On April 25, the first meeting of the Special Committee on Healthcare Reform was held, a leading part of the government's healthcare reform goal. Officials in the medical field attended the meeting; however, representatives of the Korean Medical Association (KMA) did not attend as they oppose the reform plan, including the controversial proposal to expand the quota for medical schools. In response, the committee stated that it has no plans to discuss this further, leading to ongoing conflict with physician organizations.

 

A prelude of tension in the medical world

The government is promoting healthcare reform to solve problems such as shortage of physicians in community healthcare and emergency medicine. It is referred to as the Four Essential Healthcare Policies' Package and includes content such as establishing a medical accident safety net and strengthening local medical care. Among these, the expansion of medical personnel by increasing the admission quota of medical schools for solving understaffing in the healthcare industry was attempted by the previous government too. In 2020, under President Moon Jae-in, the government pushed the expansion, but due to the COVID-19 pandemic and opposition from physician organizations, it was withdrawn with a plan to revisit the issue after the pandemic had ended. However, in the current government, a survey was conducted by the Ministry of Health and Welfare (MOHW) to show the demand for places for 40 medical schools nationwide in November 2023, for determining the specific quota to be set. The results showed that the demand for an increase from all medical schools ranged from a minimum of 2,151 to a maximum of 2,847. The government understood this to mean it was not only them but also medical schools that have an intention to increase the number. Reflecting this result, on February 6, the government announced that it will increase the quota for medical schools by 2,000 students to a total of 5,058 students from the 2025 academic year. The announcement aimed to increase the total number of doctors by 10,000 by 2035, with the goal of deploying them to areas in need of recruitment. As such, the government has shown its commitment to healthcare reform and has prepared implementation plans.
While the government is planning to expand the quota for medical schools, physician organizations, led by the KMA, are opposed to it. The KMA disputed the credibility of the government's survey, arguing that it did not specify who responded and did not reflect the opinions of professors and students. Also, they claimed that they had already conveyed their opposition to an increase in the quota for medical schools in a medical consultation meeting with the government held on January 30, 2023. Based on this, they emphasized that the policy was being pushed ahead without considering the medical community's position. Correspondingly, according to the "Inspection Results of 100 Major Training Hospitals" report which the MOHW released on February 21, approximately 71.2 percent of residents, who are training in hospitals by assisting professors in treating patients and doing surgeries, had submitted their resignations as of February 20. This collective action of residents shows that they are leaving the medical field to express their opposition to the expansion of the quota in medical schools. Following their resignations, professors at medical schools have also submitted their resignations since March. With this situation, the disruption in the medical field is likely to continue.
 

 

