Korean Med Educ Rev > Volume 26(2); 2024 > Article
An: The Abyss from Which We Must Arise Despite Our Pain: The 2024 Medical Crisis and the Moral Injury of Medical School Professors

1. The continuing standoff

As of June 12, 2024, the medical crisis in South Korea continues unresolved. On June 9, the Korean Medical Association (KMA) convened a National Medical Representatives Meeting and announced a full strike set for the 18th. Shortly before this declaration, the Prime Minister, in a national address, expressed “deep regret that some members of the medical community and doctor groups are discussing additional illegal collective actions, jeopardizing the lives of citizens.” He argued that “the extreme claims of a few should not destroy the social trust that has been built over decades between the medical community and patients [1].” In his speech, the Prime Minister misrepresented the collective stance of the majority of doctors, represented by the KMA, as the views of a minority. He also misled the public by presenting unresolved issues as if they had been settled. The 2024 medical crisis was sparked on February 6 when the government announced a plan to increase medical school admissions by 2,000 seats to expand the healthcare workforce. In reaction, resident doctors started resigning on February 19, and students submitted petitions for leaves of absence. The Minister of Health and Welfare then issued directives to commence work, maintain medical services, and refuse resignation letters. Concurrently, the Minister of Education met with university presidents and declared that leaves of absence would not be approved, threatening corrective actions for non-compliance. Most resident doctors who left have not returned, and many students continue to be absent from their studies. Could this be attributed to a conflict between the prosecutor’s sentence and the doctor’s diagnosis? Resolute in its decision, the government proceeded with the increase in medical school seats [2], and the Korean Council for University Education set the 2025 medical school quota at 4,567, marking an increase of 1,509 seats—the first large-scale expansion in 27 years.
Nonetheless, the medical community has consistently maintained that the increase in medical school seats needs to be reevaluated from the outset. As the standoff reached its fourth month unresolved, the government, on June 4, approved the resignation letters of resident doctors and suspended administrative penalties for those returning. The government’s strategy included a poison pill provision that pressured resident doctors and led to widespread academic probation among students. Medical school professors started to discuss and plan strikes, prompting the government to issue a directive for medical services and a report on the strike declaration. Despite these developments, resident doctors and students continue to be absent from their training and educational sites.

2. The moral injury experienced by medical school professors

Medical school professors are experiencing frustration and shock due to the ongoing medical crisis. These professors are not only pivotal in expanding medical school enrollment but also lead research and education within medical schools. Additionally, they are vital to the provision of medical services in university hospitals. Their significant role has contributed to South Korea’s establishment of a world-class healthcare system. The trauma experienced by these medical school professors is comparable to the moral injury faced by soldiers who must act against their moral and ethical beliefs during war, resulting in emotional, psychological, and spiritual distress. Wendy Dean describes “moral injury in medicine” as the intense psychological distress healthcare professionals endure when systemic and institutional constraints force them to act against their moral and ethical beliefs [3]. This often occurs when clinicians are unable to provide necessary patient care due to bureaucratic pressures, financial incentives, and productivity goals. The decision to increase medical school seats has inflicted similar trauma on medical educators. Healing from these wounds will be a lengthy process, and it is doubtful that they will ever fully return to their pre-crisis state. This trauma also challenges the very core of their identity, leading to profound moral injury. Given the critical need to sustain Korea’s healthcare system and continue medical education, we must find a way to recover from this low point. Therefore, we aimed to explore the extent of moral injury sustained by medical school professors in the current condition.

