Upcoming Work Style Reforms for Doctors in Japan: Simplified Guide to Penalties and Task Redistribution 

English translation of Work style reform for doctors will start in 2024! Easy-to-understand explanation of penalties and task shifting/sharing

Starting in April 2024, new regulations will limit doctors' overtime hours and mandate additional health protection measures in Japan. This article will delve into the background of these work style reforms, outline the changes brought by the revised law, and highlight key considerations for doctors adapting to these reforms.

• What is the work style reform for doctors that started in April 2024? 
• Three points of reform of doctors' work styles 
• Points to note in reforming doctors' work styles 
• What is required of medical institutions in promoting reforms in the way doctors work 
• Q&A on physician work style reform 
• Conclusion

In Japan, to protect the health of doctors and improve their long working hours, lawmakers enacted a work style reform for doctors that came into effect in April 2024. This is based on the Labor Standards Law revised by the reform of the way doctors work; employers will cap overtime work in a variety of industries.

Among them, the transportation, construction, and physician industries received a five-year grace period as a preparatory period, and the overtime work limit became effective on April 1, 2024. This reform aims to ensure an efficient healthcare delivery system while maintaining the quality of healthcare.

The current situation in which doctors in Japan overwork and the resulting health hazards have become serious social problems prompted the reform of the way doctors work. According to a survey conducted by the Ministry of Health, Labour and Welfare on the actual working conditions of doctors in Reiwa 4, 21.2% of all doctors worked more than 960 hours on holidays and overtime in terms of annual equivalents, and 3.7% of all doctors worked more than 1,920 hours.

Doctors' overwork not only degrades the quality of medical services to patients but also increases their own health risks and, in the worst case, may cause medical accidents. Furthermore, as the demand for medical care increases with the declining birthrate and aging population, there is a need to improve the working environment while protecting the health of doctors.

The following is an overview of challenges in implementing reforms to the way doctors work, based on the "Results of a questionnaire survey of working doctors" conducted by the Ministry of Health, Labour and Welfare in 2022.

Medical institutions face various problems due to the shortage of doctors.

• Shifts on duty rotate at the very last minute, and doctors cannot return home after their shift ends.
• They work for low wages due to the nature of their medical services.
• The shortage of full-time doctors means that each physician has to work long hours.
• The number of doctors is unevenly distributed in each department.

When medical institutions introduce the maximum working-hour limit as part of the reform of the working style, they will reduce doctors' working hours. This may make it challenging for institutions with a physician shortage to adequately respond to patients. 

In addition, regional healthcare experiences a serious maldistribution of doctors between urban and rural areas, making it particularly difficult for medical institutions in rural areas to promote work style reforms. Furthermore, hospitals that struggle to recruit new doctors may experience a decline in the quality of medical services, and a shortage of specialists and experienced doctors may hinder the provision of certain medical services.  

Unless medical institutions improve the current situation in which doctors face a variety of tasks other than their primary duties, such as examining and treating patients, they will find it difficult to implement reforms in the way doctors work. The following points are perceived as hurdles to the implementation of work style reform by doctors in the field: 

• Unless medical institutions reduce the workload of doctors, they will find it difficult to reform the way they work.
• The shortage of outpatient clerks has increased the amount of paperwork required of doctors.
• There is concern that the introduction of shift work will result in a decrease in salaries.
• While there is a need to shorten working hours, other industries are not sharing the work or making it more efficient.

With regard to employment management, some doctors are concerned about salary payments and the blurring of the line between work that is considered self-improvement and work that is not paid. 

• Employers are allowing unpaid overtime work to occur.
• Excessive harassment of workers for taking breaks persists.
• Many meetings and training sessions take place after hours.
• There is pressure from the hospital or university to perform.
• Achievements are required to obtain a post, but the work time is considered as self-improvement.

The challenge is that hospitals, patients, and their families do not fully understand how doctors work, resulting in the following problems:

• Some hospitals do not recognize cases of overtime work as overtime work in the name of self-improvement due to their pressure.
• Uncooperative co-medical staff increases the workload of doctors.
• Increased demands for work from patients and the public arise.
• Patients and their families do not fully understand the reforms in the way doctors work.

