Received: 2 April 2023

| Revised: 20 June 2023 | Accepted: 31 August 2023

DOI: 10.1002/jgf2.649

INVITED ARTICLE

The effects of resident work hours on well-­being, performance,and education: A review from a Japanese perspective
Kazuya Nagasaki MD, PhD| Hiroyuki Kobayashi MD, PhD

Department of Internal Medicine, Mito
Kyodo General Hospital, University ofTsukuba, Ibaraki, Japan

Abstract

Correspondence
Kazuya Nagasaki, Department of Internal
Medicine, Mito Kyodo General Hospital,
University of Tsukuba, 3-­2-­7, Miyamachi,
Mito, Ibaraki 310-­0 015, Japan.
Email: kazunagasaki@yahoo.co.jp

This article examines the impact of working-­hour restrictions on the well-­being,
performance, and education of medical residents in Japan. Despite Japan's plan to
introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive
overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the
80-­hour-­per-­week regulation in the United States and the 48-­h-­per-­week regulationin the European Union influencing other regions. The article also discusses the effectiveness of working-­hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety
and resident education are mixed, and further reduction in working hours must be
carefully considered to avoid adverse effects. The planned changes to working-­hour
limits for residents in Japan offer a unique opportunity to gain new evidence on theimpact of such regulations, which will be of interest to policymakers and researchers
worldwide.
KEYWORDS

medical education, patient safety, postgraduate resident, resident work hours, well-­being,
workstyle reform

1|

I NTRO D U C TI O N

twenties constituted the highest percentage (13.1%) of all generations of physicians in Japan who work more than 80 h weekly.3 In

Medical residents are physicians in training. In Japan, all medical

the past two decades, a growing global consensus has emerged that

school graduates who wish to become clinicians, regardless of theirresident work hours should be limited to safeguard patient safety

desired specialty, must undergo 2 years of clinical training to acquireand promote resident well-­being because of the increasing concerns

basic clinical skills.1,2 While medical residents are still learning, they

about the impact of extended work hours.

are considered an essential part of the healthcare workforce, pro-

Although Japan is lagging in implementing such measures, resi-

viding vital care to patients across various clinical settings. However,dent work-­hour restrictions are expected to be introduced in 2024.

their long and demanding working hours have been a subject of de-

The traditional medical education system in Japan emphasizes a cul-bate for decades. According to a survey conducted by the Ministry

ture of hard work and dedication. Remarkably, residents were notof Health, Labour and Welfare (MHLW) in 2019, physicians in theirlegally recognized as workers until 2005, over 30 years after theThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,provided the original work is properly cited.
© 2023 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.
J Gen Fam Med. 2023;00:1–9.	﻿

wileyonlinelibrary.com/journal/jgf2

| 1

|

NAGASAKI and KOBAYASHI

commencement of the residency training system in Japan in 1968.1,4

2|

WO R K- ­H O U R R EG U L ATI O N S

In 2004, the current clinical training system became mandatory, requiring physicians who complete 6 years of medical school and wish

The regulation of work hours for residents has been predominantly

to become clinicians to undergo 2 years of training with the goal ofenforced in the U.S., Europe, and Canada, with other nations, particu-

acquiring basic skills and regardless of their desired specialty.1 The

larly in Asia, more recently adopting similar measures (Table 1).8,10,11

impetus for limiting work hours for residents in Japan stemmed from

However, Japan is scheduled to impose such regulations in April

the work style reform initiated by the government in 2018.5 As part2024. Most countries' regulations on resident work hours consistof this reform, the Japanese MHLW introduced new regulationsof two components: the total number of working hours (e.g., hours

limiting resident work hours to 80 h weekly, with a maximum shift

worked per week) and the longest continuous working hours in a

6length of 28 h. Although this limit is comparable to those of othershift. While the specific motivations for implementing WHR differ

countries, it is substantially longer than the maximum working hours

among nations and regions, they commonly prioritize medical safety,

for all workers and general physicians. Moreover, the permissible

resident health, and workers' rights.8 This section aims to provide an

overtime level exceeds the threshold for “karoshi”, which is the pointup-­to-­date overview of the current status of resident WHR in Japan

7

at which compensation for death because of overwork is granted.

and other countries worldwide.

