Hello, everyone. I'm glad to be able to speak in such a serious place again, and I consider this opportunity very important. A while ago, I was in charge of one of the three reports quoted by the government, so I will briefly talk about that first. I hope you have read all three reports. Mine is quite arrogant, about 300 pages long, so I don't think many of you have read it all. It would be nice if you could take a look at the summary. There is a point where the world report is excellent, and the government wrote that report. My report also shows the same figures. However, I applied various scenarios in that report. In other words, when we apply the current state of medical care without any medical reform, the world report says something. The figures in that report are what the government claims to solve. This means that without medical reform, we will have to increase the number of doctors significantly.

It means it doesn't exist. In fact, so in my report, if it is realistically impossible, you can just read the summary at the very end. If it is not realistic, the level of realism should be less than 1,000 people. By saying this, it is necessary for medical reform to take place. In my report, that's why one scenario of medical reform should be included. Because at that time, which was 2020, there was a lot of social discussion about the so-called primary care system. If the primary care system is implemented, it would be different from our current discussion on medical reform. I myself do not prefer the primary care system that I mentioned at that time. However, if the primary care system, especially physician-centered primary care, plays a gatekeeper role and takes responsibility for a significant part of the patient care delivery system, what would happen? At that time, the figure was 1 to 1. But actually, we

We need to go out. It's not about the current system; we really need to create a new medical system in Korea. That's what I think. For example, today's topic is about improving the training environment for medical residents. While listening to two presentations on this issue earlier, you might find it quite complex and have a lot of thoughts. Where should we start unraveling this issue? However, as we study medicine and see patients, what we consider important is our approach, what is the most important thing. What should we do first? That's what I'm trying to say. It's been almost 10 years since 2015 when the medical residents at the time argued in the Medical Residents Association to reduce the working hours to 64 hours per week. But the fact is, this 64-hour rule means that working over 40 hours is prohibited, with a possibility of extending up to 24 hours. But at that time, how were we...

Once the decision was made, it was extended by 8 hours for a total of 88 hours for educational purposes. And at that time, when this was decided, many professors, including myself, wondered how is it possible to suddenly work 80 hours when we were used to working 20 hours. I think there is something we need to consider about this part, including myself. Currently, various issues are arising in the medical field, but fundamentally, what are we trying to do? I think we need to think about this problem. It is about normalizing medical care. In other words, that's what I think. However, if normalizing medical care means that specialists work 88 hours, then the system is considered normal medical care, which is also difficult. And many people say that the foundation for Korea's excellent medical care is here. Can we talk about being the best based on this sacrifice we are making?

I think that it's not just a simple sacrifice, but if the weekly working hours are long, medical errors increase. For example, if you work over 80 hours, the error rate more than triples. However, the responsibility for these errors lies with the individual, not the system. Even though the system led to this, it's the individual's responsibility. So, the criteria that caused the problem and the person responsible for it are different. It is important to normalize this issue. On the other hand, a recent article, you probably have all seen it, I think. Chairman Park Dan of the Daejeon Medical Association declared that if disadvantages occur to resident doctors who leave the hospital, he will not tolerate it. We are all sitting here because we have declared so. These individuals have played the role of middle managers in the exploitation, whether acknowledged or not, I think this is an undeniable fact.

People are talking about solving the problem now, but why is no group talking about improving the current training environment and working conditions for medical specialists on either side? Do you think we can go back and build medicine on this foundation again? That's my question. On the other hand, university hospitals in the metropolitan area are planning to establish branch campuses competitively near the metropolitan area by 2028, but there are no plans to change the excessive dependence on medical specialists. In fact, there are none. But then, is it the hospital's responsibility? In fact, the government says it's the hospital's responsibility. I think that the responsibility of the country, which has left the medical system commercialized to this extent, is significant. It's really heartbreaking, but I think these words are right. What do you think? So, we need to fix it.

I don't think I can say this is not a child, but at least in terms of the direction I am thinking, I believe that our major in training and working environment should have these changes, isn't it? Based on the report I organized two years ago on this fact, I am telling you today. As you know, education and training cannot be carried out due to high work pressure and working hours in the major, and we feel it is so natural for hospitals to bear the cost of education and training. However, this is why interns and majors cannot escape from the issue of hourly costs. I think this is the point where fundamental distortion occurs. With the current training methods, it is difficult to meet the common competency requirements for majors. This is what this major is talking about, at a tertiary general hospital or university hospital.

In primary care training, the opportunity to directly examine and treat first-time patients is practically very limited. Also, the current educational and training environment at dispatched and training hospitals is indeed very negative. When you go out to the field, it's also negative. Therefore, the decreasing trend of medical graduates hoping to work in essential medical public healthcare continues. Here lies the essence and starting point of the problem. I think this way. Regarding working hours and workload, both supervisors and residents in various specialties are all dissatisfied, scoring less than 3 on a 5-point scale. You would know what it means to score less than 3 on a 5-point scale, right? Additionally, in the current residency training, it is impossible to satisfy all aspects such as dispatched training, surgical education, outpatient clinic, and the number of outpatient visits. This is the opinion of the professionals. However, is it good to go on dispatch? What is the effectiveness of training when you go on dispatch?

