Introduction

In Japan, to become a board-certified surgeon, medical graduates must first complete a 2-year compulsory internship program. During this internship, they need to apply for a surgical training program that meets the standards established by the Japan Surgical Society (JSS) [1]. Since 2018, the standards have been overseen by the Japan Medical Specialty Board [2]. This is the first step to becoming a cardiovascular, thoracic, gastrointestinal, breast, endocrine, or pediatric surgeon. Despite an increase in the number of interns in Japan, the number of applicants for surgical training programs decreased from 934 in 2021 to 835 in 2023 [1]. Unlike many countries where medical graduates undergo a competitive selection process for acceptance into surgical training [3], the total number of surgical training positions in Japan exceeds the number of applicants, as reflected in a low fulfillment rate of 39.1% (835/2135) in 2023 [1]. This decrease in the number of applicants suggests that the number of trainees interested in surgery is declining. In fact, a recent report showed that the number of surgeons has decreased by more than 1000 in the past 20 years [4]. Factors such as long working hours, compromised quality of private life (QOL), and a poor work–life balance (WLB) associated with the surgical profession are thought to contribute to this trend [5]. Although the Japanese work culture is notorious for being harsh, more importance is now being placed on QOL and WLB, especially by the younger generations in Japan. In 2024, the Japanese government made workstyle reform for medical doctors a priority of the Japanese labor policy. Given these social circumstances, it is necessary to incorporate the changing perspectives into an evaluation of the surgical training system.

Unlike in North America, surveys on surgical training have been rarely conducted in Japan [6]. In 2016, the JSS conducted a survey targeting newly certified surgical residents and their program directors to assess the surgical training programs [7,8,9,10]. The results revealed a correlation between the number of surgeries performed by trainees and the self-assessed competency and a shortage of off-the-job training. However, this survey did not include questions on family background, such as marital status, or on issues related to QOL, WLB, or harassment during training. While studies have been done on the QOL and WLB of practicing surgeons in terms of the gender gap in Japan [11,12,13], items encompassing a wide range of living and working environments of surgical trainees in Japan have rarely been studied. Consequently, the JSS Education Committee has opted to undertake a comprehensive nationwide online survey to systematically identify and address any prevailing challenges or issues within the current training programs. The purpose of this survey is to clarify the overall status of the surgical training system in Japan and to unveil prevailing issues surgical trainees experience during their training.

Methods

Ethical issues

This research proposal was approved by the JSS Research Ethics Review Committee (JSS2023-1). At the start of the survey, the participants were given a detailed explanation about the study. Only participants who gave their consent proceeded with the survey. To ensure the anonymity of respondents, no personal data that could identify them, such as name, email address, training hospital or IP address, were collected.

Development of the survey

The JSS Education Committee called for applications from its members under the age of 40 to be part of the Under 40 working group (U-40). From among the applicants, 71 surgeons were selected to be part of the U-40. They were divided into 11 small groups of six or seven, according to their individual interests, such as education, WLB, uneven distribution of medical doctors, and research. Each group was assigned a topic related to the various challenges faced by surgical trainees and young surgeons, described above as members’ interests. Each group held online meetings every few weeks to develop questions to be included in the questionnaire survey. An editorial committee consisting of a representative from each group discussed the importance of each question in the pool of questions received from each group and decided which questions to select. Several group discussions were held to edit the questions. The survey draft was reviewed by all working group members and by the JSS Education Committee. The questionnaire was finalized after incorporating the suggestions from the U-40 group members and approved by the JSS Board of Directors.

Questionnaire

The final questionnaire consisted of 43 questions inquiring about the “Experience of the surgical training” (Online Resource 1). It comprised the following:

  1. 1.

    Demographic background of the participants.

  2. 2.

    Motivation for joining the surgical training.

  3. 3.

    Assessment of the training program.

  4. 4.

    Regional disparity.

  5. 5.

    Working environment during the training, including questions about the number of working hours, overtime work in addition to the normal 40 h per week, harassment, and thoughts about quitting.

Participants

The participants were trainees who completed their surgical training in 2021 and 2022. Because of the coronavirus disease 2019 pandemic, the certification test for both years was conducted in 2022, and all graduating trainees were certified together in 2023.

Online survey

The 43 survey questions were uploaded on an online platform created using the SurveyMonkey online tool (SurveyMonkey Inc., San Mateo, CA, USA, www.surveymonkey.com). The JSS secretariat sent links to the survey via email to the email address the participants had provided when registering for the training program. The survey was open from April to May 2023 and three email reminders with a link to the online survey were sent during this period. None of the questions were mandatory to answer, and participants could skip any questions that they did not want to answer. Only the questions they answered were analyzed. Only one response could be recorded from one device. The system recorded the answers as they were entered and the respondents could cancel their answer anytime before the final submission. However, after the final submission, participants were unable to retract their answers. This was because the survey was completely anonymous and no information that could identify the participants or link them to their answers was collected.

