THE work culture of modern Japan took shape after World War II, when rebuilding the economy was a top national priority. Young men were offered lifelong job security in exchange for loyalty, leading to the now infamous salaryman culture.

The salaryman works his whole life at one company, which also becomes his social life. Hierarchy is strict, with workers expected to arrive before and leave after their senpai (senior colleague). Even after the workday is done, which is typically 12 hours long, employees take part in social activities – frequenting izakaya (informal bar) for drinks and nibbles with their work colleagues in favour of going home and eating dinner with their families. Indeed, most salarymen don’t see their wives or children until the weekend.

As this fierce loyalty to the workplace escalated, the term “karoshi” was born in the 1970s, which directly translates to “death by overwork”. Workers were dying from suicide as well as cardio- and cerebrovascular disease from the effects of chronic sleep deprivation and stress.

One high profile suicide was the death of 24-year-old woman Matsuri Takahashi on Christmas Day 2015. Takahashi had been working more than 100 hours of overtime that month at an advertising firm, before taking her own life. Her company was fined approximately $6600 for violating the Labour Standards Act. While this fine may be small, it was significant in making workplaces accountable for the working hours and conditions of employees. Another woman, journalist Miwa Sado, who worked for broadcasting network NHK, died in July 2013 from heart failure aged 31. Her death was also attributed to karoshi, after she had worked 159 hours of overtime in the month leading up to her death, with only 2 days off.

Following these high profile deaths, the Japanese government passed the Work Style Reform Law, which sets limits on overtime to 45 hours a month. However, “highly skilled professionals” are exempt from this protection, which will affect doctors.

In Australia, all states but New South Wales are undergoing legislative changes to protect workers from conditions that have an impact on their physical and mental health.

The Workplace Safety Legislation Amendment Bill was passed in Victoria on 26 November 2019, and is expected to come into effect by 1 July 2020. Workers have a right to work in a physically and psychologically safe workplace, and deaths caused by failed duty of care or negligence may be punishable under this Bill as “workplace manslaughter”. This includes death by suicide from the trauma of bullying and harassment.

Moreover, not only is bullying in the workplace an offence under Occupational Health and Safety laws, it is also a criminal offence. Brodie’s Law has been in place since 2011 after 19-year-old waitress Brodie Panlock was bullied relentlessly at work and subsequently committed suicide. Her coworkers were fined and did not receive a custodial sentence. Now, bullying can be punishable with a 10-year maximum imprisonment.

What does this mean for doctors?

We already know that junior doctors are unlikely to complain due to fear of reprisal. This is especially the case for unaccredited registrars awaiting selection onto highly competitive training programs. Furthermore, there is a loophole in the legislation with working on-call, which is not reflected in the number of overtime hours worked.

While legislation may hold employers accountable for work-related deaths, there is a huge spectrum of work-related ill health that still needs to be addressed. After a certain threshold, we know that working more does not lead to more productivity. Overwork can compromise doctors’ performance and lead to burnout before the onset of physical and mental health diagnoses.

In order to prevent doctors from becoming clinically unwell, legislation is needed to put a firm limit on working hours and on-call rostering. Safe working hours guidelines, while useful, are not enforceable. Therefore, they have failed to protect doctors from morbidity and mortality.

Without legislation, doctors will continue to work overtime for their patients and for career progression, at the mercy of hospitals who will take advantage of them.

Dr Yumiko Kadota is a lecturer at the University of New South Wales Department of Anatomy, and an ex-plastic surgery registrar.

Dr Geoffrey Toogood is a cardiologist and a long-time advocate for mental health. He has swum the English Channel. He came up with the idea of crazysocks4docs day. He was the 2019 AMA President’s Award recipient.



The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

10 thoughts on “Karoshi: death by overwork. Lessons from Japan

  1. Ian Hargreaves says:

    Well put, Michel. I think the longest I worked on call during my training was about 4 weeks in a city hospital (1 in 2 roster, colleague on annual leave), unless you count the 6 months in a country hospital, as the only surgical registrar. It was not seen as a cause of mental anguish, simply what you did. Just as a new mother does not get to say “who is on-call for breastfeeding tonight?”- you knew what you were getting in for when you signed up.