Ensuring popular rest time, adequacy of educational training, satisfaction with work intensity, and the quality of training environment all scored low. So, this is a problem not only in hospital training but also in dispatching assignments. It's really not something that can be improved with just a little effort. However, I think this issue of training and working environment has become a serious problem. Other countries have experienced this to a great extent ahead of us. We have actually missed about 20 to 30 years. In the UK, after completing a degree and medical school, there are two years of foundation training. After the bachelor's degree, they immediately receive a medical license, then proceed to internship, specialization, and finally obtain a professional qualification. But many countries have three things: a bachelor's degree, certification as a doctor, or the right to practice as a doctor, and then a professional qualification.

We are managing a bit of a distinction. First of all, I would like to say that it is difficult to talk about it uniformly because it varies from country to country. In the UK, after completing the internship, they allow you to practice after one year, then you can enter some specialized fields, and then you go through the specialist process. In Austria, after completing the internship, they give you something like a provisional license, let you do an internship, and then after completing the second year, you can become a specialist. So, before entering the specialist course for two years, you go through a two-year process. However, in the UK and Australia, having walked through high school, and having faced many similar issues, I think we should look at Japan. In Japan, after completing six years of study, you go through a two-year clinical training, and then you can move on to become a specialist. At this point, you have to match your fate to be able to open your own practice.

Of course, I do not agree with this part, but we manage it to some extent. Now, what we are doing is dividing it. However, in this new country, it's all about the specialist training for us, now it's the process of becoming a specialist. Before entering the residency program, there is a period of two years, which if we follow directly in our country's system, it's the current internship. If we go that way, I think it's absolutely not right. Why these countries have done this is because they already have established community-based healthcare systems, like the UK, Australia, and Japan, so they train doctors according to that system. In this sense, it was necessary to have a connection. In our case, following the current system, the connection becomes a very obvious and predictable story. That would make the internship the connection. We shouldn't do it that way. So, I think we need to train essential local medical professionals. Why? Because this is an important current issue and a systematic way to foster them.

We need an educational training program, and more importantly, for specialized medical training, it should be supported by the government and local governments. Furthermore, we should expand training programs that allow experiences in regional medical institutions. It is necessary to establish a training network that includes primary and secondary medical institutions. To achieve this, instead of managing it in places like the training department of Seoul National University Hospital, it should be managed within a network that includes primary and secondary institutions. Therefore, a central training committee responsible for training regional medical professionals and a regional training coordination center are needed. I believe that this is essential for fostering regional medical talent. Only then can the capabilities of essential medical services and public medical services be truly developed. No matter how much we emphasize essential medical services and regional medicine in the current system, I wonder if it will actually be realized.

So, what I'm saying is, when creating a major in integrated relationship education practice, one should manage the central training institute, while allowing the autonomous selection of various tracks in educational training. The government and local governments should support educational training and establish a coordination center based on consultation. I believe that these slides contain the essential points of my speech. Therefore, let's establish relationships. However, I don't agree with maintaining the current system of six years in undergraduate medical school. At least the final year should be considered a preparatory year. After that, let's grant qualifications after two years, leading to becoming a specialist. But let's grant specialist qualifications for primary care, instead of the current internship system.

And then, after that, for two or three years, or in the case of home economics, for example, you should further develop into a comprehensive specialist. I think I need to develop in that direction. When you have two specialist courses, the actual time doesn't increase. Currently, it's 1+4, right? 2+2 or 3. So, it can decrease instead of increasing. I mean, doing that for a year, the reason I mention specialized work again is that Korean people prefer specialized work. But we can't say that's entirely bad. Why? Because everyone wants to receive the best medical care, that's why we should have specialists. Let's train primary care specialists who can serve in local communities, and then move on to specialized fields. Then, let's have specialists in departments in hospitals or general hospitals, where we can work. Let's have specialists in departments. And if needed, let's also have comprehensive specialists. The reason comprehensive specialists are needed is that when we look at the medical care in Japan in the future, it's important.

In society, the level of medical professionals responsible for telemedicine is very high. They have to handle a lot of equipment, and in a way, they have to deal with critically ill patients in the local community. Therefore, we need to develop this area. However, the years of experience are not increasing, and we should abolish the internship system and focus on cultivating specialists. By doing so, wouldn't the quality improve? For this purpose, instead of assigning them to each hospital, we should establish central training workshops and local coordination centers to provide education, training, coordination, program development, operation, and administrative support. After completing a common education and training program, they should be able to choose from various training tracks. Another very important point is not to do individual mentoring, especially when it comes to specialists.

