Exploring yarigai: The meaning of working as a physician in teaching medical professionalism

Abstract

Introduction

The shift in medical professionalism now considers the well-being of physicians, given the prevalence of burnout and the importance of work-life balance. To reconsider the question ‘Why do doctors work for the patient?’ and explore the meaning of working as a physician, this study adopts the concept of ‘yarigai,’ which represents fulfillment and motivation in meaningful work. The authors’ research questions are: How do doctors recount experiences of yarigai in caring for patients? What kind of values are embodied in their stories about yarigai?

Method

They adopted narrative inquiry as the methodology for this study. They interviewed 15 doctors who were recognized by their colleagues for their commitment to patient-centered care or had demonstrated yarigai in caring for patients. The semi-structured interviews were conducted face-to-face with each participant by the Japanese researchers, yielding 51 cases of patient-doctor interactions. After grouping the interview data, they translated the cases into English and identified four representative cases to present based on the set criteria.

Results

From the 51 case studies, they constructed four representative narratives about the yarigai as a physician. Each of them spoke of (1) finding positive meaning in difficult situations, (2) receiving gifts embodying ikigai, (3) witnessing strength in a seemingly powerless human being, and (4) cultivating relationships that transcend temporal boundaries, as being rewarding in working as a physician. The main results of the study, which are the narratives, are described in the main body of the paper.

Conclusion

The stories on yarigai gave intrinsic meanings to their occupational lives, which can be informative for students, residents, and young physicians when contemplating the meaning of their work as doctors. Rather than demanding selfless dedication from physicians towards patients, they believe it more important to foster yarigai, derived from the contribution to the well-being of others through patient care.

Keywords:

• Yarigai
• medical professionalism
• well-being
• satisfaction
• work ethic

Practice points

1. The term ‘yarigai’ represents a concept that encompasses the sense of fulfillment, satisfaction, and intrinsic motivation derived from engaging in meaningful work.

2. When individuals find their ‘yarigai,’ work becomes more than just a means of earning a living—it becomes a source of fulfillment, personal growth, and a way to contribute to something larger than themselves.

3. Narratives of physician’s yarigai can be highly informative for students, residents, and young physicians when contemplating the meaning of their work as doctors.

4. The stories of yarigai derived from caring for patients, as elucidated in our study, offer vital insights into the future role of physicians.

5. We invite international researchers who are interested in our work to explore it with culturally grounded notions in their own setting so that more varieties of culturally unique concepts and narratives could be explored.

Introduction

Medical professionalism, or the code of conduct for physicians, has experienced notable changes in recent years. This theme, which dates back to the ancient Hippocratic Oath, has been of interest to many medical educators, because it refers to the fundamental attitudes as a physician (Birden et al. 2013; Cruess et al. 2016; Hodges et al., 2019). It has so far mainly been discussed in an ethical system based on duty and rules. For example, the Physician Charter, one of the leading documents describing medical professionalism, states that doctors should follow three principles and ten commitments, such as patient welfare, patient autonomy or social justice (ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine, 2002).

However, contemporary documents on medical professionalism reflect a shift in focus by incorporating elements related to the well-being of physicians themselves. For example, the U.S. Accreditation Council for Graduate Medical Education (ACGME) includes sub-competencies such as ‘maintaining emotional, physical, and mental health, and pursuing continual personal and professional growth’ (NEJM Knowledge+, 2017). This change is driven, in part, by the prevalent issue of physician burnout in modern society (West et al. 2016, 2018). As more doctors strive for work-life balance and overall well-being (Raj 2016; Shanafelt et al. 2017), in teaching medical professionalism, the simplistic notion of working tirelessly for the sake of patients does not resonate effectively with medical students and residents. Furthermore, the rise of consumerism in healthcare during the twenty first century has further complicated this dynamic (Bishop and Rees 2007; Burks and Kobus 2012). Consequently, conveying the fundamental principle of ‘working for the patient’ has become increasingly challenging for medical educators in today’s context.

Here, we would like to reconsider the question ‘Why do doctors work for the patient?’ And instead of answering this question ideally and obligingly ‘because we have to so,’ we would like to further ask ‘What do doctors gain from working dedicatedly for their patients?’ or ‘What sort of non-monetary rewards do doctors get from working for patients?’ It might be a thank you from a patient. It could be their own growth as a professional doctor. It could be the sense of contribution to others, of being useful to others. In light of the social situation described above, isn’t now the time to approach medical professionalism from the perspective of physician satisfaction and consider the meaning of working as a doctor?