As described above, reforming the way doctors work entails many challenges. To overcome these challenges, each medical institution must understand the current situation in the medical field and take effective measures.

The reform of the way doctors work, which started in April 2024, focuses on three main points:

(1) Limits on overtime work

(2) Establishment of a center for evaluation of the working environment of medical institutions

(3) Additional health measures

Below is the explanation of each point in detail.

The reform of the way doctors work prioritizes capping overtime work. This reform sets the annual overtime limit to no more than 960 hours, or less than 100 hours per month. While general industries have an overtime limit of 720 hours per year, doctors have a special limit due to the public nature of healthcare and the need to maintain the healthcare delivery system.

Additionally, certain medical institutions have a relaxed upper limit of 1,860 hours per year, allowing overtime work beyond the standard 960 hours per year. Medical institutions are classified into three levels (ABC) based on the doctors' years of clinical experience and the characteristics of the institution. For level B and C medical institutions, the overtime limit is 1,860 hours per year. The details are as follows:

Below is a summary of the maximum overtime hours for each level of physician.

Reference: Ministry of Health, Labour and Welfare "Work Style Reform for Doctors ~Connecting Medical Care to the Future~" | "Work Style Reform for Doctors"

The following is a summary of the criteria for each level applicable to medical institutions. 

Reference: "Doctors' Work Style Reform Procedure Guide by April 2024"

Starting in April 2024, doctors will have a basic annual overtime limit of 960 hours. To establish an overtime limit of 1,860 hours, medical institutions must designate doctors as Level B or Level C. This requires formulating a plan to reduce doctors' working hours and conducting a third-party evaluation by the Center for Healthcare Work Environment Assessment.

The center ensures that the working environment at medical institutions is appropriate. It evaluates each medical institution's working environment and proposes measures for improvement. The center's establishment aims to encourage medical institutions to voluntarily improve their working environment and promote transparency through external evaluation. For more information, please visit the website of the Center for Work Environment Evaluation of Healthcare Organizations.

The law requires additional health protection measures for doctors who work more than 100 hours per month. These measures include conducting interviews and, if necessary, reducing working hours and the number of nights on duty.

Both ABC levels must implement these health protection measures if applicable doctors are present, starting from April 2024. Additionally, the revised law now mandates the following measures:

Reference: Ministry of Health, Labour and Welfare "Study Group on Promotion of Doctors' Work Styles Interim Summary"

These additional health measures are obligatory for Level A, but legally obligatory for Levels B and C, thus reinforcing efforts to ensure doctors' rest.

The reform of the way doctors work provides penalties for exceeding the overtime work limit. The same penalty system applies to general companies, and if medical institutions fail to comply with the regulations, they face “imprisonment for up to six months or a fine of up to 300,000 yen” under the Labor Standards Law.

If illegal overtime or holiday work is discovered, the Labor Standards Inspection Office issues corrective recommendations and guidance. Violations of laws and regulations by medical institutions can damage the credibility of their employees and the local community, seriously impacting their management. Therefore, medical institutions must comply with laws and regulations and adhere to work standards provisions, focusing on protecting doctors' health while maintaining the quality of care.

Many doctors face a problematic working environment where they are forced to work excessive overtime without appropriate pay. The reform mandates an increase in the premium wage rate for overtime work. Large companies have already implemented this increase in the statutory premium wage rate, and since April 2023, small and medium-sized companies, including those in the medical industry, already apply a “premium wage rate of 50% or more” for overtime work exceeding 60 hours per month.

Medical corporations and sole practitioners are classified as either large enterprises or small and medium-sized enterprises based on their size and are subject to the increased statutory premium wage rate. For medical corporations, small and medium-sized enterprises are defined by a “capital contribution of 50 million yen or less” or “the number of workers employed on a regular basis is 100 or less.”

As doctors' work reforms proceed, medical institutions must undertake specific initiatives. Below are the main points that medical institutions should address. 

Medical institutions must first create a working hours reduction plan. Specifically, the plan must specify the results of the previous year, goals for the current year, and goals for the plan period with regard to working hours, labor and health management, awareness-raising and education within the medical institution, and efforts to reduce working hours (task shifting/sharing, review of operations, use of ICT, etc.).

