1Institute of Medical Education, Hallym University College of Medicine, Chuncheon, Korea
*Corresponding author: Sun Huh,
Institute of Medical Education, Hallym University College of Medicine, 1
Hallymdaehak-gil, Chuncheon 24252, Korea, E-mail:
shuh@hallym.ac.kr
• Received: April 29, 2024 • Accepted: April 29, 2024
This is an Open-Access article distributed under the terms of the
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Two thousand new entrants at Korean medical schools
The news section of the BMJ has covered the “increased number
of places at Korean medical schools in 2025 by 2,000 entrants and the resignation of
10,000 residents and interns” [1]. In
an opinion piece published in the Journal of Korean Medical
Sciences [2], the author condemns
the government’s authoritarian attitude of treating physicians as felons,
stating, “the government will annul residents’ medical license,
prohibit hospitals from accepting residents’ resignations, or pronounce
maximum criminal sentence.” The author further states that the Korean Academy
of Medical Sciences “looks toward the government and the medical community
hoping each will take a step back and discuss these policies together to prevent
public disaster.” The Lancet has also reported on this topic
in the news section:
“The Korean government aims to address a projected shortage of 15,000 doctors
by 2035 through a new recruitment cap. Junior doctors, however, believe that merely
increasing medical school slots won’t effectively tackle physician shortages
in underserved medical areas. Instead, they assert that newly qualified physicians
will still gravitate toward high-paying fields like cosmetic surgery and dermatology
in the greater Seoul region.” [3].
It is disheartening to hear about the resignation of interns and residents,
especially against the backdrop of the Korean government's threatening stance
towards these young physicians during the beautiful days of spring. Each March and
April, general hospitals buzz with activity as new interns and residents begin
treating patients and improving their skills under the guidance of experienced
supervisors. This period also fosters interaction among various health
professionals, including nurses, pharmacists, dietitians, physical therapists,
health information managers, and radiological technologists. These
inter-professional activities mark the initial steps in alleviating the suffering of
patients afflicted by illness. Furthermore, the development of rapport among health
professionals, patients, and their families introduces a fresh sense of joy and
fulfillment in the practice of medicine. Without these vibrant interactions, March
and April become the most cruel months for young physicians.
In this opinion piece, I present the perspectives of young physicians (interns and
residents) alongside the official statement from the Korean government regarding the
government’s threat to young physicians — namely, “a
medical license suspension at least 3 months from March 2024, and related
investigations and prosecutions.” Additionally, I will share
insights from experts on critical issues and offer suggestions from the viewpoints
of educators and editors, drawing on sources such as journal articles, newspapers,
government briefings, and personal communications.
Ethics statement
This is an opinion on a policy judgment; therefore, neither approval by the
institutional review board nor the obtainment of informed consent was
required.
Korea Interns and Residents Association Emergency Measures Committee statement
240220
The official Emergency Measures Committee statement 240220 was released by the Korea
Interns and Residents Association on February 20, 2024 (Supplement 1) [4]. The Association demanded the following
steps:
□ Completely withdraw the essential healthcare policy package and the
plan to increase the number of places at medical schools by 2,000 a
year.
□ Establish a body to conduct a scientific forecast of doctor supply
and demand and discuss increases and decreases in the supply of
physicians.
□ Expand the hiring of specialists at training hospitals.
□ Implement concrete measures to mitigate the legal burden on doctors
due to unavoidable medical incidents.
□ Improve the harsh training environment for residents, who work up to
80 hours per week.
□ Withdraw all unfair orders that intimidate residents and formally
apologize to them.
□ Fully repeal Article 59 of the Medical Service Act, which infringes
upon the fundamental rights of citizens, and comply with the Republic of
Korea's Constitution and the International Labour
Organization's prohibition of forced labor.
The present number of admissions to medical school is 3,058 at 40 institutions.
According to a law from 2016, the maximum working hours for interns and residents is
80 hours, with an additional 8 hours allocated for educational purposes [5]. After the announcement of the statement,
residents started to depart from their training hospitals individually, protesting
against the government's briefing.