Statistical analysis

Descriptive statistical analysis was performed on the collected data using Microsoft Excel 2019. Missing data were excluded, but the rest of the answers were included into the data analysis. All data are presented as the number of respondents (and percentages) and continuous variables are expressed as the mean ± standard deviation (SD). General satisfaction according to the number of surgeries performed was analyzed.

Results

Demographics of the respondents

Emails with the survey link were sent to all 1410 surgical trainees who obtained their certification in 2023, and 758 (53.8%) responded to the survey. Among the respondents, 25.6% were women, 71.4% were either married or had a partner, and 53.8% answered that their spouse or partner was engaged in full-time employment (Table 1). Regarding surgical experience, 72.7% had performed over 200 surgeries under general anesthesia, 13.8% m had completed over 500 surgeries, and 52.8% were planning to pursue gastroenterological surgery as a subspeciality.

Table 1 Demographics of the surgical trainees who responded to the survey
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Motivation for each surgical training program

Fifty-four percent of the respondents decided to become a surgeon before graduating from medical school (Table 2). Interests in surgery and surgical procedures played a positive role in pursuing surgery for 88.8% of the respondents, whereas compromised QOL and poor WLB played a negative role for 63.8% (Fig. 1). On the other hand, the atmosphere of the workplace (22.0%), the workplace being their alma mater (21.6%), and the volume of surgical cases (17.1%) had the biggest influence on choosing their training programs, while QOL and WLB were negligible (1.4%).

Table 2 Applicants’ background before entering the surgical training program
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Fig. 1
figure 1

Impact of factors that influence becoming a surgeon. Each field indicates a positive, neutral, or negative impact on the choice of becoming a surgeon. The numbers in the fields indicate the number of respondents for each field

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Assessment of training and education

Satisfaction with each surgical training program was rated as high (42.0%) and satisfied (42.6%), respectively (Table 3). The number of surgeries performed correlated with the degree of satisfaction, except for the group with the largest number of surgeries (Fig. 2). The attending surgeons’ clinical skills were rated as very high or high by 96.7%, while their educational skills were evaluated as very high or high by 84.1%. Regarding off-the-job training, 88.5% had received technical skill training, while 29.9% had received non-technical skill training (Table 4).

Table 3 Evaluation of training results
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Fig. 2
figure 2

Degree of satisfaction with the training in relation to the number of surgeries performed. The numbers in the fields indicate the number of respondents for each field

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Table 4 Off-the-job training during the surgical training program
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Regarding academic education, 23.1% had never published a scientific paper. A shortage of practical knowledge was reported by 61.9%, followed by a lack of research time (47.3%) and low motivation (43.3%). One-third to half of the trainees had never watched educational lectures provided by the JSS (Table 5). On the other hand, the trainees tended to utilize materials offered by third parties.

Table 5 Degree of usefulness of various educational materials
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In response to Japan’s low incidence of trauma cases, a point-based system was implemented in 2016, allowing for the earning of points through courses and simulation education in addition to surgical cases. Despite these measures, 39.7% of respondents reported trauma as the most challenging area to meet program requirements (Table 6). Moreover, 26.2% felt that the training content did not meet the training aims, and 24.0% thought trainees did not understand the curriculum content.

Table 6 Problems with the training program
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Regional disparity

Among the respondents, 73.0% had a good impression of working in regional areas. The two most frequent positive impressions of regional areas were the number of surgeries they could perform (56.0%) and salaries (50.2%), whereas the most common negative impressions were the education system (38.7%) and QOL/WLB (32.2%).

Working conditions, harassment, and dropout rates

The mean (± SD) salary in the last year of the program was 9.27 (± 4.30) million JPY, which is approximately equal to 66 thousand (± SD) USD in 2023. Among the respondents, 31.9% worked fewer than 80 h overtime per month and 10.6% worked more than 80 h per week (Table 7). Moreover, 28.0% of trainees answered that they did not have working-hour management in their hospital. Surgery or clinical care was paid for as overtime compensation in 84.5%. However, some tasks besides surgery were less likely to be paid for, including such surgery-related work as postoperative specimen dissection and operation-related tasks (37.1%), conference participation (28.7%), preparation for outpatient care and conferences, and making surgery records (22.6%).

Table 7 Work environment during the training program
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As many as 41.5% of the respondents reported that they had experienced some kind of harassment by the attending surgeons, and 33.0% answered that they had pondered about giving up their surgery training. The two most common reasons by far for considering quitting were poor QOL and WLB (51.1%) and harassment (50.4%).

After completing each training, 56.6% continued to work in the same area. The top three priorities for choosing the next institution were education (17.0%), geographic location (16.3%), and the number of surgeries (15.7%). Compromised QOL and WLB were documented more frequently after (9.5%) than before (1.4%) training.

