| 2024 South Korean medeical crisis | |
| Date: | - present |
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The 2024 South Korean medical crisis is an medical crisis in 2024, in South Korea, due to 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 have been anxiety about patients being unable to receive timely treatment,[1] but no direct patient deaths were attributed to the labor action. There were 2 deaths in the doctors working overtime to cover residents, leading to concerns about how long this can continue before more doctors start dying out.[2]
See also: Healthcare in South Korea.
See also: Demographics of South Korea. The demographics of South Korea indicate there will be a large increase in senior citizens who were born in the two baby boom generations of South Korea (1955–1974), causing a significant increase in demand for medical care in the country in the coming decades. However, the number of doctors per capita in South Korea has been one of the lowest countries in the world, recording 2.6 per 1,000 people in 2021, below that of the United States (2.7) and the OECD average (3.7). The fact that doctors in South Korea are aging as well makes the doctor shortage problem more serious.
The shortage of doctors is more acute in rural areas. In 2023, 69% of local medical centers of Korea could not fill their doctors quota,[3] with Chungnam Seosan medical center being unable to hire enough radiologists despite offering an annual salary of 420 million won (about $300,000)[4] with 4.5 working days per week. Gangwon Sokcho medical center also increased annual salary of emergency medicine specialists to 420 million won ($300,000) because they were unable to fill in the position with lower salary.[5]
According to South Korean President Yoon Suk Yeol, 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 as one of the reasons to expand the enrolment of medical students.[6] According to data from the Organisation of Economic Cooperation and Development (OECD), South Korea has one of the lowest doctor-per-patient ratios among its members, at 2.6 per 1,000 people, similar to Canada (2.8), USA (2.7), and Japan (2.6), and far below the average of 3.7 per 1,000.[7] European countries such as Portugal and Greece, in contrast, has the highest ratios at 6.3 and 5.6 per 1,000, respectively.[7]
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.[8]
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.[9] [10]
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.[11] [12] Health finance system in South Korea is characterized as "low premiums, low medical consultation fees, low pay".[13] 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.[14] [15] [16]
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.[17] 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.[18] The failure have 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.[19] [20] [21]
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.[22] 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.[23]
Since 2006, the admission quota of medical schools has been 3,058 per academic year.[24] The number was decreased from 3,500 in 2000 which is the year where 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,[25] and emergency rooms of local hospitals were also closed.
After the admission quota was reduced to 3,058, governments tried to increase the enrolment quota but failed due to repetitive strong opposition from doctors. In 2020, Korean government announced that they are planning to increase the quota from 3 thousands by 400, which again led to a doctor strike (2020 South Korean medical strike). As done in 2024, residents and interns declared their strikes and stopped working from the training hospitals. This plan was revoked because it was during the COVID-19 pandemic.
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 United States, while in South Korea it is common to exceed more than 100 hours per week.[26] The average salary of residents of South Korea is about 70 million won (about $50,000) [27] which is above the average salary of employees of South Korea but significantly below the average salary of employed specialists which is $200,000.[28]
The fact that the number of increased quota was almost 60% of the original quota made the repulsion more significant. The fact that the increased number of admission will significantly lower the average salary of specialists is considered as another main reason why the training doctors immediately started their resignation in February. The increased quota was decreased from 2,000 to 1,500 in April by the government, but this did not result in withering the strength because doctors argued that the increased quota must be fully rolled back.
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, physician assistants (PA) are illegal to do basic activity such as suture, and also tattoo artists are illegal according to law because their activities are invasive and therefore will hurt the health of citizens.[29] 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.
On the other side, doctors believe that the shortage of manpower in some locations is not due to insufficient numbers, but rather to inadequate medical resources and treatment in those locations that made it difficult to retain staff. The Korea Times writes that even with the increased enrollment, new doctors may choose to go into more popular specialties or urban areas such as Seoul, where there are more patients along with higher pay. Meanwhile, rural areas in South Korea lack medical infrastructure, with patients often travelling long distances to large medical centers in Seoul. Therefore, the development of rural medical care has never improved, and doctors are even less willing to start their careers there.[30]
Yoon Suk Yeol's 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.[31] However, the government moved forward with the plan.[32]
Many doctors resigned collectively.[33] Many undergraduate students in medical schools also went on strike and suspended their studies.
The government raised the crisis level of the country's medical system to "serious".[34]
The Ministry of Health and Welfare announced that all clinics and treatment centers were allowed to provide telemedicine services,[35] which was originally illegal in South Korea. In the past, the controversy about allowing telemedicine was a root cause of doctor's strike in 2014,[36] and since then the services were considered illegal. It had been allowed to limited cases during the COVID-19 pandemic.
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 resigned.[37] In response, the Ministry suspended the medical licenses of two leaders of the Korea Medical Association and ordered the return of 6,228 intern doctors.[38] The government indicated that if they resumed their work by February 29, they would not be punished.[39] On March 1, there were 565 doctors who had yet to return to their duties.[40] 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.[41]
The Ministry announced that nurses would be able to assume some of the duties of doctors.[42] 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.[43]
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 continue the strike to stand against the government.[44]
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 health care reforms.[45]
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.
