hankyoreh

After President Yoon Suk-yeol vetoed the nursing bill nurses and nursing students hold a protest in downtown Seoul’s Sejong Road on May 19. (Kim Hye-yun/The Hankyoreh)

In her book “Caste,” the US journalist and author Isabel Wilkerson explains that caste systems have existed in three main forms in human history.

There is the caste of Nazi Germany, which terrorized people as it spiraled toward disaster before eventually being subdued; the caste of India, which shows little sign of disappearing despite its formal abolition; and the race-based US caste system that has persisted despite not being outwardly apparent or mentioned.

Under a caste system, people’s value is differentiated based on a predetermined hierarchy. It is decided from the outset who can do and possess what.

Members of the ruling caste issue orders to members of lower classes, policing and punishing them. They warn those lower down the ladder from them against behavior that is outside their station.

As the terms of South Korea’s nursing bill have become the subject of intense conflict lately, the term “healthcare caste” has been bandied about quite a lot. For many, the reality of the healthcare system and its robust vertical hierarchy centering on the physicians at the very top evokes parallels with a caste system.

After the nursing bill was sent back to the National Assembly with President Yoon Suk-yeol’s decision to exercise his right to request reconsideration, its passage ended up falling through in a renewed vote on Tuesday.

Article 1 of that legislation stipulates a definition of “necessary items for South Koreans to enjoy the benefits of high-quality nursing in healthcare institutions and local communities.” The Korea Medical Association opposed this wording, arguing that the reference to “local communities” would pave the way for nurses to open their own clinics.

The opposition from physician groups has been vehement, despite the fact no other provisions in the Medical Service Act or nursing bill even hint at the possibility of such independent clinics being opened. It also comes at a time when such doctors have not been showing any interest to speak of in local community home visits.

Characteristically, physicians have sought a monopoly on every kind of healthcare activity — an approach that is closely tied to rent-seeking behavior based on physician licenses.

In South Korea, 90 percent of healthcare institutions are privately owned, and it is seen as natural that healthcare professionals would seek profits. A central pillar of this is the “action-based medical fee system,” in which charges are assessed for individual treatment actions by physicians.

Kim Chang-yup, a professor at the Seoul National University Graduate School of Public Health, explained that under this system it “becomes a sensitive question who makes a profit through what activities.”

“If there is even a hint of concern that nurses will open their own clinics, they perceive that as infringing on the economic interests of physicians,” he said. Under this analysis, the Nursing Act provisions were never going to be welcomed under a system where everything revolves around physicians, from establishing clinics and hospitals to receiving money from national health insurance.

Indeed, the Medical Service Act provisions related to the scope of healthcare professionals’ duties have remained almost completely unchanged since the law was amended in 1962. The duties of physicians are defined simply as “to administer medical treatment and providence guidance for health,” while nurses’ duties are defined as “provision of assistance in medical treatment under the guidance of a physician.”

Which duties nurses perform “under the guidance of a physician” have been specified on a case-by-case basis, with some judged lawful and others not.

A nurse surnamed Cho who works at a university hospital in one major South Korean city explained, “Drawing blood is the duty of medical technologists and taking X-rays is the duty of radiology technicians, but hospitals will often assign them to nurses in order to cut down personnel costs as much as possible.” Sometimes busy physicians will instruct nurses to enter the physician’s ID to write prescriptions and input patient records for them.

During standing committee discussions on the nursing bill last year, physician groups pressed for the inclusion of wording about “assisting medical treatment.”

The original text referred to “duties necessary for medical treatment.” The physicians adamantly opposed that, explaining the omission of a reference to “assisting” left open the possibility of nurses performing their own independent treatment activities — this despite the redundancy with the previous provision about activities being “under the guidance of a physician.”

A clear example of the subordinate status that nurses hold can be found in the fact that it took until January of this year for the government’s authoritative interpretation to be amended to allow nurses affiliated with local governments to measure blood pressure and glucose during nursing visits.

This situation has sparked growing demands for expertise in nursing duties. Meanwhile, a 2020 survey of healthcare personnel showed nurses complaining of severe levels of “lack of pride as a professional.”

Nurses are severely overburdened with work, with an average of 16.3 patients per nurse at tertiary hospitals. That, combined with low levels of job satisfaction, has translated into a departure rate of close to 50% within five years of employment.

As of 2020, there was a roughly fivefold difference in average annual pay for a physician and a nurse, with the former making 230.7 million won a year to the latter’s 47.45 million won (around US$173,700 vs. $35,800). Even if this disparity is acknowledged to reflect the difference in their professional duties, the average annual rate of increase in pay over the preceding 10 years was 5.2% for physicians, compared with only 3.8% for nurses.

The issues caused by this healthcare caste system end up causing problems for patients.

“In the West, the concept of patient-centered healthcare means that team-based treatment is regarded as very important,” said Park Han-seul, a pharmacist with experience working at a university hospital.

Describing the Western model, he said that “pharmacists are able to share their opinions on medication prescriptions, while nurses can suggest the optimal care based on the patient’s age and condition.”

In contrast, the situation in South Korea, where all duties are subordinated to the physician rather than being carried out on cooperative and equal terms, makes it difficult for workers in different professions to demonstrate their expertise.

To rectify the uneven playing field in medicine, these sorts of issues must be brought to the table for public discussion. Thus far, the government and political circles have primarily concerned themselves with not stepping on the toes of physicians’ organizations in an attempt to avoid political burdens associated with physicians taking action. We’ve reached a point where the democratic and rational decision-making process has gone out the window.

In his book “Medicine’s Dilemmas: Infinite Needs versus Finite Resources,” William Kissick, a former professor of public health at Yale University, introduces the concept of the “iron triangle of healthcare” in which access, quality, and cost containment compete. The pursuit of any one of these values would be a trade-off with the others, he argues. Isn’t it time that Korea paid a little more attention to the quality of medical care?

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