South Korean President Yoon Suk-yeol is known for being tough on doctors – not without due reason. He has a history of butting heads with the medical establishment.
Prior to 2000, doctors in South Korea both prescribed and sold medicine. This sparked concerns about a conflict of interest for doctors and possible overconsumption of drugs for patients. Doctors had incentives to diagnose as many conditions and sell as much medicine as possible to jack up their revenues. In the 1990s, drug bills accounted for about a third of South Korea’s total expenditure on medical services.
In 2000, the National Assembly passed a law mandating the segregation of prescription and dispensation of medicine so that only pharmacists could sell drugs. In response, doctors of all stripes threw up their hands and closed their hospitals.
Pursuant to the Medical Service Act, which dictates that doctors and medical institutions must comply with government orders to resume medical treatment when public health is in danger, two doctors who incited other doctors into strikes were indicted and convicted and had their medical licenses revoked. It was the first time the Medical Service Act was invoked to successfully charge doctors; the lead prosecutor in the case was none other than Yoon Suk-yeol.
At the height of the COVID-19 crisis, when South Korea’s chronic lack of doctors became self-evident, former President Moon Jae-in wanted to increase the number of medical students, to build public medical schools whose students would be fully funded and required to sojourn in remote areas to provide a steady flow of medical services, and to introduce telemedicine. Doctors went on strikes, wreaking further havoc during the pandemic, until Moon backpedaled.
Yoon must have keenly felt the necessity of similar reforms. In 2023, patient after patient died from delayed treatment due to a shortage of physicians, some in roaming ambulances that failed to find hospitals with specialists at hand. In February 2024, Yoon rolled up his sleeves and the health and education ministries went ahead with plans to increase the quota for medical degrees, thereby increasing the annual number of newly enrolled medical students from 3,000 to 5,000 for the next five years. Considering their teaching capacity now, medical colleges agreed to accept 4,500 new medical students for the 2025 academic year.
In protest, more than 90 percent of South Korea’s roughly 13,000 junior doctors resigned in February, and have not come back since. The consequences are dire. Due to acute staffing shortages, some hospitals can’t admit new ambulances, leading to more preventable deaths. The number of patients that missed the window of opportunity for treatment soared by 40 percent compared to last year.
For the first half of 2024, the proportion of patients dying in emergency rooms was 13.5 percent higher than during the same timeframe last year. Reports of patients passing away in wandering ambulances or arriving too late to faraway hospitals only to die continue to harrow South Koreans on a daily basis. Even for those who survive, the effects of delayed treatment are incalculable.
Still, the doctors are justifying their prolonged walkout. They maintain that South Korea doesn’t need more doctors, downplaying the significance of the fact that South Korea has 2.0 physicians trained in Western medicine per 1,000 people – the OECD average is 3.7. Since “many OECD countries operate on a capitation model, whereas South Korea relies on a fee-for-service model,” their logic goes, the glaring difference in the numbers of doctors somehow loses its statistical potency.
Under capitation models, doctors are paid a fixed amount of money per enrolled patient. Some models impose a cap on the number of enrolled patients each doctor takes under their care in order to ensure quality care and prevent doctors from being overwhelmed and burned out. Some models don’t, meaning the doctor would get paid more for taking on more patients and collecting more per capita fees. Either way, securing enough doctors under capitation or hybrid models prompts a fairer distribution of physicians and patients and a fairer regulation of medical services.
This is not the case in South Korea, where physicians get paid for each instance they dispense medical services. A correct way to digest the OECD data is to realize that there are too few doctors in South Korea, and how many patients they rake into their too few hospitals, where clinicians have all “perverse incentives to perform ‘shiny’ services with high margins and high costs” in the fee-for-service model.
