Why Did All the Residents Resign? Key Takeaways From the Junior Physicians’ Mass Walkout in South Korea

Introduction

In February 2024, more than 90% of resident physicians in South Korea resigned, and more than 70% of medical students took a leave of absence.¹ These actions followed the government’s announcement of new health care policies, including an increase in medical student quotas. We present key insights from this event for health care professionals, administrators, and policymakers.

Problems That Call for Health Care Reform

South Korea’s health system relies on the National Health Insurance Service (NHIS), a single-payer system funded by insurance premiums (80%), government subsidies (14%), and tobacco taxes (6%). As of 2022, an impressive 97% of Korean citizens are covered by the NHIS.² All Korean physicians are mandated to exclusively work with the NHIS, which strictly controls prices for insurance-covered services.

While the NHIS has provided affordable and accessible high-quality medical services for nearly 5 decades,³ a major criticism is its low reimbursement rates for physicians. Government-set prices for patient assessment, procedures, and surgeries fall below sustainable levels, with the reimbursement rate standing at a mere 90% of the actual cost as of 2016.⁴ Consequently, hospitals offset losses from insurance-covered services by maximizing revenue from out-of-pocket medical services and nonmedical services (eg, parking lots and funeral homes).⁵ This pressure affects physicians in teaching hospitals, who must complete ambulatory encounters in less than 5 minutes and perform swift surgeries, leaving little room for trainees to learn at a safe pace.

Moreover, South Korean physicians face potential criminal prosecution (alongside civil lawsuits) even for inevitable adverse outcomes. Over the past decade, Korean media have highlighted physicians undergoing multiyear legal trials,⁶ discouraging young physicians from pursuing high-risk medical specialties like obstetrics and intensive care.

The combination of low reimbursement rates and legal risks has given rise to “deferred specialties.”⁷ These fields are marked by substantial workloads, high liability, and a lack of opportunity to offset low reimbursement rates through out-of-pocket services. In specific domains like trauma surgery or pediatrics, major Korean hospitals strategically employ only the minimum number of board-certified physicians necessary to qualify for the “tertiary center” designation.

In 2022, a tragic accident at Asan Medical Center, one of Korea’s largest teaching hospitals, exposed poor staffing of neurosurgeons.⁸ A nurse suffered a brain hemorrhage during a shift, and unfortunately, there was no in-house neurosurgeon available with the necessary craniotomy skills, resulting in delayed treatment and patient death.

Overworked and Exhausted Trainees

In Korean hospitals, the workload of residents plays a crucial role in cost reduction. These residents, who earn minimum hourly wages (or less), constitute 30% to 45% of all physicians in major Korean teaching hospitals.⁹ Despite regulations limiting weekly hours to 80, some residents work over 100 hours weekly.¹⁰ Unlike their US counterparts, Korean residents handle additional responsibilities beyond medical decision-making, without the same level of interdisciplinary support (eg, case managers and medical technicians). This multifaceted workload poses challenges for trainees to complete tasks within the regulated time frame. The prospect of higher income as board-certified physicians motivates residents to endure this demanding training.

Simultaneously, a trend has emerged among Korean medical graduates: Many pursue high-paying aesthetic medicine (eg, dermatology procedures) without postgraduate training.¹¹ This exodus from deferred specialties highlights systemic flaws within the Korean health care system.

Development of Residents’ Mass Resignation

Two months before the Korean congressional election, the government unilaterally announced health care reform plans. These included a 60% increase in annual medical student intake and a ban on mixing NHIS-covered and uncovered services in a single encounter. The government believed this would lead to reduced salaries for aesthetic medicine practitioners and encourage more physicians to choose deferred specialties.

In response, residents collectively exited their training.¹ Most medical students declined to sign up for the new academic year, and less than 10% of the graduating class opted for residency.¹² While attending physicians continued their work, large training hospitals faced financial strain.¹³ The government implemented drastic measures (see Table).

Table.

Measures Taken by the Korean Government in Response to Residents’ Mass Resignation

Government Measures	Descriptions
Return-to-work order for resigned residents	Issued for resigned residents, requiring them to return to work immediately. Noncompliance may result in license suspension.
Restriction on residents’ resignation	Prevents residents from resigning from teaching hospitals. Blocks them from working at nonteaching hospitals.
Restriction on medical student leave	Medical schools now impose restrictions on granting students’ leave.
Restriction on attendings’ resignation	Attendings in teaching hospitals can no longer freely resign from their clinical positions.
Investigation of alleged leaders of mass resignation	Former and current presidents of the Korean Medical Association are undergoing investigation for allegedly promoting mass resignation.
Announcement of stricter rules for issuing the Statement of Need	The document required for obtaining a US J1 Visa will not be issued to those who refused to comply with the return-to-work order.
Mobilization of government-employed physicians	Medical officers (in the military) and public health physicians are deployed to teaching hospitals.
Loosening restrictions for foreign medical graduates	International medical graduates with a foreign license can work at South Korean hospitals for 6 months without additional examinations.