Since Western cultures have tended to dominate global medical education, it is incumbent on the global medical education community to seek insights from non-dominant cultures (Al-Eraky et al. 2014; Nishigori et al. 2014; Wang et al. 2016; Al-Rumayyan et al. 2017; Puschel et al. 2017). In order to explore the meaning of working as a doctor, in this paper, we adopt a concept of ‘yarigai’ originated in Japan (Fujimoto and Nakata 2007; Shoji et al. 2014; Taga 2017). The term ‘yarigai’ represents a concept that encompasses the sense of fulfillment, satisfaction, and intrinsic motivation derived from engaging in meaningful work. It embodies the notion of finding personal meaning and purpose in one’s professional endeavors. ‘Yarigai’ can be related to the concept of ‘ikigai.’ (Kamiya 2004; Schippers 2017), ‘Ikigai’ is a broader Japanese concept that encompasses finding a sense of purpose and fulfillment in life as a whole, not just within one’s professional sphere, besides ‘yarigai’ specifically focuses on the professional aspect and the satisfaction derived from work-related activities. It emphasizes the importance of finding personal meaning and purpose in the tasks, responsibilities, and contributions associated with one’s chosen profession or occupation.

‘Yarigai’ can be experienced when individuals feel a sense of alignment between their personal values, skills, and aspirations, and the work they engage in (Shoji et al. 2014; Taga 2017). It involves finding a role or occupation that resonates with their passions and allows them to make a positive impact in their chosen field. When individuals find their ‘yarigai,’ work becomes more than just a means of earning a living—it becomes a source of fulfillment, personal growth, and a way to contribute to something larger than themselves (Fujimoto and Nakata 2007). It is important to note that the definition and understanding of ‘yarigai’ may vary among individuals, as does ikigai (Kamiya 2004). What brings fulfillment and a sense of purpose to one person may differ from another. It is a deeply personal and subjective experience that is nurtured by self-reflection and introspection. In this study, we employ the concept of ‘yarigai’ as a frame of reference, examining its significance in the context of contemporary healthcare and its implications for physicians in their commitment to patient care.

Based on prior research demonstrating the effectiveness of narratives as a strategy for teaching medical professionalism (Cruess et al. 2016), we would argue that it is appropriate to explore and present narratives concerning physicians’ experiences of ‘yarigai’ as a form of narrative knowledge, which would be valuable in the context of professionalism education related to work. This is because rather than instructing professionalism as a predetermined code of conduct, it allows for an emphasis on the process by which medical students and young physicians explore the meaning of ‘being a physician’ and develop their professional identities. Our research questions are: How do doctors recount experiences of yarigai in caring for patients? What kind of values are embodied in their stories about yarigai?

Methods

Ethics approval

Ethical approval for this study was granted by the Institutional Review Board at Kyoto University Graduate School of Medicine (No. 1178).

Study setting

This study is set in the context of the healthcare and medical education system in Japan. In Japan, people access healthcare services under its universal health coverage system (Ikegami et al. 2011). Its expenditure on healthcare as a percentage of GDP is 11.0% and the number of practicing physicians per 1,000 population is 2.5 (OECD 2021). Meanwhile, in the medical education system, medical students spend six years in the undergraduate course before becoming residents; subsequent rotations in major specialties last two years, serving as a foundation in postgraduate training (Kozu 2006; Suzuki et al. 2008).

Methodology

We adopted narrative inquiry as the methodology for this study. Narrative inquiry is based on the hermeneutic thinking that a story is a prominent form of communication through which we interpret experiences from everyday life (Ricœur 1984; Ricœur et al. 1992; Brockmeier and Carbaugh 2001; Bruner 2003). We organize our significant experiences by telling stories to ourselves and others, integrating them into ‘life stories’—overarching stories which relate our past, present, and future, and which we continue to write and rewrite as our life unfolds.

As an interview approach, narrative inquiry does not seek to elicit answers to predetermined questions or propositional statements on particular issues. Rather, it invites research participants to tell stories of their personal experiences. In analyzing the interview data, each story is regarded as a basic ‘unit’ and is not deconstructed into fragments of data.

