保健医療科学

2021

Vol.70 No.1 p.54－60

Topics: Recent topics in public health in Japan 2021

＜ Review ＞
Labor reforms for physicians in JapanTANEDA Kenichiro
Department of International Health and Collaboration, National Institute of Public Health

Abstract“The Work Style Reform Bill” was enacted on June 29, 2018, with proposed amendments to eight laws,
including the Labor Standards Act. Since April 1, 2020, the bill has been applied to all cases except a few
professionals including physicians, considering their current long working hours. The special committees
on physicians’ labor reform under the Ministry of Health, Labour and Welfare have reported that, behindthe long working hours, aside from the issues of organizational management, there are additional issues, including insufficient functional differentiation/cooperation in the regional medical care provision system. The
committees proposed three levels of overtime depending on the conditions of the individual physician andinstitution’s roles in a community, which should be applied by 2024.
keywords: labor reforms, work style reform, working hours, physicians, aging societies, working-age group
population(accepted for publication, January 18, 2021)

I. Why do we need labor reforms?
Japan is one of the fastest-aging societies in the world.
Its total population has already been declining (Figure 1) [1].
Consequently, it is getting increasingly difficult to sustain
Japan’s labor forces, including health care services. Basedon the National Institute of Population and Social Security
Research (IPSSR) estimates, the group of people aged 75
or older (so called the late-stage elderly) will continue toincrease and then peak around 2030 [2]. Then, it will slightly decrease but will remain constant. The ratio of the latestage elderly to the total population will rise constantly, andits value will reach 25% in 2065. That is, one of four people
in Japan is predicted to be advanced-age elderly, requiring
substantial medical services. The early stage of elderly
aged 65 to 74 years peaked out in 2016, and then it has been
gradually declining. The young population under the age of
15 years has decreased constantly. The working-age group
population has steadily increased during the post-war years
and reached its peak in 1995. However, this population has

subsequently entered a declining phase, and it is expected to fall below 70 million in 2030, eventually dropping to
53.89 million in 2050. The health care labor market will be
more competitive in the future. Thus, we need to create
better working environments for health care providers.

II. Work Style Reform Bill
“The Work Style Reform Bill” was enacted on June29, 2018. The bill is a comprehensive legal package withproposed amendments to eight laws, including the Labor
Standards Act (LSA) and the Industrial Safety and Health
Act (ISHA). Under the amended LSA, the legal limit on
overtime working hours is restricted to 45 hours per monthand 360 hours per year in principle, with penalties stipulated for employers who violate the regulations. Since April
1, 2020, the bill has been applied to all cases except a few
professionals including physicians, considering their current working hours. If the bill limits the current physicians’

Corresponding author: TANEDA Kenichiro
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
Tel: 048-458-6182
E-mail: taneda.k.aa@niph.go.jp

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J. Natl. Inst. Public Health, 70 (1) : 2021

Labor reforms for physicians in Japan

Facts(Population Census)

Population（10K people）

14,000Estimate of FY2017

12,709 (10K)% of Productive-Age Population(aged 15 to 64)

11,913

12,00010,000

8,808

3,716

60.7%

8,000

Aged 65 and over

Aged 15 to 64

6,000

6,875

Aged population Rate
(aged 65 and over rate)

26.6%

4,000

Total fertility rate

2,000
0

3,381

4,529

Aged 14 and below
1.45(2015)

1950

1960

1970

1980

1990

2000

2010

2015

1,321

2020

% of
Productive-Agepopulation
51.4%
Aged
population
38.4%

Total
fertility
rate
1.44

898

2030

2040

2050

2060

Sources: Figures until 2015-Statistics Bureau, Ministry of Internal Affairs and Communications “Population Census”. Figures Since
2020- National Institute of Population and Social Security Research “Population Projection for Japan (estimated in 2017) Medium-Variant Assumption”

Figure 1 Population Trends of Japan

overtime, many hospitals cannot sustain the current healthcare services for patients.

III. Current working hours for physicians
According to a survey of the physician workforce conducted in 2016 and 2019, around 40% of responding physi-

cians work for more than 60 hours per week or 960 hours ina year, which could be beyond the 80 hours of overtime permonth, also known as the so-called karōshi (death by overwork) line. This is the overtime limit at which people risk
death or illness. Furthermore, around 10% of responding
physicians work for more than 80 hours per week or 1,860
hours per year (Figure 2).

