The Asia-Pacific Journal | Japan Focus Volume 17 | Issue 7 | Number 2 | Article ID 5270 | Apr 01, 2019

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A “Necessary Evil”? Keeping Women Out of Medical SchoolsWon’t Fix What Ails the Japanese Medical Profession

Chelsea Szendi Schieder

Abstract

News sources revealed in August 2018 thatTokyo Medica l Univers i ty has beensystematically tampering with its entranceexam scores to reduce the number of femalestudents at the institution. This scandal led to agovernment investigation into medicalfaculties, and initial reports suggest that suchgender discrimination is widespread in medicalfaculty admissions. This issue relates to severalstubborn problems facing Japanese societytoday: It reflects how a more general context ofgender discrimination threatens to impede newsolutions to the crises facing medicine in Japanas a workplace and as a place of care, and howrecent efforts to counter discriminatorypractices and encourage “diversity” lackaccountability. This article shows how thegender gap in the medical field points todeeper problems in the profession, how recentresearch suggests that gender diversity mayimprove medical outcomes in terms of patientcare, and how this entrance-exam scandalhighlights the inadequacy and lack ofaccountability behind recent efforts to promote“diversity.”

Keywords: Tokyo Medical University, medicalprofession, women, workplace, genderdiscrimination, diversity

On August 2, 2018 an article in the Yomiurishimbun broke the news that Tokyo MedicalUniversity has been systematically tampering

with the scores of entrance exams to benefitmale applicants. The news emerged in thecourse of an investigation into the universityadministration’s bribe of a high-ranking officialat the Ministry of Education, Sano Futoshi.1*Officials at the university apparently boostedthe entrance exam score of Sano’s son inexchange for his help in securing a grant toimprove the university’s public image. Alongwith this case of cronyism, it came to light thatthe university routinely padded the scores of allmale applicants except those who had beenapplying for four or more years. Apparentlybelieving that women would not do as well inthe medical profession, Tokyo MedicalUniversity systematically reduced their chancesof admission for at least a decade. It seems thatrising rates of successful female applicantsprompted university officials to impose asystem of automatically increasing maleapplicants’ scores to reduce the ratio of femalestudents at their institution. The revelationsprompted a government investigation of 81schools, which revealed in December 2018 thatat least nine other medical faculties engaged insimilar practices.2

And yet, in 2013, the university began receivinga national grant to “support women.” Overthree years, Tokyo Medical University wasawarded over 80 million yen (about 720,000USD) through this grant. Two universityexecutives at the center of the admissionsscandal – former chairman Usui Masahiko andformer university president Suzuki Mamoru –played key roles in the Office to PromoteDiversity, founded at the university in 2016. InUsui’s opening remarks at an event tocelebrate the first anniversary of the Office in

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2017, he called on the university staff topromote “diversity.”3 At the time, the schoolpresented an increase in female admissionsfrom 26.9% to 32.4% as evidence of its efforts,even as it was actively taking steps to denyadmiss ion to women with qual i fy ingscores.4 That meant that the university was notonly taking money from the government topromote female admissions but also takingmoney from individual female applicants whomit artificially failed (sitting a university entranceexam in Japan costs 40,000 to 60,000 yen,about 360 to 540 USD). A group of 24 womendenied admission to Tokyo Medical Universitysince 2006 have joined with a team of defenselawyers to build a legal case against the school,which includes a demand for compensation forthese fees, and potentially for additionaldamages.5

The male officials and others that implementedsystematic discrimination at Tokyo MedicalUniversity have framed their actions as a“necessary evil.” The key reason cited as adefense for Tokyo Medical University’s decisionto depress female admissions was their concernthat too many female doctors would result intoo few doctors at their affiliated hospitalswhen women left their work for marriage orchildbirth. In his testimony to the legal teamcurrently investigating Tokyo MedicalUniversity’s discriminatory admissions process,Usui said that the university systematicallydepressed female applicants’ scores because“as women get older, their activities as doctorsdecrease.” 6 This rhetoric echoed thesensationalistic “Coeds Ruin the NationTheory” enunciated in the pages of theJapanese tabloids in the early 1960s. Then,Waseda University professor of literatureTeruoka Yasutaka declared his desire to setquotas to limit the number of women admittedto humanities departments because womenwould waste their educations and ruinsociety.7 Now, male administrators at a numberof medical universities secretly impose quotasfearing that too many women in the profession

will ruin medicine.8

Tokyo Medical University’s administratorssought approval for their actions throughappealing to legitimate concerns about a lackof medical professionals in Japan. But ratherthan lobbying to increase the quotas imposedby the Japan Medical Association on thenumber of doctors trained, or addressing manyof the workplace issues facing overwhelmedand understaffed hospitals, these powerfuladministrators penalized individual women,holding them responsible for a multifacetedsocial problem that was not of their ownmaking.9 On November 12, 2018, EducationMinister Shibayama Masahiko noted that agovernment investigation had found evidenceof gender bias in the admissions processes ofmultiple medical faculties.10 The resultsannounced in December confirmed thesesuspic ions, and the government hassubsequently cut off subsidies to Tokyo MedicalUniversity and reduced those to NihonUniversity, Fukuoka University, Iwate MedicalUniversity, Juntendo University, KanazawaMedical University, Kitasato University, andShowa Univers i t y based on s imi larmanipulations of entrance exams. 1 1

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A candlelight vigil held in front ofJuntendo University on December 14, 2018to protest the insitution’s discriminationagainst women in its entrance examinationpolicies. Image courtesy of the Associationto Support Victims of Entrance ExamDiscrimination at Tokyo Medical Universityand Elsewhere

This scandal is a case study related to severalstubborn problems facing Japanese societytoday. It reflects how a more general context ofgender discrimination threatens to impedesolutions to the crises facing healthcare inJapan, and how recent efforts to counterdiscriminatory practices and encourage“diversity” lack accountability. This articleaddresses how the gender gap in the medicalfield points to deeper problems in theprofession as a workplace, how recent researchsuggests that gender diversity may improvemedical outcomes in terms of patient care, and

how this entrance-exam scandal highlights theinadequacy and lack of accountability behindrecent efforts to promote “diversity.”