I believe that at least two mentoring sessions should be conducted. Let's operate a multi-disciplinary educational training for achieving regional comprehensive medical leadership. By doing so, individuals like me can acquire the skills the government is currently emphasizing. Let's focus on establishing a network-based medical multidisciplinary teamwork, enhancing communication, education, and quality management, to ultimately impact clinical practice. However, this is not happening right now. In reality, training received at university hospitals often does not have much practical application in the local community. Nevertheless, let's consider these impacts and move forward. Let's create a common educational training program based on these impacts and proceed to the next step.

And by diversifying the education training tracks, it extends the two-year period or actually, the preliminary year, making it a three-year period. By doing so, let's diversify the tracks of internal medicine, surgical medicine, community medicine, and public healthcare, making them selectable. Then, after receiving further training, one can transition to become a specialist in a specific field. As I mentioned, when two or more senior specialists provide mentoring, currently, all the training is done at the training hospital. However, now, based on the regional coordination training center, one can receive training at primary clinics, secondary hospitals, private hub hospitals, and public healthcare institutions. By confidently going out and building the foundation of regional healthcare and public healthcare, I believe that one can train in essential healthcare. In this way, without necessarily discussing other matters or establishing a separate public medical school, we can nurture leaders in essential healthcare and regional medicine. This is what I think. And in doing so, essential healthcare.

Let's enhance the support for the specialization of regional public healthcare. Strangely enough, I saw the news yesterday that the essential healthcare and public healthcare in the region, the leaders of our party, have agreed very clearly on that. Instead of making a fuss about it, I think we should improve the level of regional medical care through network healthcare. It's no longer just hospitals competing with hospitals, but hospitals, clinics, everyone is in a competitive system. Let's transition to a cooperative system within the network. Naturally, wouldn't this strengthen the region? On the other hand, this is not from the government. This was announced in 2023. They eliminated one rotation per year and introduced a two-year clinical training day. Currently, residents have one rotation per year for 3-4 years, but they improved it to have two years of clinical training and three years of residency within a single rotation. It's similar to the systems I showed you in the UK and Australia earlier. So now, this is.

I said I would do it, but let me say it again. Doing this in the system right now, even if we call it clinical training, it's still just intern training without changing the entire system. So, let's organize it. Let's improve the training environment for medical specialists. We should follow the global trend. We always talk about global standards, but it applies to the medical field as well. We need to establish primary care training programs, increase multidisciplinary team treatments, strengthen the patient healthcare system, and transition from fee-for-service to value-based fees. This is not just one country's practice; it's a principle established in most countries in Europe, the United States, Japan, and many other countries. Invest in regional coordination centers. So, in a way, this slide could be the most important slide I'm going to talk to the government about. The government asks us to believe in the sincerity of medical reform. Every time we talk, we emphasize this point.

I'm listening. The way to show sincerity is one thing, it's about preparing money. If you have money, there is sincerity. But if you don't have money, there is no sincerity. It's simple. So, this is not about talking about the entire medical contract, but about financial support measures for improving the training environment for medical specialists. If there are about 10,000 medical specialists, we need to provide around 50 million to 50 billion won. Why should we support this? As students, why should we support this? The government has set goals, aiming to reform and activate essential medical services and public medical services. If they set goals to achieve that, then the government needs to provide money to achieve those goals. Essential medical services, public medical services, and regional medical services should set goals. Seoul National University Hospital should set goals, but did the university hospitals set them up?

Did the government establish a test hospital? Yes, it was established by the government, and it is correct that the government bears the burden. However, can it be done only with specialists? What is needed is specialists who are trained. Currently, I think the ratio of training to work is about 25% to 75%. It needs to change. The ratio needs to be reversed from 75 to 25. In order to adjust these numbers, we need about 5,000 more specialists. This is because more investment in education is needed. And 50% of the salary of one specialist should be borne by the government. They need to be educated, but they also need to work for the hospital. If we assume it's 200 million, subtracting 100 million, we need 500 billion for 5,000 specialists, totaling 1 trillion. Please allocate this from the government. Otherwise, reform cannot happen. This is unprecedented, isn't it? Through the Judicial Research and Training Institute, the state fully covers the costs of training lawyers and prosecutors, right?

There is a precedent, so that's why, but what I mentioned is not about the overall cost of medical contracts. It's about the need for 1 trillion won to improve the education, realization, and working environment of the major. This is the last slide, so I am talking about a very fundamental issue. I would like to emphasize again on what basis we are standing. As I mentioned, based on the special law of the major, we had agreed that we need to improve by working a maximum of 80 to 88 hours a week. I would like to ask if this is normal. According to the Labor Standards Act, working 40 hours a week up to a maximum of 52 hours is considered normal. Is this normal? Many people might think, Oh, that makes sense, this is normal. But it's not normal. Of course, there are trainees' perspectives in the major, and there are also specific aspects of education and medical procedures.

I think I can compromise a little, but that's not the Daejeon Agreement in 2015. What is it? You can work up to 64 hours a week from 40 hours. Let's normalize medical services in this way. I would like to emphasize that this is the starting point of medical reform. Thank you.

2024.04.30 심포지엄 홍윤철

2024.04.30 심포지엄 홍윤철