Selection and recruitment of participants

Using a combination of snowball and purposive sampling techniques, we selected 15 doctors who were recognized by their colleagues for their commitment to patient-centered care and had demonstrated yarigai in caring for their patients (Table 1). We recruited them through email or face-to-face communications, and all agreed to participate in the study. Every participant provided informed consent and they received a gift card worth $10 (USD) as compensation for their participation.

Table 1. Summary of the study participants and the themes of their narratives.

Name	Sex	Post Graduate Year	Specialty	Theme
Murakami	Female	7	General Internal Medicine	Dying patient and their family
Kaneko	Female	18	GI Surgery	Avoiding total gastrectomy
Mishima	Male	15	Neurology	Medical malpractice
Asai	Male	19	Orthopedics	Baseball player
Ikegami	Male	19	Psychiatry	Out-of-hospital care
Shiba	Male	56	Internal Medicine	Socialist movements and doctors
Yoshikawa	Male	15	Pediatrics	Complaining parents
Isono	Female	17	Pediatric Surgery	Suffering of a female doctor
Hirano	Male	26	Infectious Disease	Telling bad news
Kawabata	Male	26	General Internal Medicine	Pregnancy in individuals with diabetics
Tomano	Female	11	Emergency Medicine	Sweet family
Uchida	Female	23	Dermatology	Intention to discontinue treatment
Sato	Male	20	Neurosurgery	Passing away in wedding dress
Sunagawa	Male	26	GI Surgery	Surgery on an elderly patient
Morotomi	Female	30	Opthalmology	Educating doctors

Data collection

The first author (HN) conducted all 15 individual semi-structured face-to-face interviews between May 2016 and June 2017. The interviews lasted 60 to 90 min and took place in locations the individual respondents preferred. The main interview prompt was: ‘Tell me about the patient(s) to whom you felt yarigai in your practice.’ HN adopted a narrative approach to conducting interviews; he encouraged interviewees to tell stories in their own words. HN asked questions such as ‘Why do you think that happened?’ ‘Could you provide more details about the circumstances in which this occurred?’ and ‘Could you elaborate further on the process’ so as to delve deeper into participants’ reflections. Furthermore, given the focus on yarigai in the study, he used the term ‘yarigai’ in interviews as little as possible. HN also took notes about what he observed or reflected upon during the interviews.

Data analysis

All the interviews were audio-recorded, transcribed verbatim, and anonymized. Subsequently, the raw data in Japanese were analyzed by HN and YS. They counted the number of cases and picked up their contents in the form of a single doctor-patient interaction as one case. Following this, they discussed the contents of all the cases and grouped them based on why and how participants committed to the care of their patients. From each group they chose representative cases and translated them into English. Then JB and TD discussed the categorization and choice of cases with HN and YS. After assigning pseudonyms to all persons named in the data, all four authors agreed on the final cases presented in the Results section.

Reflexivity

HN and YS, as native Japanese speakers, met regularly to analyze the data reflexively, paying attention to how dominant narratives of professionalism in medical education might influence, and potentially confound, their interpretation of what participants had said. HN also met JB and TD regularly and discussed the findings, now in the English language, capitalizing on JB and TD’s outsider perspectives on the data to clarify the unique influence of Japanese culture on participants’ experiences and narratives. These discussions, particularly for HN as the interviewer, facilitated self-reflection on his role and contributed to the reflexivity of the team as a whole, working across cultural and language barriers.

Results

In total, 51 cases, or doctor-patient interactions, were derived from the 15 study participants. We identified four major themes from all the narratives: (1) finding positive meaning in difficult situations (2) receiving gifts embodying ikigai (3) witnessing strength in a seemingly powerless human being, and (4) cultivating relationships that transcend temporal boundaries. Correspondingly, four cases were singled out as representative of these four themes, using the following criteria: one, the case tells a unique story; two, it gives deeper insights to the research questions; and three, it contains sufficient contextual information. All personal names appearing below are pseudonyms.

