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Bread and Roses: Is Your Attending Physician Working for Free?

SNA (Tokyo) — “Is there a doctor in the house?”

Someone suddenly falls seriously ill in many TV melodramas and movies. As a kid, I remember watching a fictional doctor swoop onto the scene like Superman. I wanted to be a physician when I grew up because I thought someone who saves people in trouble like that is so cool. Like Toyoko Yamazaki’s novel Ivory Tower, which was adapted to a TV drama, I understood that doctors at large hospitals can engage in ugly infighting and power struggle. But their duty to relieve those who suffer is quite simple. For a simple woman like yours truly, this was quite appealing.

It was not meant to be. No matter how hard I tried, I could not overcome my fatal failing at all things science and math. Although I had to give up my dream to become a doctor, I have retained to this day a real respect for the occupation. As a labor law scholar, I have a great interest in the labor rights of physicians (which ultimately are the same as all workers).

In particular, concern is growing over what will become of Japan’s healthcare environment, including interns’ karoshi (death from overwork), karo-jisatsu (being driven to suicide due to overwork), and over the recent scandal involving universities cheating women out of their rightful places in medical school.

In this installment of Bread & Roses, I would like to focus on the existence of unpaid grad school doctors (mukyu-i). Why doctors would not be paid even a minimal wage is an outlandish problem to me and certainly runs against the grain of the high-income reputation the profession enjoys. I first heard of it last year on an NHK news feature.

Although graduate school students, these doctors see patients just like ordinary doctors. A total of 2,191 grad school doctors work in fifty university hospitals around the country (see table), according to a June 28, 2019, report by the Ministry of Education, Culture, Sports, Science and Technology. This is out of a total 31,801 grad student physicians.

NHK’s coverage last year gave us the first look into a modern medical apprenticeship system, for what was long seen as artisans plying a tradecraft rather than a worker in an employment relationship.

The average physician at age 41 makes 12.4 million yen (about US$115,000) a year, or more than double the average across all occupations, according to a study by the Ministry of Health, Labor and Welfare. (Incidentally, nurses make far less than this under far worse conditions. That is a story for a future installment of Bread & Roses.) It’s hard to imagine a doctor working for free. So, why does it happen?

One problem is Japan’s peculiar personnel system at university hospitals. Each pyramidically structured department is called an ikyoku. Physicians are all organized into this ikyoku system. Students study medicine for six years to get certified. They work for a few years to gain some experience, then many go back to school for what in Japan is called “graduate school” (daigakuin). Four more years and a dissertation get them a “PhD in medicine.”

They pay tuition, but part of their “curriculum” is to see patients of the university’s hospital as part of their “training.” Hospitals facing doctor shortages are desperate for these grad students, but too stingy to pay.

Medical professionals, even doctors themselves, often accept this anachronistic apprenticeship system as a necessary evil or as shikataganai (unavoidable). This recalls how many in the medical profession readily accepted the inevitability of robbing young women of their spots in medical school while practicing some grotesque form of affirmative action favoring men with lower scores.

This self-stifling cave by the medical community disappointed those of us still outraged at the score-manipulating scam. Students cheating on their exams are summarily expelled, but the universities themselves can cheat with impunity. Yet, we hear the same apologetics and shikataganai-ing. How can one’s sense of justice become so dull?

It is no exaggeration to say that new doctors have the power of life and death and the same legal responsibility towards her patients. Yet some don’t get paid. My guess is that many of these unpaid student doctors feel indignant or angry about not getting paid for their hard work. But the “nail sticks out…” means they must shut up about it if they ever want to work “in this town” again.

Most mukyu-i work with no employment agreement, meaning they enjoy none of the labor protections that all workers have, including industrial accident insurance (worker’s compensation) and unemployment insurance. They have no choice but to do the work and must obey work orders from their superiors, so legally they should be considered employees (rodosha) with all the attendant protections and benefits.

Hospitals are legally obliged to pay them. I surmise that if any of them dared to “stick out” and sue, they would win back wages and be recognized. Whether the new doctors agree or not, hospitals must pay them at least minimum wage. In fact, some hospitals do pay them minimum wage, which is at least legal.

Bottom line: Physicians are workers, and it’s time they stood up and fought back.

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