30

(%)

（960 hours/year）
26.3

25

23.7
21.0

22.3
（1,440 hours/year）

20

18.4

18.9

16.1
15

（1,920 hours/year）

13.7
11.1

10

（2,400 hours/year）
10.4（2,880 hours/year）
5.6

5

0

5.0
2.5

< 40 hours/wk

40-50 hours/wk

50-60 hours/wk

Survey in 201660-70 hours/wk

Survey in 201970-80 hours/wk

80-90 hours/wk

2.3

90-100 hours/wk

1.6

1.2

≧100 hours/wk

Top 10％ in 2016（Overtime 1,860 hours/year）
Top 10％ in 2019（Overtime 1,824 hours/year）

Sources: Health and Labor Sciences Research Grant “Physicians Working Conditions Survey” in 2016 and 2019

Figure 2 Weekly Working Hours for Hospital Physicians (converted yearly working hours)

J. Natl. Inst. Public Health, 70 (1) : 2021

55

TANEDA Kenichiro
８AM
6

7

8

9

5 PM
10

11

12

13

14

15

16

17

12 PM
18

19

20

21

22

23

0

８ AM
1

2

3

4

5

6

7

8

5 PM
9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40 50* Each line shows individual
physician’s working conditions
over 24 hours.
* Color codes
by working conditions:
Inpatient care
入院診療

101

Outpatient care
一般外来診療201

ER
救急外来診療301

Home care
在宅診療・往診

401

Self-learning
自己研修

501

Teaching duty
教育

601

Research
研究701

Othersその他

901

Rest/Break
休憩800

Nap/Sleep
休憩のうちの仮眠

801

Source: Health and Labor Sciences Research Grant “ Research on Physicians Working Conditions” in 2017 conducted by Taneda K @ NIPH

Figure 3 Working Conditions of Hospital Physicians on night duty

The author’s study also reveals that many physicians onnight duty cannot take enough rests; some just continue towork throughout the nighttime (Figure 3) [3].

The Ministry of Health, Labour and Welfare (MHLW) has
set up special committees on physicians’ labor reform since2017 [4,5]. The committees have reported that, behind thelong working hours of physicians, aside from the issues oforganizational management at individual medical institutions, there are additional issues: the supply and demand
and uneven distribution of physicians, the way doctors aretrained, the insufficient functional differentiation/cooperation in the regional medical care provision system, and how
patients and citizens receive medical care. The committees
have concluded that they should consider each measure related to these issues and the reform of physicians’ labor reform comprehensively. They also said that it is necessary to
promote establishing conditions and working environments
to comply with the reform regulations.

above five per 1,000 population in Greece and Austria. The
average of the OECD countries is 3.4 physicians per 1,000
people; in Japan, there are 2.4 doctors per 1,000 people.
Additionally, Japan faces geographic disparities in the distribution of physicians. In Japan, the number of physiciansleaving major local hospitals that provide acute treatment
is increasing because of work overload. This has become arecent public health issue. Some hospitals have fallen intoa vicious cycle of increased workload for the remaining
physicians because filling vacant posts is usually difficult.
The lack of physicians is a serious problem, particularly inJapan’s obstetrics/gynecology and pediatric departments.
Globally, physicians and nurses also report higher rates ofskill mismatch than other professional workers.
A related issue is an increase in female physicians. Theirratio to the total number of physicians has been increasing, accounting for 21.1% as of 2016. In recent years, thenumber of female students at a medical school has also increased, and the ratio of females enrolled in medical schools
is now about one-third. These situations require betterworking environments for female physicians.

V. Number of physicians in Japan

VI. ”Doctorʼs Duty of Responding to Call-up”

The overall number of physicians per capita varies widely
among Organisation for Economic Co-operation and Development (OECD) countries, ranging from approximately
two per 1,000 population in Turkey, Chile, and Korea, toAnother attributable issue regarding physicians’ long
working hours is the so-called Ōshō gimu (Doctor’s dutyof responding to call-up) in the Medical Practitioners’ Law,
which sets a legal obligation for physicians to provide med-

IV. Committees on Physiciansʼ Labor Reform

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J. Natl. Inst. Public Health, 70 (1) : 2021

Labor reforms for physicians in Japan
ical services. That is, physicians are principally unable torefuse to treat patients when requested. However, the special committee on physicians’ labor reform under the healthministry discussed its legal obligation in light of the planned
reforms and they have concluded that “Doctor’s duty of responding to call-up” does not necessarily require physicians
unlimited overtime.

