• Source: 2024 South Korean medical crisis

2024 South Korean medical crisis is an ongoing healthcare crisis following the announcement of new government policies on significantly increasing the medical student quotas. Thousands of residents and interns have since resigned, which has resulted in medical school professors working to cover for residents. This has forced non-urgent, less complicated patients to no longer be treated at tertiary care facilities, leading to concerns about large university hospitals running into financial trouble. There has been anxiety about patients being unable to receive timely treatment.




Background and causes






= Demographic change of South Korea

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In June 2012, South Korea's population reached 50 million, and by the end of 2016, South Korea's population peaked at about 51 million people. However, in recent years the total fertility rate (TFR) of South Korea has plummeted, leading some researchers to suggest that if current trends continue, the country's population will shrink to approximately 28 million people by the end of the 21st century. In 2018, fertility in South Korea became a topic of international debate after only 26,500 babies were born in October and an estimated 325,000 babies for the year, causing the country to achieve the lowest birth rate in the world. In 2020 the country recorded more deaths than births, resulting in a population decline for the first time since modern records began.
In 2023, 69% of local medical centers of Korea could not fill their quota of doctors. Exmaples include Chungnam Seosan medical center being unable to hire enough radiologists despite offering an annual salary of 420 million won (about $300,000) with 4.5 working days per week and Gangwon Sokcho medical center also increasing the annual salary of emergency medicine specialists to 420 million won ($300,000).
South Korean President Yoon Suk Yeol argued the basic medical system is collapsing, with many disciplines such as pediatrics, obstetrics, and gynecology lacking manpower and thus many people are not able to receive timely treatment. He also cited the imbalanced distribution of medical services between urban and rural areas as one of the reasons to expand the enrolment of medical students.




= Government of healthcare system

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South Korean healthcare system has significant distortions. A mandatory designation system integrates all doctors and private medical institutions into public health insurance, enforcing predetermined fees and rigorous audits. Low fees necessitate subsidization from non-insurance treatments or high-volume, low-margin practices, without compensating doctors for their extensive training and experience. Medical malpractice criminalization rates in the country are extremely high, leading to an exodus of young doctors from high-risk essential medical fields. The government provides minimal support for medical education and residency training, making medical schools rely on hospital profits. Residents often work up to 100 hours a week, and university hospitals depend on their cheap labor due to strict fee controls.
Every year, the government engages in negotiations with medical professional organizations to determine the extent of the increase in medical treatment fees. Healthcare practitioners argue that South Korea's medical fees are insufficient when compared to other OECD countries, and the fees reimbursed by the government do not cover the cost of services. This debate concerning medical fees and reimbursement has persisted for several years. Virtually, medical fees have been controlled strictly by the government and remain at a fraction of the prices in the United States, and cheaper than those in China and Singapore.
South Korea has an insurance system with low reimbursement rates which encourages high turnover by hospitals and does little to dissuade patients from seeking second opinions. The health finance system in South Korea is characterized as "low premiums, low medical consultation fees, low pay". The medical policy not to give adequate payment and working condition to medical workers caused shortage of medical workers in some specialties, such as pediatrics, because these specialties involve underpaid treatments which is due to involvement with National Health Insurance. National Health Insurance, setting low medical fees and taking advantage of medical workers, made medical workers in these specialties overworked but underpaid.
When the government broadens the range of health insurance benefits, healthcare facilities tend to offer uninsured services, due to low insurance benefit payment. The cost of healthcare services covered by insurance only amounts to 87% of the original cost. Consequently, healthcare institutions get financial losses when providing services covered by insurance. Among OECD countries, South Korea has a notably low proportion of active nurses. Despite a steady increase in the overall number of nurses, the expected growth in the number of active nurses has not been realized due to persistent turnover issues. The failure has sparked opposition from medical workers, leading to strikes and public debate. South Korea is recognized as a nation that offers excellent medical services despite the relatively low burden of public health insurance premiums. Nonetheless, patients bear the responsibility of paying for medical services that are not covered by health insurance, which places a financial strain on them. Healthcare providers encounter challenges due to the significantly low prices set by the health insurance system for the medical services they offer. Healthcare providers face challenges in terms of satisfaction and burnout as they struggle to obtain sufficient treatment time due to inadequate reimbursement.
The policymaking process in South Korea neglected proper channels for professional opinions. This omission ultimately resulted in governance failure, sparking unnecessary severe conflicts among key actors such as doctors, pharmacists, civil society organizations, and the news media. One research examined how the media granted more legitimacy to the government than to the doctors. According to the study, the government's image is presented as "an actor that partially contributed to the cause of the conflict but is keen to exert its best efforts to resolve the problem in the best interest of the public and everyone involved in the conflict." The study showed the image of doctors is shaped by three major news frames: the "morality frame," the "internal dissent frame," and the "inconciliatory attitude frame." These frames depict doctors as "a group primarily motivated by economic interests, violating the ethical code of their profession, experiencing internal divisions, and refusing to engage in dialogue." According to the research, the arguments of medical providers pointing out the structural problems of our medical community, which has been made by the government, have considerable validity, the news media's bias is expressed by the use of strong labels such as "criminals" and "murderers," which are applied to medical providers.




