Expansion of medical school admission quotas in Korea, is it really necessary? | BMC Public Health

Despite opposition from physicians, the Korean Ministry of Health and Welfare has pursued a policy to increase medical school admission quotas by 2,000 students annually over the next five years, based on three physician workforce projection studies [7]. Therefore, this study examines how differences in annual physician workforce supply and demand occur, using the implementation of the medical school quota policy as the main scenario.

The authors of three research reports that were used by the Korean government to inform the policy of increasing medical school admission quotas expressed opposition to the annual increase of 2,000 students over 5 years [16]. None of the three studies directly state that an annual increase of 2,000 students is necessary; rather, they include opinions such as the need to devise incentive measures for medical specialties experiencing difficulties in securing manpower and that urgent improvements are needed not only in physician supply and demand but also in medical utilization behaviors and the healthcare delivery system [17].

Shin et al. (2020) analyzed medical utilization data from 2010 to 2018 to predict the required medical demands for 2025, 2030, and 2035. They assessed future physician surpluses or shortages by projecting the physician supply using medical personnel data from the same period. Physician supply projections calculated the available personnel for the target years using the inflow-outflow method and time series Autoregressive Integrated Moving Average (ARIMA) models. To forecast future medical demand, they applied average growth rates, curve estimation regression models such as logistic and logarithmic functions, and time-series analysis using the ARIMA model. Scenarios were constructed with 240, 255, and 265 working days. The ARIMA model analysis predicted shortages of 879–2,294 physicians by 2025, 4,094–7,168 by 2030, and 9,654–14,631 by 2035 [14].

This study has the advantage of incorporating factors such as medical benefits and veterans’ medical support, which previous physician supply and demand studies did not reflect. However, it does not apply gender weights to medical utilization weights. Additionally, setting the number of physician working days to 240, 255, and 265 failed to reflect the reality of the actual medical field.

Hong et al. (2020). used the inflow-outflow method for physician supply and applied a demand-based approach to medical demand. For supply projection, the authors algorithmized supply volume according to medical school admission quotas. On the demand side, they used 2018 medical utilization data from the Health Insurance Statistical Yearbook and Special Future Population Projections (2017–2067) of Statistics Korea. This study assumed that physician supply and demand in 2018 were appropriate and that physician productivity would increase by 0.5% annually. The results indicated that a shortage in physician supply could occur by 2067, emphasizing that regional imbalances in physician supply and demand are more urgent issues than a mere shortage in numbers [15].

This study assumed that physician productivity increases by 0.5% annually; however, this was found to be the researcher’s subjective opinion without supporting evidence. This study also constructed scenarios with 240, 255, and 265 physician working days, which failed to reflect the reality of the medical field.

Kwon (2023) projected changes in medical service demand under the assumption that the 2019 level of medical service utilization did not change in subsequent years and estimated the size of active physicians under the assumption that institutional and labor market attrition remains constant. Despite a decrease in population size, he found that medical service utilization would increase until 2040 owing to the rise in the older population. He expected the workforce size of active physicians to peak in 2044, and then shift toward a declining trend. Considering the increase in medical service demand owing to population aging and improvements in health status related to educational level, he anticipated that approximately 8,500 additional physicians would be required by 2050. He suggested that increasing medical school admission quotas by 5–7% annually from 2024 to 2030 would be the closest approach to meeting the required physician workforce size. However, he raised concerns that if medical service demand decreases owing to population decline after 2050, an oversupply of physicians could occur [18].

Generally, inpatient and outpatient care consume different amounts of resources, such as personnel, time, and equipment; therefore, conversion indices are applied for inpatient and outpatient services rather than considering them as the same unit of medical utilization [13,14,15]. Therefore, this study has the limitation of assuming that inpatient and outpatient care were in the same unit.

However, some studies argue that Korea does not have a shortage of physicians, but rather an oversupply. Oh (2020) evaluated a reasonable number of physicians in Korea using the inflow-outflow method for physician supply and projected supply and demand through the total amount of healthcare services and productivity for physician demand. Assuming a 5% improvement in physician productivity compared to 2018 and 265 working days per year, it was estimated that Korea would have an oversupply of up to 14,646 physicians by 2035 [1]. Scheffler and Arnold (2019) predicted physician demand in OECD countries based on factors such as per capita income, out-of-pocket health expenditures, and population aging. While most countries are predicted to have a physician shortage, Korea is expected to have an oversupply of 3,821 physicians by 2030 [19].

The present study included 265 working days commonly used in previous studies and the actual working days of physicians (289.5 days) to reflect realistic working conditions in the medical field, as well as 275 and 285 days. The Korean government’s claim that there will be a shortage of 10,000 physicians by 2035 was similar when using the underestimated working days of 265. When applying the actual number of physician working days of 289.5, it was found that not only would there be no shortage of physicians by 2035 but there could also be an oversupply of 3,000 physicians. If we assume that public medical utilization behavior and physicians’ working days remain at current levels while medical school quotas increase over 5 years, there is a possibility of an oversupply of as many as 11,000 physicians by 2035. A study on the determinants of healthcare expenditure in Korea found that a 1% increase in the number of physicians per 1,000 people led to a 22% increase in healthcare expenditure per capita [20]. This finding suggests that an oversupply of physicians could result in a sharp increase in healthcare costs, which warrants careful consideration.

In general, estimating medical demand is more complex than estimating medical supply, and this study has several limitations. First, this study did not consider differences in physician productivity by type of medical institution or specialty. Physician productivity can vary significantly depending on disease type and severity. However, due to data constraints, the study did not distinguish productivity by institution type or specialty and instead considered overall physician productivity.