VI. Other attributable issues
Furthermore, the maldistribution of physicians acrosscommunities and the lack of coordination of hospitals andclinics in a community are also attributable to physicians’
overtime. At the hospital level, the management of physicians comprises another issue. Some patients misuse healthcare services, and then they need to consider the necessityof hospital visits and their timings, which may increase theunnecessary burden to physicians.

VII. Recommendations by the committee on
physicians labor reform
The committee on labor reform for physicians under the
Ministry (MHLW) has been discussing how to reduce physicians’ work hours. They set the three levels as the targeted overtime depending on their working conditions, whichshould be implemented after April 2024.
1) Level A: This overtime is applied to all physicians except
for those under Level B or C below.
• 960 hours per year/less than 100 hours per month withsome exceptions (Both patterns include holiday work.)✓Face-to-face guidance for monthly overtime and employment measures or doctor orders if needed✓Best endeavors: up to 28 hours for their continuous
work and a minimum rest period of 9 consecutive
hours after the work or an alternative rest. (These
are not applied to those who are under the generalprinciples* based on the Article 36 agreement under
the Labor Standards Act their employer and the labor union sign.)* General principles of overtime- 45 hours per month/360 hours per year
- Exceptions under the Article 36 agreement that
could be applied for up to 6 months in a year: 720
hours per year/80 hours per month on average
including holiday work/less than 100 hours in amonth including holiday work✓If overtime is more than 155 hours, they need to workon concrete annual plans to reduce overtime.

2)Level B: This overtime is applied only to the designatedfacilities to contribute to the special needs of local healthcare services. The facilities that dispatch physicians toother healthcare facilities can also be designated as “Level
B for Cooperation”.
• 1860 hours per year/less than 100 hours per monthwith some exceptions (Both patterns include holiday
work.)✓Face-to-face guidance for monthly overtime and employment measures or doctor orders if needed✓Required conditions: up to 28 hours for their continuous work and a minimum rest period of 9 consecutive
hours after the work or an alternative rest
- If they cannot meet these conditions, they needto take alternative rests by the end of the next
month.
✓If overtime is more than 155 hours, they need to workon concrete plans to reduce overtime.
✓Their reform activities are reviewed by a third party tosupport them.
This Level B will be eliminated in 2035 by achieving aneven distribution of physicians and the sufficient functional
differentiation/cooperation of health care facilities in the regional medical care provision system.
3) Level C: This overtime is applied to physicians who require intensive training at the designated facilities.
- The C-1 category is for physicians under junior or senior residents programs.
- T he C-2 category is for physicians who require advanced clinical skills after 5 PGY (Post-graduate Year).
• 1860 hours per year/less than 100 hours per monthwith some exceptions (Both patterns include holiday
work.)✓Face-to-face guidance for monthly overtime and employment measures or doctor orders if needed✓Required conditions: up to 28 hours for their continuous work and a minimum rest period of 9 consecutive
hours after the work or an alternative rest
✓For junior residents, the limitation of their continuous
work is strongly requested. Consequently, there is noneed for an alternative rest.
✓If overtime is more than 155 hours, they need to workon concrete annual plans to reduce overtime.
✓Their reform activities are reviewed by a third party tosupport them.
In the future, the overtime of Level C will decrease basedon better evidence.

J. Natl. Inst. Public Health, 70 (1) : 2021

57

TANEDA Kenichiro

IX. Support centers to improve healthcare
work environments
In 2014, the amendment to the Medical Care Act took effect, and health care facilities were encouraged to improve
work environments under the Act by implementing the
PDCA cycle. Prefecture governments are required to support health care facilities to improve work environments,
and they have started establishing support centers to doso. The center is different from the Labour Standards Inspection Office. In 2017, a support center was establishedin all prefectures. In 2018, the Act on the Arrangement ofRelated Acts to Promote Labor Reform was enacted. The
support center plays a more important role in promoting
the reform by providing useful information on the website
and organizing seminars with some case studies.

