Korea’s medical field has been walking on thin ice due to recent court rulings restricting physicians.

These came on top of the government policies prohibiting doctors from refusing to admit critically ill patients to emergency rooms while revoking physicians’ licenses if they are sentenced to jail time.

That has shaken the emergency medical system for pediatric patients, the weakest link in the nation’s healthcare system. Pediatricians, who have been struggling to find sufficient medical residents for years, have begun to leave the field one by one.

Doctors in the field said they had endured the situation with the pride of treating patients. However, the fear of civil and criminal lawsuits and the anxiety that they could become "criminals" at any moment forced them to put down their stethoscopes.

A case in point was the Pediatric Emergency Center at Soon Chun Hyang University Cheonan Hospital, which has been operating on a reduced schedule since Dec. 17. Of the seven professors at the center, three have left the hospital, and two have decided to take a leave of absence. Only two professors remain at the center.

The faltering of this hospital, the first pediatric emergency center in Korea that had treated critically ill children, is ringing warning bells in the pediatric emergency medical system.

The news is causing tension among pediatric emergency centers in the Seoul metropolitan area. This is not the first time pediatric emergency rooms have become difficult to operate due to a shortage of pediatric specialists. However, the news is more shocking because the hospital has supported the pediatric emergency medical system as the backbone of the central region for 10 years.

Professor Lee Ju-young of the Department of Pediatrics has been guarding the Pediatric Emergency Center at Soon Chun Hyang University Hospital Cheonan for 10 years and has decided to remain on this thin ice.

The rapport between patients and doctors has been destroyed due to misguided medical policies and a distorted medical culture. Professor Lee has long been "burned out" by the reality of having to provide “defensive care” at every moment, but she still wants to stay until the end for the sake of the children, whom she described as “rainbows.”

Professor Lee has recently published a book, “Can We Go Out to Sea Again?” her on-duty diary as a pediatric emergency room physician.

Lee warned that the pediatric emergency medical system and the entire pediatric medical system have already begun to collapse. She also emphasized it's time to recognize the risks and find proactive and effective ways to address them.

Korea Biomedical Review caught up with Professor Lee to find out what the country must do to rebuild the broken pediatric healthcare system.

Question: What inspired you to publish your on-call diary written while guarding the pediatric emergency room?

Answer: At the time of “Jeong-in’s case” in 2020, where a 16-month-old child was abused to death, I posted an angry writing while working at 3 a.m., which was shared by many. Later, as the application rate for pediatrics majors plummeted, another angry article I wrote its reason became an issue once again. Then, I wanted to let people know how serious the situations facing the pediatrics department are. Many colleagues expressed sympathy after the book came out, but I felt sad to see them grieved by the messed-up medical reality. Patients don't trust doctors, and doctors are forced to perform “defensive treatment.”

Q: Why do you think the mistrust between doctors and patients has grown?

A: The intentions of health insurance in the 1970s were good, and I sympathize with the idea of keeping people healthy at a low cost. In the intervening years, medical science has made tremendous strides, but too much of it has been reimbursed, and the value of basic care has fallen. This has led to an environment of "quick sales at small margins." Doctors want to be nice to their patients but can't afford to be. On the one hand, they can't focus enough because the value of their services is so low. In contrast, patients seem dissatisfied because they feel they paid a lot for a three-minute consultation and got the same medicine. Specialists are ashamed, and the public doesn’t recognize professionals’ expertise.

Q: It seems skepticism is growing due to the social atmosphere that does not recognize the expertise of doctors.

A: Many of my friends who graduated from medical school in Korea and worked in “vital” departments have already gone abroad, and they say the same thing. They say they still provide vital care but are “happy to see patients.” I never felt that even a doctor's professionalism was respected in Korea. However, my former colleagues abroad have patients who believe and respect their words, even if they say little. That makes them very happy, and they feel they are doing better for patients. I felt so sad when I heard that. In Korea, if patients go to the doctor with a cold and their symptoms don't improve immediately, they say doctors are not good enough. In other countries, it takes weeks to get an appointment, and patients accept this kind of healthcare environment. Sometimes, I ask myself, “What have we done so wrong?”

Q: How long have you been working in the pediatric emergency room? Was there a particular reason you chose to work there?

A: After getting a license as a pediatric audiologist, I worked at a neighborhood clinic for three years. At that time, it was very difficult to convince patients’ parents. If the symptoms didn't disappear immediately, you would be labeled an “incompetent doctor.” You would get complaints if you didn't prescribe medication because you needed to monitor the patient's condition. The “mom café” is where these discussions are most active. All doctors are described as bad if you go to one of these chat rooms. That's why you don't want to be a pediatrician. The emergency room has a high percentage of children with bad conditions. The parents are also convinced of the doctors' diagnosis and follow it. It was the only place I could maintain my self-esteem as a doctor. Ten years have passed like that.

Q: Recently, people have said that the pediatric emergency room at Soon Chun Hyang University Hospital Cheonan is difficult to operate. We also heard that the team defending the pediatric emergency room for 10 years has been disbanded.