Healthcare as Work

The condit ions under which medicalprofessionals labor in Japan are less than ideal.A study published in 2015 on the difficultiesfacing women in the medical profession foundthat it was not only women-specific issues, butalso “poor working conditions involving longworking hours” that result from “a chronic,nationwide medical workforce shortage” thatnegatively impacted female doctors’ physicaland mental health.12 Indeed, the problemsnoted adversely affected men as well as womenmedical professionals. The stresses on themedical profession result from many factors,including government restrictions on thenumber of medical students, while femaledoctors face additional challenges. Women findtheir attention divided between theirprofessional and their familial responsibilitiesbecause of longstanding assumptions aboutfemale domestic labor. Such social expectationshinder gender equality in many societies, butthis is a particularly stubborn problem in Japan.The country consistently rates poorly in theGlobal Gender Gap Index. In 2018, Japanranked 110 out of 149 countries in terms ofgender parity, the lowest ranking of the Groupof Seven industrialized nations.13 Anecdotalevidence about the entrance-exam interviewsconducted at other medical universitiessuggests that prospective female students alsoface questions not only about their professionalbut also their personal goals, presumablybecause schools want to know if domesticcommitments will interfere with theircareers.14 Medical universities run hospitals,and they fear a staffing shortage if women – asthey are often expected to do – leave theworkplace to care for their families.

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On the other hand, government policydepresses the number of doctors certified inorder to control medical expenditures andprevent a possible surplus of doctors. TheMinistry of Health, Labour and Welfarerestricts the number of physicians and imposesa medical student quota. Yet Japan’s problem isclearly a shortage of doctors. In response tosevere shortages in 2007, the governmentincreased the maximum medical schoolenrollment quota from 7,625 to 8,828.Shortages nevertheless persist. In terms ofnumber of physicians per person, Japan has 2.4per 1,000 people. This places it 27th out of 31OECD countries surveyed, just behind theUnited States (2.6 doctors per 1,000 people)and on par with Poland and Mexico.15 At thesame time, Japan currently vies with Israel forthe lowest rate of medical graduates: 6.8 per10,000 inhabitants in 2017.16 The specialtieswi th the most severe shor tages areobstetricians, pediatricians, emergencyphysicians, and surgeons. Even though currentestimates predict that the number of physiciansper 1,000 population will rise to 3.14 in 2035,corresponding rise in demand with Japan’saging population’s medical needs haveprompted calls for strategies to increase thenumber of doctors.17

A study conducted by Japanese researcherswho examined trends from 1996 to 2006 toidentify the primary causes of the shortage ofsurgeons in Japan concluded that many generalsurgeons at hospitals, both female and male,left their positions not to fulfill childcareresponsibilities but for another job or anothermedical specialty in their 30s and 40s.18 Thiscontributed to a general lack of hospitalsurgeons. The study noted that “poor workingconditions facing hospital doctors” may accountfor this trend. Studies of doctors’ averageworking hours in Japan find a weekly median of54.4 to 63.3 working hours. However, morehospital doctors in Japan work more than 60hours per week than do workers in any otherprofession.19

Without expanding the number of physicians, itis difficult to maintain quality care standardswhile ensuring that women can take even thelegally guaranteed maternity leave period of sixweeks prior to the expected birth date andeight weeks after birth, let alone to supportneeds of medical professionals with childcareobligations. The most recent statisticspublished by the Japan Medical Associationfound that 50.1% of the medical facilitiessurveyed offered no childcare.20 Simply leavingthe burden of understaffing to male and child-free female colleagues results in a culture ofresentment when already heavy workloadsbecome even more onerous if women take timeaway from work to have and take care ofchi ldren. Because of th is perceivedinconvenience women may pose to co-workerswhen taking maternity leave, many of thephysicians (65%) who participated in a surveyafter the Tokyo Medical University scandalbroke responded that, although they did notnecessarily approve of the university’s decisionto actively tamper with scores, they understoodthe gendered logic in depressing the number offemale applicants, since “it burdens others [inthe workplace].”21

There is a gender gap in terms of working longhours in the medical profession, and this gap isused by some to justify depressing rates offemale doctors to maintain staffing levels athospitals. The Ministry of Health, Labour andWork found that 41 percent of male physiciansand 28 percent of female physicians work 60 ormore hours a week, and 11 percent of malephysicians and 7 percent of female physicianswork more than 80 hours a week. Among menin their 30s, 56.9 percent work over 60 hours aweek.22

These long hours, however, are also linked tohealth problems among doctors. Thegovernment definition of karōshi [death fromoverwork] is the sudden death of an employeewho works an average of 65 hours per week ormore for more than four consecutive weeks, or

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for 60 hours or more for more than eightweeks. A recently published study of first-yearresidents at 250 training hospitals in Japan in2011 found that residents working 80-99.9hours per week had a 2.83-fold higher risk ofdeveloping depression than those working lessthan 60 hours a week, while those working 100hours or more a week had a 6.96-fold higherrisk. Of the 1,241 first-year residents surveyedby the study, 7.8 percent worked 100 hours ormore a week, of which 45.5 percent displayed“clinically significant depressive symptoms”after three months.23 Another study conductedin 2004 found that residents in Japan worked amean of 84.9 hours a week, and 16.4 percentworked more than 100 hours a week.24