Finding positive meaning in difficult situations: Dr Mishima

Dr Mishima, a male doctor in his thirties, decided to become a doctor when he was still in primary school; his grandmother died of adrenal cancer and witnessing the death of close kin for the first time in his life instilled in him a desire to ‘make incurable diseases curable.’ In medical school, he found himself attracted to neuroscience and decided to be a neurologist as it gave the opportunity to pursue both interest in human mind and interest in frontier of medicine based on a newly developing field of life sciences.

One of the stories Dr Mishima shared with us during the interview was about a patient, Mr. Miyazaki, whom he met just after finishing his residency. Mr. Miyazaki in his eighties was diagnosed with Parkinson’s disease and Lewy body dementia. When Mr. Miyazaki was hospitalized, a misunderstanding about how a drug should be administered led to Mr. Miyazaki’s accidental intake of oral medicine in powder form. Consequently, Mr. Miyazaki developed severe aspiration pneumonia and his condition deteriorated rapidly. Informed of the patient’s deterioration, his eldest daughter, who suffered Parkinson’s disease herself and was a main caregiver, was unsurprisingly upset and accused the medical staff of negligence.

Some doctors in similar cases might try to avoid the family member who disagreed with the treatment strategy; however, Dr Mishima was determined to do whatever he could. For example, Mr. Miyazaki’s daughter was inquiring about his condition night and day and Dr Mishima had to give her updates on the patient’s recent condition. For this purpose, Dr Mishima would take blood samples twice every day, once in the morning and once in the evening, check kidney function and electrolyte level, and examine inflammatory condition. ‘Some might wonder if it was medically necessary to do that much…Some might say that I did what I did just to ease my mind. But I just wanted to make sure that I had exhausted all possibilities.’

The daily routine continued for the three months. In the course of time, Mr. Miyazaki’s daughter‘s attitude gradually changed. As her trust in medical staff was gradually restored, she began to share stories about her father. One day, she told Dr Mishima how her children had loved their grandfather (Mr. Miyazaki) and how her grieving and remorse had made it difficult for her to convey the situation to her children. Dr Mishima listened to her patiently and empathetically. Upon Mr. Miyazaki’s death, her daughter visited Dr Mishima and expressed gratitude to him. To Dr Mishima’s surprise, Mr. Miyazaki’s daughter also willingly agreed when asked for consent for autopsy. Dr Mishima felt his dedication to Mr. Miyazaki’s care was rewarded. Dr Mishima stated, ‘Although I cannot say I fully understand her feeling of disappointment, anger and sorrow, I tried to be compassionate. Perhaps I did what I did partly for self-satisfaction. But I feel my dedication also touched Mr. Miyazaki and his daughter as well.’

After the autopsy, nurses prepared Mr. Miyazaki’s body for his ‘departure.’ When Mr. Miyazaki was finally departing to the crematorium, Dr Mishima participated in the solemn ceremony of parting with the deceased patient. Together with nurses, he made up the face of the deceased. They stood in a row in front of the hospital and made a long bow until the hearse carrying Mr. Miyazaki’s body left the hospital. Having recalled this moment, Dr Mishima stated:

This was one of the patients with whom my involvement was the most intense and earnest. Lives of doctors are full of troubles and accidents. There are cases when patients and families are dissatisfied or disappointed. There are cases too when I have to deal with lots of complaints. However, in those difficult circumstances, I would recall the case of Mr. Miyazaki, which makes me feel there are more things that can be done and reminds me of the value of ‘doing the best.’ That is how I find yarigai in facing difficulties and adversities.

Dr Mishima’s story can be read as the story of fulfilling the duty of a doctor professionally despite the adversity. However, it is to be noted that this was not the only source of sense of fulfilment. There was fulfilment also from his dedication being appreciated. Although not all patients and their families show such appreciation, the memory of Mr. Miyazaki’s and similar cases sustained Dr Mishima’s sense of yarigai as being a doctor.

Receiving gifts embodying ikigai: Dr Kaneko

Dr Kaneko, a female doctor in her forties, first decided to become a surgeon when her grandmother passed away. The grandmother had been diagnosed with stomach cancer at the terminal stage and underwent a total gastrectomy. She became unable to ingest food orally, became increasingly depressed, and passed away before long. The family, who did not expect a rapid deterioration of the patient, was left with a bitter feeling of not being sufficiently informed. This experience led her to become a gastrointestinal surgeon who could not only cure disease but also deliver care to sick people and their families.

