On August 7, Yeouido Park in Seoul was crowded with thousands of medical interns and residents who gathered to protest against the new medical reform policies that the government proposed. Following this gathering, doctors from all across the country went on a general strike on August 14, seeing that the government showed no intention of withdrawing the policies. After the first general strike, a second one took place for four days, from August 26 to 29. As of September 4, however, the seemingly endless clash between the two parties came to an end. The Korean Medical Association (KMA) and the Korea Centers for Disease Control and Prevention (KCDC) signed a statement of agreement to return to the discussion after the situation with the coronavirus disease (COVID-19) settles down.

Amidst the COVID-19 pandemic that has left the entire world in chaos, the standoff between doctors and the government in South Korea has brought even greater disorder in the country. The conflict was triggered when the South Korean government proposed four new medical reform policies. The first policy proposed an increase of the total number of doctors in the country by 4,000 over the course of 10 years. The second policy proposed to establish public health and medical colleges in regions of the country that lack medical schools. The third policy proposed to expand health insurance on herbal medicine, and the final policy proposed to promote non-face-to- face medical treatments.

Doctors were especially discontent with the first reform policy — the increase in the number of doctors. In order to express disagreement with the government’s proposal, doctors across the country went on a series of general strikes. However, not all stakeholders in the medical field shared the doctors’ point of view. For example, nurses were under much pressure due to the lack of helping hands in hospitals. Also, with the conflict between the government and the doctors, the inextricable problems in the medical field have also risen to the surface. Fortunately, KMA and KCDC reached an agreement to bring a temporary halt to the conflict until after the situation with the virus improves, bringing relief to the public.

The Four Medical Reform Policies in More Detail

Out of the four policies, the first two have caused most controversy. The government has proposed a plan to increase the total number of doctors in South Korea by 4,000 over 10 years, starting in 2022. Hankyoreh reports that the government is planning to allocate 3,000 of these doctors to specific regions of South Korea for a mandatory labor of 10 years. The other 1,000 doctors will be allocated to shunned or special areas of medical studies, such as epidemiologic surveys and pediatric surgery, in order to strengthen research in those fields.

According to South Korea’s Ministry of Health and Welfare (MOHW), such a policy is necessary because the number of doctors per 1,000 people in South Korea is 2.3, which is too low compared to the average number of 3.4 doctors in other nations of the Organization of Economic Cooperation and Development (OECD). The government also proposed to establish public health and medical colleges in the blind spots of healthcare in order to resolve the problem of the lack of doctors in these regions. According to the Korea JoongAng Daily, students who enroll in these colleges will be exempt from paying the tuition fee but are obligated to work 10 years in medically vulnerable zones upon graduation.

The other two policies, on the other hand, did not cause as much tension between the doctors and the government. Starting in October, the government planned to extend the application of health insurance to herbal medicines. This policy, however, built up tension between KMA and the Association of Korean Medicine (AKOM) as the two parties’ stances on the policy clashed. Finally, the government’s proposal to practice non-face-to-face medical treatments has been mutually agreed upon due to the concern of the spread of COVID- 19 through face-to-face interactions.

Dissatisfied Medical Fields

The medical field consists of several different personnel, including medical residents, interns, and specialists. Whereas a medical intern is in the course of training through various experiences in the hospital, a resident undergoes advanced clinical training in a specific field with more expertise. After these two courses, doctors can finally become specialists. Therefore, the Korean Intern Resident Association (KIRA) and KMA are the main interest groups that are engaged in the current controversy. Although KMA does often conduct activities for public utility, it is clearly an interest group that puts its highest priority on its own interest, and now their interest and the government’s pursuit of public health do not seem to correspond.

KIRA and KMA have expressed vehement opposition toward the new policies with several concerns. First of all, about the government’s decision to expand the medical school quota, KMA pointed out that it is problematic to judge the degree of access to health care only by the simple statistics of the OECD average or the number of doctors by region. According to the 2019 Annual Report of Health and Welfare Statistics, the average number of times citizens received outpatient care in 2018 was 16.9 times, which was much higher than the OECD average of 7.1 times and already among the world’s highest levels. In addition, as South Korea’s birthrate is expected to continue decreasing until the 2040s and 2050s, expanded medical human resources would lead to another problem — an over-supply of medical personnel.

Thresholds regarding the establishment of public medical schools were also pointed out. KMA insisted that public medical schools would not be as effective in enhancing public medical service and resolving the imbalance in the supply of medical services. Complaints were raised focusing on the policy that requires 10 years of mandatory service in underserved regions. KIRA has been concerned that working on duty would reduce doctors’ free will to work, which would cause degradation in its quality.

According to an interview with a plastic surgeon practicing in Seoul, instead of forcing doctors to work in underserved rural areas, employing competent doctors to hospitals in rural areas by giving incentives would be a more effective policy. In addition, he pointed out that it is important to realize the fact that an increase in the number of doctors will definitely lead to an increase in medical expenses. Also, the policy, which has also been tried in Japan several years ago and resulted in failure, is expected to have a high possibility of widening the gap between urban and rural areas as the doctors finished with their mandatory service in the rural areas would crowd around the cities.