3. Doctors are defined as enemies of medical reform and their achievements are denigrated

The government argued that the starting point for medical reform should be an increase in the number of doctors. This assertion was based on studies concerning doctor workforce projections—which have been subject to varying interpretations and which the authors argue have been misrepresented by the government—and the fact that South Korea’s doctor-to-population ratio falls below the Organization for Economic Cooperation and Development (OECD) average. Additionally, a statement by a professor who later became a proportional representative congressman, claiming that “a 35-year-old general hospital specialist’s annual salary is 400 million won … due to a shortage of doctors,” further supported the push for more doctors [4]. Thus, it was argued that increasing the doctor count was a prerequisite for medical reform. In promoting this policy, the government outright denied the achievements and the level of excellence achieved by the South Korean medical community and its doctors, despite facing systematic and structural challenges. The government evaluated the South Korean healthcare system as subpar compared to the OECD average, labeling it as a system in need of reform and enhancement. In its assessment, the government selectively referenced indicators from the OECD health report, omitting any mention of the report’s explicit acknowledgment of South Korea’s healthcare excellence and achievements [5]. This selective citation is an unfair treatment. It is not difficult to find other reports that acknowledge the excellence of South Korea’s healthcare system [6-8]. The Legatum Institute, a UK-based research organization, annually publishes the Legatum Prosperity Index Report, which compiles various indices [8]. According to a recent edition, South Korea was ranked 29th out of 167 countries globally in overall prosperity. Specifically, in healthcare and education, South Korea was ranked third worldwide, only behind Singapore and Japan, underscoring the exceptional quality of its healthcare system. South Korea’s healthcare accessibility is indeed superior to that of major OECD countries. The sensationally pointed-out issues of “emergency room ping-pong” and the “pediatric clinic open run” are relatively minor complaints in a situation where healthcare accessibility is already guaranteed in South Korea, which offers much safer and more secure access to healthcare than other OECD countries. The fact that the starting line was different was also obscured.
In response, the KMA and medical school professors pointed out that the government had unfairly denigrated the state of healthcare in South Korea. The government labeled the collective criticisms and social advocacy of medical students, residents, and doctors as “doctors’ illegal collective actions.” Subsequently, a national healthcare crisis was declared at the highest risk level. The “Central Disaster and Safety Countermeasures Headquarters for Doctors’ Collective Actions,” led by the Prime Minister, was established. In line with changes in digital media, the Emergency Response Headquarters conducted daily public briefings, marking an unprecedentedly swift governmental response. Additionally, a large-scale campaign was launched to bolster government policy. Posters featuring the President's commitment were displayed on public buses and subways, and promotional videos, which had not been seen for a long time, reappeared in movie theaters. Moreover, screens inside apartment elevators broadcasted the government’s message against “emergency room ping-pong” and “pediatric clinic open run.” This was an unprecedented, massive promotional campaign. Throughout this ordeal, doctors and the medical community were portrayed as a self-serving cartel, a characterization cemented by the President in a national address. This portrayal marked doctors as adversaries to be eliminated rather than as partners in healthcare reform [9]. Furthermore, this situation has significantly undermined the trust that forms the foundation of the doctor-patient relationship in healthcare. The government possesses the authority to govern, and it must wield this power justly. This is not to suggest that the medical community is entirely correct or that the government’s position is wholly without merit. However, disparaging the medical community’s achievements to advance a policy and branding doctors, who are integral to the healthcare system and should be allies in reform, as a self-interested cartel represents an unjust exercise of power. Using all available means to cast doctors as enemies constitutes an abuse of power.

4. Excluded from discussions, expert opinions ignored

The increase in medical school seats has become a contentious issue and is central to medical education. The responsibility for training competent doctors rests with medical school professors. Consequently, their opinions should be considered in the policymaking process related to medical education. This not only aligns with the common-sense principle that expert opinions should influence decisions within their specialty areas but also demonstrates trust and basic respect for the professors who bear the responsibility of educating future doctors. However, in the 2024 decision, medical school professors and medical educators were excluded. The government argued that the decision to increase the number of medical school seats falls within its authority [10]. Yet, the implementation of this policy occurs at medical schools. These institutions must ensure they provide quality medical education to meet the needs of Korean society, and the professors charged with this task should have a say in the feasibility of the government’s policy decisions. This is more a matter of duty than authority. Unfortunately, this consultation did not occur. Medical school professors, through emergency forums on medical education, questioned the basis of the government’s decision and criticized the policy based on evidence, only to be accused of acting out of collective self-interest. Their serious concerns that a rapid increase in seats would compromise the quality of medical education were ignored. The government insisted that the addition of 2,000 medical school seats was the minimum required based on scientific evidence. Yet, it later accepted a recommendation from the presidents of national universities to “allow the recruitment of new students autonomously within the range of 50%–100% of the increased seats for the 2025 university admissions process,” setting the 2025 medical school quota at 4,567 [11]. This decision seems to consider university opinions, but also suggests that the previously stated increase of 2,000 seats was not, in fact, the minimum feasible number.
The professional authority of medical school professors (doctors) in society is founded on the respect accorded to their rational persuasion and professional insight [12]. The source of reliable insights into medical education is typically medical school professors. Yet, these professors were excluded from discussions and decisions about medical education. Does this exclusion not suggest a diminishment of the social authority that medical school professors hold as experts? Such a loss of authority in education and training could inevitably lead to a diminished authority of doctors as caregivers in the clinical field, which inherently involves an educational component. To effectively fulfill their duties, both responsibility and authority must be granted. How can we expect professors to fulfill their duties and maintain their positions when their essential authority over education has been undermined?

