In February 2024, the resident physicians in South Korea resigned in waves. This was not a strike; striking seemed meaningless, and the residents went right on quitting. This occurred after the Korean government promulgated health care reform plans to tackle major problems brewing under the nation’s universal health insurance system. One of the plans–to increase the medical school quota across the nation by 66 percent (2,000 more medical students a year) immediately–particularly drove the young physicians into hopelessness. We would like to examine factors that may have contributed to these young doctors losing hope about their training and their future bound to the nation’s singular insurance company.
Young physicians gave up hope for the resolution of the perpetuating problems in the health care system after hearing the government’s plans. The lifesaving (called “essential” or “필수[pil-soo]” in Korea) medical fields–such as cardiothoracic surgery, neurosurgery (brain), pediatrics, pediatric surgery, and obstetrics–have been long fighting for their existence in Korea for two major reasons. First, the reimbursable costs for most medical procedures were set and strictly regulated by the government; the costs were set on average at 80 to 90 percent of their prime cost. The inevitable monetary loss inflicted on the hospitals from these low price tags had to be compensated by adding more non-regulated medical procedures or unnecessary non-medical services. The result was that the Korean tertiary hospitals could not hire enough attending physicians in these “essential” fields, which barely had room to compensate for their big revenue loss. Second, there have been an increasing number of reports on medical accidents resulting in criminal prosecutions, risking the medical license. Young doctors grew unwilling to pursue these fields; their “calling” was outweighed by the mounting risks. Instead of addressing these two issues, the Korean government decided to pour more physicians into the broken pipeline, hoping somebody would eventually “trickle down” to the now underserved fields.
Furthermore, the lack of scientific evidence in the new reform plan made young physicians hopeless. The new medical school quota was not based on the pooled results from the three projective analyses of future physician supply in Korea. Even the lead researchers rebutted the way the government extrapolated and distorted their analytic results. The government refused to explain how the figure–exactly 2,000, not less or more–was concocted. Rather, the government insisted that the number of physicians per capita (2.6 per 1,000) was smaller than the average (3.7 per 1,000) among the Organization of Economic Cooperation and Development (OECD) countries with highly varied health care systems. The government’s non-budging stance on the number of new quotas further fueled frustration among the trainees. The trainees’ daily pursuit for excellence in evidence-based care was disparaged by the evidence-less policy. Even more, the abrupt expansion of the medical school quota–thus more residents–meant a worsening of the training quality for the residents. Korean residents work up to 80 hours a week and up to 36 hours a shift with minimal supervision. For the teaching hospitals in Korea to generate revenue at the low medical fee, they had to rely heavily on the residents’ workforce. Now, the resident physicians constitute approximately 35 to 45 percent of physicians in Korea’s five biggest teaching hospitals; while this figure hovers around 10 percent for the leading U.S. teaching institutions. Under this structure, attendings and residents could hardly spend time together for teaching and learning to occur. Their roles are stretched so thin to cover as many patient encounters as possible. Their scanty time together is generally filled with a military-style top-down mode of communication, depriving the residents of the opportunities for in-depth discussion and direct (or indirect) supervision.
It was only when we stepped into the U.S. training hospitals that we, the authors, realized that the training could be different. In Korea, the residents’ scutwork comprises a constellation of jobs undone by other professions in the hospital. We, as a resident, performed electrocardiograms, inserted nasogastric tubes, dressed the wounds, did enemas, and scheduled the transfers, surgeries, and imaging studies. We had no protected time for didactic series but rather had to prepare for scholarly presentations after work to educate each other. At times, we took care of 20 or more inpatients without being teamed up with a senior resident. But nobody could complain since we knew that the attendings were seeing more than 100 patients a day in their clinic downstairs. The field of psychiatry was no exception: Psychiatry residents graduated without being able to observe a full 60-minute psychiatric assessment done by anybody at their teaching hospital. Korean residents were often forced by the department leadership to corroborate with the false curriculum and fabricate documents to check off the training requirements set by the ACGME-like governing bodies in Korea. Korean President Yoon is chanting a hollow reassurance that the training quality will stay the same even with 60 percent more trainees. This may be true; there is barely room to go down from here.
Last but most importantly, trainees grew hopeless by the fact that their constitutionally reserved rights for freedom could be taken away at any moment for the “collective good of the people.” Anticipating a medical crisis amidst the trainees’ absence, the Korean government ordered the teaching hospitals not to approve the residents’ resignation. Another executive order followed, forcing the residents to return to their hospitals by the end of February–or face medical license suspension for three months or longer. Furthermore, the government pressured young physicians to be held accountable for medical accidents attributable to their vacancies. Despite the government’s threats, as of March 9, 2024, a total of 11,985 (92.9 percent) residents were still not at work. The World Medical Association released a statement that “in civilian life, doctors, like any other professionals, have the autonomy to select their roles. If working conditions become untenable, they reserve the right to advocate for improvements or choose alternative employment.” The Korean media were in full throttle to depict the resigned residents as “greedy betrayers” for relinquishing patient care duties “merely for better compensation.” The viewers’ responses visible under online news articles were filled with responses approving the government’s swift, unwavering stance toward the resigned residents. The residents suddenly came to realize that they would be forced to work by the government that does not address trainees’ dire working/learning conditions and that brought a wrong remedy to clearly elucidate problems in the health care system. Hopelessness has trickled down from residents to the medical students, who refused to show up in their classrooms for the new academic year.
What keeps resident physicians from carrying on with their under-appreciated, tenuous work is the feeling of hope. They should be able to project themselves into the future and reassure that they will be working under a reasonable reimbursement system, have the right to quit if the job is unsustainable, be protected from criminal prosecution for medical accidents, and be educated under a sufficient degree of supervision. If a health care reform suddenly makes most young providers’ future opaque, policymakers should listen to their concerns. If a health care policy reduces the role of resident physicians into a cost-saving cogwheel, they will walk away. What other options do the young physicians have in this toxic environment? We hope the Korean government shows a willingness to come up with new reform plans that all parties–the national insurance entity, providers (trainees and attendings), patients, and healthy citizens–can somewhat agree upon. The Korean government must embrace physicians–particularly the trainees–as inevitable partners: providers who could tangibly translate the policy into better health outcomes for its people.
Joo-Young Lee is a child and adolescent psychiatrist. Jinwook Park is a nephrologist.