Aside from sheer number of hours, doctors inJ a p a n a r e o f t e n r e q u i r e d t o w o r kextraordinarily long shifts. When working nightduty, they may work a daytime shift on eitherend, sometimes working almost 36 consecutivehours at one go. In July 2015, when anobstetrics and gynecology resident physician inthe Shinagawa Ward of Tokyo killed himself, asubsequent investigation of hospital recordsshowed that he had logged 143 to 208 hours ofovertime in the six months before his suicide,and the four monthly night shifts he workedsometimes contributed to 30-hour shifts.25

Of course these problems are not limited to themedical industry in Japan. In the United States,the conversation often focuses on “burnout” –emotional exhaustion and cynicism in one’swork. Studies have found that residentphysicians in the United States, who also worklong hours, reported rates of burnoutsymptoms (45.2% of the 3588 second-yearresident physician respondents).26 Doctors inthe United States have higher rates of suicidethan any other profession.27 Critics of U.S.healthcare point out that Japan might serves asa potential model for the U.S., particularlyconsidering how universal coverage andgeneral affordability have benefited patients inJapan.28 But Japan also faces rising demand

that will place more and more stresses on thesystem as it has existed so far, and on thedoctors who work within that system.

There have been calls to reduce physicians’workloads by distributing more tasks to nursingstaff, but Japan’s aging society has createdshortages in nurses as well. Even though Japanhas a relatively large number of nurses – 9.06per thousand residents, more than the 8.30OECD average density – Japanese health carehas faced a nursing shortage since the 1990sbecause of rapidly rising demand.29 Althoughdemand for care workers is high, wages arerelatively low for nurses and certified careworkers, perhaps because it is also a feminizedworkforce, while extensive pre-employmenttraining must be paid for privately. Fewerpeople see care work as an attractive careeroption. In 2007, only 16,696 people applied for26,095 places at 419 training institutes forcertified care workers.30 The government hasagreements with Indonesia, the Philippines,and Vietnam to accept foreign nurses, but thelanguage and nursing training requirements seta high bar to clear; in 2016, among theparticipants in the “Indonesia-Japancollaboration on the enhancement of nursingcompetency through an in-service training”program, 104 of 209 (49.8%) who attemptedthe national exam to become a certified careworker passed, while only 65 of 447 (14.5%)who attempted the national nursing exampassed. These are both far below the nationalaverage pass rates of 72.1% for the certifiedcare worker exam and 88.5% for the nationalnursing exam.31

There are only limited studies about burnoutand job satisfaction among physicians in Japan,although both appear related to workingconditions and seem to contribute to laborshortages at government hospitals anduniversity hospitals.32 A 2007 study found thatburnout and poor mental health were directlyrelated to job dissatisfaction and short sleepingtime among doctors.33 Researchers examining

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physician retention at hospitals found a highcorrelation between frequent night duty shiftsand a desire to change hospitals.34 The studyfound that a lmost 35 percent o f therespondents to their survey wanted to changehospitals, and the rate was particularly high forphysicians at government hospitals anduniversity hospitals (44.3 percent and 41.5percent respectively).35 While this study did notdistinguish between male and femalerespondents, it did emphasize that the medicalfield needs to think about approaches that willallow it to retain its workforce and create aworkplace in which doctors find their worksatisfying in order to provide sustainable andhigh-quality health care.

The discussions coming out of the admissionsgender discrimination scandals frame womenas less committed to the workplace but doesnot cite the health hazards of overcommitmentto the workplace. Gendered ideas aboutwomen’s responsibilities in the home and thecurrent workplace demands in the medical fieldrequire women physicians with children todramatically reduce their working hours. At thesame time, in a work culture that encouragesoverwork, the demographic most vulnerable toaccumulated workplace fatigue is actually maleworkers in their 30s and 40s. As Scott Northhas described in his study of death fromoverwork (karōshi), karōshi victims “come fromall walks of life, all classes, and all occupationalcategories,” but are overwhelmingly malebecause of the gendered ideology linkingmasculinity and overwork.36 So a conversationabout how to improve the conditions underwhich those in the medical profession labor isnot just a conversation about improvingwomen’s lives, although the discussion needs toinclude analyses of how women experience thesqueeze between a workplace culture thatdemands long hours and societal expectationsthat they manage domest ic and careobligations.

The pronounced M-curve in female doctors’

employment – a mid-career dip in rates ofwomen working in the profession – is mostoften the result of life events like childbirth(responsible for 70 percent of femalephysicians’ decision to take leave) and childcare (38.3 percent). According to the Ministryof Health, Labour and Work’s statistics, thismeans that the employment rates for womendoctors reach a low of 73.4% percent twelveyears after becoming certified (male doctorshave an 89.9 percent employment rate twelveyears after certification), then creeps up butdoes not match the rates of male physicianemployment until both are in their seventiesand employment rates for both are on adownward slope. At this point, interestingly,employment rates for women overtake thosefor men, and there are 5-10 percent morefemale doctors still working in their late 70sand through to their 90s than there are maledoctors. The M-curve for lifetime femaleemployment is not dissimilar from a widergendered tendency in employment in Japan. Inthe case of female doctors, however, 60.4percent return to work within a year of takingleave.37

Source: Ministry of Health, Labour andWelfare38

In short, many female doctors reduced workinghours when they gave birth to children.