5. The collapse of standards in medical education and training

The Ministry of Health and Welfare has announced that it will accept the resignation letters of resident doctors and is considering changes to the regulations for specialist training. These changes would allow returning residents to qualify for specialist certifications. Due to the current insufficiency in the training period for specialists, the Ministry suggests that candidates should take the specialists’ board exams first and complete any outstanding training thereafter. This approach represents a flexible adjustment to the standards. In total, 96.7% of intern trainees, who have a 1-year training period, have not yet begun their training. Under the current intern training standards, even if their training were to start immediately, these trainees would not be eligible to enroll in specialist courses next year because they would not meet the mandatory training period, and intern training is a prerequisite for specialist training. The Ministry of Health and Welfare has indicated that it will modify the standards governing the intern training period to allow these individuals to apply for specialist training next year [13]. The government claims that this change is intended to reduce barriers in the medical field. However, it effectively lowers the standards as a way to address issues arising from government policies. The government has pledged to reform and improve healthcare to meet OECD standards, yet it has openly stated that it will reduce training standards by amending laws and regulations. There is no hesitation in these changes to the standards, demonstrating a remarkable level of flexibility. Despite lacking a solid rationale, the government remained rigid in its decision to increase medical school seats, a decision that could have benefited from a more flexible approach through dialogue with experts. In contrast, it shows flexibility by altering regulations to avoid challenges in upholding the national medical standard, which necessitates strict adherence to educational and training standards.
The situation for medical students is the same. Students collectively submitted petitions for leaves of absence to voice their social opinions. Although these petitions adhered to the school’s established procedures, they were deemed illegal, and the Ministry of Education mandated that they should not be approved. Consequently, students who left their classrooms to apply for leaves of absence were considered to have skipped classes without permission, as the universities could not approve their requests due to the Ministry’s policy. The educational policy dictates that students who fail to meet the required number of educational hours should be held back or expelled. Therefore, schools were forced to delay the start of the semester and modify the academic calendar. Additionally, the Ministry of Education issued guidelines to amend school regulations to schedule academics annually rather than by quarter or semester. Moreover, the Vice Minister of Education suggested that “downloading videos by students could be recognized as class participation,” a disruption in education unprecedented even during the severe coronavirus disease 2019 crisis [14]. While the academic term commenced for commissioned military students and those who either did not want or could not take leaves of absence, most students are not attending classes. This is the reality, despite government reports claiming that most of the 40 medical schools have resumed classes. No previous government has simultaneously driven residents away from training and compelled most medical students to take leaves of absence. This demonstrates a remarkable policy capability indeed! The Ministry of Education has consistently maintained that leaves of absence and holding students back are not permissible, even though students have been unable to study effectively. To address this, they are mandating changes to the educational standards and systems. Under the current standards, promotion is impossible, yet they are now being instructed to amend these standards to allow for promotion. What the government is doing is akin to altering the diagnostic criteria for a severely ill patient, who should be diagnosed as abnormal and in need of treatment, to declare them healthy and normal. If a doctor were to adopt such an approach, what would society think of that doctor? Would the government allow such a medical practice to continue unchecked? Yet, such disruptions of standards continue unabated.
Universities and professors should operate schools and guide students according to educational philosophy and school regulations. The government’s use of financial and administrative power to undermine the foundational principles of education represents governance by law—a means of forcefully exercising the power to establish regulations and orders, known as rule by law. This significantly deviates from the rule of law. Facing this reality, medical school professors express their dismay, wondering, “Is the government now supposed to go to these extremes?” This expression is a sigh of frustration from experts who have elevated Korean healthcare and medical education to its current status despite structural contradictions and limited resources. For professionals to function effectively, the values they pursue, the norms defined by those values, and the practices following those norms must be preserved. This system of values, norms, and practices forms the backbone and maintains order within the professional community [15]. To be recognized as professionals committed to the health of the community and its members, doctors have established standards for education, training, and practice. They have autonomously and responsibly implemented these standards. Institutionally, they have created educational institutions, associations, and licensing systems to regulate the profession, ensure standards, and protect members. Additionally, they gain cultural authority through the public’s trust in their medical expertise [12]. Doctors, including medical school professors working in critical medical fields, focus on protecting local healthcare and aim for healthcare that benefits national medical finances and patient welfare. These decisions and actions epitomize medical professionalism, which is feasible only when the standards and values of the professional community are clear. However, these standards are now under threat. While expecting professional actions and decisions from doctors, the government is undermining the standards that underpin the professional community. Or is it trying to establish a standard that rule by law is acceptable if it holds power? After dismantling and undermining the norms related to healthcare and medical education, on what basis does the government now expect to demand professional behavior from doctors?

