In 2024, the South Korean government proposed an “Essential Medical Care Package Policy,” including an increase in medical school admissions, to prepare for the country’s transition to a super-aged society, and strengthen regional, and essential medical services [1]. The medical community opposed this plan, criticizing the abrupt and significant increase in medical student admissions as being excessive and insufficiently discussed. Nevertheless, the government implemented the policy and maintained its stance of increasing the intake of number of medical students until a target of 2,000 is reached [2–4]. The implementation of the new policy has led to a wave of resident physicians resigning, citing concerns over the government’s misguided approach to expanding essential medical services, the unintended consequences of this decision, and the immediate inability of medical schools to accommodate the increased number of students, all of which they fear will ultimately compromise the quality of patient care. As the conflict continues, the remaining medical staff face an increased workload, and patients are exposed to significant risk to their health care. University hospitals, which depend heavily on resident physicians, are particularly affected, and this has resulted in reduced bed occupancy and limited Emergency Room (ER) operations.

In response to this crisis, the National Fire Agency have implemented emergency patient transport measures to prioritize patients with life-threatening conditions, and the 119 emergency medical control center became responsible for selecting hospitals to receive patients (in order to minimize delays in emergency patient transport). Severe and critical patients were directed to regional emergency medical centers and large hospitals, whereas mild and nonemergency patients were transported to local emergency medical institutions or nearby clinics and hospitals [5].

As the conflict between the medical community and the government continues, large hospitals face financial strain and severe burnout of experienced medical staff [6,7]. During this crisis, the government has injected health insurance funds to maintain the emergency care system, raised copayments for ER visits by noncritical patients, and dispatched public health and military physicians to fill the affected sites [8]. These measures have been criticized for not addressing challenges on the ground and the impending collapse of the emergency medical system. Nevertheless, the government has reported that the emergency medical response system is operating smoothly, despite some difficulties [9].

This study aimed to analyze the impact of the reduced numbers of resident physicians caused by the ongoing conflicts surrounding trauma patient care. Using data from a single institution, the National Health Insurance Service (NHIS) Ilsan Hospital, the study will assess trauma admissions, emergency department length of stay, trauma severity, patient mortality, and staff workload distribution across departments during inpatient care. The findings may help identify challenges within the trauma care sector and suggest directions for future improvements.

In 2023, there were 1,182 patients who arrived at the Emergency Department with trauma, while from March to August 2024, excluding January and February when the conflict between the medical community and government began, there were 204 patients with trauma (Table 1). The average monthly number of patients with trauma in 2023 was 98.5, with patients with severe trauma (ISS ≥ 15) comprising 10.7%. In contrast, from March-August 2024, the average monthly number of patients with trauma was 34.2, showing a substantial decrease in the total number of patients with trauma. However, the monthly average number of patients with severe trauma showed a smaller decline, from 10.6 in 2023 to 7.3 in 2024. The proportion of severe trauma cases increased to 21.5% in 2024 compared to that in 2023 (Figure 1).

The median age of the patients at the time of arrival showed no significant difference between the 2 groups; however, the proportion of male patients was higher in 2024 compared with trauma patients in 2023. The ER length of stay significantly decreased from 295 minutes in 2023 to 187 minutes in 2024 (p < 0.001). The most common mechanism of injury in both periods was the patient slipping down. In 2023, the Department of Orthopedic Surgery accounted for over 50% of the inpatient care; however, this percentage dropped to 24.02% between March-August 2024. The proportions of patients who underwent neurosurgery (29.41%), and trauma surgery (24.02%) were relatively high in 2024, indicating a shift in the distribution of inpatient departments for patients with trauma within the hospital (p < 0.001). Additionally, the proportion of severe trauma cases significantly increased from 10.7% in 2023 to 21.5% in 2024 (p < 0.001). The percentage of patients classified as Korean Triage and Acuity Scale Levels 1 (1.96%), 2 (21.57%), and 3 (47.06%), along with the proportion of Intensive Care Unit admissions among inpatients (31.22%), also increased significantly in 2024 (p < 0.001). The in-hospital mortality rate increased from 2.96% in 2023 to 5.39% in 2024, although this increase was not statistically significant (p = 0.076). The proportion of cases that required surgery prior to admission decreased from 5.3% in 2023 to 2.9% in 2024, although this change was not statistically significant (p = 0.144). However, the time to emergency surgery (defined as the duration from Emergency Department arrival to surgery) significantly decreased from 249 minutes in 2023 to 137 minutes in 2024 (p = 0.033; Table 1).