Looking back on the fifteen years of her career as a surgeon, she stated ‘There were some turning points in my career as a doctor, and my patients were always involved.’ One such patient was Mr. Tezuka. He was in his eighties, and like her grandmother, had stomach cancer.

Dr Kaneko, who was in charge of him, had just seen another patient with a similar type of stomach cancer. The patient had deteriorated rapidly after a total gastrectomy, especially in terms of activities of daily living (ADLs). ‘Other surgeons might well have gone for the total gastrectomy, but I was worried that his ADL would deteriorate quickly. I did not want that to happen again.’ Although she ‘did not know what to do,’ Dr Kaneko consulted with her senior surgeon and they decided to perform an atypical procedure, which would retain the patient’s digestive function. Surgery was successful and the patient recovered well. Five years after the operation, he is still in good condition and continues to farm.

‘He was so pleased with the result. He said that he could drink sake and eat delicious meals, so he was motivated to keep farming. The patient still visits me every month, even when there is no check-up scheduled! He gives me vegetables from his farm and homemade pickles!’ Dr Kaneko believes that Mr. Tezuka would have been unable to continue farming if they had gone for a total gastrectomy. Dr Kaneko went on to state: ‘He is healthy and can still do farming, which for him is what makes his life worth living. He was on the verge of losing that, but, because of that, he enjoys farming even more. I think he cherishes his life and health now and that is why he gives me these gifts.’

After telling the story, Dr Kaneko stated in a reflective mood that ‘Sometimes, my patients bring me gifts, vegetables and things like that. That gives me a reassurance. I feel that I have something to contribute to. That gives me a sense that I have my place here. That means a lot to me.’ She continued

Patients who feel joy of living invigorate me and make me feel the meaning of life. As I have told you, there were times, especially when I was a teenager, when I was haunted by a question regarding the meaning of life: is my life worth living? I think being a doctor I am healed by my patients, healed by spending time together with them. There are hardships, but they still live. I would say I have learned the hope of being alive. Of course, all of us die in the end. But there are family who continue to live. And the relationship between the deceased and their loved ones also survives. […] That is why I am grateful for being a doctor.

The ‘meaning of life’ is a phrase that Dr Kaneko used several times throughout the interview. Her story of Mr. Tezuka illustrates how she learnt the meaning of life from the patient. Mr. Tezuka was grateful to Dr Kaneko not only because he could drink sake and eat delicious foods but also because he could continue farming, which was his ikigai. Mr. Tezuka expressed his gratitude in the form of gifts of homegrown vegetables and homemade pickles which embodied his ikigai. Dr Kaneko, in receiving those gifts embodying ikigai, also receives the reassurance, sense of belonging, and lessons on the meaning of life.

Witnessing strength in a seemingly powerless human being: Dr Murakami

Dr Murakami is a female internist in her mid-thirties and works at a community-based teaching hospital of around 400 beds. According to Dr Murakami, a doctor should not only cure but also care for the patient. She stated:

As a doctor, we need to make diagnoses and give medical treatment to our patients. To do that, we need medical knowledge and skills. Those are bare minimum requirements for us as doctors. Certainly, we should update our knowledge and skills. However, we also have to strike a balance between curing and caring. What’s more, when I feel I can achieve this, I feel the sense of fulfilment.

In the past, she often struggled with the aspiration of being a good care giver. During residency, she was ‘too busy with learning skills and knowledge.’ She often could not devote enough time to individual patients. ‘I constantly felt torn apart during that time,’ she stated. She was also often ‘isolated’ as her senior doctors and colleagues were not as interested in caring for patients as she was. Dr Murakami shared with the interviewer an experience she had during the second year of her residency. Her senior doctor was going to be away from the hospital during the weekend and had instructed her to attend to his patient who was at the terminal stage. He then let her practice writing the death certificate. ‘I was so shocked at the time. He was not yet dead! I said ‘Are you kidding me? Write it after the patient has passed away!’ That is how I felt.’

As she matured as a doctor, she began to feel less frustrated and learned to reconcile the demands of her work and find balance. With this, she also developed a unique view of what it is to be a caring and compassionate doctor. She expressed it with a story of eating noodles and rice balls with the family of a dying cancer patient.