As a result, there is an ongoing debate in Japan regarding the appropriateness of the maximum work hours for residents.
The impact of work-­hour restrictions is complex and depends

2.1 | Japanon various factors. A large body of literature evaluates the impactof resident work-­hour restrictions (WHR), primarily in terms of

In 2018, the Japanese government implemented a series of measuresresident well-­being, patient safety, and resident education. Most

aimed at promoting reforms in the workforce.4,5 These reforms wereresearch investigating the consequences of weekly work-­hour lim-

primarily motivated by the decline in the working population because

itations involves observational studies conducted before and afterof falling birth rates and an aging demographic, as well as long work-

the imposition of work-­hour limits. The weekly work-­hour limit

ing hours. Among the measures enacted were revisions to the Labor

varies among countries, with the United States (U.S.) and Europe

Standards Law, which introduced new regulations on working hours

having set limits between 80 and 48 h weekly, respectively. 8 How-and interworking interval systems. Effective since April 2019 in large

ever, there is limited literature available from Japan in this regard.

companies mainly, these new regulations have limited overtime

Randomized controlled trials have predominantly been conducted

work comprising 45 h per month and 360 h per year. In Japan, thein the U.S. and have mainly focused on the effect of shift length,

legal working hours are 8 h per day and 40 h weekly, with any hours

rather than weekly work hours.9 As a result of the potential impacts

worked beyond these considered overtime. Prior to these regula-and differences in healthcare systems and cultures across coun-tions, there was no limit for overtime work hours in Japan.

tries, there is currently no consistent agreement on the ideal global
limits for working hours.

Notably, the enforcement of the working-­hour reform for physicians (including residents) was postponed until 2024 because of

Given the ongoing controversy surrounding resident work hours,

the unique nature of their profession. To ensure the effectiveness of

it is important to understand the current evidence on this topic. This

the healthcare system, the MHLW's Study Group on Working Hourcomprehensive review provides an overview of the literature on res-

Reform for Doctors has suggested setting a standard limit of 960

ident working hours, concentrating primarily on their global regula-

overtime hours per year for physicians, with the option for longer

tory landscape and the influence of their limitation, with a specificworking hours in specific cases and proposing extended working

emphasis on the available Japanese literature. This review aims tohours for physicians involved in community medicine, emergency

help Japanese and international readers consider the optimal bal-

medicine, and those undergoing training.6,12 As a result, a bill on theance of resident working hours.

reform of physicians' working practices (the Medical Care Act) came

TA B L E 1 Work-­hour regulations in Japan and worldwide.

Country

Regulation source

Maximum weekly
working hours

Maximum continuousworking hours

Implementation year

ReferenceJapan

National laws

80 h

28 h

2024

3

The United States

ACGME

80 h

28 h (2017 revision)

2003

16,19,20

Europe

EWTD

48 h

13 h

2004 (Varies by countries)

9,10

CanadaLocal agreement by
each province

60–­90 h

24 h Quebec: 16 h

Varies by provinces21–­23

South Korea

National laws

80 h

36 h

2015

24

TaiwanNational laws

80 h (2018 revision)

32 h

2013

25,26

Abbreviations: ACGME, accreditation council for graduate medical education; EWTD, European working time directive.