In the distribution of inpatient departments for patients with severe trauma, approximately 59.8% were admitted to the Neurosurgery Department in 2023, which increased to approximately 75% in 2024. Conversely, orthopedic surgery, which accounted for approximately 10% of severe trauma admissions in 2023, had no severe trauma admissions in 2024. Trauma surgery showed similar rates of 23.6% in 2023 and 20.5% in 2024 (Figure 2).

There is currently a shortage of resident physicians in trauma care in South Korea. A reduced number of physicians in trauma care can result in a reduced number of trauma care patients being treated at the appropriate institution. The results of this study indicate that the average monthly number of patients presenting at the Emergency Department with trauma decreased by more than half in 2024 when compared with 2023 (Figure 1). The National Fire Agency implementation of an emergency transport system, and the 119 emergency medical control center (responsible for selecting hospitals to receive patients to minimize delays in emergency patient transport) may therefore have consequently played a role in the decreased number of trauma patients being received at this institution. The shortage of ER personnel and the decreased capacity of supporting departments are likely the primary causes of the reduced intake of trauma patients. The proportion of patients with severe trauma being treated in the Department of Orthopedic Surgery, which relies heavily on resident physicians, had an average of 6× the number of trauma patients treated per month in 2023 compared with 2024, which clearly illustrates this issue further. In this study, for each shift, the Department of Emergency Medicine previously had 1 emergency medicine specialist, 2 residents, and 1 intern. Currently, only 1 specialist is responsible for all tasks.

During the period of study where there was medical conflict, the length of stay of patients with trauma in the ER significantly decreased, and the time from Emergency Department arrival to emergency surgery significantly decreased. This result may appear paradoxical but it can be interpreted in 2 ways. Firstly, the overall capacity of the Emergency Department to accommodate patients decreased, resulting in a reduction in the number of patients treated in the ER. Secondly, the reduced number of residents eliminated the need for intra-resident communication and notification processes. In other words, attending physicians from supporting departments directly managed patient care, enabling faster decision-making regarding patient health care.

Based on these findings, the government’s emergency contingency system for resident shortages, may appear to function without significant disruption. However, this reflects a system where a single physician now assumes multiple roles, and nurses are taking on responsibilities traditionally managed by residents, and this exacerbates workload. Departments unable to provide adequate support for the ER are deferring decision-making, regarding patient admissions, to the Department of Emergency Medicine.

If this situation persists, the accumulating fatigue amongst the Department of Emergency Medicine and supporting department staff is likely to reach a critical threshold, potentially resulting in an irreversible collapse of the emergency care system. This issue cannot be resolved through temporary government financial support or temporary measures such as the dispatch of military and public health physicians. Without fundamental reform, it may lead to institution financial exhaustion and create new issues including gaps in medical services within military units and local healthcare systems.

When considering the redistribution of trauma patients and the need for Regional Trauma Centers this raises the question, “where did all those trauma patients go?” Typically, in the northern Gyeonggi Province, patients with severe trauma are transferred to the Regional Trauma Center, whereas those with mild-to-moderate trauma are treated at Regional Emergency Medical Centers like our hospital. Even for severe trauma cases, if the estimated transfer distance to the Regional Trauma Center exceeds 30 km or if the travel time is over 45 minutes, our hospital is equipped to receive and provide comprehensive treatment for these patients [15]. Following the resignation of residents due to conflict, the total number of patients with trauma transported to our hospital initially dropped significantly, owing to a temporary reorganization of the emergency transport system (Figure 1). This can be interpreted as a result of mild trauma patients being redirected to primary care facilities rather than hospitals with resident training programs like a tertiary hospital. This likely led to issues such as overcrowding of local ERs and transfer inefficiencies, with patients potentially being repeatedly redirected between facilities without receiving the appropriate care. In addition, the number of severe trauma patients likely fell due to the redirection of transport to the Regional Trauma Center. This likely overwhelmed trauma specialists and their supporting departments in the absence of resident and intern assistance.