Dr Murakami recalled, ‘I was in charge of two terminal patients at our hospital. It was a tough period, busy with controlling pain, doing paracentesis, and so on.’ There came a point when one patient was dying. She anticipated that the patient’s last moment would arrive in the next few days and advised his family to call other relatives so that they could bid farewell to the patient. Family members gathered at the patient’s bedside. The patient could barely talk; he sometimes opened his eyes slightly as they talked to him in tears.

Dr Murakami was on duty that night and had been called to see another patient. On the way to the ward, she passed by the canteen at the palliative care ward and noticed the dying patient’s family members. On her way back to the duty doctors’ room, she stopped by and spoke to them. She recalled, ‘They said, ‘doctor, join us and eat with us.’ So, I did. We began to chat while eating noodles, rice balls and things like that.’ She described the moment.

All of us knew what was going to happen. We were calmly waiting for the final moment. The mood was different from when they arrived. We did a lot of reminiscing about past episodes. We sometimes even laughed together. One of them said, ‘Doctor, you cheer us up.’ Their loved one was going to pass away. That was certain and there was not much I could do. The family members, however, were not in much sorrow. I did not intentionally try to cheer them up. But I felt that my presence, my being there, was accepted and appreciated. It was as if I were a part of them.

‘I don’t know if they still remember it, but I sometimes recollect the noodle I ate with the family now and then,’ she stated. She continued by stating ‘Come to think of it, it is a strange thing to talk like that and eat like that at someone’s deathbed. But there was something heartwarming there.’

The narrative from Dr Murakami illustrates her distinctive sense of what it means to care for patients and their families. With terminal patients, she sometimes feels ‘powerless’; as a technical expert, she cannot do anything. However, for her, that feeling is not necessarily a negative one. The feeling of inadequacy can also be a source of compassion, since the patient and family must also be feeling ‘powerless.’ Moreover, she witnesses ‘human strength’ that shines through this state of powerlessness.

Some can no longer eat. Others can no longer excrete. They may whine a lot. They are powerless but…how can I say…I feel a sort of strength within powerlessness. I don’t say I understand them but keeping company with them makes me feel that I share something with them.

According to Dr Murakami, the opportunity to be in company with the sufferer, witness strength in a seemingly powerless human being, and be included in the patient’s family, is the ‘privilege of being a doctor,’ and is also the source of yarigai in her everyday work.

Cultivating relationships that transcend temporal boundaries: Dr Kawabata

‘I think rewarding moments come,’ stated Dr Kawabata, a male internist in his fifties, ‘when a patient, with whom I spent a lot of time, left me and, after some time, heard good news from him or her.’ He explained further.

Suppose there is a patient who is suffering or for whom things do not go well. You work hard for the patient, but you don’t feel rewarded at the moment, do you? You work hard, and it’s tough…After a while, what I have done may yield a good result. A patient, for instance, accomplishes something in his or her later life, and tells or shows what they have achieved. That’s the most rewarding moment! It’s like that. Hmmm…Come to think of it, most of the rewarding moments are similar kinds. I kind of realize that now!

Dr Kawabata was trained in general internal medicine. One of the episodes he described was caring for a female patient while working in a secondary hospital in a country town. There was no specialist in diabetes in the hospital; Dr Kawabata was in charge of outpatient care of diabetic patients. During the interview, he recalled his involvement in the care of Ms Shinkai.

Ms Shinkai was in her twenties, married, and had type 1 diabetes. One day, she told Dr Kawabata that she wanted to have a baby. When she got pregnant, she went to see the obstetrician, Dr Hirano, in the hospital. Unfortunately, the response she got from Dr Hirano was unfavorable, which let her down. Dr Kawabata was similarly disappointed when he went to see Dr Hirano himself. Dr Kawabata had told him that, from the internist point of view, it is possible to safely manage the pregnancy of patients with type 1 diabetes. To this, Dr Hirano’s response in Dr Kawabata’s words were that ‘He then aggressively shouted at me, ‘So you are going to take responsibility, aren’t you? And control her blood sugar?’’