What KIRA suggests is establishing medical centers with enhanced capabilities in rural areas. Building big hospitals in the rural areas where people have relatively low access to medical services and the government actively investing in them is being considered as a better plan for improvement in the regions which lag in care. In the interview, the surgeon continued to mention, “If the government wants to deploy medical facilities in rural areas, it should spend the government’s budget to establish public hospitals and continue to invest into those that are running into deficit, so that they can be maintained,” pointing out the necessity of the government to convince citizens to pay additional taxes for the enhancement of health service in rural areas.

Voices of opposition to the public medical school policy did not end here. Since the students recommended by governors and mayors are going to be allowed to enter the public medical school, controversies about the preferential treatment during the entrance exam were being raised. Although the government denied the possibility, KIRA and KMA have continuously raised suspicion. In addition, the mandatory service in rural areas can also be considered as a violation of one’s freedom to decide on a job, according to KIRA.

The policy of expanding insurance coverage for herbal medicine was being faced with opposition from doctors as well. Doctors took a critical stand on its medical reliability and safety. They argued that covering herbal medicines without sufficient verification will only cause a waste of health insurance, with the criteria for the distribution of medicinal herbs not being fully institutionalized at the same time. Accordingly, the oriental medical community strongly opposed this stance, claiming that the doctors’ stance only showed egoism that turns a blind eye to the health of citizens.

Strong Actions Taken by KIRA and KMA

KIRA and KMA have been in continuous conflict with the government, eventually leading to the collective action of suspending medical examinations, beginning from August 14. Until the day before, the government and medical professionals tried to find an agreement. However, their efforts were unsuccessful. The first collective action lasted for four days, from August 26 to 29. From doctors who own their own private hospitals to those who are in large hospitals such as Asan Medical Center and Samsung Medical Center, a significant number of medical interns and residents have suspended their medical examinations, causing setbacks in treating patients.

As KIRA continued its suspension, medical school students have also decided to refuse to take the state medical examination and go on a unified student strike. According to Munhwa Broadcasting Corporation (MBC), among 3,036 residents who were eligible to take the medical examination, 93 percent canceled it. In addition, more than 90 percent of all medical students in Korea decided to take a leave of absence from school.

Responses of Other Agents

Some other agents in medical fields showed somewhat different stances from those of doctors. In particular, hospitals were faced with the setbacks caused by doctors who suspended their examinations. Emergency rooms of leading medical institutions, where doctors play a pivotal role, were especially influenced. Despite professors carrying on duty in the emergency room and medical office, difficulty caused by the shortage of labor force was inevitable. It has been reported that the Director of Asan Hyundai Medical Center, Park Hyun Seo, openly criticized emergency room doctors who went on strike, leaving their patients behind.

Doctors of Korean medicine have also made their own arguments. The Association of Korean Medicine (AKM) criticized the doctors in the strike as being irresponsible while requesting the government to actively utilize a wide range of medical resources, including Korean medical doctors themselves, for public health and the management of the current quarantine situation. Furthermore, they pointed out the monopoly structure of western medicine doctors in the Korean medical field.

The Korean Nurses Association (KNA) took a somewhat different approach than the aforementioned agents. On August 27, KNA issued a statement criticizing doctors for going on strike in this urgent pandemic situation in which the second wave of COVID-19 began. In addition, they stressed that the doctors’ strike only caused a disruption of nurses’ working environment and an increase in their workload, with some nurses even undertaking illegal medical procedures that should have been done by doctors. Although some doctors requested nurses to cooperate in their struggle against the government, KNA has pledged that they will devote themselves to the well-being of patients, under the Nightingale Oath.

Strong Measures and Deepening Gap

The government also reacted strongly to the doctors’ backlash against the policies. According to the Cheong Wa Dae spokesperson Kang Minseok, President Moon Jae-in has ordered that action must be taken through strict law enforcement regarding the doctors’ strike. Accordingly, on August 28, the government issued a work initiation order to doctors and accused 10 doctors who did not carry out the order, later expanding the range of the order from the metropolitan area to the whole country. Additionally, the government decided to conduct an intensive investigation into roughly 30 hospitals, checking doctors’ attendance. The MOHW explained these strong measures as actions for the sake of patients’ safety.

However, these strong measures of the government did not seem to be effective. For instance, 47 out of 60 doctors in Korea University (KU) Guro Hospital handed in their resignation to show their resistance to the government policy. According to the Joong Ang Daily, the president of KMA, Choi Dae Zip, criticized the government’s measures as wrongful exercises of authority, which added fuel to the fire. Not only the doctors but also other political communities showed voices of opposition toward the government. For example, on August 27, Ahn Chul-soo of the People’s Party claimed that the reason for introducing the problematic policy at the threshold of the second spread of COVID-19 does not seem reasonable.

