, revised every two years, were cut by 1.3 percent in fiscal 2002 and by another 1.36 percent in fiscal 2006 to mitigate the increase in the nation’s medical costs. The cuts have hit hospitals hard.

Tamura of Ota Hospital said his hospital had to cut bonuses and did not award basic pay raises to its staff to cope with the reductions.

The introduction of a new medical internship system in 2004 also exacerbated the poor work environment at hospitals, according to Kawabuchi.

Medical interns who had just passed the state qualification examination used to take jobs for two years at hospitals connected to the universities they graduated from, and the universities would dispatch doctors to nearby hospitals.

However, the new system allows interns to choose between hospitals. As a result, many interns go to famous hospitals in urban areas, while other medical institutions, especially in rural areas, are suffering a shortage of doctors, Kawabuchi said.

Another factor that drives doctors away from hospitals is the increasing risk of getting sued by patients and their families, experts say.

Excessive criticism by the media or patients of doctors when treatment worsens someone’s condition or causes death could discourage doctors from continuing to work at hospitals that handle difficult or emergency cases, Miwa of Zenkoku Ishi Renmei said.

This appears to be prompting doctors to turn away from hospitals.

According to the health ministry, the number of doctors in Japan increases by 3,500 to 4,000 annually. As of 2006, there were 277,927 doctors, including 168,327 hospital doctors and 95,213 doctors at clinics. The remainder includes doctors who teach medicine at universities and graduate students.

However, the percentage of hospital doctors decreased to 60.6 percent in 2006 from 64.6 percent in 1998.

Miwa’s group hopes to create a union in which doctors at different hospitals can join individually to help solve disputes over their working conditions, he said.

In addition, it will provide support to doctors who did their best to help patients but were sued or indicted over their treatment, and will press doctors who committed malpractice to accept responsibility, he added.

The excessive workload on doctors and nurses is resulting in a deteriorating quality of medical care and causing treatment delays, which lead to a worsening of symptoms and to increasing doctors’ work, said Tamura of Ota Hospital, who is not involved in the new group.

“We are in this vicious circle,” he said.

To alleviate the heavy workload on hospital doctors, the government has begun taking measures, including increasing medical students at some universities and medical fees paid to medical institutions by 0.38 percent in fiscal 2008.

About ¥150 billion was allocated to support hospital doctors who treat high-risk patients in obstetric and pediatric services and handle emergency patients.

But Kawabuchi said the increase is too little to solve the current problems.

He wants the government to allow Japanese or foreign doctors who obtained medical licenses overseas to work in Japan and consider retraining dentists as doctors.

“People are not interested in (the current situation),” Kawabuchi said. “This country will not change until it sinks into the worst crisis.”