The conflict escalated, with media narratives depicting physicians as money-mongers violating the Hippocratic Oath.¹⁴ South Korean President Yoon’s meeting on April 4, 2024 with Dr Dan Park, the trainee representative, failed to yield any resolution.¹⁵ Optimists speculated that the gridlock might ease after the ruling party’s landslide defeat in the election.

Despite opposition from deans who feared a decline in educational quality (one school’s class size increased from 49 to 200), the government swiftly allocated 2000 new annual quotas for medical schools. The medical community filed a lawsuit seeking to suspend the reform. However, the Seoul High Court dismissed the suspension request in favor of the “well-being of the public” (May 16, 2024).¹⁶

Meanwhile, more than 90% of residency positions remain unfilled. A recent survey revealed that 34% of the residents and medical students expressed reluctance to pursue residency in the future.¹⁷

Reasons Behind Korean Residents’ Mass Resignation

The mass resignation of Korean residents shares similarities with health care professionals’ strikes. The first key factor is “personal agency,” as described in Li and colleagues’ conceptual model for health care strikes.¹⁸ Korean residents likely assume ownership of critical issues within their health care system and training environment. This assumption is evident through the 7 major requests promulgated by the residents after their resignation (see Box). Empowered by their self-efficacy, residents shed light on inadequately justified health care reforms. Notably, the current postgraduate year 4 cohort previously acted as a collective group of medical students to challenge the government’s plan to establish a public medical school in 2020 due to its controversial admission criteria and unplanned educational procurement.

Box Seven Requests Announced by Resigned Residents Through the Korean Intern Resident Association

1. Complete withdrawal of the government’s unidirectional health care reform

2. Establishment of a scientific committee for accurate physician supply projection

3. Increased hiring of attendings at teaching hospitals

4. Mitigation of legal risks around inevitable adverse medical outcomes

5. Enhancement of the residency training environment

6. Retraction of and apology for undue executive order placement

7. Complete retraction of return-to-work orders

Another reason for mass resignation is residents’ beliefs about “social justice.”¹⁸ South Korea’s plans to increase the number of new physicians perpetuate the low-cost operation of teaching hospitals with an influx of more shift workers.¹⁹ The government’s reform, aimed at filling positions in deferred specialties through a trickle-down effect,²⁰ fails to address the root causes of physician exodus and damages morale. Additionally, the lack of logic in arriving at the figure of 2000 added frustration among young physicians who practice evidence-based medicine. The failure to publicize the expected rise in health care expenditure due to the fee-for-service model and more physicians could jeopardize NHIS funds, already projected to be depleted within the next decade. Residents likely acted based on a responsibility beyond individual patient interactions: an obligation to pursue social justice and the greater good.

Third, the presence of attending physicians influenced residents’ moral justification for their abrupt departure from patient care. While residents are cautious about actions that might harm patients directly, the potential increase in patient safety risk poses ethical dilemmas. Surprisingly, historical data indicate that patient-related adverse events have not risen during resident strikes or slowdowns.^21,22 This knowledge may have empowered trainees, making the ethical challenges less burdensome. In preparation for attendings providing care during their absence, residents signed off on their patients before resigning. Attendings in Korean teaching hospitals expressed support for residents’ collective actions, yet only a small number formally resigned. Specifically, at Seoul National University Hospital, only 3.5% of attendings resigned due to concerns about patient safety.

Lastly, individual motivations played a role. Rather than acting collectively, many residents likely resigned to pursue careers as generalists. South Korea does not mandate postgraduate training for full medical licensure. These trainees found it challenging to justify enduring years of harsh training under the anticipated reform. They weighed the advantage of starting early as generalists against a delayed start in a specialty.

Implications

The recent mass resignation of South Korean residents highlights how physicians justify collective actions. By focusing on the impact of health care reform on quality and sustainability of care delivery, residents find moral justification for prioritizing (broadly interpreted) patients’ well-being.¹⁸ The residents’ pursuit of systemic justice has made them unafraid of government orders and public hostility.

While residents are learners, they can also function as a cost-effective workforce for hospitals. This complex notion requires thoughtful examination during health care reform. The South Korean government’s effort to saturate other specialties with physicians—until new medical graduates opt for deferred specialties—failed to convince residents and medical students that this reform adequately protects their training environment and career prospects. Persecutions and sanctions further discourage young physicians from participating in negotiation bodies.²³

In European nations, physician unionization often accompanies news of residents going on strike.^24,25 Similarly, an increasing number of young physicians in the United States are joining unions, as private health care institutions intensify cost-control initiatives and centralize payment systems.^19,23 While unionization may be one solution, it may not fully address the unique challenges faced by South Korean residents.²⁶

Major health care reforms can lead to strikes by health care professionals. Residency training programs should incorporate conflict resolution learning into their curriculum. By understanding collective action methods, including strikes, future physicians can better navigate complex negotiations. South Korea’s experience may serve as a case vignette for discussing the impact of collective action and individual responses in such situations.

Author Notes

Disclaimer: The authors’ views in this article do not necessarily reflect the position or policy of their affiliated institutions.