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2TA B L E 2 Work-­hour regulations among Japanese physicians.
Category

Types of physicians

Maximum annual
overtime

Maximum weekly
working hours

Maximum continuousworking hours

Implementationyear

All workers

360 h

48 h

No limit

2019

Level AAll physicians

960 h

60 h

24 h (recommendation)

2024

Level B

Physicians in community
health care1860 h80 h

24 h (requirement)

2024 (Until 2035)

Level B for
Cooperation

Physicians dispatched tocommunity health care1860 h80 h

24 h (requirement)

2024 (Until 2035)

Level C-­1

Postgraduate residents andresidents in specialty
training

1860 h80 h

24 h (requirement)

2024

Level C-­2

Physicians requiring advanced
clinical skills training

1860 h80 h

24 h (requirement)2024

Note: This table provides an overview of work-­hour regulations in Japan, which were obtained from a reliable source cited in reference.3 The table
distinguishes between different types of physicians, with Levels B and C being exclusively carried out at designated hospitals. It is worth noting that
Level B is scheduled to be eliminated in 2035, while the details of the reduction for Level C are yet to be determined.

into effect in May 2021.3 Under this bill, the upper limit for over-consecutively (24 h plus 6 h for transitions of care and education).16

time work for general physicians is 960 h per year (equivalent to a

In 2011, additional restrictions were imposed, restricting continu-

60-­h work week), which is designated as “Level A” (Table 2). Excep-

ous duty hours to 16 h for first-­year residents, while second-­year

tions will be granted to physicians working at medical institutions

residents and above were limited to 28 h (24 h plus 4 h). After ran-providing community and emergency medical services, designateddomized controlled trials demonstrated minimal effects on medical

as “Level B,” and postgraduate residents and residents in specialty

safety and resident burnout with relaxed continuous duty hours,17,18

training seeking to acquire advanced skills, designated as “Level C.”

the ACGME conducted a study in 2017 to evaluate the impact of the

The latter are allowed to work up to 1860 h of overtime per year

new regulations on first-­year residents, allowing them to work for up(equivalent to an 80-­h workweek). To ensure health and safety, Lev-

to 28 consecutive hours (24 h plus 4 h).19,20

els B and C require no more than 28 consecutive work hours and aminimum interworking interval of 9 h.
It is important to note that Level C is not mandatory for all resi-

2.3 | European union

dents but is only applicable to those working in medical institutions
designated by the prefecture based on actual work conditions. The

The European Working Time Directive (EWTD) has been in place

proportion of residents who will take Level C has not yet been dis-since 1998, restricting working hours to ensure the health and safety

closed and it is feasible that only a limited number of training hospi-

of workers across all occupations in the European Union (EU). The

tals will be classified as Level C (otherwise, they will be categorized

law limits working hours to 48 h weekly, with a minimum of 11 h ofas Level A). Additionally, by 2035, Level B will be eliminated and in-rest within a 24-­h period.8,10 Nevertheless, the degree of resident

tegrated into Level A, whereas Level C will be gradually phased out.

compliance with the EWTD guidelines varies in each country and

The details of the execution of this reduction remain undetermined.

has not been consistently reported. In some cases, residents canchoose to opt out of the EWTD regulations, allowing them to exceed
the 48-­h weekly limit.

2.2 | The United States
In the U.S., a medical incident that occurred in New York in 1984,

2.4 | Canada

known as the Libby Zion case, triggered the implementation ofregulations on resident work hours.13 This incident involved the un-

There are no nationwide regulations or laws governing resident

fortunate death of an 18-­year-­old woman as a result of a resident's

working hours in Canada. 21 Instead, some provinces consult withmedical error and brought attention to the arduous working con-provincial governments and resident unions to set guidelines for res-ditions that residents face. In the aftermath, several studies wereident working hours. Currently, Manitoba, the Maritime Provinces,conducted and reported that prolonged working hours are associ-and Quebec have established weekly working hour limits of 89, 90,

14,15

In

and 72 h, respectively. 21–­23 Quebec has also instituted a limit of 16

response to these findings, the Accreditation Council for Graduate

consecutive hours per week, while other provinces have established

Medical Education (ACGME) introduced a regulatory measure in

24 consecutive hours. Each province has its own specific regulations

2003 to limit the working hours of residents to 80 h weekly and 30 h

regarding rest periods and overtime calls.

ated with increased risks of medical accidents and errors.

