Japan might boast universal health cover and some of the world's best medical technology, but an acute shortage of doctors is leaving some hospitals unable to treat even car crash victims.
Gruelling work hours are discouraging people from entering the medical profession in a country where the population is rapidly ageing, foreign doctors are barred and a swelling public debt caps doctors' salaries.
The strains are even being felt here at the Hyogo Brain and Heart Centre in the western city of Himeji, one of Japan's best-known neurology and cardiology hospitals.
"We toil like workhorses," said Teishi Kajiya, the hospital's vice director and a cardiologist, taking some time for an interview before heading to the operation room.
"It's become the norm for doctors to work 36 hours straight, which is emotionally and physically exhausting. We never know when one of us might collapse," he said, looking weary despite his tidy coat.
"If this routine continues, doctors' abilities during surgery will drop and could increase the likelihood of medical errors."
At the root of the problem is the steady decline in the number of so-called "level-two" hospitals which treat common injuries that require immediate hospitalisation, particularly in rural areas with falling populations.
The burden has shifted to "level-three" hospitals, which offer emergency services for patients with life-threatening injuries, such as that in Himeji.
"Since the number of level-two hospitals here fell by half in the past 10 years, our hospital is overwhelmed by patients," Kajiya said.
"Now that we are forced to accept patients with lesser injuries, there's a great risk that we're unable to treat patients whose lives are truly in danger," he added.
He said the hospital has turned down at least 100 patients in each of the past two years, adding that he was unaware of what happened to those who were rejected.
"The reality is that we've been forced to reduce emergency treatment to a portion of our patients since there are too few doctors. It simply can't be helped," Kajiya said.
The hospital, which has a total of 60 medical staff including doctors and resident students, is able to ensure only a bare minimum of three doctors on duty at all times for emergency patients, he said.
The situation is more dire for level-two hospitals. A recent poll by the Mainichi Shimbun showed that nearly 60 percent of such non-emergency hospitals had only one doctor on duty after hours.
By medical standards, at least three doctors are required to attend to a single emergency patient at any one time.
The human toll is already being seen across Japan.
In January, an injured motorcyclist died from his wounds after being forced to wait one hour before being hospitalised.
Osaka, Japan's second city, last year reported 3,800 cases in which ambulances had to call multiple hospitals to ensure treatment.
In one case, an 89-year-old women stricken with vomiting and diarrhea died of a heart attack after her local fire department spent two hours contacting 30 medical facilities -- all of which refused to accept her, citing insufficient beds, shortage of on-duty doctors or because she had not sought previous medical treatment.
-- Doctors become victims themselves --
Doctors say they are also suffering as they come under intense emotional and physical stress, prompting some to leave the medical profession or resulting in death due to overwork or even suicide.
In Japan's health care system, the government regulates the fees charged by all hospitals both public and private. Employers buy insurance for workers; those without stable jobs can buy coverage through local governments.
The set-up is credited with providing equal care in a nation that prides itself on a small gap between rich and poor.
But doctors have often complained that it has kept their salaries stagnant even though specialists would earn lucrative incomes overseas.
Unlike in some Western countries that welcome medical professionals from abroad, the gap in Japan cannot be filled by foreigners.
Japan has virtually no foreign doctors due to strict immigration rules, although it took the landmark step in 2006 of allowing in a limited number of nurses from the Philippines.
In a bid to encourage more people to become doctors, reforms four years ago allowed medical school interns to choose their specialities and work locations. In the past, professors assigned posts to students.
"These reforms have disorganised the system," admitted Seizan Tanabe, chief officer for emergency medical care at the health ministry.
"Now students prefer professions like ophtalmology since all the wages are the same. Also, they prefer to live in cities where they can go out more, start families and have their children go to good schools," he said.
The risk of being hauled to court by patients for malpractice is another reason why doctors are seeking to go into less taxing fields rather than surgery, officials and experts said.
"Students now think more about themselves," said Yasuhiro Yamamoto, chairman of the department of emergency and critical care medicine at Nippon Medical School.
"For a senior doctor like myself, the priority isn't money but the patient's recovery. For me, it is a holy job. Now it's a money job," he said.
But in Himeji, Kajiya thinks otherwise.
"Patients used to be very thankful to doctors. Today, they are demanding and very critical. It's not that doctors have become less willing to save lives. That hasn't changed. Rather, the environment has," he said.
The government recently earmarked 150 billion yen (1.4 billion dollars) to ease the doctor shortage.
But doctors say that amount is a fraction of what is needed and is unlikely to trickle down to salaries because of hospitals' mounting debts.
"Doctors who work more and in difficult conditions should have wages and respect proportionate to that," Kajiya said.
"This kind of thinking is hard to be accepted in Japanese society, but it might need to change," he said.