Second, the demand-based method used to estimate the need for physicians does not determine whether current or future medical utilization rates are appropriate, nor does it specify what an appropriate level of utilization might be. Consequently, it remains unclear whether the physician demand estimated by the model accurately reflects the healthcare system. Furthermore, delegation or support among medical professionals, such as physicians and nurses may lead to overestimation or underestimation of the demand for medical personnel [21].

Lastly, with regard to estimating medical demand, this study did not consider the impact of various healthcare policy changes on the medical demand underlying physician demand. Although the WHO recommends including expansions in education and training, reduction of workforce imbalances, enhancement of staff performance, improvement of staff retention, and short- and long-term goals and cost estimates for adapting to major healthcare-sector reforms [4], there is lack of foundational research on short- and long-term goals for healthcare reforms, cost estimates associated with changes in medical fees and payment systems, and the influence of various non-economic factors on medical demand, making it difficult to incorporate these aspects into this study. In estimating medical demand, this study applied medical utilization rates weighted by sex and age. This approach is used when it is difficult to reflect the numerous factors influencing medical demand due to data constraints, allowing all such factors to be collectively considered in medical utilization [22, 23].

Various medical experts have warned that side effects may occur because of medical school quota policies. They are concerned that this may collapse the medical system, exacerbate regional and specialty imbalances, and anticipate an explosive increase in paid medical expenses [24]. Early economic theories proposed that increasing the number of physicians could lead to higher healthcare costs through the phenomenon of “physician-induced demand” [25]. In a paper focusing on geographic accessibility and availability of qualified personnel, the reduction of regional disparities was attributed to the intervention of other policies rather than to an increased supply of physicians [26]. In the United States, regions with higher physician density have been observed to incur higher medical costs [27]. Moreover, factors such as the shift toward chronic-disease monitoring, an overcrowded competitive medical environment, and patients’ greater access to information have led to predictions that non-physician clinicians will take over primary care, raising concerns about the potential collapse of primary care [28].

From the perspective of medical education, there is significant concern about the decline in educational quality. Medical education deals with life and must foster actual competencies through practical training in addition to classroom education [29]. The process of experiencing patients through hospital practice is crucial, and it is evident that the training environment is deteriorating because of the overwhelming number of trainees. In the United Kingdom, a study of 10,873 university students divided into five groups according to class size showed that larger class sizes had a negative effect on academic achievement [30]. Additionally, between 1996 and 2008, a survey of 48 professors and 1,928 courses at a university in the eastern United States found that simultaneously teaching a large number of students reduced teaching effectiveness. Large classes and large student numbers induced professors to alter courses in ways that were not beneficial to students, resulting in negative effects on academic performance and satisfaction [31]. In 2006, a survey of 110 clinical faculty members at U.S. medical schools indicated that increasing medical school admissions quotas could lead to shortages of space, training hospitals, and resources; limited patient exposure; insufficient mentoring; and difficulties in faculty recruitment [32].

There were cases in which medical school quotas were increased, but later reduced because problems such as specialty and regional imbalances were not resolved. Japan’s Ministry of Health, Labor and Welfare has increased medical school quotas since 2009 due to regional and specialty imbalances. However, problems such as low birth rates, physician oversupply, and soaring medical expenses have arisen, leading to considerations to reduce medical school admission quotas starting from 2023. In this process, Japan formed a consultative body centered on medical experts to establish supply and demand plans through sufficient communication and cooperation, promoting policies such as resolving imbalances and adjusting physician training processes [33]. This demonstrates that the medical workforce issues cannot be solved simply by increasing the number of workers.

According to OECD Health data, Korea has 2.3 physicians per 1,000 people, which is lower than the OECD average of 3.6. However, the annual number of outpatient visits per capita, which indicates medical accessibility, is 15.7—more than twice the OECD average, making it the highest globally. Additionally, health indicators such as life expectancy, mortality rates for major diseases, and infant mortality rates show that Korea has significantly better outcomes than other OECD countries [34]. This is because in Korea, primary care is largely provided by specialists, and these highly trained professionals deliver outpatient care very efficiently. Korea maintains top-tier health indicators, with fewer physicians and lower costs. These indicators counter the claim that Korea lacks physicians. There is no relationship between avoidable mortality and numbers of general practitioners and family physicians per capita, specialists per capita, nurses per capita, doctors and nurses per capita, or health expenditures per capita. These findings should move us to recognize that a larger number of available doctors will not necessarily translate into better healthcare outcomes [35].

Future advancements in artificial intelligence technology (AI) could significantly enhance physician productivity. AI can improve work efficiency by reducing the time spent on unnecessary medical record entries and administrative tasks, thereby allowing physicians to focus more on patient care [36, 37]. Up to 36% of existing workloads can be automated through this method [36]. Such productivity improvements can offset the projected shortage of 3.5 million healthcare professionals by 2030 across all OECD member countries [38]. Additionally, studies suggest that AI can assist in the analysis of imaging tests and diagnostic processes, thereby increasing physicians’ clinical efficiency and reducing consultation times [39]. This can greatly alleviate concerns about future shortage of physicians.

Government-led unilateral physician supply and demand plans are unlikely to be successful. Continuous discussions with healthcare providers and related organizations are necessary to agree on mid- to long-term supply and-demand projection models and methods that consider Korea’s medical environment. Therefore, long-term physician workforce policies should be established by using periodic supply and demand projections [2]. It is reasonable to assume that Korea has an imbalance in the regional and specialty distribution of physicians, rather than an absolute shortage in numbers [1]. Therefore, the government should move beyond the simplistic idea of solving the problem by increasing the number of physicians and seeking ways to alleviate their concentration. In addition, legal safeguards should be provided to enable physicians to practice confidently in essential medical fields with a high risk of medical accidents.