South Korean doctors’ average annual income is $223,000, the highest among OECD countries and almost seven times higher than that of an average South Korean worker. If other OECD members had fewer doctors, their salary would spike, too, whether on capitation models – more patients assigned to each doctor, or more per capita fees collected – or on fee-for-service models. It’s just that other OECD countries managed to produce enough doctors to be able to afford balanced capitation models.
That each OECD country has different medical remuneration schemes hardly means we get to gloss over the statistical implications: South Korea should overhaul its number of doctors and its flawed fee-for-service structure.
In order to mitigate the travesty of an unrestrained fee-for-service model, the Yoon administration announced that it would ban physicians from administering reimbursed and unreimbursed treatments simultaneously. Covering life-saving and most efficient and necessary treatments, reimbursed services are so called because the national health insurance, not the patient, pays the medical institutions and physicians. There are price caps on these procedures, so doctors prefer administering unreimbursed services – the glitzy, redundant ones not covered by the national health insurance. The norm is for South Korean doctors to prescribe both services, so that patients have no choice but to accept the unreimbursed procedures on top of the essential, reimbursed services.
Physicians are as much against the government’s proscription of this practice as against increasing the medical school enrollment cap.
Doctors also cite South Korea’s vastly contracted demographics in the future as another reason to oppose recruiting more medical students. Indeed, South Korea’s population is expected to plunge by 30 percent from 51 million today to 36 million by 2072, and their glib explanation is that fewer people will mean less demand for medical services and doctors. Yet, what this argument intentionally leaves out is the fact that old people require on average three times more medical care than young adults.
The most probable demographic trajectory for South Korea will see people aged over 65 account for 40 percent of the population by 2050 and 50 percent by 2072. Even in the short term, due to the aging population, patients’ average length of hospitalization will jump by 45 percent. Meanwhile, more than 30,000 doctors will retire by 2035.
Boosted demand won’t be limited to geriatrics. Market dynamics are expanding demand for genetic engineering, clinical research, digital healthcare, and biotechnology. Pharmaceuticals, research outfits, and the government require in-house physicians to devise and oversee health projects and policies.
The second reason for doctors’ objection to the government’s enrollment reform is the concern for universities’ education capacity. This is a valid point. Although South Korea boasts significantly low student-to-professor ratios and low student-per-school numbers compared to developed Western countries, discrepancies exist between top-tier and lower-tier schools. Following the increase in enrollment, some schools will struggle to offer proper courses in preclinical medicine. There’s a lack of lecture rooms and labs, too, with lessons taking place in meeting rooms and staff lounges. A shortfall in cadavers for students’ anatomy lessons and hands-on experience is also problematic.
Though legitimate and understandable, these issues hardly negate South Korea’s need for more doctors. The argument might make a convincing case for slowing down or shaving the size of new enrollments, so that schools can better prepare – but not for scrapping the enrollment reform entirely. The government needs to address the structural vulnerabilities, and the time is already too late.
Ultimately, South Korean doctors’ core defense against the Yoon administration’s decision to hike college intakes of medical students is that a better distribution, not more recruitment, of doctors will plug South Korea’s healthcare gaps.
It is true that low compensation rates and higher litigation risks for critical medical services have driven doctors in droves into comfortable, money-minting specialties. Most doctors opt for private practices in lucrative fields such as dermatology, plastic surgery, ophthalmology, and orthopedics where average annual salaries range from $350,000 to $457,000. This has led to a chronic shortage of physicians in such crucial fields as emergency care, cardiothoracic surgery, pediatrics, neurosurgery, internal medicine, etc. In 2022, for instance, hospitals ran a shortfall of 80 percent in their junior doctor recruitment for obstetrics. Meanwhile, 82 percent of specialists trained in cardiovascular surgery have switched to other fields.
Making matters worse, the few remaining specialists converge on top-tier hospitals in metropolitan areas, leaving a gaping medical void in rural areas where there are higher rates of preventable deaths. Doctors are rightly worried that this trend will only accelerate as big, reputable hospitals are adding more wings to bring in more doctors.