Why would gifted young physicians, who represent the hope of Korea, issue such a
statement? This appears to be a reaction to the "Emergency Briefing on the
Physician Workforce Expansion Plan" announced by the Ministry of Health and
Welfare on February 6, 2024 (Supplement 2) [6]. This emergency briefing can be summarized as follows:
Four essential healthcare policy packages will be implemented to allow physicians to
focus on regional and essential healthcare services: 1) expanding the healthcare
workforce, 2) strengthening regional healthcare, 3) establishing a safety net for
medical accidents, and 4) enhancing fairness in the compensation system. The medical
school admissions quota will be increased by 2,000, from 3,058 to 5,058. Starting in
2025, an additional 2,000 students will be admitted annually.
A more specific proposal is presented in the Essential Medical Policy Package
(Supplement 3).
Ongoing resignation of residents and the government's threat of judicial
proceedings
The Minister of Health and Welfare stated on February 27, 2024 that "starting
in March, it will be necessary to suspend the licenses of those who have not
complied and to initiate related judicial proceedings" [7].
Following the statement issued by the Korea Interns and Residents Association on
February 20, 2024, residents at training hospitals continued to submit their
resignations. By February 28, a total of 9,997 residents, representing 80.2% of all
residents, had submitted their resignations, although not all were accepted by the
hospitals in compliance with a directive from the Korean government. Consequently,
9,076 residents, or 72.8% of the total, successfully left their positions [8]. The Korean government ordered 13 residents
to commence work on March 1, 2024 [9] under
Article 59 (2) of the Medical Service Act [10].
Article 59 (Guidance and Order) of the Medical Service Act is as follows
[10]:
(2) The Minister of Health and Welfare, a relevant Mayor/Do Governor, or
the head of a relevant Si/Gun/Gu may order medical personnel or founders of
medical institutions to resume medical service if there is a reasonable
ground to believe that suspension of medical service by the medical
personnel without any justifiable ground, or temporary shutdown or closure
of medical institutions by a group of the founders causes or is likely to
cause significant difficulties in giving medical treatment to patients.
<Amended by Act No. 8852, Feb 29, 2008; Act No. 9932, Jan 18,
2010>
Therefore, under the current circumstances, most residents who have ceased working
after submitting their resignations may face criminal penalties. Moreover, doctors
risk criminal punishment, which can include imprisonment or more severe
consequences, potentially leading to the revocation of their medical licenses. In
Korea, the professions subject to legal mandates to resume work are medical doctors
and pharmacists (including medicine manufacturers and pharmacy owners) and cargo
drivers (involved in freight transportation businesses and operations).
On April 1, 2024, a statement was issued by the Korean presidency addressing the
nation [11]. Regarding the scale of the
increase in medical school admissions, the government repeatedly stated, “the
government has decided to increase medical school admissions by 2,000 students based
on clear grounds and sufficient discussion,” and emphasized, “if the
medical community argues that the increase should be reduced from 2,000, instead of
collective action, they should properly present a unified proposal with clear
scientific grounds to the government.” This statement also noted that
“the average number of physicians of OECD countries is 3.7 per 1,000
population, but it is 2.1 in Korea.”
The President continued, “if they bring a more reasonable and rational
solution, we can discuss it anytime,” and said, “if better opinions
and rational grounds are presented, government policies can change for the
better.”
At the same time, he emphasized, “However, we can never accept attempts to
force their will through power without proper logic and grounds. They must
immediately stop illegal collective actions and bring rational proposals and
grounds.”
The President said, “I will create a proper medical system through medical
reforms,” adding, “we will make massive financial investments to make
the competitiveness of our country's medical and healthcare industries the
best in the world.”
Mitigation of threats to young physicians by the Korean government after a
meeting between the President and the leader of residents and interns
After the presidential statement, a meeting took place between the President and the
President of the Korea Interns and Residents Association on April 4, 2024, in the
Presidential office. It remains uncertain whether this meeting will serve as a
catalyst for resolving the ongoing conflict regarding the increase in medical school
admissions by 2,000 in Korea. No official announcement has been made about the
content of their discussion. Following this meeting, the Korean government ceased
its threats toward the residents. Nevertheless, the government continued to reject
the resignations of medical residents in accordance with its directive.
