A Survey Study on the Causes of Annual Paid Leave Being Left Untaken by Japanese Physicians from the Perspective of Hospital Managers

This paper focuses on the issue of annual paid leave that is left untaken by physicians in a difficult working environment from the perspective of hospital managers and clarifies the reasons why physicians cannot (will not) take leave through interviews with these managers and main causes of this through qualitative analysis. The results show that the main causes of annual paid leave being left untaken are “the lack of substitute physicians due to management constraints” and “physician’s ethics and overwork” which are different from the results of conventional research into annual paid leave. While also exposing the issue of supply and demand such as the uneven distribution of physicians, this paper raises the necessity of human resources management for physicians such as reconstructing the supply and demand coordination framework by improving the medical services payment system for physicians in order to make sure that demand for physician labour is met and to build and maintain a system for the provision of safe and secure healthcare in the future.


Introduction
In the medical field, hospital physicians are expected to perform under demanding conditions, including long working hours.Supply issues, such as uneven distribution of medical professionals, are also problematic.In the future, in order to satisfy the labor demand for medical professionals while establishing and maintaining systems that ensure safe and reliable medical services, it is urgent that comprehensive efforts be made to improve labor conditions for medical professionals, and, from a labor policy perspective, that organization be re-established to adjust for supply and demand [1].
In 1998, an intern (then 26 years old) in the otorhinolaryngology department at Kansai Medical University died from an acute myocardial infarction.When the intern's father, a labor and social security attorney, filed a lawsuit seeking acknowledgement of his son's death being caused by overwork, the society began to turn its attention to physicians' health hazards due to extreme workloads [2].In recent years, as many researchers relate medical accidents to the overworking of hospital physicians, more attention is being given to the dangers of fatigue and stress from hospital physicians' extremely demanding work environments, and consideration is being made from the perspective of preventing medical accidents and improving hospital patient care [3].
According to a study by the "Commission on Supply-Demand of Physicians" in Ministry of Health, Labour and Welfare (2006) [4], physicians' average working hours are 63.3 hours per week; and according to the Japan Federation of Medical Workers' Unions (2007) [5], the average hospital physician's working hours are 10.6 hours per day and 58.9 hours per week, while the overtime working hours per month are 62.9 hours.According to the same data source, 30.9% of physicians exceed the 80 overtime hours per month, which the Ministry of Health, Labour and Welfare sets as the base number for certifying death due to overworking.All these numbers reveal how demanding the work environments for Japanese physicians are.It is common for a physician just completing his/her night shift to work continually with outpatient and operative procedures; and continuous working hours of more than 32 are not even unusual. 1Some physicians are forced to fill in night shifts twice or three times per week, which raises a concern for medical accidents due to lack of sleep and overworking.
Under such work environments, it has emerged that physicians are strongly seeking an "environment in which it is easier to take holidays" in order to resolve physical fatigue and lack of sleep [6].
It is clear that taking annual paid holidays is necessary for physicians in order to attend to accumulated fatigue and ensure mental and physical rest.According to the results of "Research on Acquisition of Annual Paid Holidays" by Japan Institute for Labour Policy and Training (2011) [7] targeting Japanese general workers (Figure 1), approximately half of workers take more than 6 days of paid holiday leave.On the contrary, according to the "Survey on the Status of Annual Paid Holiday Acquisition by Physicians" (2010) conducted by MedPeer [8], a company that manages a community website for physicians, physicians who had not taken any annual paid holidays in one year accounted for 30% of the total, and those who took annual paid holidays for less than 5 days accounted for 40%; this result shows that 70% of physicians have taken annual paid holidays for 0 to less than 5 days (Figure 2), indicating how difficult it is for physicians to take annual paid holidays.Since most of the categories regarding the provided number of used annual paid holidays in each of the studies annual paid holidays are different, a simple comparison between the two studies may be difficult.However, even for the same categories, the ratio of physicians who did not claim any annual paid holidays is nearly twice that of general workers. 2  Physician labor is a topic that has attracted attention in recent years.Social scientific studies targeting the physician labor include those that focus on how female physicians work [9] [10] as well as those which examine physicians' employment types and the industry's internal structures [11].However, there have been very few social scientific studies focusing on physicians' paid holiday acquisition and work hours. 3 Igusa (2013) [13] focused on the acquisition of annual paid holidays by physicians and conducted semistructured interviews in order to unravel in detail why physicians cannot actually take annual paid holidays.Based mainly on opportunistic sampling, interviews were conducted with 12 full-time hospital physicians.
The main factors of unused annual paid holidays include: "employment relationship, employment and contract system", "hopelessness that (they) cannot take a break", "uneven distribution of physicians among medical 1 According to the Japan Institute for Labour Policy and Training (2007), more than 70% of hospital physicians have been engaged in 32 consecutive hours of work 3 times per month.32 hours include a day shift (8 hours), a night shift (16 hours) and working hours directly after the night shift (8 hours). 2 "Research on Acquisition of Paid holidays" and "Survey on the Status of Paid holiday Acquisition by Physicians" have different survey methods, periods and target structures, caution is required when the results are compared. 3A medical economic study has examined whether work conditions of physicians are statistically and significantly different depending on ages, genders, clinical departments, or hospital physicians and physicians in private practices.According to this study, those under demanding work environments included young physicians, and physicians of obstetrics and gynecology as well as pediatric departments.On the contrary, those in private practice and those of dermatology, obstetrics and gynecology and ophthalmology departments indicated higher possibility to work in relatively less stressful work conditions [12].departments", "vocation as a physician", "lack of management systems for physicians' work hours", "ambition to improve medical techniques", and "controlling power (influence) of medical offices".The study found that exterior systems (insufficient number of physicians and physician training systems), interior systems (employment types and the way information is distributed) and factors of each physician are creating a complex web of causes for unused annual paid holidays. 4owever, especially concerning employment-related and contract system issues, it is important to investigate the employer side as well.In other words, in addition to the opinions of physicians, it is necessary to examine the opinions of the management side-the side that makes decisions and arrangements-with regard to "why the Labor Standards Act does not apply to hospital physicians" and "why annual paid holidays are not given to hospital physicians" in order to depict the unused paid holiday issue from a more comprehensive and multidimensional perspective.Such a process enables the creation of objective, overall paid holiday acquisition policies, which has been traditionally conducted, to evolve into discussions on promoting concrete paid holiday acquisition policies; it likewise contributes to the improvement of a paid holiday rate.
In order to incorporate the perspectives from hospital management entities, this study conducted interviews with hospital administrators and collected their feedback as data.

