Happy New Year to all members of the Japanese Association for Thoracic Surgery. 2025 has begun, so a quarter of the way through the 21st century has passed. As someone who grew up in the 20th century, I am amazed at how fast time flies. When I became a surgeon in the Showa era (1926–1989), I never imagined that surgery would be performed by looking at a monitor or operating a robot with my back to the patient. The technological innovations over the past 40 years have drastically changed. I feel that many lives could have been saved if we had had the technology and medicines we have today. On the other hand, technological innovation has not always been a good thing: While the infant mortality rate in developing countries has been dramatically reduced through the efforts of WHO, UNICEF, and others, the babies who have reached adulthood are pouring into North America and Europe as economic refugees because there are not enough jobs available in the country. Cancer and cardiovascular diseases, which were once deadly diseases, have become curable diseases, contributing to the growth of the elderly population. The increase in the elderly population, the declining birth rate, and the shrinking workforce are all signs of an unstable society unlike any we have yet experienced. In our field of thoracic surgery, the number of surgeries and workload are increasing along ageing society. On the other hand, the number of surgeons has not increased in comparison to the increase in workload. In the past 20 years, the number of thoracic surgeons has remained the same while the number of surgeries has increased 2–3 times. We, thoracic surgeons, have been coping by increasing labor productivity through the introduction of clinical passes and the standardization of surgery, but this is reaching its limits. Since the population has begun to decline, the number of surgeries should peak out soon, but the number has not declined as much as expected due to accumulation of cases through natural selection of facilities and an increase in the number of surgical indications. Since the work style reform is taking place there, task shifting is inevitable. JATS has introduced a registration system for nurses who have completed specific training in thoracic, cardiac, and vascular surgery and an associate membership system. This is in response to the new system obligating such the nurses to belong to cardiovascular departments which the Japanese Board of Cardiovascular Surgery will start. It is expected that nurses will soon join the staff of the department in the daily practice of thoracic surgery. Although nurse practitioners, NPs, are not nationally certified, they are closer to physicians because they have completed a master’s degree program and have studied pathophysiology in addition to performing the specified medical acts. At last year’s conference in Kanazawa, the president of the NP Society was invited to participate in a roundtable discussion. The presentation showed that there are still only a few hundred NPs in Japan, and it is clear that a number of NPs are still insufficient. When seeing the distribution of NPs, the number of NPs working in thoracic surgery is small compared to other fields. We need to think about this issue.

On the other hand, what are the tasks shared with NPs or the specified nurses? For the specified nurses, it may be various routine procedures on the ward; for NPs, it may be more extensive ward work or assisting in surgery; NPs do not have authority of prescription, so they cannot prescribe, but some hospitals allow them to enter prescriptions on their behalf. Of course, the physician’s approval is required, but it may be possible to share tasks such as DO prescriptions at the time of admission or discharge from the hospital, or inputting DO prescriptions. They may also be able to check results of routine examinations. However, the treatment of postoperative patients who deviate from the clinical passes is still our job as physicians. The reasons of the good surgical outcomes in Japan depend upon well postoperative managements intervening with patients before they get sick and preventing them from becoming seriously ill. It goes without saying that the time gained from task-sharing should be used to focus more on the patient management.

In addition to letting NPs and the specified nurses belong to the department, policy issues that we have been working on include issues of facility consolidation and surgical fees. Consolidation of facilities will start with the field of pediatric cardiac surgery, but consolidation in all areas is inevitable, and in rural areas, consolidation is already occurring spontaneously. In considering the future of medical care in Japan, the most urgent issue is to stabilize the economical status of local core hospitals. While medical fees have not increased, drug prices, material costs, utility costs, and personnel costs have continued to rise. With the current lack of surplus in medical expenses in Japan, it may be difficult to solve the problem of surgical fees. At the previous roundtable discussion, a MHLW participant commented that the number of surgeries per surgeon per year in Japan is one-tenth that of the United States and Europe, and that surgical fees may be difficult to obtain under such circumstances. If the number of surgeries is not going to increase in the future, the number of thoracic surgeons will have to be reduced to one tenth in order to obtain the surgical fees. That may be the reality, but it is hardly the ideal. I understand that surgeons need to concentrate on surgery to perform 10 times as many operations, and they will leave postoperative management to NPs and residents. But to reduce the number of surgeons one tenth less, you have to select surgeons. I think it is difficult to say, “If there are 10 new surgeons, can the Japanese cut the heads off 9 of them except for one excellent one?” In the U.S., only those who are selected in this way become thoracic surgeons. In Japan, however, a large number of residents are needed for postoperative management and miscellaneous duties, and there is a long history of admitting those who wish to become thoracic surgeons, regardless of their talents. While the unqualified are spontaneously leaving, the fact that the middle-level surgeons are moving to relatively small hospitals (which is the right exit strategy for the medical office) prevents the consolidation of facilities. On the other hand, from the patient’s point of view, this is a good thing, because they do not have to travel far to receive medical care. The caveat, of course, is that “only standard care with little difference in results” should be provided.

The nationwide decline in the number of residents majoring surgery may be a slow resolution to the self-contradictions we all contain. There is a saying, “A pinch is an opportunity”. It is true that due to various external factors such as those I have mentioned, Japan’s medical care system has reached a turning point. However, I believe that our job for the next several decades will be to maintain the world-famous good surgical results we have established and to make internal changes to move away from the old system that has existed since the Showa era and into a new system. The Japanese are not good at developing new things, but they are good at improving them. Let us improve the current system so that it will be easier for us to use and produce better results, rather than following medical systems of the West.

Finally, since we are an academic society, we need to create and product new findings. The seeds of research lie in many places. We can break through by cutting into the areas where “something seems to be the case, but we don’t have the words to express it yet”. I hope that this year, too, there will be some achievements in Japan that will be published in the Lancet or NEJM.