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.[46] [47]
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.[48] 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 seizured 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.[49]
At 11:00 am local time, more than 11,994 intern and resident doctors remained absent, representing 92% of the trainee doctors.[50] On March 11, the Ministry had issued a notice of suspension of medical licenses to 5,566 intern and resident doctors.[51] The Ministry indicated that those who returned to work before the completion of notification process would be dealt with leniently.[52]
Medical schools reported that they had received 5,445 applications.[53]
On March 11, the government announced that military doctors and doctors from public health clinics would be deployed to hospitals affected by the strike.[54]
Senior doctors and professors from 20 hospitals had indicated that they would submit their resignation letters from March 25 to back the strike.[55] But instead, they began cutting back on hours spent in practice on March 25.[56]
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.[57]
The South Korean government reduced the increasing quota of medical school admissions from 2,000 to 1,500 for one upcoming academic year.[58] [59] 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.
The high court of South Korea judged that increasing the quota of medical schools is necessary for the greater good.[60]
The South Korean government issued a return-to-work order for private practitioners on Tuesday as more doctors including medical professors join the months-long strike to protest increasing medical school admissions.[61]
As of July 18, 2024, only 8.4% of the 12,000 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, allowing them to be employed elsewhere. However, Park Dan, the head of the Korean Intern Resident Association, accused hospital directors 'interfering' with these resident doctors' efforts to be reemployed.[62]
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.[63]
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.[64]
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.[65] [66] However, the Korea Medical Association (KMA) rejected the proposal on April 24 and claimed that the increased quota must be completely rolled back.[67]
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".[68] [69]
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 millions in 2024[70] and the ratio of international marriage of South Korea reached 10% in 2024 as well.[71] A collaboration between South Korea and the Middle East/African countries from 2010s reported that over 130 doctors from 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.[72]
South Korean President Yoon Suk Yeol lambasted the strike and denied that the increase in medical students would lead to a decline in quality of medical education. He stated that the strike should not threaten the lives and health of the population, and that the proposed increase of 2,000 students is the minimum required.[73] [74] His government stated that if the doctors on strike did not return to work, their medical licenses would be suspended.
To address the shortage of medical workforce, the government deployed military doctors and public health doctors to major hospitals. Nurses were also given legal protection to perform certain medical procedures typically handled by doctors, such as administering CPR and medication to emergency patients.[75]
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.[76]
The Education Ministry introduced guidelines to prevent boycotting medical students from failing their semesters due to insufficient class attendance.[77] Measures included:
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 and The Korea Medical Association pointed out that the planned enrollment increase will not be able to fix the immediate manpower issue as training doctors typically takes ten years.[78] 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.[79] 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.[80] 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.
The Korea Medical Association believes that the root cause of the shortage in South Korea's medical services is not the lack of doctors, but the uneven distribution of medical facilities between urban and rural areas, poor labor conditions, and high litigation risks. Therefore, the union believes that increasing the number of doctors will not resolve the shortage or disparities.
The Korea Medical Association stated that the right to strike and resign by doctors are protected by the constitution.[81] 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.
Medical students began to boycott attending their classes, as declared by the Korean Medical Student Association, in support of the strike since February 20. As a result, Gachon University postponed the start of the semester from mid-February to March 4 initially, then once more till 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.[82] 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.[83]
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.[84] [85]
Patient groups in South Korea spoke their concerns about the continuing conflicts between the government and the doctors.[86] In July 4th, 92 patient groups including Union of Korea Breast Cancer Patient, 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.[87] An interviewee, Cha Jae-Hwan, said that both the government and doctor group are problematic because the government did not go through a proper social discussion and the doctor group is reacting without proper consideration of patients. The chief of Korea Alliance of Patients Organization, Ahn Ki-Jong, claimed that they will support legislation for preventing practicians in life-critical areas from performing group actions against patients in South Korea.
Lee Jae-myung of the Democratic Party also opposed the strike and supported the increase in enrollment of medical students.[88] Groups representing cancer and ALS patients have also called for the quick return of striking doctors.[89] The Korean Buddhist order, Jogye Order had also urged the return of striking doctors on February 22.[90] A Gallup Korea poll found that 76% of those polled supported the increase in enrollment, with only 16% opposing it.[91] A survey published on March 5 by the Yonhap News Agency found 84% of respondents supported adding more doctors, while 43% indicated that the doctors on strike should be sternly punished.
Severance Hospital, Seoul National University Hospital, and many other hospitals were forced to cancel or postpone many surgeries.[92] Some hospitals also decided to shorten the time to operate on patients or give priority to critically ill patients.[93] There have been claims about bad outcomes to patients from the strike. One person on social media blamed the death of their grandmother as a result of the strike.[94] There was another claim that a woman died due to a lack of staffing and beds,[95] [96] but it was later determined that this woman had end-stage cancer and already had advance directive to Do-Not-Resuscitate (DNR).[97] There were real casualties among the doctors, however. An ophthalmology professor in his 40's died of brain hemorrhage on March 24, 2024[98] and an internal medicine professor in his 50's 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.