After that, the Prime Minister said on April 19, 2024, “regarding the 32
universities whose medical school quota has been expanded this year, if desired, we
will allow them to recruit new students autonomously only in the 2025 school year
within the range of 50% to 100% of the increased number” [12].
The Minister of Health and Welfare said on April 22, 2024 that “the Special
Committee on Medical Reform will be launched this week for social discussions on
medical reform tasks” and “the government will do its best to present
each other's opinions on major issues of medical reform, such as the
direction of investment in essential medical care, through the committee, and to
prepare reasonable alternatives through open discussions.” He asked
“the Korean Medical Association and the Korea Interns and Residents
Association to participate in the special committee on medical reform so that
developmental and constructive discussions can take place, not just turn a blind eye
in connection with the quota of medical schools” [13].
As of late April, there were no further changes in the actions of the residents, who
continued to resign from training hospitals. Despite this, the government persisted
in its efforts to increase medical school quotas, although the presidents of some
medical schools reduced certain quotas. The Korean Medical Association and the Korea
Interns and Residents Association still refrained from participating in the
government's proposed special committee.
What are the fundamental issues in the present situation in Korea: new placement
of 2,000 entrants at Korean medical schools and medical residents’ mass
resignation
First, is the increase of medical school students by 2,000 based on
scientific evidence or a policy judgment?
The Korean government has consistently stated that the increase is "based on
clear grounds and sufficient discussion" and urged physicians to present a
unified proposal with well-founded scientific justification [11]. Three reports are the basis of the government’s
argument [14–16].
However, the authors of these three reports, which the government cited as scientific
evidence, have denied that they constitute a basis for the government's
increase of the medical school quota by 2,000 (https://www.medicaltimes.com/Main/News/NewsView.html?ID=1157769).
Professor Yun-Chul Hong at Seoul National University stated that his research [14] did not support an increase of 2,000
students. Instead, the report presented various scenarios, with the most reasonable
one suggesting an increase of 500 to 1,000 students. He highlighted that although
Korea will experience a physician shortage from 2045 to 2050, an oversupply is
anticipated thereafter. Therefore, he recommended that medical school quotas be
adjusted to reflect these projections.
Dr. Junghyun Kwon from the Korea Development Institute (KDI) has also pointed out
that the government's policy inaccurately interpreted her research [15]. Her proposed scenarios include increasing
admissions by 1,000 students annually starting in 2024 for a total of 4,000
additional students, maintaining a 5% annual increase until 2030 to reach 4,500
students, and 7% and 10% annual increases. Notably, her scenarios do not include one
where admissions increase by 2,000 students each year for five years to add 10,000
students.
Dr. Youngseok Shin, an Honorary Fellow at the Korea Institute for Health and Social
Affairs, expressed his disagreement with the government's plan to increase
medical school admissions by 2,000 students, arguing that the proposed pace is too
rapid [16]. He suggested that even if a total
increase of 10,000 students is deemed necessary by the government, it would be more
prudent to distribute this increment over 10 years rather than 5, taking into
account the medical market conditions at the time the new doctors graduate.
However, the Second Vice Minister of the Ministry of Health and Welfare said,
“Those three reports are policy suggestions, and when the administration
makes policy decisions, of course, those suggestions are considered and referenced.
We make policy decisions by taking into account all the other surrounding conditions
and factors, as well as the demands of other organizations. Therefore, it is up to
the government to make policy decisions” [17].
Considerations for future estimates of the number of physicians
The 18th president of the Korean Society of Epidemiology highlighted
three key factors to consider when estimating future physician demand: healthy
aging, the integration of artificial intelligence (AI) into medicine, and the
regulation of outpatient visits. In an aging population, the prevalence of
diseases may not necessarily rise; rather, the number of individuals enjoying a
healthy old age is increasing. With advancements in AI that are currently
difficult to foresee, we are nearing an era where AI can undertake tasks
traditionally performed by medical professionals [18]. If the work performed by AI programs is recognized for
medical billing, healthcare facilities might not need as many specialists. At
present, AI interpretations are not accepted for billing purposes. However,
AI's diagnostic capabilities are anticipated to exceed those of human
specialists in various fields. When this occurs, AI-generated diagnostic results
could be eligible for billing, and only the more complex cases might require the
attention of a specialist.