= Admission quota of medical schools of South Korea

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Since 2006, the admission quota of medical schools has been 3,058 per academic year. The number was decreased from 3,500 in 2000 which is the year when another strike of South Korea doctors happened. The strike was due to the proposed plan of government to strictly separate the job of physicians and pharmacists, which could cause a significant damage to the income of doctors. Residents and interns refused to work, and emergency rooms of local hospitals were also closed.




= Repulsion from residents

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The announcement of increasing medical school from the government immediately caused repulsions from the residents and interns because they have claimed that the welfare of trainee doctors must be improved first. According to the Korea Intern Resident Association, intern and resident doctors in South Korea work 36-hour shifts, in comparison to the United States where they work less than 24 hours. About half of these doctors would work no more than 60 hours per week on average in the United States, while in South Korea it is common to exceed more than 100 hours per week. The average salary of residents of South Korea is about 70 million won (about $50,000). It was surveyed that 100% of thoracic surgery residents, 82% of surgery residents, and 77.4% of neurosurgeons work more than 80 hours a week. This is one of the aspects of cheap and high-quality medical care in Korea that the government has been boasting about.




= Skewed distribution of doctors in South Korea

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Doctors and the government posited that it is not the number of medical school admissions but the government policy and laws about healthcare of South Korea that made the doctors move to the profitable field rather than the field for vitality of patients. In South Korea, according to the law, it's illegal for physician assistants (PA) do basic activity such as suture, as well as for tattoo artists to do tattoos, because their activities are invasive and therefore will hurt the health of citizens. Skin care treatments such as laser treatment and neurotoxin are only legally allowed to doctors, making general practitioners (medical students who passed Korean Medical Licensing Examination) work in the beauty market without being a training doctor.
The core issue for local public hospitals in South Korea lies in the inherent conflict between serving public interest and achieving profitability. They are mandated to fulfill a public mission, encompassing tasks like establishing a medical safety net for low-income individuals and managing financially unsustainable medical facilities and emergency healthcare situations. Simultaneously, they are expected to pursue profitability by delivering high-quality care through competition and operating as an independent, self-sustaining entity following private business principles. The decline in inpatient revenue at local public hospitals can be attributed to several factors, including low reimbursement rates, the provision of charitable care to individuals with low incomes, and the delivery of low-revenue-generating services such as obstetrics and gynecology and pediatric services in medically underserved regions. Local public hospitals have received very little from the central government.




Events by time



February 6
The government announced they will increase medical school enrollment by 2,000 every year from 2025, setting the quota to 5,058. Doctors have collectively opposed Yoon's proposal, stating there are already sufficient doctors in major hospitals. However, the government moved forward with the plan.

February 20
Many doctors resigned collectively. Many undergraduate students in medical schools suspended their studies.

February 22
The government raised the crisis level of the country's medical system to "serious".

February 23
The Ministry of Health and Welfare announced that all clinics and treatment centers were allowed to provide telemedicine services.