21897948, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.649 by Cochrane Japan, Wiley Online Library on [25/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License| 3

NAGASAKI and KOBAYASHI|NAGASAKI and KOBAYASHI

2.5 | Asia

The 80-­h limit on workweeks, primarily in the U.S., is likely to havea positive effect on mental health by mitigating burnout. In 2011, aConcerns about extended working hours for resident physicians

systematic review showed that five out of eight studies examining

in South Korea led to the implementation of a law in 2015 aimed

the impact of the WHR introduced in the US in 2003, resulted in de-at improving their working conditions and status. The legislation

creased burnout levels, particularly emotional exhaustion.31 Martini

mandates a maximum of 80 working hours weekly and 36 h con-et al.32 discovered a reduction in burnout levels from 77% to 43%

tinuously.

24

A survey conducted by the Korean Intern Resident As-

among postgraduate year 1 (PGY-­1) residents after the implementa-sociation indicated a decline in weekly working hours from 114 totion of the 2003 WHR. They also reported that, before the implemen-

88 h between 2016 and 2019, which led to increased satisfaction

tation of the WHR, those working more than 80 h weekly had higher

with training.

24

burnout rates compared to those working less (69.2% vs. 38.5%).33

The Ministry of Health and Welfare in Taiwan introduced guide-

Similarly, studies conducted on internal medicine and surgical res-lines for resident working conditions in 2013. 25 The guidelines spec-

idents have also indicated improvements in emotional exhaustion

ified a limit of 88 weekly working hours, with a maximum of 32 h

after the implementation of 2003 WHR.34–­36 Although these early

consecutively and a 10-­h interworking interval. Further regulationspre-­and post-­intervention studies were limited in size, with fewer

were implemented in 2018, capping weekly working hours at 80 hthan 200 participants, subsequent large observational studies andand mandating that residents take 1 day off per week. 26 Moreover,studies conducted in other countries have validated these findings.

since 2019, residents have been protected under the Labor Standard

For instance, Ogawa et al.37 found that in a sample of 1241 first-­

Act, which limits their work hours, ensures a regular day off, andyear residents in Japan, those working 80–­100 h weekly, or more

provides flexibility in arranging their own working schedules.

than 100 h weekly, had three and seven times higher risk of developing depressive symptoms, respectively, compared to those working

3 | WO R K H O U R A N D R E L ATE DO U TCO M E S

60 h. In a large cross-­sectional study of 6000 residents in Japan published in 2022, working more than 90 h weekly was associated witha higher prevalence of burnout and depressive symptoms.38 Studies
conducted in Canada, France, and Taiwan have similarly reported

Residents' working hours have decreased in the past two decades,that extended work hours (70–­80 h or more weekly) for residents areprimarily in Europe and the U.S., with other countries following suit

linked to a greater incidence of burnout.39–­41

with the primary objective of safeguarding medical safety and resi-

Two key points warrant attention regarding the impact ofdent well-­being8; however, the efficacy of such measures has yielded

weekly work hours on mental health. First, the widely implemented

mixed results.9 Moreover, some studies have suggested that WHRs

80-­
h-­
per-­
week limit may not represent the optimal threshold. Al-

may have a negative impact on resident education and patient care.

though several studies have established an association between ex-

Most high-­quality intervention studies have concentrated on inter-ceeding this benchmark and compromised psychological well-­being,

ventions for single-­shift lengths instead of total hours worked perother investigations have revealed a dose–­response relationship be-

week, and there is limited evidence to determine the appropriate

tween work hours and depressive symptoms, as exemplified by Ogawa

weekly hours worked. Nonetheless, these findings offer valuable

et al.'s study. A study published in 2022, analyzed 17000 U.S. interns

insights for Japan, which will implement WHRs in 2024. This sec-from 2009 to 2020,42 and reported a link between longer working

tion provides a synopsis of the consequences of working-­hour limi-

hours and a gradual increase in depressive symptoms, evaluated using

tations, with specific emphasis on weekly hours, for resident health,the PHQ-­9 questionnaire. Among the interns who worked more thanperformance, and education.

