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 it is a job where lives are entrusted to you, it is only natural to work yourself to the bone. You must not expect anything in return."

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

At that time, we were in a position known as "unpaid doctors." In reality, a salary of about 25,000 yen per month was paid, but it was not an amount one could possibly live on. A senior once told me, half-jokingly, "Ask your parents to cover your rent for that portion." Looking back now, 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 doubting those words, not only young doctors but many physicians worked. Without deeply understanding the salary structure or social security systems, they simply worked single-mindedly for the sake of medical care. Even so, it was an era where we continued to run to our patients, supported by a sense of mission toward medicine.

Even as one gets older and begins to earn a salary sufficient for a comfortable life, values imprinted during youth do not change easily. If a patient asks, "Doctor, why won't you see me right away?" it leaves a lingering sense of guilt, and one heads to the hospital even at the cost of sacrificing time with family or loved ones. I believed without question that being a doctor was simply that kind of profession.

However, there are limits to this way of working. In reality, doctors appeared who suffered physical and mental health issues and left the medical field. It is a complete reversal of priorities if doctors collapse in the 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, overtime limits were introduced for doctors' work hours. 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, has come to be questioned by society as a whole.

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

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. On the other hand, however, sustainable medical care cannot exist unless the health and lives of the doctors themselves are protected. 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 implementation of this system. Under the Hospital Director, a secretariat was established with the Vice Hospital Director in charge of work-style reform as the responsible party, and a system composed of multiple professions, including Assistant Hospital Directors, nurses, and administrative staff, was organized. 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 administration 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 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 the future of medical settings, new ways of working that utilize both human resources and technology will be required. Through these initiatives, 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, it must be said that 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 taking away the time needed to grow as a doctor?

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 work 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.

Additionally, regarding task shifting and task sharing, which are being promoted as important means of reducing the workload of doctors, another challenge has emerged. While the burden on doctors is reduced by transferring their tasks to other professions, the perspective of whether the workload of those other professions is increasing excessively is also indispensable. Medical care is a team effort involving multiple professions, and a structure where the burden is concentrated on specific professions cannot be called 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 above all, what is important is not to spare investment for that purpose.

Work-style reform for doctors is not mere labor hour regulation. 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 to answer 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 of "creating an environment where doctors can exercise their abilities sustainably."

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