Discussion

This is the first nationwide survey to investigate various aspects of the current surgical training system in Japan. The survey investigated the backgrounds of the trainees, their motivations for embarking on surgical training, their evaluation of the training system, and the working conditions they faced during the training. The results showed that the overall satisfaction with the training system was high. More than half of the respondents (54.1%) decided before graduating from medical school to pursue surgery as their specialty and most (84.6%) expressed satisfaction with the training program. However, there were some significant issues with the training environment. Notably, 68.1% of respondents reported working more than 80 h of overtime per month [14] and 41.5% reported harassment by attending surgeons. Moreover, harassment and compromised QOL/WLB were the two leading causes for considering dropout. These findings provide valuable insights into the present status and future goals of the surgical training system in Japan.

Most of the trainees (84.6%) were satisfied with their training program. Therefore, the currently offered surgical cases appear to meet the trainees’ demands. Moreover, the survey found that the degree of satisfaction correlates with the number of surgeries each trainee performed and the fact that the surgical applicants were attracted to surgical procedures supports this finding. A previous survey in 2016 showed that self-competency was related to the number of surgeries performed [7, 8], which underscores this evidence. However, the current survey showed that when the number of surgeries surpassed 500, the overall satisfaction decreased slightly, which might be due to overwork and compromised QOL. Further analysis is needed to find the optimal number of surgical procedures for the training period.

While the satisfaction rate was high, long working hours were a fundamental problem in the training system. Values are changing now, to avoid long working hours and to prioritize the QOL of each medical doctor in Japan. As part of the workstyle reform, the Ministry of Health, Labour and Welfare of Japan has limited the working hours for medical doctors and implemented the reformed policy in April, 2024 [14]. Nevertheless, 63.6% of the respondents worked over the limit stipulated by this policy and 10.6% worked more than 80 h per week, which is the policy limit in the USA, and still used for the assessment of each program. This policy was adopted after considering the medical errors attributed to overwork [15]. The negative relationship between long working hours and academic ability, as described previously [16], might be reflected in the shortage of research time reported by 47.3% of our respondents. Another serious problem revealed by our study is an insufficient or complete lack of working-hour management. As many as 28.0% of trainees did not receive attendance or working-time management, which increases their risk of being overworked. The surgical trainees might feel obliged to cover various tasks in addition to surgical training [5]. Being exposed to or feeling obliged to comply with this conservative view of a surgeon`s working style, which contradicts the recent changes in societal values, might perpetuate the growing reluctance of medical students and junior residents to pursue an interest in the field of surgery.

Another important revelation of this survey was that 41.5% of respondents experienced some kind of harassment in each surgical training program. However, our survey was only able to get response from around half of the graduating residents, making it difficult to assess the true percentage of trainees experiencing harassment. Moreover, in this survey, instances of harassment were reported subjectively by respondents, based on their personal interpretation of the term “harassment”, similar to past research in this field [6, 17, 18]. It should be acknowledged that while this figure may include incidents unequivocally recognized as harassment under objective standards, it might encompass a range of behaviors, such as stern but educational reprimands, reflecting the diverse interpretations of ‘harassment’ in the contemporary era. The Japanese Ministry of Health, Labour, and Welfare reported that the prevalence of workplace harassment and sexual harassment is 31.4% and 10.2% in Japan [19]. The current survey revealed that harassment was one of the main reasons for trainees considering dropping out. The prevalence of harassment in surgery has been reported in various institutes and has been linked to deteriorating mental health and suicide [20]. Furthermore, harassment was described as a risk factor for medical errors and a worse patient prognosis [21, 22]. The JSS is committed to addressing harassment by fostering awareness and understanding, developing educational frameworks for mentors, prioritizing trainee wellness, and refining daily instructional methods.

Yet another issue highlighted by our survey is that while opportunities for technical skill training are improving, opportunities for non-technical skills training, off-the-job training, and didactic material training remain unsatisfactory. Non-technical skill training is described as useful, but the current survey shed light on its low attendance rate (22.9%). A non-technical skill program for surgical trainees has not been developed by the JSS. Moreover, 36.3 to 55.1% of the respondents had not used the education materials developed by the JSS. Providing online streaming and short summary videos [23] could potentially enhance usability and effectiveness.

This survey has several limitations. First, although the response rate was a robust 53.8%, we could not collect the answers of nearly half of the certified trainees. Second, it did not include trainees who had already dropped out of the training or remained uncertified. These limitations were likely to have caused a selection bias and an underestimation of the problems with the surgical training programs in Japan. Third, although we performed several simulation tests to prevent technical errors and limited the number of questions as much as possible to reduce satisficing, the actual reliability of each answer is unknown. Finally, this paper presents a descriptive analysis of the present overall status of the surgical training programs in Japan. Further subgroup analysis is needed to unveil detailed issues and gain deeper insights.

Conclusion

This nationwide survey revealed that while the trainees were satisfied with the overall training system, significant issues such as long working hours and harassment were prevalent. Working to improve these problems could make surgery a more attractive career option for young trainees.