90 h weekly, the increase in symptom scores was three times higher
than that among those who worked 40–­45 h weekly. Second, inter-

3.1 | Well-­being

ventions on shift length may have less of an impact on residents' well-­being and mental health, as suggested by a 2015 systematic review
that reported their ineffectiveness in enhancing overall well-­being.43

Extended work hours and excessive workload have been linked toThis is further supported by the results of two subsequently con-adverse health effects, including mental disorders (e.g., depression

ducted randomized controlled trials, indicating that extending shift

and burnout), sleep disorders, cardiovascular diseases, and sui-length did not exacerbate resident burnout.17,44 These results werecide.7,27,28 Residents' health is primarily evaluated through psycho-significant enough to prompt a regulatory change in the U.S., which led

logical assessments. Research indicates that residents experienceto the deregulation of shift length of PGY-­1 residents in 2017.

higher levels of stress and burnout than attending physicians, particularly during the transition from student to resident. 29,30 Whileburnout is the primary outcome measured when assessing the im-

3.2 | Performance

pact of work hours and its limitations on resident well-­being, studies
have also examined factors such as depression, sleep quality, andInadequate sleep and fatigue from long work hours have been associ-overall quality of life.

ated with decreased attention and cognitive performance.45–­47 One

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4

study suggests that chronic sleep deprivation of 6 h or less is equiva-

However, supervisors and residents have raised concerns regarding

lent to 2 days of total sleep deprivation in terms of cognitive perfor-

the potentially negative implications of these measures on educa-

mance deficits.47 Despite expectations that limiting work hours would

tional aspects. The impact on education has been objectively meas-

increase patient safety and improve medical outcomes, the available

ured through various parameters such as training opportunities,

evidence is insufficient to support the conclusion that WHRs en-

number of case experiences, and examination performance.31,53,56

hance medical safety, as study findings have been inconclusive.10,48

A substantial body of research has scrutinized the impact ofThe lack of published studies examining the association between

WHRs on the number of case experiences, with a specific focus onresidents' work hours and medical errors was unexpected. Landrigan

the surgical experience of surgical residents. Several studies have

et al. (2004) conducted a randomized controlled trial that comparedestablished that resident caseloads either decrease or remain un-

1530-­and 16-­h shifts for intensive care unit interns.

The intervention

changed. A systematic review conducted in 2011 examined the im-

resulted in a reduction of 15–­20 work hours weekly (77–­81 vs. 63 h)pact of work-­hour restrictions on caseloads and found that out of 37

and a corresponding 5.6-­fold increase in medical errors among interns

studies, 11 (30%) revealed a reduction in surgical experience, whileon the 30-­h shift schedule. Similarly, a study conducted in the UK

25 showed no significant change.56 Out of the 11 studies that demon-

evaluated interns working under a 48-­h-­per-­week limit and found thatstrated a decrease in surgical experience, six were conducted in thethe intervention group working 48 h or less weekly had a significantly

U.S. and five in the U.K., implying that a less than 80-­h-­per-­week

lower likelihood of committing errors than the control group work-

limit, whether a 48-­or 56-­h limit, could result in a decrease in caseing 56 h or less weekly.49 Conversely, a US-­based prospective cohort

experience. However, the sample sizes of these studies were rela-study examining the impact of work-­hour restrictions on pediatrictively small, and the observations were short-­term. A significant

residents found no significant changes in their sleep or work hours, or

study published in 2013 analyzed ACGME case logs in general sur-their drug prescription or self-­reported medical errors.50 Moreover,gery and reported that the number of surgical cases declined tempo-

a cross-­
sectional study investigating self-­reported practice errors

rarily after the 2003 WHRs but subsequently recovered.57 Similarly,

among internal medicine residents found no association between ana 2014 study on thoracic surgery revealed no significant change in

80-­h workweek limit and suboptimal care or medical errors.51

the number of cases before or after the work-­hour restriction.58

Multiple systematic reviews have shown that implementing work

Limited data are available on whether surgical experience has recov-

hour restrictions for residents (2003 WHR) is associated with a de-ered in the UK or Europe, but it is plausible that the 80-­h work weekcrease in patient mortality.

