A week of protests lays bare many inherent vices of Korean health care system

Posted on : 2024-02-27 17:53 KST Modified on : 2024-02-27 17:53 KST
An overreliance on underpaid and overworked trainees, insufficient fostering of public medical center capabilities, and muddled divisions between the duties of doctors and nurses have all contributed to the current crisis
A doctor walks through the halls of a hospital in Seoul on Feb. 25, 2024, amid a mass walkout by residents and interns in protest of a government plan to increase the medical school admission cap. (Yonhap)
A doctor walks through the halls of a hospital in Seoul on Feb. 25, 2024, amid a mass walkout by residents and interns in protest of a government plan to increase the medical school admission cap. (Yonhap)

The mass resignations of medical residents and interns that kicked off on Feb. 19 have left massive vacuums in the Korea’s health care system, a demonstration of the system’s inherent fragility. The strikes and resignations in protest of government policies have shown how dependent the country’s best hospitals are on the labor of residents and interns, while the holes in patient treatment have shown how feeble the country’s public health care system is. Now in the midst of a crisis, all these problems have risen to the surface at once.  

To make matters worse, medical school graduates who were on the verge of signing intern contracts have decided to forego employment. On top of residents, some medical school professors are also threatening to stop seeing patients, prompting forecasts of continued chaos in the health care system for the foreseeable future. 

The presidential office is sticking to its guns, however, by insisting that a 2,000-student increase in annual medical school enrollment is a “necessary figure” to make up for shortages. 

According to the Ministry of Health and Welfare, as of 10 pm on Thursday, 8,897 interns and residents in 94 teaching hospitals (78.5%) have tendered their resignations, while 7,863 (69.4%) are no longer working. The number of operations at the five largest hospitals in Korea — Samsung Medical Center, Seoul National University Hospital, Seoul St. Mary's, Asan Medical Center, and Severance Hospital — has diminished by 30% to 50%. The situation hearkens back to 2020, when over 80% of residents left their posts for nearly a month. 

The country’s health care system is rocked every time interns and residents commit to collective action, indicating hospitals’ heavy reliance on the low-cost, long-hour labor of these doctors in training. As of December 2023, residents and interns comprised 39% of doctors on duty at the abovementioned five major hospitals in Korea. Residents work in medical wards and critical care centers. They assist in surgeries and provide post-operational care. They are the backbone of hospitals, and are critical to their function. 

According to a survey conducted by the Korean Intern Resident Association, 52% of interns and residents reported having worked more than 80 hours per week — meaning that a majority had worked hours in excess of the legal weekly limit. 

According to a survey on working conditions for medical personnel conducted by the Korea Institute for Health and Social Affairs, residents and interns received an average annual salary of 68.82 million won (US$51,700) and 72.80 million won (US$54,690), respectively, in 2020. This is about a third of the salary of a fellow, which averages 236.9 million won (US$178,000).  

Many critics and observers are calling for hospitals to rely less on residents and interns and more on fellows. Such a proposal advocates for reducing the working hours of residents and interns and allowing them to focus more on education and training. It would also increase the number of fellows, professors and specialists that would contribute to night shifts and ward maintenance. 

Yet hiring additional specialists would incur heavy costs, so hospitals are reluctant to hop on board with this proposal. 

“University hospitals already have a shortage of specialists, so a sudden shortage of residents and interns inevitably leads to a vacuum,” said Kim Ho-jung, a professor of emergency medicine at Soonchunhyang University Hospital. 

“Everyone is aware of the issue, it just hasn’t been solved,” Kim added. 

The government’s response to the mass resignations of residents and interns has exposed a severe lack of publicly run hospitals and secondary care. On Friday, the government increased its health care crisis alert to “severe,” and extended working hours for medical personnel at public hospitals to the maximum permissible level. The government also called on 12 military hospitals to open their emergency rooms to the public. Yet public hospitals only account for 5% of hospitals in the country, comprising a mere 10% of all hospital beds. 