February 26
Ministry of Health and Welfare stated that among the 100 hospitals, 10,034 interns and resident doctors submitted resignation letters with 9,006 of them resigning. In response, the Ministry suspended the medical licenses of two leaders of the Korea Medical Association and ordered the return of intern doctors. The government indicated that if they resumed their work by February 29, they would not be punished. On March 1, there were 565 doctors who had yet to return to their duties. The government stated that they would take action against those who refused to return to work by March 1 and threatened administrative sanctions and other possible judicial measures.

February 27
The Ministry announced that nurses would be able to assume some of the duties of doctors. On March 1, the Ministry issued a return-to-work order to 13 intern and resident doctors who formed the committee of the Korea Intern Resident Association.

March 3
The Korea Medical Association held a general meeting at Yeouido island located on the Han River in Seoul, condemning the government's pressure on the doctors and mobilizing doctors to protest against the government.
South Korean Prime Minister Han Duck-soo chaired a response meeting, acknowledging that a large portion of the doctors had yet to return to work. Han stated that the government would urgently prepare a budget to employ replacement doctors and reward those who stayed in the hospitals. Various committees under the government would also work to implement healthcare reforms.
In order to ensure that regional emergency centers were able to treat severe cases, the Ministry began to classify patients into critical and non-critical groups.

March 4
The Ministry announced that it would conduct a second inspection at 50 hospitals for the return of intern and resident doctors. If these doctors returned to their posts by then, they would not pursue further discipline. However, if they still haven't returned to work, they would face punishments on the following day. Those who did not comply with the government's order to return to work would have their medical licenses suspended for at least three months, delaying their qualification as medical doctors by more than a year. Further administrative sanctions would also be recorded in their employment records.

March 7
Online users of a doctor community MediStaff collaboratively wrote "참의사 목록" (a list of true doctors) that lists residents who were still working in hospitals. Since only those who certified their doctor licenses during membership registration could read the articles in MediStaff, this list was exposed to the public only after an anonymous resident revealed this incident on a public online community. The name ("참의사 목록", a list of true doctors) sarcastically expresses that the doctors in the list are in the hospitals because they more value the wellness of patients. The list contained the names and associations of working residents in 70 hospitals. Seoul police later searched and seized 5 doctors who were suspected to lead the crime (April 19), and the head of the Korea Medical Association (KMA), Lim Hyun-taek, asserted that this is tyranny against doctors.

March 8
At 11:00 am local time, more than 11,994 intern and resident doctors remained absent, representing 92% of the trainee doctors. On March 11, the Ministry had issued a notice of suspension of medical licenses to 5,566 intern and resident doctors. The Ministry indicated that those who returned to work before the completion of the notification process would be dealt with leniently.

March 11
The government started sending out 158 military and public health doctors to hospitals.

March 16
Senior doctors and professors from 20 hospitals had indicated that they would submit their resignation letters from March 25 in support of junior medics' walkout. But instead, they began cutting back on hours spent in practice on March 25.

April 4
President Yoon gave a speech to the nation for almost an hour. He reaffirmed his will to expand the number of medical school admissions and appealed to the public for support.

"As the president, I regret not being able to promptly address the public inconvenience... All rational people will agree that the country faces a shortage of medical doctors."
May 1
The South Korean government reduced the increasing quota of medical school admissions from 2,000 to 1,500 for one upcoming academic year. The number was determined after receiving updated numbers from universities who wanted to shrink the quota in order to minimize the conflict between the medical school professors and other faculty members. However, the Korea Medical Association (KMA), residents and interns kept their stance.

May 16
The high court of South Korea judged that increasing the quota of medical schools is necessary for the greater good.

July 18
As of July 18, 2024, only 8.4% of resident doctors who had left their jobs in protest had returned to work. Their terminations were finalised on July 15 on instructions from the government

July 22
To fill in the empty positions, recruitment of 7,645 residents for the second half of the year began at teaching hospitals across the country.