6. Breakdown of professor-student and professor-resident relationships

When government policies conflict with the consensus of medical school professors and university decisions, undermining the autonomy of educational institutions and the social authority of professionals, how do medical students and residents view their professors? Do they see them as helpless elders confronted with an absurd reality? Do they perceive it as a reflection of the professors’ incompetence? This self-deprecating anxiety is prevalent among medical school professors. The statement by the head of the Korean Intern Resident Association that “hospital professors are middle managers in the chain of exploitation,” even though it references others’ opinions, painfully highlights the deteriorated relationships between professors and their residents and students [16]. As a “Community of Practice,” the medical education community has experienced a severe setback, akin to a pot that, already cracked for various reasons, finally shatters. How can we manage education and training, and how can we mend these broken relationships?

7. The abyss from which we must arise

Medical school professors are exhausted in a frustrating situation with no visible way out, and those who value traditional teacher-student relationships are experiencing betrayal and frustration. When principled declarations lead to increased pressure and evidence-based arguments are dismissed as mere self-interest, a pervasive sense of helplessness intensifies. The workload in medical care has escalated, and with the deteriorating management of hospitals, financial strains are compounding, pushing the professors’ endurance to its limits. Consequently, sensitivity among medical school professors is on the rise. Concerns loom about the potential implications if residents are unable to commence their programs next year. Reflecting on the challenges faced in 2000 and 2020, some argue for a realistic approach to the current situation.
Regardless of how the crisis is eventually resolved, and from whatever low point we must begin, it is the medical school professors who bear the crucial responsibility for training and education. The question remains: what will be the foundation upon which medical school professors stand? According to the annual graduation survey conducted by Yonsei University College of Medicine, students opting for so-called “essential medical specialties” primarily cited personal values and preferences as their reasons for their choice, a trend consistent across both popular and essential specialties. However, those drawn to essential specialties demonstrated a higher commitment to aligning their career choices with their values. These students acknowledged the challenges of opening a private practice, the uncertainty of income, and the lower social prestige associated with essential medical fields. Despite these obstacles, they expressed a strong inclination to pursue these fields [17]. Regrettably, the recent medical crisis has led to a sharp decline in the number of students choosing essential medical specialties, with a significant drop in those seeking residency training. Furthermore, those still interested in essential fields are now considering training opportunities abroad [18]. Government policies aimed at bolstering medical personnel in essential fields and developing regional healthcare systems have made it increasingly difficult to secure specialists in these areas. This abyss is the starting point for medical school professors.
Therefore, we must prepare for future education and training, which at a minimum involves initiating a discussion. If some residents return without a plan to enhance their training, we will inevitably fall back into our old ways due to a lack of preparation. In such a scenario, it is predictable that residents will express their frustration, remarking, ‘See, nothing has changed at all.’ Currently, medical school professors are overwhelmed, and it is unclear which solutions should be implemented. However, even in the absence of immediate solutions, it is crucial that we confront and discuss these issues.