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However, the majority of female doctors whowork while raising infants still work full-time –76.5% in 2017 – somewhat lower than the88.8% of working female doctors withoutchildren who work full-time. However, the mostsignificant difference between the workinghours of female doctors with and withoutchildren is in the hours indicated by “full time.”In 2017, of the female doctors with childrenages 6-12, almost half (49.3%) worked under 40hours a week, while only 4.7% worked 65 hoursor more a week. Only about one-fifth of femaledoctors without children worked under 40hours a week, while 27% of female doctorswithout children worked between 48 and 60hours a week, 18% worked between 60 and 65hours a week, and 22.6% of them worked 65hours or more a week.39

Domestic labor in Japan is assumed to bewomen’s labor, and working women withchildren find that housework burdens themwith a “second shift.” A 2012 study found thateven female doctors without children spentmore of their time on housework (15 hours aweek) than male doctors with children (threehours a week). Unsurprisingly, female doctorswith children did the most housework (36 hoursa week including childcare). Adding up totalwork time – paid medical work and unpaidhousework – demonstrates that female doctorsworked the longest weeks on average, puttingin over 70 hours at home and at work. Whilemen without children worked longer hoursoutside the home, their paucity of houseworkand childcare responsibilities put their totalwork week at just a little over 50 hours onaverage.40 A recent study found that femalemedical students in Japan feel pressure toaccommodate family responsibilities, and bythe time they finish their clinical internships intheir final year of medical school, theirunderstanding is that they must choose toprioritize either family or medicine, whereastheir male peers feel no similar conflict andpursue their careers based exclusively on theirmedical practice.41 Tokyo Medical University’s

logic in reducing female admissions reflects acalculated strategy based on current gendereddivisions of labor and a culture of overwork inwhich men can participate most fully in theirprofessions because they participate so little inthe household.

Reducing female medical school students in aneffort to retain hospital physicians is not thesolution to a medical industry under stress.When we think of women as a liability becauseof their theoretical future childbirth and careleave, we focus on only one aspect of bodiesand when bodies can or cannot work. Perhapsmore importantly, by defining the value of workin terms of full-time work that is inherentlyexhausting, with punishing hours and highlevels of stress, we accept working conditionsthat are not healthy for any bodies, female ormale. As Kyoko Tanebe put it in her editorialcalling for an examination not only of genderdiscrimination but also of a health care fundingcrisis: “The current system relying on doctorswho can withstand overwork is vulnerable, bothas a system of labor and in terms of medicalsafety.”42

Quality of Health Care

Japan is certainly not the only society facing a“crisis in care” that is simultaneously a laborproblem and a public health issue as well as anissue of gender discrimination. The resoundingcriticism of the handling of gender issues in theJapanese health care system from the Westernmedia, in particular regarding this issue, hasprompted different reactions in Japan; thereare expressions of shame at Japan’s failure toproperly implement “modern” global standardsfor gender equality, but there are alsoaccusations of Western, particularly American,hypocrisy. After all, while this scandal providesa headline-worthy smoking gun of mostcertainly illegal systematic sexism, the UnitedStates’ global rankings for female participationin the medical field are only slightly better than

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those of Japan. Japan ranks last among the 34member countries that make up the OECD forshare of female doctors (20.3% in 2015). Butthe United States is fourth lowest (34.1% in2015), well below the OECD average of46.1%.43

This is a pressing issue for those concernedabout the quality of medical care, since there isevidence that more women in the medical fieldmakes for better medicine. A study ofhospitalized Medicare beneficiaries found that“elderly hospitalized patients treated by femaleinternists have lower morta l i ty andreadmissions compared with those cared for bymale internists.”44 This study estimated that,annually, “approximately 32,000 fewer patientswould die if male physicians could achieve thesame outcomes as female physicians.”45 Otherstudies have found that female doctorsperformed better than male doctors in thecontext of diabetes care.46

In an article in The Atlantic , Ed Yongintroduced research showing that more USpatients suffering from a heart attack,particularly female patients, die when treatedby male doctors than by female doctors. It isuncertain why this is, but it suggests thatfemale patients stand to gain most when theyhave access to female doctors, and that malephysicians who work with female colleaguesdid better at treating female heart-attacksufferers. This is not to say that women areinherently more attuned to nurturing and care,but the findings do suggest, as the University ofChicago’s Vineet Arora noted, that a gender-diverse work environment is a plus and “thatfemale physicians are an asset not just for theirpatients, but for their male colleagues, too.”47

The positive impact of gender diversity can alsobe found in medical research. A recent studythat analyzed 1.5 million medical-researchpapers published between 2008 and 2015found that female co-authorship increased thelikelihood that research addressed gender

differences. This is important becauseneglecting gender-related differences indisease and treatment outcomes affects healthoutcomes, sometimes with life-threateningconsequences.48

Similarly, if crushing workloads are theexpectation for all medical workers, thatpresents another issue for patient safety.Several studies have found a higher risk ofmedical error and also traffic accidents amongmedical staff who have been working longhours.49 Such studies expose the links betweenthe quality of working conditions in the medicalindustry and the quality of healthcare.

The problems created by a shortage of hospitalphysicians and a maldistribution of thosephysicians in Japan are also particularlydangerous for some of the most medicallyvulnerable. One high-profile case, in which ninehospitals turned away a pregnant woman whosuffered a miscarriage after the ambulancecarrying her collided with a minivan on its wayto a tenth hospital, prompted investigationsabout hospitals refusing to provide emergencycare for pregnant women. A subsequent surveyof 27 prefectures found that between 2004 and2006, there had been 2,780 cases in which apregnant woman had been denied admission byone or more hospitals. Of those, in at least 191cases a pregnant woman transported byambulance had been turned away by five ormore hospitals because of a lack of specialiststaff or beds.50

Gendered Stereotypes

As the points outlined above show, thinkingabout how to improve the healthcare industryin the future would benefit from thinkingfurther about the healthcare industry as aworkplace and about improving the overallquality of healthcare. This requires a deepquestioning of gendered ideologies that assignwomen the roles of care and support, both in

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the home and in the hosp i ta l , whi lesimultaneously dismissing women’s capabilitiesin what are considered more prestigious“specialist” positions. It would requirerecognit ion of women’s outstandingperformance in significant areas of health care,as well as the burdens of discrimination underwhich they labor.