In addition, as mentioned above, medical institutions seeking accreditation at the B, Collaborative B, and C levels must undergo a third-party review from the Center for Healthcare Work Environment Assessment in order to obtain prefectural designation. Medical institutions must continuously improve their working environment through this cycle of planning and review.

Implementing a system for objective working hour management and clarifying overtime work application procedures enables us to manage working hours appropriately. Accurately recording working hours is crucial in the medical field, where emergency responses are often required. If doctors currently manage their working hours through self-reports, we should consider introducing an attendance management system. 

Additionally, if not already in place, we must conclude and file a 36 agreement based on the Labor Standards Law. A 36 agreement allows overtime work beyond the legal working hours, and without it, overtime work is not legally permitted. Therefore, medical institutions must thoroughly manage labor and adhere to legal procedures to ensure an appropriate working environment. 

The promotion of task shifting (transfer of work) and task sharing (sharing of work) is essential for the successful implementation of physician work style reform. Specific examples include the following: 

Introduce task shifting/sharing that can proceed without specific qualifications.

• Increase the number of clerical staff to share the work of document preparation and data entry that doctors used to do

• Patient transfer and guidance

• Receipt of routine examination explanations and consent forms

• Patient transfer and guidance in the hospital

Nurses traditionally provide medical assistance to doctors and may be responsible for the following tasks:

• Perform specific medical procedures (e.g., adjusting the amount of medication during continuous infusion, ventilatory management, insertion of central venous catheters, etc.).

• Administration of drugs and blood draws according to protocols.

• Blood draws and tests in the emergency room based on the physician's advance order.

Pharmacists can be responsible for the following tasks: 

• Dosage adjustment of prescription drugs based on agreed protocols

• Explanation of drug therapy

• Prescription proposals and support for doctors

• Technical guidance for self-injection, etc.

As physician work style reform advances, doctors and medical institutions have raised several questions and concerns. We provide easy-to-understand explanations to frequently asked questions about these reforms. 

The overtime work limit includes hours worked at side jobs and part-time jobs. Therefore, doctors need to monitor their own working hours and ensure they do not exceed the upper limit.

Medical institutions must also check the working hours of doctors who work part-time or at side jobs and permit them to work within an appropriate range.

Depending on the nature and timing of their studies, doctors may count study hours as working hours. The following types of hours must be treated as working hours:

• Practice of procedures that are essential for both the preparation and follow-up care of medical treatment.

• Work ordered by the supervisor

• Case studies and thesis writing required for the job.

• Training and education required as part of the job.

Time spent studying outside of scheduled working hours, without a supervisor's direction and done voluntarily, is not included in working hours if it is not essential to the job.

If the Labor Standards Inspection Office grants a medical institution a "Shift Permit," the hours worked on shift duty are not included in working hours. The criteria for the day shift permit require sufficient time intervals between shifts and rare cases of emergency patient care. With this permission, the duty shift is considered rest time, allowing the physician to reduce the total number of overtime hours worked and use the duty shift as a sideline.

Understanding how working hours are treated for doctors on duty is crucial for their working conditions.

The reform of the work style of doctors in Japan, which began in April 2024, will limit the number of working hours per year to 960 hours and the number of hours worked to less than 100 hours per month. Certain medical institutions have relaxed the upper limit to 1,860 hours per year, but this will be reduced in stages. Additionally, mandatory health measures have been implemented to protect doctors' health.

Creating a healthy working environment for doctors is crucial for providing high-quality and safe medical care to doctors, patients, and the public. To maintain a sustainable medical system, doctors must raise their own awareness and comply with legal arrangements. Medical institutions must take initiatives, cooperate with other professions, and ensure patients understand these measures.

The physician work system reform is currently in operation, and its effectiveness varies widely depending on the region, medical institution, and department. Compared to past work system reforms, many medical institutions are making considerable progress in discussions, partly due to the penalties involved. However, the system's nature has introduced various wrinkles. It is not an exaggeration to say that this reform has clearly defined the medical structure, which has been sustained by doctors' volunteer efforts. We believe the reform will continue for several years with distortions in the system.