Korea's physician-to-population ratio, at 2.6 per 1,000 people in 2021
(2.1 when excluding Oriental medicine doctors), is lower than the OECD average
of 3.7 per 1,000 people. However, the disparity in physician numbers per 1,000
population between Korea and countries such as Japan (2.6), the United States
(2.7), and Canada (2.8) in 2021 is minimal. Despite this, Korea records the
highest number of outpatient visits per capita among OECD countries, with an
annual average of 15.7 visits, significantly higher than the OECD average of 5.9
visits in 2021. The avoidable mortality rate, which quantifies the number of
patients who died due to not receiving timely medical treatment, stands at 142.0
per 100,000 in 2020. This figure is less than half of the OECD average of 293.1
in 2020 [19].
The current supply of healthcare services in Korea ranks among the highest in
OECD countries, and the Korean people benefit from top-level services while
incurring low routine medical costs. However, it is essential to evaluate
whether the high frequency of medical visits indicates an excessive demand for
healthcare. It is crucial to assess whether to maintain the low contribution
rate to health insurance and unrestricted access to medical facilities, or if
controls are necessary.
Dr. Jung said the following about the politics of healthcare reform in Korea
[20]: “First and foremost,
policymakers need to escape the recurring trap of scapegoating and blame
avoidance. The government should establish a new governance framework to foster
a sustainable national-physician relationship. This framework should provide a
space to consider a new healthcare system that ensures health equity and
accommodates demographic and technological changes. Simply increasing staff
numbers will not suffice to improve the healthcare system. While it is essential
to increase the number of physicians, this must be part of a broader set of
policy measures. However, if the essential trust-building between these two
parties continues to deteriorate in the quest to normalize interest group
politics, achieving effective governance will become increasingly
difficult.”
Second, is threatening residents with an order of forced labor reasonable
in Korea, a liberal democratic society?
The government’s threat was noted above [9]. Additionally, the Second Vice-Minister of Health and Welfare
provided a more detailed explanation of this matter [21]:
“Submitting the resignation letters of medical residents collectively does
not genuinely reflect their intent, allowing for the possibility of legislative
invalidation. I mentioned this earlier, didn't I? Consequently, this
action will likely lead to a legal dispute under public law. Under the Medical
Service Act, which is a part of public law, the collective resignation request
was not accepted. However, if the residents fail to report to the hospital and
withhold medical treatment, they violate the mandatory work commencement order.
Such violations are punishable under the Medical Service Act, with penalties
including up to three years of imprisonment. Non-compliance with the work
commencement order will prompt actions from the Minister of Health and Welfare.
Concurrently, the Korean government will initiate legal proceedings by filing a
complaint and accusation. This will trigger the judicial process, starting with
an investigation. The findings of the investigation will lead to an indictment,
followed by a trial. If the trial results in a prison sentence, or even after
the initial verdict, the government will implement administrative measures.
These measures could include the revocation of the residents' medical
licenses once the verdict is announced.”
Although the judicial processes were halted following a meeting between the
Korean President and a medical resident leader, this could still be considered a
demand for forced labor. The Korean government retains the authority to resume
these judicial actions at any time. Meanwhile, hospitals are unable to accept
the residents' resignations due to a government directive, preventing the
residents from seeking employment elsewhere. As a result, they have been without
income for two months.
An opinion presented by a lawyer suggests that the order to commence work, which
the Korean government is threatening to impose on resident doctors, may
potentially be unconstitutional [22].