After stressful negotiations, Dr Kawabata finally succeeded in getting the obstetrician involved. After Ms. Shinkai was hospitalized, things went well for some time. However, one day, Dr Hirano became angry for no reason and began to insist that she should move to another hospital. Although there was a younger obstetrician who was willing to accommodate the patient, he had to obey Dr Hirano who was his senior. ‘The patient felt hopeless. She even said that she wanted me to take care of her delivery. I told her that it was impossible because I was not an obstetrician.’ Dr Kawabata managed to appease Dr Hirano and convince him to continue the management of her pregnancy. The stressful situation continued until Ms Shinkai finally gave birth to her child at the hospital.

Even after the delivery, there were difficult moments. Ms Shinkai was stressed by childrearing. Dr Kawabata asked Mr Shinkai, her husband, to come to the hospital to discuss how to support Ms Shinkai better. ‘She had to self-inject insulin and raise her baby. It was tough. I talked with her husband a lot. I attended to her until her child entered the nursery.’ More than fifteen years had passed when he received a New Year’s card in which Ms Shinkai thanked Dr Kawabata. The message was ‘Thank you, doctor! My son became twenty this year and I attended the coming-of-age ceremony! Thank you!’ ‘It was really rewarding! I was so glad that I chose medicine as my profession!’ stated Dr Kawabata.

The story of his experience of caring for Ms. Shinkai illustrates how Dr Kawabata feels yarigai in his life as a doctor. The relationship, commitment, sharing of time with a patient, and the passing of time before receiving unexpected returns are conditions for his feeling of being rewarded as a doctor. In this specific case, cultivating relationships that transcend temporal boundaries appears to exert a significant impact on his perception of yarigai.

Discussion

In all four stories on yarigai, presented in this paper, the interviewees managed to relate their medical practice to their own positive feelings; medical practice was presented as a source of gratification, joy and satisfaction or sense of approval, belonging, esteem, reward and fulfillment. This gave intrinsic meaning to their occupational lives, which in turn became a source of motivation and commitment.

Because we recruited physicians committed to patient-centered medicine, their yarigai were all based on their relationships with their patients. Among four stories that we have seen, Dr Mishima’s story is arguably the most exemplary in terms of a narrow sense of ‘professionalism,’ focusing on the physician’s duty. In his story, Dr Mishima, an experienced neurologist, decided to do what he could and carried that through to the end. Evident in his story is the sense of achievement arising from fulfillment of his professional duties and responsibilities even in difficult circumstances. However, more careful reading suggested that his sense of fulfillment was related to the patient’s family members recognizing his dedication; he felt this keenly when they unexpectedly thanked him and gave consent for the autopsy.

The significance of patients’ appreciation for the sense of doctor’s sense of yarigai is clearly evident in Dr Kaneko and Dr Kawabata’s stories. In Dr Kaneko’s story, she was able to protect the patient’s ikigai, which came from farming, and the patient expressed gratitude in the form of gifts of farm products. Receiving the gift seemed like that her dedicated care was actually worthwhile. Dr Kawabata’s story is similar to Dr Kaneko’s but it is different as it involves the passage of time. The arrival of an unexpected letter made him recall a patient who notified the growth of a child which he helped to give birth. The letter not only gave him a belated sense of reward; it also acted as a reminder of the existence of other patients, who, even without sending letters to him, might have benefited from the result of his medical care and remained grateful. Thus, the letter reminded him of the meaningfulness of working as a doctor.

In comparison to the other three stories, one thing stands out in Dr Murakami’s story: a sense of being given unique opportunities to witness life and death, weakness and strength of human beings. The invitation to dine together with the patient’s family members was not so much a gift of food as of a precious opportunity to be with the family when they were about to see off the loved one. It lifted the barrier separating Dr Kaneko and the dying patient’s family; the sense of comradeship and intimacy she felt at that time. They seem to have given her an unforgettable experience of belonging.

Dr Kamiya, a psychiatrist, published the book ‘On Ikigai’ in 1966 (Kamiya 2004). Describing the concept of ikigai as having a distinctly Japanese ambiguity and the consequent sense of lingering resonance and expansiveness, Dr Kamiya stated that ‘the greater the struggle, the greater the sense of ikigai’ is attained, a sentiment that resonates with Dr Mishima’s story. Furthermore, she expressed that individuals experience the greatest sense of ikigai when their personal desires align with their sense of duty, which can be seen as expressing the characteristic of yarigai in the work of physicians, where selfless service to patients is required. Moreover, her assertion that ‘ikigai shapes a single form of value within the heart of the individual who possesses it’ could also be interpreted as referring to the relationship between ikigai and the professionalism of physicians.