The consequences of gendered stereotypes aremore serious than simply whether individualwomen entering the workforce can advance.Japan has the fourth-highest relative povertyrate among OECD countries, and the gendergap in wages and in full-time employment hascreated particularly vulnerable groups ofwomen.51 Most single parents are mothers, andthe poverty rate for working single-parentfamilies is 56 percent. This is due in part to thegender wage gap, which is the highest in theOECD.52 The current public pension systemoffers generous benefits to married women andwidows, but penalizes women who divorced orwere never married, and hence are unable toaccess a pens i on based on a man ’ s“breadwinning” wages. A recent study notedthat, since the 1980s, the marriage ratedecreased and the divorce rate increasedsignificantly, with the consequence that moreand more elderly women will face the risk ofpoverty thus increasing poverty rates ingeneral. Already in 2010, poverty rates forelderly women were almost double those ofelderly men: 11.1% versus 6.1%. However,projections put the poverty rate of elderlywomen at 25% in the near future, more thandouble the predicted 10% for elderly men. Forwomen who were never married or aredivorced, the poverty rates are predicted to be50%.53

The government-driven rhetoric of “creating asociety in which women shine” does little tochallenge a dominant narrative highlightingwomen’s unique relationship to care andfemininity that perpetuates this kind ofgendered and imbalanced poverty and

precarity. In a September 2014 speech to theWorld Assembly for Women in Tokyo in whichhe outlined his vision for promoting women inthe workplace, Prime Minister Abe Shinzōprovided examples of the kinds of contributionshe thought women could “bring to corporatemanagement.” He cited examples of femaleemployees who had suggested car doors thatopen wider to accommodate children, or hadcollaborated to design laptop computers thatone can open without destroying a manicure.Abe concluded that “The most difficult partmay be transforming the division of roles basedon gender, something that is, unwittingly,firmly ingrained within us.”54 However, Abe’sown interpretation of that “certain perspectivethat only women can provide” – the woman’stouch – is precisely based on an ingrainedstereotype of women’s abilities and women’sinterests.

The admissions scandal at Tokyo MedicalUniversity also exposed the emptiness ofvarious recent initiatives to promote greatergender diversity. As mentioned above, TokyoMedical University received grant money to“promote women’s activities” and SuzukiMamoru, then-president of the university andan initiator of the quotas on female admissions,publicly endorsed policies advocated by theGender Equality Bureau Cabinet Office’sannua l “Genera l Assemb ly o f Ma leLeaders.”55 The quotas Suzuki imposed situneasily alongside the “action plan” publishedon the Bureau’s homepage, which includes“disrupting the status quo” by taking “everychance to ask the questions below and advancechanges in the mindset in the wholeorganization: Why are there no women? Whyare women 30% or less? Why isn’t the ratio ofmen to women fifty-fifty (50:50)?” That hepublicly subscribed to such initiatives whileactively imposing a policy to cap femaleadmissions at 30% required a powerfulcynicism. Although he may have sympathizedwith the diversity ideal in the abstract sense,he sabotaged it in fulfilling his responsibility to

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train physicians.

It is in the gap between an often tone-deafrhetoric at the level of the national genderequality initiatives and a complete lack ofaccountability in governance that thissystematic gender discrimination persists. Thisstory doesn’t seem limited to a few powerfulmen at one institution. Observers of thestubborn imbalance in acceptance ratesbetween men and women to medical schoolshad already voiced suspicions that universitieswere controlling the student ratio. In an August2017 report for the Japan Joint Association ofMedical Professional Women, Kyoko Tanebenoted that the rates for female admissions tomedical schools seemed artificially depressedover the last fifteen years in light of recenttrends in other fields. So-called “cram schools”which prepare students for universityadmissions exams and obsessively track thesestatistics also observed similar gender gaps inthe admissions rates at other schools. Arepresentative from Ace Academy, a cramschool for medical universities, noted thelopsided pass rate for young men and women atSt. Marianna Medical University, ShowaUniversity, and Nihon University in the second

round of entrance exams, which consist ofinterviews and written essays, in spite ofgeneral parity on earlier rounds of subjectexams.5 6 Juntendo University was alsosuspected of rigging entrance exam results tofavor male applicants.57 Others have called thisdepression of female acceptance rates tomedical schools an open secret. The Ministry ofEducation’s nation-wide investigation into theadmissions practices of 81 medical facultiesconfirmed these suspicions and found thatseveral other medical faculties engaged insimilarly suspect admissions’ practices,including Nihon University, JuntendoUniversity, Showa University, Iwate MedicalUniversity, Kanazawa Medical University,Kitasato University, Kobe University, andFukuoka University.58 Perhaps this scandal will offer an opening todebates about how to address long-standinggendered inequalities in the medical field andbeyond. One hopes it will also initiate furtherdebates about the social costs of suchdiscrimination on the medical profession as aworkplace and a place of care.

(https://apjjf.org/#_ftnref54)

Chelsea Szendi Schieder is an Associate Professor in the Faculty of Economics at AoyamaGakuin University in Tokyo, Japan. She writes contemporary histories about contentiouspolitics for academic and general audiences. Her book on the gendered politics of the postwarstudent movement in Japan, entitled Co-Ed Revolution: The Female Student in the JapaneseNew Left, is forthcoming with Duke University Press.

Notes1 Japanese names are written according to Japanese conventions, with last name first, exceptin cases in which the last names are published last in scholarly journals and English-languagepublications.2 “Japan medical schools ‘rigged women’s results.’(https://www.bbc.com/news/world-asia-46568975) BBC News (December 14, 2018) (accessedJanuary 31, 2019).