Turbulence for the issues of healthcare

There are several issues in the conflict between the government promoting healthcare reform and physician organizations opposing it. Among them are the concentration of hospitals in the capital and the weakening of local healthcare due to lack of support. According to Statistics Korea in December 2023, Seoul City had the most doctors and Sejong City had the least as of 2022, and Seoul was the only city in the country with more than four doctors per 1,000 people, indicating a concentration of doctors in the capital. This is happening because in the situation where the overall population is shrinking, especially in rural areas, doctors are flocking to metropolitan areas with more patients to treat. Not only is the number of local doctors low, but local medical facilities are also closing. On March 19, Ungsang Central Hospital, the only general hospital in Ungsang, South Gyeongsang, closed due to deficits. To address these gaps in the local healthcare system, the government has announced that they have a plan of implementing a "contract-based local medical doctor system" to assign the growing number of medical personnel to regions as they expand. According to them, the system will provide benefits in terms of wages, housing, etc. to encourage doctors to work in regional medical fields instead of metropolitan areas, which guides doctors to voluntarily choose to work in those regions. However, physician organizations countered that the system is not mandatory which means the choices are left to the doctors, and that the priority should be to expand medical facilities in non-metropolitan areas rather than increasing the number of doctors. They argued that increasing the number of doctors will not solve the concentration of doctors in metropolitan areas when local healthcare facilities are closing due to deteriorating finances. While both the government and doctors' organizations agree on the challenges facing the local healthcare system, they have differences on how to solve them.
Another area of disagreement is how to address the labor shortage in essential medical fields. Essential medical care refers to fields such as emergency medicine and trauma surgery, which are directly related to people's lives, or pediatrics and obstetrics and gynecology, where there is a medical gap due to low supply compared to demand. According to the "Resident Recruitment Selection Results for the First Half of the Year for 144 Hospitals Nationwide" report released by the MOHW in December 2023, unlike plastic surgery and dermatology, which had an application rate of over 100 percent, obstetrics and gynecology were unable to secure enough to fill their recruitment goal. It shows that compared to dermatology and plastic surgery, which are popular due to their high wages, these essential medical fields receive fewer volunteers due to their low wages and high risk such as intensive surgery. This situation highlights the imbalance of staffing in the medical field. Therefore, the government has proposed expanding the quota in medical schools to ensure an ample supply of doctors for deployment in essential medical fields. Physician organizations have pushed back against these plans, arguing again that increasing the number of doctors is not the solution. Jeon Jin-han, the director of policy for the Korean Federation Medical Activist Groups for Health Rights, said, "If there is no inducement for the additional 10,000 doctors to work in essential and community healthcare by 2035, there will be a rush to open cosmetic and plastic surgery practices, which will overheat the non-essential market and neglect essential care."¹⁾ This argues that increasing the number of doctors would exacerbate the imbalance when there is already a preference for certain specialties. Rather than increasing the number of doctors, they called for the creation of a public healthcare organization to redeploy existing personnel. It seems that a consensus between the two sides is needed to settle the issue of essential and local medical care.
Increasing the quota for medical schools also requires enlarging facilities to teach students accordingly. Since medical students are expected to be able to handle patients in hospitals after graduation, universities offer both theoretical and practical classes. In particular, a certain number of full-time professors is required in those practical classes to teach students. Reflecting these characteristics of medical schools, the government has announced a plan to increase the number of professors at national university medical schools to 1,000 by 2027 to accommodate the growing number of students. However, physician organizations criticized the government's plan, saying that it is not realistic to secure enough professors in a short period of time to keep up with the increase in the number of students. Rebutting this, Jeong Tong-ryeong, a public health policy officer at the MOHW, said, "In addition to full-time professors, medical schools have various types of professors, including endowed professors and clinical professors. Currently, about half of the professors in hospitals are endowed or clinical professors, and there should be an expansion method of converting them to full-time professors."²⁾ This indicates that the government has a plan to address the raised concerns by converting existing professors of various types to full-time professors at schools. As such, conflicts between the government and physician organizations continue in each of the areas targeted by healthcare reform.
 

 