It was Honda who proposed the concept of yarigai exploitation (Honda 2008). She proposed this concept based on her analysis of situations in which companies exploited their workforce by providing them with yarigai. She argued that easily exploitable yarigai has ‘hobby,’ ‘service,’ ‘game,’ and/or ‘circle/cult’ natures. Physicians’ work has a strong ‘service’ nature, which is enshrined in the code of conduct for professionalism. While it is important to communicate yarigai of physicians to residents and medical students, we as medical educators need to be aware of the possibility that this act itself may lead to yarigai exploitation.

Our paper can be seen as a contribution to the growing body of research into medical professionalism in non-Western cultural contexts. Specifically, we have explored how medical professionalism is culturally embedded in Japanese traditional virtues such as ones espoused by Bushido (Nishigori et al. 2014). A related study was reported in Al-Eraky’s article on medical professionalism in the Arabic cultural context, which highlighted the concept of ‘Ehtesab’ (Al-Eraky et al. 2014). The methodology we adopted, narrative inquiry, is a strength of our article because it provided a wealth of data on ‘yarigai’ of doctors. Exploring narratives grounded in Japanese physicians’ lived experiences allowed us to arrive at a multifaceted description of the concept of yarigai. We suggest that future studies might look into physicians’ stories in other cultural contexts and explore how those stories articulate concepts similar to ‘yarigai.’ Such studies would help develop a trans-cultural understanding of the phenomenon of medical professionalism.

Our research has several limitations. One is the small number of study participants. There remain other varieties of yarigai stories that doctors could tell. Stories of yarigai may also differ depending on specialty, working environment, and personal values. We do not claim to have comprehensively covered all possible varieties of doctors’ narratives on yarigai, hence further study is required. It is also important to note that we conducted this study in a Japanese setting based on a culturally grounded notion of yarigai; we do not claim any universal applicability of the above findings. Instead, we invite international researchers who are interested in our work to explore it with culturally grounded notions in their own settings so that more varieties of culturally unique concepts and narratives could be explored.

When considering the implications of this study for the practice of medical education, it is evident that narratives of physicians’ yarigai can be highly informative for students, residents, and young physicians when contemplating the meaning of their work as doctors; for example, we may encourage students to listen to yarigai stories of experienced physicians and share them with classmates to foster medical professionalism. Even without citing examples such as the American College of Physician’s ‘On Being a Doctor’ (LaCombe 2000), the stories derived from physicians’ experiences provide valuable insights into the purpose of their work. By reevaluating the narratives of physician experiences within the conceptual framework of yarigai presented in this study, unique perspectives on the meaning of work as a doctor may be gained. In an era where generative AI systems like ChatGPT are poised to transform the world, the role of physicians is being reconsidered. As Eric Topol suggests, future physicians will primarily focus on building meaningful relationships with patients, addressing their suffering, and providing relief (Topol 2019). In light of this, the stories of yarigai derived from caring for patients, as elucidated in our study, offer vital insights into the future role of physicians. Furthermore, as Alfred Adler posits, rather than demanding selfless dedication from physicians towards patients, we believe it more important to foster yarigai, derived from the contribution to the well-being of others through patient care (Adler 1956).

Ethical approval

Ethical approval for this study was granted by the Institutional Review Board at Kyoto University Graduate School of Medicine (April 10th, 2015; Number 1178).

Geolocation information

Japan.

Acknowledgements

The authors wish to thank all the interviewees who participated in this study, all those who supported Hiroshi Nishigori during his PhD studies at Maastricht University, and all the members of the Nishigori lab.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Japan Society for the Promotion of Science (JSPS) KAKENHI, Grant-in-Aid for Scientific Research (B), Number 15H04750.

Notes on contributors

Hiroshi Nishigori

Dr Hiroshi Nishigori is Professor, Center for Medical Education, Nagoya University, Japan.

Yosuke Shimazono

Dr Yosuke Shimazono is an Assistant Professor, Centre for Global Initiatives, Osaka University, Japan.

Jamiu Busari

Dr Jamiu Busari is an Associate Professor, Educational Development and Research Department, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands.

Tim Dornan

Professor Tim Dornan is Professor, Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, UK.