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3 “ ‘Daibaashiti suishin honbu kaisetsu kinen, Tokyo Ika Daigaku danjo kyōdō sankakusokushin seminaa’ ga 1-gatsu 11-nichi ni kaisai saremashita [‘Commemoration of the foundingof the diversity promotion headquarters, Tokyo Medical University gender equality promotionseminar’ held on January 11th](http://www.tokyo-med.ac.jp/news/2017/0113_235900000115.html)” Tokyo Medical Universitywebsite (January 13, 2017) (accessed August 10, 2018).4 “Tokyo Idai ni ‘josei katsuyaku’ hojo 8000 man en genten giwaku no jiki, kuni kara 3 nen dekōfu [Tokyo Medical University received a government grant of 800 million yen for threeyears to support “women’s activities,” a period in which it is suspected of reducing scores](http://www.tokyo-np.co.jp/article/national/list/201808/CK2018080402000125.html)”Tokyoshimbun (August 4, 2018) (accessed August 6, 2018).5 “Women demand compensation from Tokyo Medical University over rigged entrance exams(https://www.japantimes.co.jp/news/2018/10/30/national/crime-legal/women-demand-compensation-tokyo-medical-university-rigged-entrance-exams/#.XGuCHJMza1s)” The Japan Times(October 30, 2018) (Accessed November 2, 2018)6 “Chōsa hōkokusho [Inquiry report](http://www.tokyo-med.ac.jp/news/media/docs/20180806houkokusyo.pdf)” Gakkō hōjin TokyoIka Daigaku naibu chōsa iinkai [Tokyo Medical University, Inc. internal inquiry committee](August 6, 2018) (accessed August 10, 2018).7 Hara Kimi, “Joshi kyōiku no tenkai to shakai hendō [The development of women’s educationand social change]” in Shakai hendo to kyoiku [Social change and education] (Tokyo: TokyoDaigaku Shuppankai, 1976), 51–69; Nobuyuki Kuroda and Michiko Tanaka, Joshi gakusei[Women’ s education] (Tokyo: San'ichi Shobo, 1969), 158–161.8 “Japan medical schools ‘rigged women’s results.’(https://www.bbc.com/news/world-asia-46568975) BBC News (December 14, 2018) (accessedJanuary 31, 2019).9 “Tokyo Idai no kokusai nintei torikeshi: hyōka kikō, nyūshi fusei de [Tokyo MedicalUniversity international certification canceled: citing evaluation mechanism, unfair entranceexams] (https://www.nikkei.com/article/DGXMZO3811549022112018CC1000/)” Nikkeishimbun (November 22, 2018) (accessed December 4, 2018)10 “Fuksuu igakubu, nyūshi de danjo ni sa o settei daigakume wa meigen sezu [Multiplemedical faculties established gender gaps in entrance exams, school names not announced](https://www.asahi.com/articles/ASLBD36HFLBDUTIL00M.html)” Asahi shimbun (October 12,2018) (accessed December 4, 2018)11 “Government cuts off subsidies to Tokyo Medical Unviersity over entrance examdiscrimination(https://www.japantimes.co.jp/news/2019/01/22/national/government-cuts-off-subsidies-tokyo-medical-university-entrance-exam-discrimination/#.XGt-sJMza1s)” The Japan Times (January22, 2019) (Accessed January 30, 2019)12 Kyoko Nomura, Yuki Yamazaki, Larry Gruppen, Saki Horie, Masumi Takeuchi, Jan Illing.“The difficulty of professional continuation among female doctors in Japan: a qualitative studyof alumnae of 13 medical schools in Japan.” BMJ Open (2015), 5(3): 1-7.13 “Japan crawls up to 110th in global gender gap ranking but women’s participation still low(https://mainichi.jp/english/articles/20181218/p2a/00m/0na/020000c)” Mainichi Japan

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(December 18, 2018) (Accessed January 30, 2019)14 Tanaka Shino, Kinkozan Masako. “Tōkyō idai dake janai? Nyūshi de no danjo sabetsu. Ishiraga shōgen “idai zentai ni aru to makoto shiyaka ni uwasasareteita” [Not just Tokyo MedicalUniversity? Gender discrimination in entrance examinations. Doctors’ testimony: ‘There areplausible rumors that it happens at all medical universities’](https://www.huffingtonpost.jp/2018/08/01/toukyouika-joseisabetu_a_23494326/)” HuffpostJapan (August 2, 2018) (Accessed January 30, 2019)15 OECD (2018), Doctors (indicator). doi: 10.1787/4355e1ec-en (accessed on 20 November2018)16 OECD (2018), Medical graduates (indicator). doi: 10.1787/ac5bd5d3-en (accessed on 20November 2018)17 Koichiro Yuji, Seiya Imoto, Rui Yamaguchi, et al. “Forecasting Japan’s Physician Shortage in2035 as the First Full-Fledged Aged Society” PLOS ONE (2012), 7(11).18 Yasuhiro Mizuno, Hiroto Narimatsu, Yuko Kodama, Tomoko Matsumura, Masahiro Kami.“Mid-career changes in the occupation or specialty among general surgeons, from youth tomiddle age, have accelerated the shortage of general surgeons in Japan.” Surgery Today(2014) 44: 601-606.19 “Doctor’s suicide after monthly overtime exceeded 200 hours recognized as work-related(https://www.japantimes.co.jp/news/2017/08/10/national/social-issues/doctors-suicide-monthly-overtime-exceeded-200-hours-recognized-work-related/#.XAYrARMza1s)” Japan Times(August 10, 2017) (accessed December 4, 2018)20 “Josei ishi no kinmu kankyō no genkyō ni kan-suru chōsa hikaku shōsai han [Investigationinto present conditions of women doctors work environment: comparative detailed edition](https://www.med.or.jp/joseiishi/2018hikakusyosai.pdf)” Nihon ishikai danjo kyōdō sankakuiinkai / Nihon ishikai josei ishi shien sentaa [Japan Medical Association gender equalityplannning committee / Japan Medical Association women doctor support center] (June 2009)(accessed on 20 November 2018)21 “Ishi 65% ‘joshi genten rikai dekiru’ jinzai kaisha netto chōsa [65% of doctors: ‘understandreducing women’s scores’ on an HR recruitment agency’s online survey](https://www.asahi.com/articles/ASL884F1XL88UTIL017.html)" Asahi shimbun (August 8,2018) (Accessed August 30, 2018).22 “Josei ishi kyaria shien moderu fukyū suishin jigyō no seika to kongo no torikumi ni tsuite /shiryō 3 [On the results and future initiatives of the project to promulgate and promote careersupport for female doctors / document 3](https://www.mhlw.go.jp/file/05-Shingikai-10801000-Iseikyoku-Soumuka/0000197435.pdf)” Ministry of Health, Labour and Welfare (March 14, 2018)(accessed November 20, 2018)23 Ryoko Ogawa, Emiko Seo, Takami Maeno, Makoto Ito, Masaru Sanuki, Tetsuhiro Maeno.“The relationship between long working hours and depression among first-year residents inJapan.” BMC Medical Education (2018) 18: 50.24 Tetsuhiro Maeno, Asumi Nakamura, Takami Maeno, et al. “Shinrinshō(https://en.wiktionary.org/wiki/ō) kenshū seido ni okeru kenshūi no sutoresu [Resident stressin the new postgraduateclinical training system].” Igaku kyō(https://en.wiktionary.org/wiki/ō)iku [Medical Education]. (2008) 39(3): 175–82.