Data
Materials for the analysis in this study consist of responses obtained from the semi-structured interviews based on opportunistic sampling.The survey period was from November 2012 to February 2013.Two male hospital directors participated in the survey. 5,6 Regarding the data, the number of samples is extremely small compared to a large scale survey, and the representation of the samples is not ensured by random sampling or other sophisticated extracting techniques.Therefore, it is unclear that the samples could provide representative examples with regard to unused annual paid holidays.It is certainly important to ensure random sampling, representation and comparability when conducting a scientific study; however, particularly when conducting interviews with hospital administrators, it is extremely challenging to choose a subject appropriate to a study.Therefore, opportunistic sampling was chosen in this study, which requires an awareness of the presence of biases when conducting an analysis.
The study adopted a qualitative and descriptive research method.The survey was conducted with the condition that the contents would be publicized anonymously.The survey subjects are indicated as A and B in the following analysis and materials.The indented sections are cited from the interviews on the survey subjects.

The Causes of Annual Paid Leave Being Left Untaken by Japanese Physicians
As indicated in the following comments, infringements by hospitals against the Labor Standards Act can be explained from an institutional aspect.At FY2007 closing, approximately one fourth of private incorporated hospitals and one third of private incorporated clinics marked deficits [14].One of the reasons that the number of hospital beds is excessively high in Japan compared to other OECD countries stems from the supply issue, in which a profit-cost ratio per physician is low due to high physician salaries, but payment for medical services provided by physicians is low.Under severe management environments, hospitals have kept the number of physicians at the minimum required by law while increasing the number of beds [15].In other words, although there is some difference among medical departments, it is financially very difficult to maintain replacements during annual paid holidays.Additionally, in medical fields, those who have national licenses are engaged in work permitted by those licenses, thus it is necessary for hospitals to hire medical professionals for each medical field such as physicians, nurse practitioners, pharmacists, radiologists, and medical technologists.Differing from other industries, in medical fields it is impossible to staff a busy department with someone from another department (this causes high labor costs).Not only from a financial aspect but also from a specialization aspect, it is likewise difficult to secure replacements for physicians taking annual paid holidays since the replacements have their own fields of practice.
A: Since hospitals are now in the era of competition, it is imperative to adopt the latest medical equipment.This equipment is expensive; for example, a personal computer for a medical use exactly like a regular one often costs one digit more.Also, today's comprehensive medical care has created a distressing payment system for services in which the more considerate and meticulous medical services cause the hospitals to lose more money.These issues combined could ultimately cause losses to the business.In order to avoid these issues, hospitals have introduced night-time medical services and medical examinations, which further worsen work conditions for medical professionals.In order to save labor costs, medical services are provided by the minimum number of staff members.Therefore, small number of staff members and expanding tasks makes it impossible for physicians to take annual paid holidays.
B: You cannot tell when an emergency surgical procedure will happen.Although our hospital puts up signs indicating internal and surgical medicine departments, a physician on duty is from either internal or surgical medicine department.If a physician from internal medicine department is on duty, a surgical physician may be called up anytime.An operation cannot be done by one person, and the operation and outpatient schedules for the following day are already fixed, so [the surgical physician who assisted an emergency procedure] has to work continuously.Officially physicians are told to show up at 9 and leave the hospital at 5, but there is no way this could happen due to lack of staff.Because payments for medical services have been reduced, surgical hospitals cannot hire many physicians either.It is impossible to secure annual paid holidays.Because physicians can only cover their own field of practice, if we are to comply with the Labor Standard Act, especially paid vacation, you would find no physician at a hospital.
