Koichi Fukunaga: Doctors Aren't Supposed to Work to Their Limits!? — The Current State and Future of Work-Style Reform for Doctors at Keio University Hospital

"Doctors aren't supposed to work to their limits." To be honest, I was a little bewildered when I first heard that.

"Doctors must work with all their might for the sake of their patients. Since you are entrusted with lives, it is only natural to work yourself to the bone. Do not expect anything in return."

Thirty years ago, when I first became a doctor, these were the words my senior colleagues taught me. Residents were, so to speak, in an "apprenticeship." It was taken for granted that you would rush to the hospital immediately if called in the middle of the night. Even after graduation, we were told, "Live in Shinanomachi (near Keio Hospital) so you can run here within 10 minutes if contacted."

At that time, we were in a position known as "unpaid doctors." In reality, we were paid a salary of about 25,000 yen a month, but that was hardly an amount one could live on. A senior once told me, half-jokingly, "Ask your parents to cover your rent for that portion." Looking back, it feels like a story from a different era, but many young doctors at the time took their first steps as physicians in such an environment.

Without questioning those words, not only young doctors but many physicians worked tirelessly. Without a deep understanding of salary structures or social security systems, they worked solely for the sake of medical care. It was an era where we continued to run to our patients, supported by a sense of mission toward medicine.

Even as we aged and began to earn salaries sufficient for a comfortable life, the values instilled in our youth did not change easily. If a patient asked, "Doctor, why won't you see me right away?" I would feel a sense of regret and head to the hospital even at the cost of time with my family or loved ones. I believed without a doubt that being a doctor was simply that kind of profession.

However, there are limits to this way of working. In fact, some doctors suffered physical and mental health issues and left the medical field. It is self-defeating if doctors collapse in their effort to protect medical care. Against the backdrop of this reality, movements to review the long working hours of doctors finally gained momentum in Japan, and "Work-Style Reform for Doctors" began.

In April 2024, upper limits on overtime work for doctors were introduced. This is a historic turning point where the way doctors work is changing significantly as a system. The value that "doctors are meant to work to their limits," which had been accepted as a matter of course until now, is being questioned by society as a whole.

In other words, this is a major transformation within the medical community.

Of course, medicine has aspects that differ from general occupations. The mission to protect the lives and health of patients is extremely heavy, and doctors are required to have high levels of expertise and responsibility. However, on the other hand, unless the health and lives of doctors themselves are protected, sustainable medical care cannot exist. The essence of work-style reform is not merely the regulation of working hours, but the construction of a sustainable medical system while maintaining the quality of care.

Keio University Hospital has been working on work-style reform for doctors since 2018, prior to the enforcement of this system. Under the Director General, a secretariat was established with the Vice Director in charge of work-style reform as the responsible officer, creating a system composed of multiple professions including assistants to the Director General, nurses, and administrative staff. Furthermore, doctors at the associate professor or lecturer level are assigned to each clinical department as "Labor Management Managers," serving as a bridge between the hospital executive and the front lines.

In meetings held every other month, data such as overtime hours are shared, and examples of initiatives from each clinical department are introduced. In one department, overtime decreased due to a review of task allocation, and in another, meetings outside of working hours were reduced through the introduction of online conferences. By sharing these efforts within the hospital, a mechanism has been created where small success stories ripple through the entire organization.

One of the pillars of work-style reform is task shifting and task sharing. As medical care becomes more sophisticated, the duties of doctors are increasing, but many of these tasks can be handled by other professions. By having all professions that support the hospital—including nurses, pharmacists, clinical laboratory technicians, radiological technologists, clinical engineers, and medical administrative assistants—exercise their respective expertise, the workload of doctors can be reduced while maintaining the quality of care.

Furthermore, we are promoting the introduction of Medical DX (Digital Transformation), such as AI-based medical interviews, remote viewing of electronic medical records, and chat-based communication tools. Such digital technologies can be important means of improving operational efficiency while enhancing the quality of care. I believe that in future medical settings, new ways of working that utilize both human resources and technology will be required. Through these efforts, the number of doctors working long hours at Keio University Hospital is steadily decreasing. Meanwhile, the number of inpatients and outpatients is actually increasing, showing that we are able to advance work-style reform while maintaining clinical activities (see figure).

However, while work-style reform for doctors has certainly progressed, I must say we are still only halfway there in terms of whether it has led to work-style reform in the true sense. Certainly, time regulations for medical acts have been established. However, a new question has arisen: are these time regulations depriving doctors of the time they need to grow as professionals?

How do we pass this on to the next generation in a sustainable way? Particularly in medical institutions like university hospitals that handle research and education in addition to clinical practice, research that supports the future development of medical sciences and education that fosters the next generation of doctors are vital missions. While time management for clinical duties has become stricter due to work-style reform, we must carefully consider whether time for these activities—which could be called "creation" or "investment in the future"—is being squeezed out.

Securing time for research and education and maintaining motivation for medicine will ultimately lead to an improvement in the quality of care. Creating an environment where doctors can work healthily and enthusiastically is important not only for the patients in front of us but also for the advancement of medical sciences.

In addition, regarding task shifting and task sharing, which are being promoted as important means of reducing the workload of doctors, another challenge has emerged. While transferring doctors' duties to other professions reduces the burden on doctors, it is also essential to consider whether the workload of those other professions is becoming excessive. Medical care is a team effort involving multiple professions, and a structure where the burden is concentrated on specific professions is not sustainable.

Work-style reform for doctors is not simply a system to limit working hours; it is also a question of how to pass on the endeavor of medicine to the next generation in a sustainable form.

To solve these challenges, it is essential to secure more medical personnel and build a system where multiple professions can maximize their respective expertise. At the same time, it is necessary to increase productivity in the medical field by utilizing DX to promote operational efficiency and information sharing.

And most importantly, we must not hesitate to invest in these efforts.

Work-style reform for doctors is not just about labor hour regulations. It is a social project that supports the sustainability of medical care and the future of medical sciences. At the same time, it is an initiative that answers the question of how to pass on the social endeavor of medicine to the next generation in a sustainable way.

From an era where "doctors are meant to work to their limits" to an era where "we create an environment where doctors can exercise their abilities sustainably."

Creating medical care where doctors do not collapse also means creating a society where medical care does not stop.