August 16
At a National Assembly parliamentary hearing, Health and Welfare Minister Cho Kyoo-hong said the ministry plans to announce additional reform measures related to increasing medical school admissions early next month.




Resolutions and negotiations






= Adjusting the increased quota

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The government offered to adjust their healthcare reform plans to let medical schools determine their own admissions for the 2025 intake, lowering the designated quotas by up to 50% for 2025 while maintaining the original increased quota from 2026 onwards on April 19, 2024.




= Hiring doctors from foreign countries

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As the medical crisis remained unabated, the government in May 2024 sought to allow vetted foreign doctors to work in South Korea. In response, the head of KMA, Lim Hyun-taek, shared a screenshot of a news report of newly graduated Somali doctors in his Facebook with the text "Coming Soon.", a message connotating that doctors from foreign countries are inferior to South Korea doctors. Although it was subsequently removed, it was deemed as "racist" and "exploiting Islamophobia and stereotyping against developing countries".
The government's proposed plan was an extension of preparing the new medical environment for upcoming plural society of South Korea, which is already becoming reality since the number of people from foreign countries in South Korea reached 2.5 million in 2024 and the ratio of international marriage of South Korea reached 10% in 2024 as well. A collaboration between South Korea and the Middle East/African countries from 2010s reported that over 130 doctors from the Middle East are already working as specialists in South Korea in 2024 as a part of the official government program for international healthcare collaboration of South Korea. According to the news, these foreign doctors are overall satisfied with their hospital environment.




Reactions






= Government

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South Korean President Yoon Suk Yeol denied that the increase in medical students would lead to a decline in quality of medical education. He stated that the proposed increase of 2,000 students is the minimum required. The government stated that if the doctors did not return to work, their medical licenses would be suspended.
The Ministry of Health and Welfare deployed military and public health doctors to affected hospitals to ensure emergency patient care. The government warned the trainee doctors of potential license suspensions for their collective action. The South Korean government tried to expand the role of nurses in emergency care units at general and training hospitals. The Ministry of Health and Welfare planned to release guidelines allowing experienced nurses to perform certain tasks typically assigned to doctors, such as CPR and administering medication to critical patients.
A Central Disaster and Safety Countermeasure Headquarters was established, headed by the Prime Minister, to coordinate the government's response to the crisis. Regional emergency situation rooms were also set up to manage the transportation of severely ill patients in major regions.
The Education Ministry introduced guidelines to prevent boycotting medical students from failing their semesters due to insufficient class attendance. Measures included:

Allowing medical schools to determine academic failure on a yearly basis instead of a semester basis.
Permitting schools to extend or shorten the duration of semesters or operate three semesters per year instead of two.
Offering classes at night, online, or on weekends to help students meet their academic requirements.




= Experts in Medicine

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Medical professionals argue that the plan would impair the quality of medical education. However, commentators pointed out student-to-faculty ratio in Korea is one-third of Germany's and half of the United States, with each Korean medical professor handling 1.6 medical students on average.
Medical professionals pointed out that the planned enrollment increase will not be able to fix the immediate manpower issue as training doctors typically takes ten years. If a fresh medical student wants to qualify as a specialist, they must undergo a six-year study, a one-year internship and three to four years of residency training after graduation. This implies that not only the increased quota of medical schools but more immediate actions such as partially allowing doctors from overseas to work in South Korea is necessary.
Medical professionals also point to high rates of medical malpractice litigation. Approximately 750 South Korean doctors are criminally charged for medical malpractice every year. That is 14.7 times higher than Japan, 580.6 times higher than the United Kingdom, and 26.6 times higher than Germany. A 2019 study found that one-third of doctors had experienced a medical malpractice in the past 3 years. These litigations often occur in more critical medical specialties such as emergency medicine, cardiothoracic surgery, gynecology, and pediatrics. A criminal charge due to medical malpractice does not lead to revocation of their doctor license according to the law of South Korea, but this can still be a significant threat to doctors in the specialties.




= Korea Medical Association

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The Korea Medical Association stated that the right to resign is protected by the constitution.