    You were powerless, but there was less of a sense of powerlessness, because you were a volunteer, not a conscript. Most new mums will often resent their screaming baby’s demands, but few will leave it in the casino carpark, because overall, they love it. And there is the hope that it’ll eventually be less intrusive!

    But without nostalgia for the bad old days, the present situation (my son is a registrar) is worse for the lack of collegiality and job security. I grew up watching MASH, and my workload and stupid bureaucracy was similar, without the being shot at. But we were all fighting on the same side. For my son, knowing that there are 40 applicants for 6 jobs, and that all applicants fulfil all the selection criteria, adds a level of stress. And it’s not the accreditation that matters – anaesthetics has accredited the entire hospital, not the individual post. That’s what gives so many qualified applicants for each job.

    Energy that might have been channelled into free-range creativity is focussed on completing a Master’s Degree, because that is a better tick box response to an interview panel. By the time he finishes training he’ll be older than Mozart was when he died, so yes, a lot of creative time wasted.

  2. Michel Hoenig says:

    I have had a few aspiring surgeons as patients and I can say that the cause for their mental anguish has not been the overtime. Rather, it has been the feeling of powerlessness in their life. The feeling that they have no control in their own career progression and their ability to secure an accredited training position. They universally felt depressed and anxious about being on a treadmill to nowhere for an indefinite amount of time.

    I think the root cause of this is the lack of training opportunities for these doctors. I think most of them would be happy to do 1 in 2 call if they were on a training program. They would see it as a benefit to reaching their ultimate career goals and becoming proficient consultants.

    Having said that, one of the authors of this article was doing 12 out of 14 nights on call and that is insanity. But in general, aspiring surgeons are people who self-select for working long hours and I suspect would be happy to do 1:2.

    What I view as a negative development is the legitimization of the unaccredited registrar roles. Some of these bright doctors will rot in limbo and may never secure a position. Meanwhile, the best years of their life pass them by.

    When I have spoken to established surgeons, many of them don’t seem to be able to relate to this. In their time, training took about a decade. Which is a reasonable amount of time for mastery. These days, it will be more common for doctors to begin training a decade out of medical school – unless they have a powerful backer.

    The problem with minting older consults is especially pertinent when it comes to translational research. In his amazing book titled “Creativity”, Mihaly Csikszentmihalyi (this is the author of “Flow”) notes that creativity generally decreases with age and with life events such as marriage. So this is particularly pertinent to aspiring clinician-scientists and perhaps less pertinent to those who just want to practice their craft.

  3. Anonymous says:

    Thanks so much for this insight information

  4. Anonymous says:

    And yet , annually , in the NMBA survey ,we are advised not to list hours on call as hours worked .

    Hours on call are hours worked .

    There is an issue here for the NMBA in their responsibility to protect the public from potentially fatigued health professionals who are being exploited by bureaucracy, budgets , and health administrators.

    The NMBA have the data ,-high time they grasped the nettle.

  5. Hung Nguyen says:

    There are so many factors driving the stress levels for the junior doctors compared to what the training used to be previously as Ian Hargreaves stated. The patients are older and sicker, their tolerance for margin of errors is far less than younger and fitter people. The emergency junior doctors are less confident resulting in a larger number of consults. The patients are led to expect a lot more. The public system has to handle more. There are fewer resources. The bureaucracy is worse. Conflicting expectations of the senior staff from jurisdictions and college perspectives creat a schizophrenic environment that greatly contribute to the stress level. The shifting goal posts of ‘meritocracy’ means being the best doctor is no longer enough, you have to also be the best interviewee, the best article writer, the best talker, the best exam taker The number of exams and courses multiply as frequently as are the number of educationalists in each college. These are rattled off the top of my head in five minutes, are not even near to being an exhaustive list of difficulties the junior doctors face. No wonder they are stressed and unhappy. These are the brightest of people and the most resilient years of their lives and it is a shame that we keep breaking them

  6. Anonymous says:

    It is great that we get to have a nice work-life-balance reinforced nowdays. However, this is hindering my surgical training. I honestly rather work 1 in 2-3 and become a competent surgeon at the end of my training program as opposed to require additional years of training thanks to working hour restrictions.