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25 “Doctor’s suicide after monthly overtime exceeded 200 hours recognized as work-related(https://www.japantimes.co.jp/news/2017/08/10/national/social-issues/doctors-suicide-monthly-overtime-exceeded-200-hours-recognized-work-related/#.XAYrARMza1s)” Japan Times(August 10, 2017) (accessed December 4, 2018)26 Liselotte Dyrbye, Sara Burke, Rachel Hardeman “Association of Clinical Specialty withSymptoms of Burnout and Career Choice Regret Among US Resident Physicians” JAMA 2018320(11): 1114-1130.27 Brendan Murphy, “AMA seeks more data on physician, medical student suicide(https://www.ama-assn.org/practice-management/physician-health/ama-seeks-more-data-physician-medical-student-suicide)” AMA Physician Health (November 13, 2018) (accessedDecember 3, 2018).28 Tomoko Otake “Japan’s buckling healthcare system at a crossroads(https://www.japantimes.co.jp/news/2017/02/19/national/japans-buckling-health-care-system-crossroads/#.XAhpmBMza1s)” The Japan Times (Feburary 19, 2017) (accessed December 4,2018)29 Sakamoto H., Rahman M, Nomura S, Okamoto E, Koike S, Yasunaga H et al. “Japan HealthSystem Review” Asia Pacific Observatory on Health Systems and Policies. Health Systems inTransition Series (Vol 8, No 1): 72, 86.30 Ibid. 139.31 Ibid., 90-91.32 Makiko Ozaki, Seiji Bito, Shinji Matsumura “Developing a Japanese hospital physiciansatisfaction scale” International Journal of Health Care Quality Assurance (2008) Vol. 21,Issue 5: 517-528.33 Yasuharu Tokuda, Keiko Hayano, Makiko Ozaki, Seiji Bito, Haruo Yanai, Shunzo Koizumi“The Interrelationships between Working Conditions, Job Satisfaction, Burnout and MentalHealth among Hospital Physicians in Japan: a Path Analysis” Industrial Health (2009) 47:166-172.34 Kato Ken, Kazunobu Yamauchi, Makoto Miyaji, et al “Factors relating to doctor’s desire tochange hospitals in Japan.” International Journal of Health Care Quality Assurance. Vol. 25,No. 1 (2012): 19-40, 35.35 Ibid., 27.36 Scott North, “Karōshi Activism and Recent Trends in Japanese Civil Society” in Going toCourt to Change Japan: Social Movements and the Law in Contemporary Japan. Ed. PatriciaSteinhoff (Center for Japanese Studies, The University of Michigan: 2014): 45-72, p. 47.37 “Josei ishi kyaria shien moderu fukyū suishin jigyō no seika to kongo no torikumi ni tsuite /shiryō 3 [On the results and future initiatives of the project to promulgate and promote careersupport for female doctors / document 3](https://www.mhlw.go.jp/file/05-Shingikai-10801000-Iseikyoku-Soumuka/0000197435.pdf)” Ministry of Health, Labour and Welfare (March 14, 2018)(accessed November 20, 2018).38 “Josei ishi kyaria shien moderu fukyū suishin jigyō no seika to kongo no torikumi ni tsuite /shiryō 3 [On the results and future initiatives of the project to promulgate and promote careersupport for female doctors / document 3](https://www.mhlw.go.jp/file/05-Shingikai-10801000-Iseikyoku-

