Vulnerable Shadows in Splendid Korean Big Hospitals

A nurse of Seoul Asan Medical Center, the largest hospital in Korea, died on July 30, 2022 in Seoul National University Hospital due to subarachnoid hemorrhage caused by rupture of a cerebral aneurysm which occurred on duty, July 24, 2022. It must have been a shocking news. The mass media reported this case day after day, "Does it make sense to say that there is no doctor to perform the emergency operation? Why not punish the doctor who was away on vacation that day! If the patient had been a doctor and not a nurse, wouldn't the surgery have been performed? Was the patient transferred to another hospital because the patient was a nurse?" Almost all mass-media pointed out witch-hunt accusations against the cerebrovascular surgeon at Asan Medical Center and the loopholes in the emergency treatment system.

The essence of this case, as I see it, is the “shortage of absolute number of available and skilled cerebrovascular surgeons in Korea.” It is questionable how many percentages of the Korean people know that there are only two cerebrovascular surgeons in the largest hospital in Korea, Asan Medical Center. To this, some will ask, "Even if there are only two doctors, does it make sense that both doctors leave the hospital simultaneously?" However, not only in Korea, but among people around the world, if you are asked to hold overnight watch or on-call watch for more than 180 days a year, even when you are over 50 or around 60, in fact, what percentage of people can accept it? I want to ask that it is possible to accept this kind of life and maintain such a job only with responsibility of job mission. Of course, even if Asan Medical Center did not make legal fault, it is a problem that can be reprimanded for failing to somehow create a watch-watch system in which two doctors do not leave at the same time. However, more fundamentally, even if a hospital tries to recruit a skilled cerebrovascular surgeon, it is almost impossible due to seriously limited pool of human resources.

The real challenge is that the more the hospital does brain surgery, the less the hospital wants to invite cerebrovascular surgeons because of negative balance of the surgery. In this context, the hospital does not want more cerebrovascular surgeons. Most doctors prefer neurointervention rather than open vascular surgery because the learning curve is relatively short and the procedure takes much less time. As time goes on, the number of skilled cerebrovascular surgeons does not increase, but decreases. I think there are many doctors who say that “replacing neurosurgery by neurointervention is an inevitable global trend.” However, there must be some patients who essentially require neurovascular surgery. I think everyone who knows “where the current neurosurgical level is in Europe” will know the answer. Look at the reality of Europe in 2020, the early days of the COVID-19 crisis, with so many infectious deaths in Europe and the inability to cope with the seriously ill conditions. I remember the words of a fifth-year student at a French medical school who recently went to practice at my hospital, “I think all serious medical care in France has collapsed. It's a big deal now, but it's even bigger in the future because talented surgeons are eager to move to Switzerland and other countries instead of staying in France.”

Korean medical cost is very low among OECD countries. Assuming that the cost in the US is 100, the average of the OECD is 72, 71 in Japan, and 48 in Korea. Even the cost of cerebrovascular surgery is worse, accounting for one-fourth of that in Japan. I believe that incidents such as the “death of a nurse at Asan Medical Center” will continue to occur in the future. The improvement of the present fee-based policy in which the overall size of fee budget is fixed and the fee for one section is lowered in order to increase that of other cares or departments. That policy will dry up cerebrovascular surgeons quickly, and there will be few skilled cerebrovascular surgeons left in the next 10 to 15 years. I don't think there is an answer to this other than the innovative policy that the government reduces populistic health care policies such as expanding MRI benefits and adding new health insurance finances for serious diseases or difficult medical practices. Also it is essential to accept the fact that cerebrovascular surgery requires team approach of skilled doctors, nurses, and paramedicals. It is definitely a matter of money strategy to ensure basic quality of life for medical experts in high risk medical care for critical diseases. Without such policy support, it is absolutely not possible to prevent disappearance of cerebrovascular surgeons just by raising the doctor's salary or on-the-spot fee.

As neurosurgeons are locked up in the operating room for a week and do their best to save patients, they are completely alienated from the state-led policy of cardiovascular surgery. Instead, doctors who do not perform actual surgeries or procedures have created a table-top discussion. If we follow the present cardio-cerebrovascular law as it is, it is clear that the similar death of the present case at Asan Medical Center will happen again. Because we still live in the Confucian culture that despises engineers from the Joseon Dynasty, doctors especially surgeons are regarded as low class technicians in Korea. I think the general public cannot understand the reality of severe medical care. In the government's medical policy, neurosurgery itself is excluded from the “departments of essential medical care.” If cerebral hemorrhage occurs in a person's head, the cerebrovascular surgery must be "essential medical care" to save the life. I think that putting neurosurgery into the category of “departments of essential medical care” is a top priority.