This opinion is as follows:
“The concerns raised about the directive for medical residents to commence
work under Article 59 of the Medical Service Act stem from the perception that
it has been crafted as an overly forceful approach, exceeding what is necessary
to fulfill a specific administrative goal. In practice, as evidenced by actions
taken against residents, this mandate could potentially serve as a convenient
legal instrument for the government to manipulate medical professionals and the
broader medical community at its discretion. The extent to which the government
might attempt to exert control over the medical sector is profoundly troubling.
After all, doctors are not military physicians who are subject to punishment for
insubordination or for failing to comply with legitimate orders from their
superiors, are they?”
Young physicians must be liberated from despair, fear, and depression
The crux of this issue regarding the government's threats toward resident
physicians revolves around the question: who is responsible for nurturing our
doctors? The idea that physicians trained entirely in the private sector should be
treated similarly to military doctors under Article 59 of the Medical Service Act is
baffling to young doctors. Those of us born in the post-generation (1955-1963),
including myself, served selflessly and without complaint, adhering to the demands
of our senior physicians in the pursuit of national revival, regardless of the
hardships faced. During my internship at Seoul National Hospital from May 1985 to
February 1986, I recall working over 140 hours a week. When the Resident Law, which
limits on-duty hours to 88 per week, including 8 hours for educational purposes, was
enacted in 2015, I was thrilled. I saw this 80-hour limitation as a crucial first
step toward improving both patient safety and the well-being of residents [23].
The post-war generation has successfully achieved the national revival of Korea.
Today's young physicians represent a new generation with values distinct from
those of the post-war era; they have a strong sense of self and are not inclined to
engage in forced labor simply because they are instructed to do so. Failing to adapt
to this shift will hinder our ability to understand, communicate with, and solve
problems alongside the younger generation. It should be clear that coercive measures
such as threatening these young physicians—who will be responsible for our
future—with license suspensions and denial of resignations will not address
the underlying issues. As of April 2024, the government's practice of
vilifying resident physicians in public advertisements can also be seen as a form of
this pressure tactic (Supplement 4). I remember the French artist, Bernard Buffet
(1928–1999)’s message when he was criticized by the public:
“La haine dont je suis entouré est, pour moi, le plus
merveilleux cadeau que l'on m'ait fait”
(“The hate that surrounds me is, for me, the most marvelous gift that anyone
has given me”).
These various measures drive our future healthcare system toward self-destruction;
therefore, attempts to resolve the issue through further threats must cease. When an
individual undertakes work, there must be a purpose, the ability to ascribe value to
that purpose, and commensurate compensation. Moreover, tasks not chosen by oneself
no longer hold meaning for this generation. We must remember that these young
physicians, nurtured by our nation's people and society, are the rising stars
responsible for safeguarding our health in the future.
Clinical faculty members are also under burnout due to long working hours and
frequent duty at night
My junior doctors at university hospitals express feelings of helplessness, anger,
and depression due to the current wave of residents' resignations. They are
among the finest physicians and surgeons globally, yet they are already experiencing
burnout. The primary source of this burnout has been identified as “excessive
regulation by the government or university” [24]. This situation could lead them to leave university hospitals,
driven by a fear of death from overwork. They require psychological support in
addition to the provision of assistant personnel.
Role of the Korea Institute of Medical Education and Evaluation
In March 2024, the Korea Institute of Medical Education and Evaluation (KIMEE)
released the newly revised accreditation criteria, “ASK 2026 (Accreditation
Standards of KIMEE 2026, https://kimee.or.kr/board/data/).” This update replaces the
previous ASK2019 standards [25]. If there are
substantive changes, including an increase in the admission quota, a mandatory
evaluation of the substantive change plan must be undertaken according to the
KIMEE's accreditation process [26].
Failure to secure accreditation means that graduates may lose their eligibility to
sit for the Korean medical licensing examination. As stipulated by the Medical and
Higher Education Act [27], only graduates
from KIMEE-accredited institutions are eligible to take the medical licensing
exam.
The Director of KIMEE stated the following (https://www.docdocdoc.co.kr/news/articleView.html?idxno=3016783):
“As the head of the accreditation agency, I am not at liberty to discuss the
outcomes of forthcoming evaluations in detail. It is essential to understand that
developing a single expert takes more time and effort than one might anticipate.