8. We must confront reality by testifying

Even though the statements from medical school deans and professors did not cause a public uproar, the universities and faculty members faced significant pressure from relevant government departments after voicing their opinions. University leaders were particularly worried that their involvement in national projects might be jeopardized. It would be more precise to say that they became apprehensive. While no one publicly acknowledged this pressure, it was undeniably a concern for university authorities. The autonomy of universities, along with the academic and research freedom that higher education institutions should possess, are essential for the growth and sustenance of scholarship and education. However, in light of the 2024 medical crisis, it is imperative to reevaluate whether Korean universities truly enjoy sufficient policy autonomy and academic freedom.
Therefore, one might wonder about the significance of medical school professors speaking out on education and training in such circumstances. Expert opinions and well-reasoned arguments based on professional insights are not always accepted or considered. Isn’t it typical for groups entrusted with power to make decisions that consolidate their own authority? While there are reasons and justifications presented, the primary driver of policy decisions is ultimately voter support. The government’s decision to increase medical school seats was framed as a part of medical reform, but the discussions and decisions on pressing medical reform issues were sidelined, rendering the decision largely ineffective for the current medical landscape. Political critics and the media perceive the rushed announcement of this decision, which increases educational responsibilities and burdens the medical sector without thorough consideration and consensus, as a politically motivated act in anticipation of elections. In this context, it is indeed challenging for expert opinions that oppose government policies to be taken into account.
Nevertheless, even if their views are not embraced, experts must identify issues and offer solutions to rectify the mistakes. This is the responsibility of medical school professors as both educators and specialists. Two letters from the dean of Yonsei University College of Medicine, made public during the medical crisis, captured the media’s attention. The first letter, dated April 19, described the disruption in education at that time as follows [19]:
 As April passed, it became difficult for Yonsei University College of Medicine to uphold the educational standards it is responsible for, and it became difficult to restore the ongoing deterioration and disruption of medical education. Given the standards and principles that Yonsei University College of Medicine has consistently pursued and upheld, we cannot ignore the current disruptions in medical education. This issue was addressed at the meeting of the chair professors’ council, where all chair professors concurred that “allowing students to advance without sufficient learning, or producing doctors who have received such an education, does not fulfill our social accountability. Making decisions that ensure the necessary learning time is the school’s method of protecting and responsibly guiding students.”
This publicly acknowledged the disruption in medical education. It reinforced the educational principle that providing students, who lack the necessary knowledge to become competent doctors, with another opportunity to study is a way of protecting these students. The dean’s letter served as a message to society about the disruption in medical education and conveyed, through the media, the opinion of medical school professors that advancing students who have not completed their learning does not fulfill the social responsibility of the medical school adequately. In a subsequent letter dated May 20, as the absence of students became prolonged, the dean expressed the educators’ urgent desire for students to return and resume their studies. However, for those students who could not return, the letter stated that “to maintain proper medical education, at some point, we have no choice but to approve leaves of absence,” as decided in the general professors’ meeting [20]. This was a letter expressing the dean’s regret. The media also highlighted this letter as the first public acknowledgment that the students’ petitions for leaves of absence could be approved. The dean’s letter, which aimed to uphold the educational responsibility, was seen as conflicting with the current government policy, leading to media inquiries. Consequently, Yonsei University had to clarify that there was no established policy regarding leaves of absence yet.
As confirmed through the dean’s letters from Yonsei University College of Medicine, publicly declared opinions of professors are likely to be rejected or met with pressure. Nevertheless, it is crucial to clearly state the current situation and what needs to be addressed because, by opposing the government, we uphold what is right and advocate for proper education. When the valid concerns of medical school professors clash with the government’s unreasonable policies, these legitimate claims are often dismissed. Despite this, I believe it is essential for us to persistently advocate for just and reasonable opinions. This advocacy is part of the responsibility that professors, as experts and professionals, owe to society. Even if rational persuasion, grounded in expert insights and credible evidence, is disregarded, and even if the social authority of experts in our society is diminished and severely undermined, we must continue to fulfill our duty to present necessary opinions as experts. In this conflict-ridden context, if medical school professors are committed to supporting Korean healthcare, they must steadfastly maintain the responsibilities they bear.