X. Other measures to support health care facilities• Instruction for management to improve the work environment in health care has been published. It proposes
the following four areas to work on:1) To improve how to work and how to take rests
2) To support employee’s health3) To improve work environments including both hardware and software4) To motivate employee• To raise awareness that it is important not to misuse
health care services among patients and citizens: For example, patients are suggested to have their own primarycare doctors, consult via designated telephone services
first, and refrain from misuse of ambulances. There
are also some commercials broadcasted on TV to raiseawareness.
• To amend relevant laws, if needed, in order to facilitatetask-sharing with other health care professionals such as
medical assistants, nurses/midwives, pharmacists, medical radiographers, clinical laboratory technologists, clinical engineering technologists, and emergency medical
technicians.
- It is essential to work as a team in collaboration withvarious professionals.
• To provide health care facilities with a financial subsidy tofacilitate the labor reforms

XI. Conclusion
The current pandemic of coronavirus has further increased the burden of physicians and other health careproviders and the subsequent risk of burnout. Burnout is a58

manifestation of the enormous strain on the health workforce and can be a threat to safe and high-quality care [6].
Burnout also contributes to attrition, exacerbating humanresource shortages [7]. The reform of physicians’ labor isan urgent but challenging issue in Japan. Our institution,
the National Institute of Public Health, Japan, has also contributed to the reform and better-coordinated health careservices in a community by conducting research and holding workshops for hospital directors recommended by eachprefecture in collaboration with the MHLW since 2019.
Now is the moment to tackle the issue together as a teamat all levels to sustain safe and quality care services.

References[1] Statistics Bureau, Ministry of Internal Affairs andCommunications. Population Census. https://www.stat.
go.jp/english/data/kokusei/index.html (accessed 202101-18)[2] 国立社会保障・人口問題研究所．日本の将来推計人
口(平成29年推計)．http://www.ipss.go.jp/pp-zenkoku/
j/zenkoku2017/pp_zenkoku2017.asp (accessed 202101-18)
National Institute of Population and Social Security
Research, Ministry of Health and Welfare. [Population
projection for Japan (estimated in 2017). Medium-variant assumption (as of October 1).] http://www.ipss.
go.jp/pp-zenkoku/j/zenkoku2017/pp_zenkoku2017.asp(in Japanese) (accessed 2021-01-18)[3] 種田憲一郎，研究代表者．厚生労働科学研究費補助金特別研究事業「病院勤務医の勤務実態に関する研究」（H30-医療-指定-011）平成30年度総括研究報告書．
2019.
Taneda K. [Health and Labor Sciences Research Grant“ Research on Physicians Working Conditions” in 2019
report.][4] 厚生労働省．医師の働き方改革に関する検討会．
https://www.mhlw.go.jp/stf/shingi/other-isei_469190.
html (accessed 2021-01-18)
Ministry of Health, Labour and Welfare. [Committees
on physiciansʼ labor reform under MHLW.] https://www.mhlw.go.jp/stf/shingi/other-isei_469190.html (inJapanese) (accessed 2021-01-18)[5] 厚生労働省．医師の働き方改革の推進に関する検討会．https://www.mhlw.go.jp/stf/newpage_05488.html(accessed 2021-01-18)
Ministry of Health, Labour and Welfare. [Committees
on physiciansʼ labor reform under MHLW.] https://www.mhlw.go.jp/stf/newpage_05488.html (in Japanese)(accessed 2021-01-18)[6] Dyrbye LN, Satele D, Shanafelt TD. Healthy exercise

J. Natl. Inst. Public Health, 70 (1) : 2021

Labor reforms for physicians in Japan
habits are associated with lower risk of burnout andhigher quality of life among U.S. medical students.
Acad Med. 2017;92(7):1006-1011.
[7] Organisation for Economic Co-operation and Development. Feasibility Study on Health Workforce Skills

Assessment: Supporting Health Workers Achieve Person-Centred Care. 2018. http://www.oecd.org/health/health-systems/Feasibility-Study-On-Health-Workforce-Skills-Assessment-Feb2018.pdf (accessed 202101-18)

J. Natl. Inst. Public Health, 70 (1) : 2021

59

TANEDA Kenichiro＜総説＞
日本における医師の働き方改革
種田憲一郎
国立保健医療科学院国際協力研究部

抄録
2018年 6 月に働き方改革関連法が成立した．これは労働基準法など 8 つの法律を改正するもので，2020年 4 月 1 日からは全職種に適用されているが，医師など少数の職種においては現在の長時間労働を考慮して猶予されている．厚生労働省の医師の働き方に関わる検討会においては，医師の長時間労働の背景には，医療機関における業務・組織のマネジメントの課題の他に，地域の医療提供体制における機能の分化と連携が不十分であるなど様々な課題が報告されている．検討会からは 3 つのタイプの医師の時間外労働規制が提案され，2024年までに適用される．
キーワード：働き方改革，勤務時間，医師，少子高齢化，生産年齢人口60

J. Natl. Inst. Public Health, 70 (1) : 2021