At NHIS Ilsan Hospital, the Shock and Trauma team, composed of 5–6 specialists in trauma and critical care, provide primary care for trauma patients. This team is not only responsible for trauma patient care but also manages critical patients who have undergone nontraumatic abdominal surgeries, hospitalist services, and rapid response team duties [10]. Operating without resident support, the team provides consistent, round-the-clock care for trauma and surgical critical care patients, even amidst ongoing medical conflicts. Although the overall number of trauma patients decreased, the proportion of severe trauma cases did not decline significantly, remaining at approximately 70% (Figure 1). This underscores the critical role of the Shock and Trauma team at NHIS Ilsan Hospital in managing severe trauma patients and contributing to the regional trauma care system by acting as a buffer between the local ER and the Regional Trauma Center.

In the United States, the Trauma Center Level is defined by the American College of Surgeons and the American Trauma Society, categorizing hospitals into Levels I through to V based on capacity to treat trauma patients [11]. Similarly, South Korea has designated 17 hospitals capable of providing high-quality definitive trauma care, equivalent to Levels I and II, as Regional Trauma Centers. However, Local Trauma Centers, similar to Level III or IV, such as NHIS Ilsan Hospital, are not categorized to manage moderate-to-severe trauma cases. In the case of Level III centers, they are not as comprehensive at giving trauma care as Levels I and II, but are designed to provide critical services such as resuscitation, emergency surgery, and stabilization. They also play a crucial role in establishing an efficient transfer system, ensuring appropriate patient transfers to higher-level trauma centers when necessary.

Considering Korea’s current situation and future direction, it is necessary to establish and expand the system of Local Trauma Center at the general hospital level, rather than at tertiary referral hospitals. Firstly, trauma patient rapid transfer and treatment at the nearest facility is essential. Since the trauma center was initiated a decade ago, and is now established, the preventable trauma death rate has significantly decreased nationwide [16,17], but prehospital preventable death rates remain high [18,19]. Given these characteristics, creating a wider network of Regional Trauma Centers capable of treating patients with severe trauma would facilitate quicker access to appropriate treatment. This model is also suitable for acute abdominal emergencies requiring surgical intervention. Integrating trauma care with emergency systems for acute abdomen could be an effective solution [20]. Secondly, during crises such as medical system breakdowns, disasters, or pandemics, Regional Trauma Centers can play a buffering role by coordinating seamless transfers to higher-level hospitals. A more efficient and stable transfer system can be established if the current hourglass-shaped system is transformed into a pyramid structure with intermediate-level regional hospitals operating nationwide. This change would benefit trauma care and extend to essential medical services such as obstetrics, pediatric emergencies, acute abdominal conditions, and coronary artery disease, by ensuring the provision of appropriate emergency medical care reflecting the severity of injury at the right time and place, and aligning with the government’s current initiatives to establish community-based medical services [21].

This study addresses a timely issue by examining the impact of shortages in the number of residents in Emergency Medicine and healthcare conflicts, on trauma care management. The data in this study offers a persuasive and practical perspective. However, as this was a retrospective study conducted at a single institution, the findings are limited in the changes observed in trauma patient care patterns. Nonetheless, given that severe trauma care requires comprehensive support from various departments, and represents the broader capacity of essential medical fields, we believe that the data presented in this study holds significant value. Research utilizing multicenter data or nationwide databases is needed to generate generalizable results that more accurately reflect the overall state of the South Korean healthcare system.

This study analyzed the impact of resident shortages on trauma patient care using data from the NHIS Ilsan Hospital, which is a Regional Emergency Medical Center. Ironically, the reduced number of residents in the Emergency Department has exposed critical shortcomings in essential medical services in South Korea, providing insight into potential directions for future healthcare policy reform. This study suggests that the reduced number of residents has increased the workload and fatigue of both the Emergency Department and supporting department staff. Furthermore, the government’s transfer system, intended to alleviate the burden on resident training hospitals, may have unintentionally exacerbated the polarization of trauma patients.

These challenges are unlikely to be resolved with short-term funding or temporary personnel alone, and may continue to impact patient safety unless fundamental issues are effectively addressed. The introduction of a Local Trauma Center, to improve the trauma system, that functions as a Level III trauma center, could serve as an intermediary between local emergency facilities and Regional Trauma Centers, managing mild to moderate trauma cases. It may significantly enhance the efficiency of the transfer system and provide a crucial buffering effect during crisis situations.