Eventually, the pain and damage affected the citizens as well. Medical vacancies have, indeed, become a reality. Delay in medical treatment and surgery continued to occur in major hospitals such as Seoul National University (SNU) Hospital and Seoul Asan Medical Center. Numerous patients who were scheduled to have surgery despaired in the face of the uncertainty of the situation. In a situation in which even the treatment of emergency patients suffered from a setback, some professors temporarily took the role of doctors, but difficulties in managing the whole situation continued to exist.

As the harsh wind and waves consequently caused severe hardship to citizens and patients, the government and KMA tried to reach an agreement. Finally, on September 4, the ruling party and KMA agreed to review the legislative measures related to policies to expand public health care from scratch. It was decided that the expansion of the medical school quota and establishment of the public medical university will be discussed after the COVID-19 situation stabilizes. Therefore, the collective adjournment, which has been continued for nearly 15 days, finally came to an end.

However, this did not mean a complete end of controversy. “The majority of students who took a leave of absence from school are currently experiencing confusion because of the one-sided announcement which seems to be under the guise,” said Park Yeonju (College of Medicine, Chung-Ang University), a student studying medicine, hoping for a profound communication to be achieved as soon as possible.

The History of Medical Education in South Korea

The government’s medical policies and its conflict with the doctors point to the undeniable flaws in the current medical field in South Korea. Therefore, in order to gain a deeper understanding of the situation, it is necessary to look into how the medical education in South Korea has changed throughout time and how this history could have shaped the current issues in the medical field.

Professor Park Kyong Hwa (College of Medicine) explained how the medical curriculum in South Korea has changed since the 19th century. According to Professor Park, “Upon liberation from the Japanese colonialism, the six-year medical education curriculum has become the norm in South Korea.” However, the education curriculum has experienced changes when five medical schools have been switched to medical graduate schools in 2004, and 27 more have also partly or entirely been switched to such in 2006.

Professor Park explained that South Korea initially attempted to incorporate the medical graduate school system of the United States (U.S.), but the medical graduate schools were eventually abolished in 2015, and now only three of them remain. She highlighted that “in implementing a system from the U.S., a country that holds different cultural, historical, philosophical, and social background and situation, South Korea failed to go through a careful planning stage.” However, the Professor Park added on that “although medical graduate schools have not resulted in a success, such an attempt to open up medical graduate schools in South Korea encouraged the country to focus more on improving the quality of medical education.”

Upon graduating from medical college and completing a year of internship, students go through three to four years of resident training. According to Professor Park, South Korea has introduced resident training as part of the medical education curriculum since 1955. Here, she commented that “the educational content and quality regarding the resident training has been the same for 65 years and only experienced a slight change when the special law for residents was introduced in 2018.” Professor Park further mentioned that the reason for such a reality is due to several reasons, including the high work burden of training hospitals followed by excessive reliance on residents, lack of time of the resident training staff, and lack in management of the training program.

Professor Park concluded that other countries that are also incorporating western medicine are providing adequate public funding on the training of residents and nurturing doctors. On the other hand, the South Korean medical system lacks governmental support. Thus, some of the major problems in the current medical field of South Korea seem to be coming directly from this very reality.

The Underlying Problems in the Current Medical Field

As aforementioned, the conflict between KMA and the government has revealed the underlying problems in the current medical field of South Korea. In a research paper written by Professor Lee Sang Yi (Department of Preventive Medicine, Jeju National University), the author gives an explanation of the problems of South Korea’s medical supply system. First, he points out that South Korea has an extremely low proportion of publicly funded health care. According to a graph he presents regarding the proportion of public hospitals out of all hospitals in the OECD nations, South Korea has less than 10 percent of public hospitals, ranking at the lowest of the OECD nations.

Professor Park proposed a suggestion for the improvement of the current problems of the medical field. According to Professor Park, “the medical field has been putting in a significant amount of effort to provide the type of medical agents and services that society asks for.” However, she pointed out that the resources and capital spent on nurturing doctors so far have been based mostly on private capital. The professor explains that “the modern society recognizes the right of health and equal access to medical service as part of the basic human right.” Therefore, following this trend, the medical field has recognized medical treatment as a form of public responsibility.

However, as mentioned, South Korea currently lacks in publicly funded health care. Professor Park explained that the medical field’s lack of public funds is prominent in educational programs. She emphasized that “in order for the medical field to nurture responsible medical professionals who can fulfill the expectations of the people, publicly funded medical education programs will be needed.”

For example, Professor Park mentioned that “in terms of shortening the working time of residents, the medical curriculum should focus more on nurturing the core competence necessary for professionals instead of continuing the apprenticeship education where doctors stay in hospitals for a long time treating patients.” At the same time, she pointed out that “in advising plans for providing substitutions in the labor force in response to shortening the working time of residents and implementing programs to nurture core competence, the funding currently comes almost entirely from private capital and significantly lacks in government funding.”

Indeed, the government’s medical reform policies were initially for the betterment of the medical supply system in South Korea. However, the KMA side also raised compelling voices going against the policies. Fortunately, the agreement reached by the two parties to continue their discussion when the situation with COVID-19 settles down is expected to bring about a positive effect on the current dire situation. It would be advisable for both parties to take an open-minded approach instead of forcing their decisions in order to resolve and improve the medical field for all.