Everyone’s accurately aware of the uneven distribution of doctors. The surefire way of addressing this problem is establishing public medical schools to train fully-funded students who will be government-employed physicians with mandatory medical service periods in difficult fields and the countryside. But South Korean doctors have historically been categorically against this.
So the Yoon administration presented some second-best alternatives: jacking up the government-mandated medical fees of essential services to further incentivize practitioners to stick to difficult but critical specialties, handing out cash bonuses to those staying put in the countryside, and increasing the proportion of students from the countryside for medical college admission, among others. Yet striking doctors won’t even budge to consider any other option unless the government scraps the college cap reform.
The fundamental hurdle is this: However much the government spruces up the countryside and injects financial incentives in every step of administering essential services, doctors will still be attracted to profitable fields. Only if private clinics and their physicians start seeing their profits shrink can there be less disparity in the pay scales of disparate specialties. And the only feasible way is to saturate the supply side of the medical market for “popular” fields with more doctors. Once more doctors split the same volume of medical services in plastic surgery, dermatology, and other sought-after specialties, their income would dip somewhat. Then junior doctors would consider twice before fixing their specialties, and may look to other fields.
Behind many of South Korea’s healthcare problems is a hidden issue: the cohort for medical school admission is extremely insular. Around 80 percent of medical students in South Korea hail from households in the top 20 percent income bracket. Students from the richest districts in Seoul score best in exams and pick medical schools as their first choice. This is in stark contrast to other developed countries where education policies are in place to accept medical students from diverse socioeconomic backgrounds to take into account vocational pride and ethics, civic virtues and emotional aptitude – all of which are known to enhance medical care and research.
Given the field’s limited demographic profile, South Korean doctors represent the epitome of herd mentality coagulated around extreme self-interest. A renowned South Korean medical professor encapsulated their mindset perfectly: “Their victim complex, where they believe the government is to blame for all the ills of South Korea’s healthcare system, and their expedient distortion of data are constantly justified and replicated within their exclusionary clique, eventually transmogrifying into a majority faith.” Compromise is impossible, he diagnosed.
Besides junior doctors, more than 95 percent of medical students are refusing to show up in school. Their plan is to choke up their schools’ teaching capacity by having to retake the courses they missed this year, and thus thwart the enrollment of new students next year. Ahn Cheol-soo, a South Korean legislator and formerly a doctor himself, was right in pointing out that ultimately, these junior doctors and medical students believe it’s unfair that getting into medical school would become easier for others. They can’t condone the idea that the government is ruining their future plans.
Cynical as it may sound, no amount of well-conceived medical reforms would achieve a balanced distribution of doctors among specialties and regions with this personnel pool. Still, this could happen over the long term by increasing the medical college enrollment quota and lowering the ridiculously high test score bar, so that those with genuine care for patient well-being and public health can have a chance at holding the scalpel.
Even though the doctors have flouted the Medical Service Act and the government’s order to restore public health, the Yoon administration showed restraint by deciding not to suspend their licenses and allowing hospitals to accept their resignation. This is an olive branch for yet another round of discussion. Yet the healthcare crisis has driven down Yoon’s approval rating to the low 20 percent range. People are barking up the wrong tree.
The opposition Democratic Party surely benefits from faulting Yoon’s every policy, so it’s no surprise it is siding with the doctors. Even the ruling People Power Party is broaching the possibility of mothballing the medical reforms as relentless news on patients’ suffering and dying nibbles at its approval ratings. But is it really Yoon’s fault? It is true that he has generated many scandals and showcased appalling indifference to public sentiment on many fronts – but we should be able to say something’s right when it’s right.
Meanwhile, a doctor has compiled a blacklist of the doctors not participating in the strike and continuing to treat their patients. He leaked their personal information in online medical communities in an attempt to humiliate and ostracize them. It is deplorable, but we now at least know who South Korea’s real doctors are.