The operating room is filled with tension. Surrounded by assistants and nurses, the surgeon holds a scalpel and cuts open the patient under the bright light of the surgical lamp above.

While all doctors strive to save lives, surgeons are sometimes called the “doctors of doctors,” as they stand in the front line of the fight against death. Often, they are the subject of admiration.

But the reality of the job, with its poor working conditions and unclear future, has long made the surgery department one of the least popular among those aspiring to be doctors.

“When we entered medical school, I saw many who said they wanted to become surgeons. But now that we are graduating, I am one of the few who still plan to apply for the surgery department,” Kim Hyun-joon, a senior at the Inje University College of Medicine, told The Korea Herald. 

In a survey in which Inje University students were asked to state the departments of their choice, only a few selected the surgery department at the five branches of the Paik Hospital, Kim said. The hospital is associated with Inje University. The situation appears to be similar in other medical schools, Kim added.

Every year, surgery-related departments fall short of filling the places on their residency programs. In 2018, the neurosurgery department at hospitals across the country filled 93.4 percent of its residency places, with the rate lower for other departments: 77 percent for the obstetrics department, 69 percent for the general surgery department and 52 percent for the cardio-thoracic department, according to data provided by surgeons’ associations here.

The dermatology and cosmetic surgery departments filled their places completely.

Considering the rate at which the departments continue to fall below their quotas and the expected retirement of surgeons, Korea may have to “import” surgeons in the future, an official from a thoracic surgeons’ organization said.

The Korean Society for Thoracic and Cardiovascular Surgery expects it will lack some 400 surgeons in 2022.

Sacrificing life for life

Some of the reasons that medical students turn away from surgery are the harsh working conditions and relatively low compensation.

“We are put under extreme stress and a heavy workload as thoracic surgeons. Because all our patients need intensive care after an operation, we always have night duties,” Oh Tae-yoon, the board president of the Korean Society for Thoracic and Cardiovascular Surgery, told The Korea Herald.

“The operation fees are low, so the departments often suffer from financial deficits. There is also a lack of personnel at the same time. So one surgeon would have to take on multiple surgeries a day, each lasting hours,” he said. Spending time with family and taking breaks are unimaginable.

As surgeons are involved in high-risk procedures, they also face legal disputes, Oh added.

The average work hours of surgeons often surpasses the legal limit of 80 hours per week. (Surgeons are exempt from the standard limit of 52 hours a week).

According to the Korean Neurosurgical Society, more than 98 percent of surgical residents said they worked over 80 hours per week in 2017, with the average at 104 hours per week.

A petition by a thoracic surgeon on the presidential website in April complained about the lack of “personal time.”

Highlighting how he sometimes regretted his decision to become a thoracic surgeon, as the life of a thoracic surgery resident is so difficult, he said, “I love my job. But would it be impossible for surgeons to have their life and family, while happily taking on the job?”

Thoracic and cardiovascular surgeons work an average of 76 hours per week, with 6.5 overnight shifts a month.

Uncertain future

Even a short operation takes several highly skilled physicians, expensive medical equipment and support staff. Difficult surgeries often take hours. Despite the high cost of preparing for a surgery, surgeons are not paid enough, a surgeons’ organization claims.

For instance, a hospital receives about 1 million won for an appendectomy, the surgical removal of the appendix.

The actual surgery lasts about an hour, and requires preparation and several staff. However, only about 280,000 won of the fee goes toward this. The rest of the fee is spent on injections and hospitalization, Jeong Young-jin the chairman of the Korean Association of Surgeons, told The Korea Herald.

For the surgical removal of an ovarian tumor, the examination would bring the hospital about 1 million won, while the actual operation would bring in about 500,000 won.

“In the end, a radiologist would be paid double the salary of a surgeon,” Jeong said.

Even the simplest procedures involve at least several assistants and sterilization surgical tools.

“Just to drain pus, we have to sterilize surgical tools and give regional anesthesia. For all that (the hospital) would be paid 12,000 won. Treating one cold patient would bring in just about the same amount,” Jeong added.

While the job is meaningful, and doctors may feel a sense of accomplishment, the social perception that they should make sacrifices without commensurate compensation paints a grim outlook for aspiring doctors, Jeong said.

Even if aspiring surgeons endure years of hard training as interns and residents, their career is not guaranteed, because hospitals lack the funds to hire them as anything other than temporary workers.

These temporary positions are insecure have relatively poor pay and benefits, while still having long hours, so few surgeons stick it out for more than a few years.

The result is that hospitals cannot keep these positions filled -- there are 210 vacant positions in heart surgery alone, according to this year’s estimate by the Korean Society for Thoracic and Cardiovascular Surgery.

“Not all can be hired as professors in university hospitals. And the rest of the surgeons who complete their residency do not have anywhere to go,” Kim, 30, explained. “If you were to undergo major surgery, wouldn’t you want to be operated on in a university hospital or a large general hospital?”

Unlike other medical specialties, it is difficult for surgeons to open their own hospital businesses with a surgical ward, if they fail to be hired as professors, Kim said. It is also difficult for an individual to take on the financial burden of setting up a hospital with expensive surgical equipment and a team of surgeons.

“Skilled surgeons who wish to remain as surgeons are left with turning to other departments, or to open proctology hospitals.”

This is partly because it is easier to set up and run small clinics in proctology and other fields than major surgery. Once this happens, trained surgeons are effectively lost to the system.

Kim, who transferred from a pharmacy college to medical school in the third year to become a surgeon, said he is also worried about choosing his department.

Non-surgeons filling the gap

In November, the Welfare Ministry introduced the Act on Improvement of Training Conditions and Status of Medical Residents in an effort to prevent residents from working over the limit of 88 hours per week -- an additional eight hours of training is allowed on top of surgeons’ usual 80 hours.

The law aims to reduce the workload of doctors. But doctors fear that funding constraints mean that rather than hiring more qualified surgeons to cope with this, hospitals will instead hire physician assistants to fill in for surgeons.

The physician assistants are nurses and other types of medical staff, have no legal basis, and it is illegal for them to perform surgical procedures. But it is an open secret that hospitals hire physician assistants because otherwise they become financially inviable.

“I do not think there is any hospital that does not hire PAs. It is just impossible to run surgical departments without them,” Jeong said.

Oh of the Korean Society for Thoracic and Cardiovascular Surgery expressed hope that the situation will improve in the future.

“The situation is getting slightly better. As for the thoracic department, we saw a slight increase in the residency application rate, because a lot of the existing professors are expected to retire in the coming years,” Oh said.

“We now calculate the entry and retirement cycle (of surgeons) to balance the workforce. Legal measures are in the works to reduce the burden of the surgery department students, and we will continue to make efforts too.”

Jeong of the Korean Association of Surgeons said they need civil society, lawmakers and the government to putt their heads together to resolve the problem.

By Jo He-rim (herim@heraldcorp.com)