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Soumuka/0000197435.pdf)” Ministry of Health, Labour and Welfare (March 14, 2018)(accessed November 20, 2018)39 “Josei ishi no kinmu kankyō no genkyō ni kan-suru chōsa hikaku shōsai han [Investigationinto present conditions of women doctors work environment: comparative detailed edition]” ((https://www.med.or.jp/joseiishi/2018hikakusyosai.pdf)https://www.med.or.jp/joseiishi/2018hikakusyosai.pdf) Nihon ishikai danjo kyōdō sankaku iinkai / Nihon ishikai josei ishi shiensentaa [Japan Medical Association gender equality plannning committee / Japan MedicalAssociation women doctor support center] (June 2009) (accessed on November 20, 2018)40 Kosuke Yasukawa and Kyoko Nomura. “Ishi ni okeru seibetsu yakuwari bundan: shinryōjikan to kaji rōdō jikan no danjo kikaku [The division of labour by sex among Japanesephysicians: comparison between men and women in time spent on clinical care a and timespent on housework]” Igaku kyōiku [Medical Education] (2012): 42: 315-319.41 Aoki Hiroe, Hoshino Naoko, Kanda Asuka et al. “Danjo igakusei wa dono yōna kyarianinshiki o yūshiteiru no ka? Intabyū chōsa kara miete kita mono [How do male and femalemedical students perceive their own career? Implications from a student viewpoint]” Nihonpuraimari kea rengō gakkaishi [Journal for the Japanese Primary Care Association] (2016)39(4): 191-204.42 Kyoko Tanebe, “Japan’s medical school scandal must prompt health care funding debate(https://asia.nikkei.com/Opinion/Japan-s-medical-school-scandal-must-prompt-health-care-funding-debate),” Nikkei Asian Review. (August 17, 2018) (accessed August 31, 2018).43 “Women make up most of the health sector workers but they are under-represented in high-skilled jobs.(http://www.oecd.org/gender/data/women-make-up-most-of-the-health-sector-workers-but-they-are-under-represented-in-high-skilled-jobs.htm)” OECD (March 2017) (accessed November20, 2018).44 Yusuke Tsugawa, Anupam Jena, Jose Figueroa, John Orav, Daniel Blumenthal, Ashish Jha.“Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated byMale vs Female Physicians.” JAMA Internal Medicine (Feb. 2017) 117:2: 206-213.45 Ibid., 212.46 Kim C, McEven LN, Gerzoff BR, et al. “Is physician gender associated with the quality ofdiabetes care?” Diabetes Care. (2005) 28(7): 1594-1598; Berthold KH, Gouni-Berthold I,Bestehorn KP, Böhm M, Krone W. “Physician gender is associated with the quality of type 2diabetes care.” J Intern Med. (2008) 264(4): 340-350.47 Ed Yong, “Women more likely to survive heart attacks if treated by female doctors(https://www.theatlantic.com/science/archive/2018/08/women-more-likely-to-survive-heart-attacks-if-treated-by-female-doctors/566837/)” The Atlantic (August 6, 2018) (accessed August15, 2018)48 “Gender Perspectives” Nature. Vol. 553 (4 January 2018), 119.49 Ken Kato, et al “Factors relating to doctor’s desire to change hospitals in Japan.”International Journal of Health Care Quality Assurance. Vol. 25, No. 1 (2012): 19-40, 12.50 “191 multiple refusals of pregnant women found.(https://www.japantimes.co.jp/news/2007/09/28/national/191-multiple-refusals-of-pregnant-women-found/#.W_OCpJMza1s)” The Japan Times (Sept. 28, 2007) (Accessed Nov. 20, 2018) Inthe United States, the law requires all hospitals with emergency rooms to care for women in

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labor, although some rural facilities without obstetrics units violate this law. Julie Lasson-Fromowitz, “Despite law, hospitals turn away women in labor(https://www.courier-journal.com/story/news/2017/03/03/despite-law-hospitals-turn-away-women-labor/98521898/)” Courier Journal (March 3, 2017) (Accessed March 1, 2019)51 Relative poverty means that a household earns an income that is less than fifty percent ofthe average median incomes.52 Alana Semuels, “Japan is no place for single mothers(https://www.theatlantic.com/business/archive/2017/09/japan-is-no-place-for-single-mothers/538743/)” The Atlantic (September 7, 2017) (accessed August 8, 2018).53 Seiichi Inagaki. “Dynamic Microsimulation Model of Impoverishment Among ElderlyWomen in Japan (https://doi.org/10.3389/fphy.2018.00022)” Frontiers in Physics (March 14,2018) (accessed September 10, 2018).54 Abe Shinzō (https://en.wiktionary.org/wiki/ō), “Opening Speech by H.E. Shinzo Abe, PrimeMinister of Japan, at the Open Forum, World Assembly for Women in Tokyo” (presented at theWorld Assembly for Women, Tokyo, Japan, September 12, 2014).55 There is not an equivalent group for “female leaders,” but the Gender Equality Bureaubegan holding events to train women for leadership in 2017. “Josei riidaa ikusei [Trainingfemale leaders] (http://www.gender.go.jp/policy/sokushin/leaders_training.html)” GenderEquality Bureau Cabinet Office (accessed December 4, 2018).56 “Igakubu no josei sabetsu, tarōsei sabetsu mondai matome(https://xn--0kq33cz5c8wmwrqqw1d.com/?p=8859)” Igakubu juken baiburu October 18,2018 (accessed December 4, 2018).57 “Jutendo and Showa universities’ medical faculties suspected of rigging entrance examresults based on gender(https://www.japantimes.co.jp/news/2018/10/14/national/juntendo-showa-universities-medical-faculties-suspected-rigging-entrance-exam-results/#.XAYvUxMza1s)” () Japan Times (October14, 2018) (accessed December 3, 2018)58 Yajima Daisuke and Doi Shinpei “Nichidai igakubu to kantō no shidai, futekisetsu nyūshi kamonkashō ga shiteki [Ministry of Science and Education identifies inappropriate entranceexams at Nihon University’s medical faculty, private universities in the Kantō region](https://www.asahi.com/articles/ASLDC7D4DLDCUTIL06C.html)” Asahi shimbun digital(December 12, 2018) (Accessed January 31, 2019