A collective of over 40 civic groups, including the Korean Health and Medical Workers' Union, has released a joint statement lambasting “government irresponsibility and neglect” for public hospital’s lack of capacity to provide emergency care, saying that “the Yoon Suk-yeol administration blocked the expansion of public hospitals, citing economic reasons.” 

The same goes for measures that send patients with non-life-threatening conditions to secondary facilities. Many of these facilities cannot perform basic operations like tumor removal or sutures for trauma wounds, requiring patients to roam around until they find a facility that can treat them.  

Delineating the duties of nurses and doctors is also an issue that should have been dealt with before the current crisis. A shortage of doctors has resulted in over 10,000 physician assistants (PAs) and nurses currently on duty. Such personnel perform surgical procedures and treatments, write prescriptions, and even draft patient consent forms, filling medical gaps by performing duties outside their professional purview. Many of them are taking on the responsibility of residents and interns. Yet current laws forbid nurses and PAs from performing treatments without MD supervision.  

The government has proposed using PAs and nurses to fill the gaps left by absent doctors. Yet the state has ignored nurses’ demands to revise the relevant legislation concerning their professional jurisdictions. They are essentially placed in a legal purgatory while facing increasing demands. If a nurse or PA is called on to take on duties that were originally performed by residents and interns, they are at legal and financial risk if they are involved in a medical accident.  

The “essential health care policy package” announced by the Ministry of Health and Welfare fails to address these critical issues in the current health care system. The package addresses overworked residents and interns by shortening their 36-consecutive-hour work shifts. It also proposes an increase in the number of fellows at national university hospitals. Yet the proposal does not address basic concerns such as financial feasibility. It also offers no clear way to increase the number of fellows and medical professors at private hospitals. Moreover, it completely neglects hospitals in areas outside of the capital region and public hospitals. 

Amid the clash between doctors and the government, experts are calling for policies that allow medical institutions to perform their respective roles properly. 

“Professors at the top major hospitals need to be able to focus on critical and terminally ill patients, while residents and interns need to be able to operate in a wide spectrum of hospitals after becoming specialists. This means they need to train and work at various secondary and tertiary hospitals, which requires a nationwide system for training residents and interns,” said Jo Seung-yeon, the director of the Incheon Medical Center, a public hospital.

At a press briefing on this day, presidential office spokesperson Kim Soo-kyung said that an increase of 2,000 medical students per year is “the bare minimum and a figure we arrived at after compromising to the best of our ability.”

“You’ll be hard-pressed to find another country where doctors respond with such extreme behavior to a government policy initiative by holding patient lives hostage and tendering mass resignations, and where medical students go on collective leaves of absence,” Kim added, essentially reiterating the government’s original position. 

To address the country’s health care crisis, the government convened a meeting of the Central Disaster and Safety Countermeasures Headquarters, under the Ministry of the Interior and Safety, where they called for prosecutors and police agencies to cooperate with the administration. The government also decided to dispatch state prosecutors to the Health Ministry to offer legal counsel regarding the doctors participating in collective resignations. 

Yet it looks like it’s going to get worse before it gets better, as more doctors are expected to leave their posts. A whopping 60 interns matched with Chungnam National University Hospital have decided to forgo their first contracts. Many interns and residents throughout the country were originally scheduled to begin working in early March, but have opted to not sign employment contracts in protest of the government’s policy initiatives. Many fellows employed through annual contracts are refusing to renew their contracts to protest excessive work hours and to join the collective resignation movement of residents and interns.  

The faculty senate of Yonsei University College of Medicine issued a statement on Feb. 24 declaring, “If the state unjustly punishes our pupils and students, we [medical professors] will not idly stand by.”

Chung Jin-haeng, who heads the Seoul National University medical school faculty association’s emergency leadership committee, posted on her personal social media page, “It’s become clear that we [doctors] can reach an optical conclusion through rational discussions [with the government],” indicating that medical school faculty are willing to mediate the dialogue between doctors and the government. 

By Cheon Ho-sung, staff reporter; Kim Yoon-ju, staff reporter

Please direct questions or comments to [english@hani.co.kr]

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