31,52

For instance, Fletcher et al. (2011)

may have had a negligible impact on surgical experience. Addition-

conducted a meta-­analysis and found that the odds ratio of patientally, a U.S. study that surveyed surgical residents' opinions following

death decreased to 0.9 (95% Confidence Interval [CI]: 0.84–­0.95)

the 2003 WHRs found a decrease in case experience but an increase

after the implementation of 2003 WHRs compared to the before.31

in reading time.59 This finding suggests that the quality of education

However, the interpretation of these findings should be approachedmight have been maintained through the acquisition of knowledge

with caution. Baldwin et al.'s52 systematic review in 2011 indicatedfrom sources other than direct medical experience.

that there were no significant differences in patient mortality before

The effect of the 80-­h work-­week restriction on exam scores has

and after 2003 WHRs among the teaching hospital and the non-been primarily studied in the U.S., and it appears that it does not nec-

teaching hospital groups. Thus, the reduction in mortality rates may

essarily worsen scores. According to a 2011 systematic review, out

not be a direct consequence of resident WHRs but may be influencedof 10 studies that evaluated in-­training exam scores, two reported

by other factors such as technological advancements, promotion of a

improvement, two reported worsening, and the remaining six foundculture of medical safety, and improved levels of physician practice.

no significant differences.31 Moreover, a 2014 study that analyzed

Investigations have also been undertaken regarding the effect of

the U.S. Internal Medicine Board Examination showed no significant

WHRs on complications, with systematic reviews presenting inconclu-

change before or after the implementation of the 2003 WHRs.60 A

31,52,53

Conversely, a systematic review conducted in 2014

recent cross-­sectional study conducted in Japan,61 involving 5500

on surgical residents revealed a potential escalation in complications andresidents, revealed that resident in-­training exam scores tended tosive findings.

even increasing mortality as well.

53

In 2017, a large cohort study docu-

decrease when residents worked less than 60–­65 h weekly and didmented 110 million hospitalizations before and after the enforcement

not improve when residents worked longer. This result suggests thatof the 2003 WHRs and showed that inpatient complications surged,

decreasing work hours to 60 h weekly rather than 80 may have aparticularly in teaching hospitals, with a reported increase of 10%.54 A

limited effect on exam scores.

study comparing surgical patients before and after 2003 WHRs found a

The influence of WHRs on other educational outcomes has alsosignificant reduction in provider-­related complications (48% vs. 39%).55

been examined. Investigations on the effects of the 2003 WHRs on
U.S. internal medicine residents have revealed limited engagement

3.3 | Educationin educational activities.34,62 Conversely, Jagsi et al.63 found that
WHRs did not significantly diminish case or procedural experience,or sense of clinical preparedness among 1770 residents, despite a

The primary objective of implementing WHRs is to enhancedecrease in patient care hours from 48.5 to 42.3 h. Edson et al.64 re-

the working conditions of residents and improve patient safety.

ported a negligible impact on residents' learning time resulting from

21897948, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.649 by Cochrane Japan, Wiley Online Library on [25/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License| 5

NAGASAKI and KOBAYASHI|NAGASAKI and KOBAYASHI

work-­hour restrictions. Meanwhile, a large national observational

practice is limited, potentially rendering these effects insignificant. It

study conducted in Japan found that resident self-­study time wasis important to acknowledge that the purpose and realities of resident

shorter for those working less than 60 h per week compared to thosetraining vary across countries, which presents limitations when apply-

working 60–­65 h per week, and there was no significant increase ining research from other countries to Japan. Therefore, it will be neces-

self-­study time for those working over 65 h per week.65

sary to evaluate the impact of work-­hour limitations in Japan and makefuture improvements based on the results.