Additionally, it is important for society to recognize that this investment is
crucial for professionals to fulfill their roles effectively. Medical education
should extend beyond merely passing exams; it must focus on quality and foster an
appropriate educational environment. KIMEE is dedicated to improving the quality of
medical education and making a significant contribution to public health, which is
aligned with these objectives.”
We must consider whether the accreditation system established by KIMEE for quality
management in medical education is capable of effectively responding to the sudden
increase in medical school enrollments by 2,000 students annually.
Editor’s perspective on this policy judgement
From an editorial perspective, it is unfortunate that the three reports cited by the
government as evidence have not yet been published in scholarly journals. Scientists
typically submit their research findings in the form of reports, which are then
published in peer-reviewed scholarly journals. Although the three studies in
question are noteworthy, their scientific credibility would have been increased if
they had been published in academic journals, as is customary for research reports.
Looking ahead, submitting and publishing such policy-related research in
international peer-reviewed journals would promote a wider understanding among
researchers and readers globally, thereby enriching future policy discussions.
Since I am not a specialist in health policy but a retired basic scientist and
teacher, I am unable to intervene in the current turmoil. It appears that both the
Korean government and the medical residents are hesitant to abandon their positions
quickly, likely due to a lack of mutual trust. Consequently, the resignations among
the current residents are expected to persist for an extended period. In this
situation, the two groups most at risk are the patients requiring care in university
hospitals and the clinical faculty members working there. Patients concerned about
delays in their medical care should consider transferring to another general
hospital where residents have not resigned, especially if their wait for surgery or
therapy becomes excessively long.
My greatest concern is the burnout and exhaustion of clinical faculty members who are
required to care for patients during night shifts, a role typically assigned to
residents. I am acutely aware of their dedication to patient care, often at the
expense of their own physical well-being, as I have personally experienced this
during my four years as a clinician, both as a public health physician and an
intern. Therefore, it is crucial for hospital managers to prioritize the reduction
of their workload. One potential strategy could be the introduction of physician
assistants, although this is not a comprehensive solution. Continued experiences of
depression and hopelessness among these faculty members could lead to a breakdown in
the delivery of high-quality healthcare. The primary reason I value living in Korea
is the exceptional level of medical care provided by Korean physicians, healthcare
personnel, and medical institutes. The thought of such a collapse is deeply
troubling.
At present, the situation is dire and demands immediate action. I conclude this
opinion by citing a recommendation from my senior doctor, a specialist in health
policy [28]: “A country's
healthcare policy must first establish a comprehensive dialogue on healthcare, and
then assess the supply and demand for healthcare human resources based on clearly
defined objectives and specific detailed plans. This process also necessitates the
involvement and consensus of the professionals and hierarchical organizations tasked
with healthcare provision. Healthcare policy is a complex and challenging issue that
demands extensive collaboration. The time is now for the Korean government to
formulate a cohesive short- and long-term plan, incorporating expert input, to
guarantee the delivery of sustainable, top-tier healthcare services.”
Authors' contributions
All work was done by Sun Huh.
Conflict of interest
Sun Huh has been the editor of the Ewha Medical Journal since
September 2023. However, he was not involved in the peer review process or
decision-making. Sun Huh is also a member of the Korean Association of Medicine
(KMA); therefore, his ideas and opinions may be biased toward those of KMA and
clinical faculty members, although he was a basic scientist and has already
retired from his university. He may be unable to present a neutral position on
the health policy issue. Otherwise, no potential conflict of interest relevant
to this article was reported.
Supplement 1. The official Emergency Management Committee statement 240220 of the
Korea Interns and Residents Association, released on February 20, 2024
Supplement 2. "Emergency Briefing on the Physician Workforce Expansion
Plan" announced by the Ministry of Health and Welfare on February 6,
2024
Supplement 3. Essential Medical Policy Package announced by the Ministry of
Health and Welfare on February 6, 2024
Supplement 4. Video file publicizing the Korean government’s medical
policy in public places in Korea
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