I think many people hold the following preconceived notions of what it means to be a physician. Doctors, we believe, are:
- highly specialized (and only a few can become MDs)
- have high social status and income
- have a noble mission to protect human health and help us live longer
- get twice the satisfaction and sense of achievement most of us enjoy, while working in a high-intensity environment
- are constantly having to learn the latest cutting-edge medical technology
Many women’s magazines advertise matchmaking services with copy such as: “Calling all women who’d like to marry a doctor. Only high-income male physicians can register with us.”
The existence of kyōiku mama, or so-called education mamas (and papas), is a well-known phenomenon in Japan. From nursery school age they send their little ones to juku (cram schools) and later lavish them with special training to help them pass entrance exams that lead to a good university and the final goal: a job as a doctor.
One such mama, Ryoko Sato, has become famous thanks to her book “Juken wa Hahaoya ga Kyu-wari” (roughly translated, “With Test-taking, Mother is 90 Percent”). In her tome she describes in painful detail how she managed to get all four of her children into medical school by devoting every waking hour to advancing their studies, ignoring her husband, banning television in the house and prohibiting her kids from getting into romantic relationships. The prize? They were all accepted to the University of Tokyo, which is considered the top school in Japan. Sato is now worshipped by wannabe education mamas across the country.
Incidentally, in a 2015 survey by Dai-ichi Life Insurance that asked children what they wanted to be when they grow up, “doctor” came in at fifth place among boys and fourth among girls. That’s right, our daughters want to be doctors more than our sons.
Physicians are also far and away the highest-paid professionals among all the jobs requiring national certification, with an average annual salary of ¥10.98 million.
It seems most people agree that physicians are a class apart, boasting high social status and very generous compensation into the bargain. But recently, an incident occurred that challenged this rosy view of the profession, revealing the brutal reality of working conditions for many doctors. It was another unfortunate case of karōshi, or death from overwork.
On May 31, the Niigata Labor Standards Inspections Office (Rokisho) certified the suicide death of a 37-year-old physician as having been caused by overwork. This is known as a karō jisatsu, or suicide due to overwork.
Having no certification whatsoever to begin with, Aya Kimoto started her career as a nursing assistant. While working, she studied hard and was able to get into medical school at Niigata University. After six years she graduated and started doing internships. For her second internship as a digestive system surgeon beginning in April 2015, she had to move to the Niigata City General Hospital, and it was there that her work environment changed dramatically. Her emergency on-call hours skyrocketed, and there was an increase in graveyard and holiday shifts.
Her routine began to change in the autumn of that year. She stopped walking her dog, no longer conversed with her husband after work, and increasingly went straight to bed upon arriving home. Her friends noted that she had lost all her energy and had no desire to go to the hospital or even meet people.
On the evening of Jan. 24, 2016, Kimoto left her home without telling anyone where she was going. She was recorded as missing. Her family began looking for her, and her mother-in-law eventually found her lying on top of a pile of snow in a park near their house. Beside her in the snow was a bottle of alcohol and some sleeping pills. The cause of death, however, was hypothermia. There was no suicide note or will, but the police determined the death to be a suicide.
Kimoto’s family hired an attorney to help conduct an investigation. They discovered she had worked more than 200 hours of overtime per month for four straight months. During the nine months of her second internship, her overtime hours averaged more than 190 per month. In August 2016, the family applied to the Labor Standards Inspection Office for recognition that the cause of her death was depression brought by an excessive workload that eventually led to her suicide.
The hospital denied that long work hours had led to her suicide. Their own records, based on Kimoto’s self-reporting, indicated that she worked a monthly average of only 48 hours overtime, posting totals close to zero some months and 95 hours during the busiest month of July 2015. Regarding the discrepancy, the hospital suggested that perhaps the investigators were including her time spent giving academic presentations, writing dissertations and studying. The hospital said these self-study hours should not be counted toward her overtime hours.
The labor office, however, recognized that she had worked what is considered to be “extreme long hours” as defined by the Ministry of Health, Labor and Welfare, meaning more than 160 hours of overtime a month. The office also deemed that these long hours drove her to clinical depression and ultimately to her taking her own life. This enabled her surviving family to claim benefits under Japan’s rōsai (workers’ compensation) system. The labor office also rejected the hospital’s claim that the hours she needed to spend studying did not count as work hours.
Pressure from above
I am not defending the hospital in any way, but I don’t think Kimoto’s excessive work was solely the fault of the hospital. In fact, it’s likely that all general hospitals (specifically those that can take emergency cases) fit into this mold.
There is a serious dearth of physicians, particularly in the countryside, available to work a graveyard shift, and this shortage is only getting worse. These rural hospitals have been pleading for some kind of relief from these shortages. Without it, the doctors end up taking on the extra — and enormous — burden themselves. The death of a young, motivated physician in her 30s at Niigata City General Hospital is something that we as a society cannot ignore.
Part of the problem is the image we have of doctors that I described earlier. With all the status, money and glory attached to our stereotype of a physician, we forget that they too are workers who have to follow orders from their employers. They too are in a weak position vis-a-vis their bosses.
If a doctor were to dare complain about their working conditions, they would no doubt be lectured about how they are not simply a salaried employee at a company; that they get paid much better than average, and that their higher pay factors in the extra hardship. True, perhaps a simple comparison between doctors and company employees is difficult. But it is also true that they should be able to complain. Doctors work in a high-pressure workplace where people’s lives are at stake. That’s all the more reason they should be able to take proper breaks and vacation. There is a Japanese term, isha no fuyōjō, which refers to a doctor who doesn’t practice what they preach — who doesn’t take care of their own health. For the sake of preventing medical mistakes and for the health of many patients, it is critical that we do not ignore this.
Another problem doctors face is that their work is seishoku (a sacred profession). They must save the person suffering in front of them and forget about issues of money and time. Teaching is seen in a similar way. When doctors or teachers bring up issues such as salary and work hours, their concerns are often scoffed at. They are sometimes even accused of caring more about money and hours than their patients and students. Such attitudes generate obligations that foster dangerously long work hours in both professions and prevent corrective measures from being taken. The medical system in Japan will simply collapse if it continues to sacrifice individual doctors on the altar of gaman (perseverance).
This year the government came out with its conference on reforming our work habits. They set up an (outrageously high) limit to overtime work hours, at “below 100 hours.” But even this dangerously high maximum will not apply to doctors until five years from now. I suspect that robust lobbying by the Japan Medical Association, a strong supporter of the ruling Liberal Democratic Party, is behind the delay. The JMA needs to take the issue of excessive work hours among doctors more seriously.
Doctors are human beings and workers and Japan needs to address the issues they face head on. Kimoto worked hard to achieve a career dream only to lose her life in her mid-30s. We need to ensure that such tragic situations do not repeat themselves, and improving the working conditions and environment of doctors will be a start.
Hifumi Okunuki teaches at Sagami Women’s University and serves as executive president of Tozen Union. She can be reached at firstname.lastname@example.org. Labor Pains appears in print on the last Monday of the month.Your comments and Community story ideas: email@example.com