4|

FU T U R E D I R EC TI O N S

Although the exact percentage remains unclear, a considerable
number of Japanese residents are expected to be subject to Level
A regulations. The work week restriction of 60 h weekly is compara-

According to Level C-­1 regulations in Japan, the maximum weekly

ble to that in Europe, and there is considerable uncertainty regard-working hours for residents will be limited to 80 h weekly starting in

ing its potential impact. Research has indicated that there may be

April 2024. This is in line with the work-­hour limit observed in the U.S.,

a dose–­response relationship between working hours and resident

and findings from the U.S. context may be applicable to Japan. The

well-­being and that even greater improvements in well-­being may be

implementation of this regulation is anticipated to have a favorable im-achieved with limits below 80 h weekly.37,42 However, there is con-pact on the well-­being of residents; however, it may have adverse con-cern that resident education may be negatively affected, as previous

sequences for education (Figure 1). Concerns have been raised about

research indicates that less than 60 work hours weekly may lead tothe educational implications, especially in relation to the reduction

decreased in-­training examination scores and less self-­study time.

of case experiences, particularly in surgical settings, which has been

Therefore, it is imperative to closely monitor the situation to deter-

noted in other countries. Nonetheless, the impact of such limitations

mine whether any adverse effects on education emerge, accounting

may be limited in Japan as residents receive uniform training aimed

for factors such as number of case experiences and educational op-

at obtaining standard basic clinical skills unrelated to their specialty.

portunities. While decreased fatigue and sleep deprivation may lead

The effect of restricting work hours on the occurrence of practice er-

to expected improvements in decreasing the incidence of medicalrors is uncertain and may not yield the desired outcomes. Positive anderrors, there is a possibility that the number of residents exhibiting

negative effects on mortality and morbidity have been demonstrated.

suboptimal medical skills may increase, and this outcome warrants

However, the degree of responsibility of Japanese residents for theirfurther investigation.

F I G U R E 1 The potential impact of resident duty hour regulations versus to no regulations in Japan. Japan is poised to implement
working-­hour restrictions for both physicians and residents in April 2024. The upcoming regulations will mandate different weekly working-­
hour limits for residents based on their categorization as either Level C-­1 or Level A. Level C-­1 residents will be subject to a maximum weekly
working-­hour threshold of 80 h in consideration of their current workload, whereas Level A residents and all physicians will be subject to a
standard weekly limit of 60 h.

21897948, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.649 by Cochrane Japan, Wiley Online Library on [25/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License6

It is crucial to examine residents in specialty training (PGY-­3, 4,
and 5) when evaluating the effects of resident work-­hour limitations inJapan. The introduction of a new physician specialty training system in2018 mandated a minimum of 3 years of specialized training for physicians seeking to acquire a subspecialty.66 These residents may be subject to Level C regulations similar to those of medical residents (PGY-­1
and 2). However, residents in specialty training require more specialized and rigorous training and are entrusted with a significant numberof decision-­making and patient care responsibilities. As such, there is aheightened concern regarding the impact of work hours on educationand patient care performance. As a result of the highly individualized
nature of each specialty in setting appropriate working hours, it is crucial to secure the cooperation of each specialty's associated societies.

5|

CO N C LU S I O N

The Japanese government announced its intention to implement
weekly work-­hour restrictions for residents in 2024. The restrictions
involve a combination of 80-­and 60-­h weekly limits for each training hospital. While these measures are anticipated to enhance residents' well-­being and work-­life balance, there is apprehension thatstrict work-­hour limitations may compromise the quality of resident
education and patient care. Despite the global acceptance of the
80-­h-­per-­week threshold following its introduction in the U.S., theincorporation of dual work-­hour restrictions in Japan is expected torepresent a significant social demonstration experiment. Comprehensive studies examining the impact of work-­hour limitations inJapan could provide pivotal evidence for other countries to devise
appropriate working-­hour limits.
C O N FL I C T O F I N T E R E S T S TAT E M E N T
The authors declare that no conflicts of interest exist.
E T H I C S S TAT E M E N T
None.
ORCID
Kazuya Nagasaki

https://orcid.org/0000-0002-8312-7802

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How to cite this article: Nagasaki K, Kobayashi H. The
effects of resident work hours on well-­being, performance,and education: A review from a Japanese perspective. J Gen
Fam Med. 2023;00:1–9. https://doi.org/10.1002/jgf2.649

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