The ripple effects of conflict

The disagreements between the government and physician organizations over healthcare reform are also affecting overall healthcare operations. As residents and professors have submitted their resignations, hospitals have been unable to accept as many patients as usual because there are fewer physicians to perform surgeries. According to the "National Survey on the Management Status of Training Hospitals" conducted by the Korea Hospital Association on April 1, the average revenue of 50 hospitals nationwide between February 16 and March 31 fell by about 8.76 billion won compared to last year. This indicates that as the number of patients visiting hospitals decreases, so does revenue, making it difficult for hospitals to operate normally. To cope with this situation, hospitals are asking employees to take unpaid vacations or voluntary retirement to reduce losses and considering the fatigue of remaining professors, some hospitals such as Seoul National University Hospital are closing the whole system once a week. These disruptions are not only affecting the economic situation of hospitals, but also the patients. Na Kyeong-chang, who was hospitalized after undergoing surgery, said, "I can see that the remaining professors are busy and struggling because of the strike and understand that they should take a break. But what should the patients do if the hospital is not operating well?"³⁾ In other words, the unstable situation in the hospital is causing anxiety for patients who have a right to get proper care. Unless the government and doctors' organizations come to an agreement, the harm to third parties is likely to continue.
Confusion in medical operations is also affecting the nurses who have been mobilized to fill them. In response to the prolonged resignation of doctors, the MOHW implemented the Dedicated Nurse Pilot Project to temporarily allow nurses to perform surgical assisting roles previously performed by residents. This aims to ensure that hospitals can continue to operate through the division of labor between medical professions. However, as the current law defines a nurse's duties ambiguously as "performing medical auxiliary acts under the guidance of a physician," there is a possibility of leaving them without legal protection in the event of a problem. One nurse at a large hospital expressed her frustration with the current situation saying, "I am stressed out by the scope of my work, which is not legally protected, and afraid for not only my job insecurity due to unwanted leave or unpaid vacation, but also the survival of the hospital and the healthcare system itself."⁴⁾ This indicates that the nurses were brought in to deal with an unstable healthcare situation, but now a new set of problems are emerging in the field. Both patients and nurses are being harmed due to the conflict over healthcare reform.
Along with this problematic situation, as the conflict has become more significant in the medical field, there have been changes on both sides. To address objections from physician organizations, the government revised its stance to allow universities to set the number of recruits within a range of 50-100 percent of the original proposal of 2,000 for new students in 2025 on April 19. That is, the number of recruits will be reduced to between 1,000 to 1,500 depending on the university's autonomous judgment. Despite these changes, Lim Hyeon-taek, the newly elected chairman in the KMA, has stated that he will lead a general strike of doctors and is sticking to the position that medical school quotas should be reduced. Furthermore, this lack of a consensus is also causing confusion for universities, which are required to submit their 2025 medical school enrollment projections to the Korean Council for University Education by April 30. As of April 28, national universities such as Chungnam National University and Pusan National University had not decided on the number of applicants, stating that they were still under review. This lack of an agreement between the two sides has also led to criticism of both the government and the medical community. Ahn Ki-jong, president of the Korea Alliance of Patients' Organization, said, "Patients are fighting their diseases on their own. Both the government and the medical community should take a step back and resolve the prolonged medical gap first, but they are not even discussing it, let alone considering people's lives."⁵⁾ This indicates that the government and doctors' organizations are missing the main point of healthcare: fulfilling its responsibility to protect patients' lives. As people are being harmed by the current conflict over the future direction of the healthcare system, it seems necessary to take action to end the conflict.
 

 

Calls for collaborative behavior

The background of the government's healthcare reform program is a series of problems in the healthcare system, such as the rural system and essential care. Both the government and physician organizations agree that improvements are needed in these areas but disagree on the specific solutions. The conflicts driven by these disagreements are affecting hospitals, nurses, and even patients, causing confusions. To resolve them, it seems that the two sides need to work together in the long term, rather than sticking to their positions.

 

1) Lim Il-yeong, "①Speed Up Healthcare Reform ②Incentivize Essential Medical Departments ③Support Local Doctors", The Seoul Shinmun, February 8, 2024

2) Gwak Seong-sun, ""National University Hospital 'Hiring 1,000 More Professors,' Begins Coordination Before Increasing Medical School Quota"", Young Doctor, April 8, 2024

3) Hyung Min-woo, "Some Hospitals Suspend Weekly Outpatient Visits and Surgeries... Increasing Patient Anxiety", YONHAP NEWS AGENCY, April 23, 2024

4) Lee Yeong-jin, Kim Ja-ram, "Current Nurses "Healthcare Strikes Are Frustrating and Scary"", ohmynews, April 26, 2024

5) Kim Byeong-gyu, Kwon Ji-hyun, "[Medical Strike Two Months] ①No Exit for Conflicts... Only 'Repeating Claims' on Both Sides", YONHAP NEWS AGENCY, April 18, 2024