  7. John Caska says:

    I agree with the comments about the ever increasing CPD obligations foisted upon us.
    They are supported by “research & pseudo statistics” & justified by researchers who live in a totally different world that is untouched by long hours of frontline face to face contact with a huge range of medical & other patient problems.
    The high rate of ” false positives” found must then presumably be “rechecked” showing that the “experts” don’t really know what they are doing. How is the “rechecked” doctor meant to react with their whole livelihood at stake?
    This only causes great stress & anxiety especially on GP’s& all the self reflection, reviewing of results etc is totally useless & is promoted by those who really don’t understand the “Art of Medicine ” & will ultimately succeed in destroying especially General Practice with these never ending brain explosions that are presented as progress & science claimed to be essential for patient safety & management.
    Are any studies available that show how many patients actually suffered significant adverse outcomes from those doctors deemed to be incompetent. How did so many ” false positives ” occur if so much research & effort was dedicated to such a vital & extremely important matter? This reeks of a very incompetent process. We could talk forever on these matters.

  8. Anonymous says:

    Indeed times have changed and the need for all doctors organisations including the AMA, Colleges and craft groups to come together on this issue becomes ever more urgent. The stringencies, real or perceived, of the past should not blind the senior members of the profession from the very real denormalising impact of the work demands on this younger generation of doctors.

    The inflexibility and unresponsiveness of government policy, hospital budget management and the self interest of stakeholders risks creating a collapse in professional stability and community respect. The time to act on this issue is now not when the situation becomes even more parlous.

    It is good to see university based academics raising the issue and following the younger doctor groups who have witnessed the suicide deaths of so many in their cohorts. Maybe Drs Kadota and Toogood can bring the Australian Universities together to advocate to government a winding back of medical school numbers to lessen the front end driver of the issue. That is of course if the Deans of Medicine can put aside their self interest and Vice Chancellors can overcome the ambitions to expand the number of medical schools in order to secure, in their minds, legitimacy and prestige for their campuses. Maybe Australian public hospitals can restrain their intractable habit of using Section 457 visas as an industrial weapon to restrict doctors’ incomes in their hospitals and stripping doctors out of the countries who can least afford to lose them.

  9. Ian Hargreaves says:

    It is a tricky issue, because when I was a junior registrar it was expected that you worked like a Roman galley slave, but you were pretty much guaranteed a consultant position when you finished your training. There was always the fall back of a general practice career if you failed in general medicine or in surgery.

    Now there are far more junior trainees because of safe working hours, and the backstop of general practice has been removed by making this a specialty. Because the trainees are competing for senior positions, they may be working fewer official hours, but are also studying for a Masters or PhD in their ‘spare’ time. All of the colleges have compulsory training courses which eat into the ’non-working’ time. Then there are the family pressures, because instead of starting medicine at 17 and graduating at 22, finishing specialist training before age 30, many trainees now have their own families and child-rearing responsibilities.

    Some countries like Denmark have solved the problem by a single government coordinating medical school positions, trainee and consultant jobs, with safe working hours legislated. They don’t train too many, they don’t overwork the ones they have. Our (rather antiquated) federal system precludes this.

    The unanswered question, is how does the stress compare between working 1 in 2, and knowing that you and your colleague are both going to get a job at the end of the tunnel, versus working 1 in 6, and knowing that you have to beat at least 4 of your colleagues to get a job?

  10. Anonymous says:

    The karoshi for the medical profession is not the over work but the distortion of the professionals life by the ever-changing and more complex CPD activities – this affects professional life , the family life of the professional, the flow on to their children and of course all this is justified by the mantra ‘of protection of the public’ – which allows unregulated free for all by the committees who have no concept of the quality of life issues of society – at least not the quality of life of the profession. Legislation should be enacted to limit these ever expanding and shifting CPD activities.

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