A: The team of seven female doctors in the pediatric emergency department in their 40s had been working for nearly 10 years without making a single noise. Even amid the difficult situations, such as overseas training, sick leave, childbirth, and Covid-19, the team was so strong that there was no sound of regret. We showed “superhuman” teamwork, as they say. As the No. 1 pediatric emergency center, we received critical patients from various places, including Pyeongtaek, Seosan, and Taean, but we survived for 10 years because it was fun working together.

However, there have been no applicants for the pediatrics major for more than three years. During the three years of Covid-19, professors in their 50s and 60s were on call and were already exhausted. Even when critically ill patients come in, they cannot be transferred to other hospitals. Finally, the Emergency Medical Care Act enforcement rules, which specify the criteria for refusing to accept emergency patients, were revised, and the Medical Practitioner License Revocation Act passed the National Assembly last autumn. In addition, a series of excessive judicial rulings have changed the atmosphere.

Q: How do judicial rulings and policy changes affect the emergency medical field?

A: There are so many closed pediatric emergency rooms at university hospitals. Ours is the only pediatric emergency room in the central region, so critically ill patients come from everywhere. I go to work once a week, and I've done CPR three times in one day. There's one doctor, two or three nurses, and a resident who comes in for a night shift. If the resident is a third- or fourth-year trainee doctor, they are reliable, but specialists must teach them if they're a first- or second-year resident. Patients keep piling up, and you're stuck with one or two critically ill patients. You cannot hospitalize or transfer those patients to other hospitals. Patient complaints keep coming in, and there may be critically ill patients hiding in the ER, but you don't know. Meanwhile, the calls for transfers to our facility keep coming in.

The other day, I got a call from the paramedics asking me to take in an unconscious patient with convulsions. When I told them that the convulsions had stopped but that we couldn't admit him to our hospital and that he'd better find another hospital, they said they couldn't accept it and asked for my name so they could record it. If I had accepted the patient to avoid the responsibility, who might have been responsible for the lost golden time for treatment? I understood the paramedics did what they had to, but now I am scared. Everyone I talk to who has left the ER says, "I'm going to lose my medical license if I do this. If I go to jail, who would watch my kid?”

Q: We are curious why you chose to stay in the pediatric ER despite those things.

A: Three physicians have left the hospital recently. One decided to take a leave of absence due to health reasons. The physician should have left earlier for health reasons but had endured not to leave burdens to the remaining ones. The doctor decided to leave as the team broke up. The other took maternity leave. If the team were still together, she would return after maternity leave, but it would be difficult because it was already disbanded.

I decided to stay because I wanted to do more pediatric emergencies. There are a lot of vacancies for specialists right now. Nurses are also busy training. The pediatric emergency center is still running but is maintained by overtaxing doctors and nurses.

Q: It must not be the crisis only in the pediatric emergency department of your hospital.

A: No, it is not. Not only our hospital but the whole country is in crisis. We cannot hospitalize some patients in wards, nor can we send them to other hospitals, so we must keep them, but the situation is like a ticking time bomb. In the past, such bombs would come by accident. You could defuse them if you called quickly and asked them to turn it off because it was urgent. However, the fuses are burning up, and there is no place to send them even after more than 20 calls. I feel anxious and scared every time I go to work. I feel the ecosystem has already collapsed, and a first-year resident won't be able to enter this situation. The real problem has just begun.

Q: What are you most concerned about?

A: I'm most concerned about the collapse of the training system. I said this to my teachers. I told them that it was an honor to learn from them during the heyday of Korean pediatrics. Now, the residents are not learning as much as we did. There should be all the sub-departments and many professors, full-time doctors, and patients. There are no hospitals where you can train under these conditions. Increasingly, many departments in university hospitals do not see critical patients and do not accept inpatients. Even the big five hospitals have no support for small departments and full-time doctors. This is probably the peak of Korean medicine, with well-trained doctors in their 40s and 50s still active. At this rate, many surgical techniques will disappear in 10 years, and critical care will be difficult to provide.

Q: The government is proposing various policies for defibrillation and CPR. How does the medical field evaluate them?

A: The government policies are making it harder. To prevent “emergency room pilgrimage,” they have made refusing to accept emergency patients illegal. The public has welcomed it, but doctors are leaving the ER in the meantime. They say they are expanding the Moonlight Children's Hospital to treat pediatric patients at night but also need to provide night and weekend care. The government also promised to provide a monthly training subsidy of 1 million won ($770) for minor and full-time doctors, but it totals only 36 million won in three years. There is talk of choosing the cosmetic departments without training in pediatrics. It doesn't make sense.

Q: What should medical authorities do first to prevent another collapse of pediatrics?

A: They need to create a system where only the sick go to the emergency room and change how parents think about healthcare use. They also must create a system where doctors can see their patients more confidently. Right now, doctors hesitate to diagnose at every turn. The ruling and opposition parties have proposed a national compensation bill for pediatric malpractice but failed to pass it, meaning that the National Assembly doesn't have the will.

Self-esteem must be restored to prevent the “vital” department's collapse. Doctors are people who care about their patients. I'm doing everything I can to make my patients fare better, so I'm not leaving the field unless I get in trouble for a reason that doesn't make sense legally at that point, and I have patients, guardians, and colleagues around me who recognize that.