9. We must confess, “even if we fall and stumble tonight, we cannot stop here,” but... [21]

During the emergency briefing by the Minister of Education on June 14, followed by a Q&A session with high-ranking officials from the Ministry, I understood that they were determined to ensure that leaves of absence would not be approved [22]. I hope I misunderstood or misinterpreted their statements, and I would welcome correction if that is the case. The officials suggested that modifying school rules and regulations would enable them to maintain educational quality; however, this raises a question: Will the Minister of Education and Ministry officials take on teaching roles themselves? How can they assert this feasibility when medical school professors, who are directly responsible for education, claim it is impossible?
Even if leaves of absence are approved, education remains a challenge, and without such approvals, the situation is already difficult. If the difficulties persist regardless, shouldn’t we value the insights of medical school professors who are directly involved in education? Shouldn’t we also respect the decisions made by the students? Unless the government plans to import medical school professors—as the vice minister of Ministry of Health and Welfare suggested might happen with foreign doctors—the authorities should refrain from excessively pressuring educators. Medical school professors are accustomed to demanding workloads. They have tolerated these burdens because of the rewards associated with saving lives, discovering or implementing new treatments, and enhancing healthcare standards. However, they cannot be expected to endure unreasonable demands that compromise their principles. No medical school professor will willingly comply with directives to administer incorrect diagnoses or harmful treatments. If the government, having already alienated residents and students from the field, does not wish to similarly drive away medical school professors from education, training, and medical service, it must at least consider the opinions of those responsible for medical education and training. This issue is not about victory or defeat. A significant wound has been inflicted on the government, the medical community, and society at large, leaving scars that will not fade. For healing to begin, both the government and the medical community need to step back and choose not the best option, but the least bad option.
What was the mindset of the poet who said, “Even if we fall and stumble tonight, we cannot stop here / Because the road ahead is long,” amidst the ruins after the war [21]? Since we cannot abandon healthcare, I strive to inspire my fellow professors to find a path to recovery. However, I sometimes question whether I am placing too heavy a burden on colleagues who are also grappling with this harsh reality. As an educator committed to learner-centered education, I find the criticism and rebuke from students and residents both painful and stinging. Although their critiques are justified, they are not entirely correct. Critical educational decisions must remain the responsibility of the professors. While learners should have the opportunity to express their opinions fully and democratically, the duty to maintain educational principles and standards rests with the professors. This is not a matter to be settled by leveraging collective power. Even if the government is rapidly and flexibly dismantling educational standards, and even if governance by power and law prevails, professors must still affirm what is right and reject what is wrong. This is the essence of not giving up, even if we fall and stumble tonight. We must ensure that, even if our opinions are overridden, the fact that they were overridden is recorded in history. Moreover, we must continuously reflect on, discuss, demand change to, propose improvement for, and reform this healthcare system, given that the system immediately becomes a national medical emergency when residents in training leave the field. No matter how arduous the journey ahead, even if today finds us at our lowest point, we must persevere.

NOTES

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Authors’ contribution

Shinki An: collected data, wrote the manuscript, wrote the references, and conducted the overall writing of the paper.

Supplementary materials

Supplementary files are available from https://doi.org/10.17496/kmer.24.023
Supplement 1.
Korean version of “The abyss from which we must arise despite our pain: the 2024 medical crisis and the moral injury of medical school professors”
kmer-24-023-suppl1.pdf

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Shinki An
https://orcid.org/0000-0002-9822-7961

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