As described in the comments, physicians have "humanitarian goals".According to a medical economist, Farley (1986) [16], physicians concern themselves in part with the consideration of patients; such is not optimally preferable in terms of the physician's monetary benefits.However, because it is better for the patient, services are prioritized over staff salary considerations.Therefore, the more a physician performs in accordance with specialization ethics, the more difficult it is to take annual paid holidays.
A: In general, with regard to the relationship between a patient and a physician, I think that these days the priority seems to be for patients, not physicians.Especially, today's medical education teaches students that the relationship between a patient and a physician is the base of medicine.And when trust is built between a patient and a physician, patient satisfaction as well as compliance to treatment increase, promotes treatment results.Many of the physicians working in our hospital are relatively young and grew up with such an education.They come to the hospital to see their patients even when we have them take annual paid holidays during the summer.Despite the fact that they are giving up their annual paid holidays, they are satisfied.They feel the same way even for the routine tasks.Treatments create the most profit when physicians are being "reasonable" in their practices, but some of them are doing too much.I guess that it is the physician's ethics.I would like to have them take at least summer holidays, but in this way, it is difficult to do so.
B: Because our hospital cares for patients in an acute phase, physicians are concerned [and invested in patient welfare].It is also an issue from the physicians' perspective since they do not take annual paid holidays even when they are given opportunities to do so. 7

Toward Improvement with Paid Holiday Acquisition
Due to limitations of space, this section provides a short proposal for improving paid holiday acquisition based on the previous discussion.Even though unused annual paid holidays infringe upon the Labor Standards Act, the issue has been left unsolved due to lack of replacements from hospitals' financial and specialization problems, in addition to physicians' ethical views.However, from the comments provided by hospital administrators, the study found that the management side also struggles between the intention to have physicians take their annual paid holidays and the reality that it is difficult to do so (or physicians do not take annual paid holidays) due to the previously mentioned issues.
Failure to take "annual paid holidays", which are for resolving accumulated fatigue and providing appropriate rest for mental and physical states, not only affects the health of physicians but also causes a risk of decreased task management and of triggering medical accidents, thereby compromising the supply of high-quality and safe medical services.Therefore, improving paid holiday acquisition for hospital physicians and realizing a work system in which physicians can fulfill their abilities is an issue that the society as a whole should work to improve.The two measures to be proposed for improving paid holiday acquisition are as follows: 1) "Improvement of medical service payment system" for hiring replacements to work during annual paid holidays The government should adopt a medical service payment system for improving paid holiday acquisition for hospital physicians so that added medical service payments are used, according to the purpose of the system based on specialization, for increasing physicians at hospitals and medical departments where annual paid holidays are not used.
2) Improvement in awareness of the "significance of physicians' paid holiday acquisition" by hospital administrators, physicians, patients and residents Hospital administrators, physicians, patients and residents need to recognize the importance of "physicians' taking annual paid holidays" in order to maintain the quality of medical services.It is also important for patients and residents to deepen their understanding of the appropriate use of hospitals, appropriate consultation and duties of physicians, to establish good physician-patient relationships rather than putting too much emphasis on patients, and to establish a work system that improves paid holiday acquisition. 8

Toward Improvement for Acquisition of Annual Paid Holidays
Since this study was restricted to publishing a limited amount of individual data, future research would be conducted based on interviews going into depth, and measures for encouraging annual paid holiday acquisition would be studied from a multifaceted perspective.
If we could obtain a thorough and extensive understanding on the detailed aspects of the complexities of annual paid holiday through qualitative research, it would become possible to propose...

Figure 1 .
Figure 1.Number of used annual paid holidays by general workers.Note: The subjects of this figure include full-time employees only.Source: Compiled by the author based on Japan Institute for Labour Policy and Training (2011), p. 24.

Figure 2 .
Figure 2. Number of annual paid holidays taken by physicians.Source: Compiled by the author based on the "Survey on the Status of Paid Holiday Acquisition by Physicians" [8].