= Korean Health and Medical Workers' Union

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The Korean Health and Medical Workers' Union has voted in favor of a general strike. This decision was made following a vote where approximately 91% of health workers from 61 hospitals across South Korea supported the strike action. The strike is a response to the emergency measures implemented by hospitals due to financial pressures, which include furloughs, unpaid leave, and mandatory overtime. After that, unionized hospital workers called off their planned strike after negotiating with hospitals for pay raises and improved working conditions.




= Residents

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The Korea Intern Resident Association wanted the government to withdraw the plan to increase the enrollment of medical students and cancel the return-to-work order.




= Students' boycott

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Medical students began to boycott attending their classes since February 20. As a result, Gachon University postponed the start of the semester from mid-February to March 4 initially, then once more until March 25, while Gyeongsang National University delayed the start to March 15. By March 6, 5,401 students (28.7%) had applied for leave. However, if including improperly filed applications, the number of applications would potentially be over 14,000. Due to ongoing boycotts by medical students over increased admissions, only 2.7 percent of students attended classes, with just 495 out of 19,345 enrolled students returning as of July 22. Attendance rates varied, with first-year pre-med students at 1.7 percent and medical school seniors at 3.5 percent. Government concessions have not significantly increased attendance.




= Media

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The government labeled the collective criticisms and social advocacy of medical students, residents, and doctors as "doctors' illegal collective actions," leading to a declaration of a national healthcare crisis at the highest risk level. The "Central Disaster and Safety Countermeasures Headquarters for Doctors' Collective Actions," led by the Prime Minister, was established. In line with changes in digital media, the Emergency Response Headquarters conducted daily public briefings, marking an unprecedentedly swift governmental response. A large-scale campaign was launched to bolster government policy, featuring the President's commitment displayed on public buses and subways, and promotional videos in movie theaters. Screens inside apartment elevators also broadcast the government's message against "emergency room ping-pong" and "pediatric clinic open run," representing an unprecedented promotional campaign. Doctors and the medical community were portrayed as a self-serving cartel, a characterization cemented by the President in a national address. This portrayal marked doctors as adversaries rather than partners in healthcare reform, significantly undermining the trust that forms the foundation of the doctor-patient relationship.




= Patient groups

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Patient groups in South Korea spoke their concerns about the continuing conflicts between the government and the doctors. In July 4th, 92 patient groups including the Union of Korea Breast Cancer Patients, Korea Alliance of Patients Organization and Korean Organization for Rare Diseases gathered and claimed stopping the collective actions of doctors and promoting a law that will prevent the patients-damaging action from happening in the future.




= Opposition parties and the public

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Lee Jae-myung of the Democratic Party also opposed doctors and supported the increase in enrollment of medical students. Groups representing cancer and ALS patients have also called for the quick return of doctors. The Korean Buddhist order, Jogye Order had urged the return of doctors on February 22. In a poll conducted by Gallup Korea from February 13 to 15, 2024, 76% of respondents were more positive about the government’s proposal to increase the number of medical school students by 2,000. Only 16% expressed opposition. In a poll conducted by Gallup Korea from March 12 to 14, 2024, 49% of respondents said that the government’s response was inadequate compared to the medical community’s opposition to expanding medical services.




Impact


Severance Hospital, Seoul National University Hospital, and many other hospitals were forced to cancel or postpone many surgeries. Some hospitals also decided to shorten the time to operate on patients or give priority to critically ill patients. An ophthalmology professor in his 40's died of brain hemorrhage on March 24, 2024 and an internal medicine professor in his 50s died of intestinal obstruction on April 20, 2024, causing significant concerns about health risks to the medical school professors who were overworked trying to cover for all of the resident doctors who have resigned.




See also



Healthcare in South Korea
2024 in South Korea




References

Kata Kunci Pencarian:

• Tencent
• John F. Kennedy
• 2024 South Korean medical crisis
• 2024 in South Korea
• Economy of South Korea
• Demographics of South Korea
• Suicide in South Korea
• Healthcare in South Korea
• Aging of South Korea
• South Korea
• Yoon Suk Yeol
• Medical support in the Korean War