Resident shortages and their impact on surgical care, defensive medicine, and patient management: a retrospective study in South Korea
Article information
Abstract
Purpose
This study aimed to evaluate the impact of declining surgical residency program enrollment on patient care and outcomes in colorectal cancer surgeries.
Methods
This retrospective observational study included 676 patients (410 males; median age: 69 years) who underwent colorectal cancer surgery at Pusan National University Hospital between January 2018 and June 2024. Patients were divided into Group A (before December 31, 2023; with residents) and Group B (after January 1, 2024; without residents). All surgeries were performed by a single attending surgeon.
Results
Preoperative variables were comparable between groups. Group A had more emergency and open surgeries, and a higher proportion of advanced-stage cancers. Overall complication rates were similar, but Group B had a longer hospital stay (9.72 days vs. 11.95 days). Specific complications such as anastomotic leakage and surgical site infections differed significantly. The overall number of surgical procedures declined markedly in 2024 compared to 2018 (77.1% vs. 49.9%).
Conclusion
The absence of residents did not increase overall complication rates but was associated with longer hospital stays and shifts in clinical practice. Greater reliance on attending surgeons contributed to more defensive decision-making and conservative patient management. Addressing these issues requires systemic reforms, including multidisciplinary collaboration and legal protections to improve surgical care.
INTRODUCTION
The healthcare system in South Korea is currently facing substantial challenges, including a shortage of physicians, suboptimal working conditions, an increase in medical errors, and escalating litigation. While the total number of medical specialists has grown at an average annual rate of 3.3% over the past decade, the expansion of key specialties such as general surgery, cardiothoracic surgery, obstetrics and gynecology, and pediatrics has been limited to approximately 1% [1]. General surgery, a cornerstone of essential healthcare services, has experienced a marked decline in interest, reflected in the continuous reduction in resident applicants over the past decade [2]. For instance, at our institution, the only national university hospital in Busan, resident enrollment has steadily decreased from ten in 2018 to four in 2022 and only one in 2024 (Fig. 1). As a result, patient care has been critically compromised by the near-complete absence of surgical residents.
Annual resident enrollment trends from 2018 to 2024.
Surgeons are integral to providing operative management for a wide range of pathologies, including traumatic injuries, and directly impact patient morbidity and survival outcomes. The increasing demand for surgical interventions is driven by population aging, the rising prevalence of chronic diseases, and innovations in surgical techniques and technologies. This growing demand underscores the indispensable role of surgeons in the healthcare systems [3,4]. Surgical residents play a pivotal role in providing intraoperative assistance, contributing to perioperative care, and responding to surgical emergencies. Therefore, the diminishing number of surgical trainees may adversely affect the quality of surgical care, highlighting the urgent need for systemic interventions to mitigate this workforce deficit [5].
This study aimed to evaluate differences in postoperative morbidity and length of hospital stay among patients undergoing colorectal cancer resection at our institution before and after the decline in resident staffing. Furthermore, the study addresses various systemic issues encountered in patient management, including workforce shortages, the practice of defensive medicine, and deficits in specialized medical expertise. We hypothesized that these findings would provide insights into potential strategies for addressing these challenges.
METHODS
Patient population
This retrospective observational study included 676 patients who underwent surgical resection for a confirmed diagnosis of colorectal cancer at Pusan National University Hospital between January 2018 and April 2024. All procedures were performed by a single attending surgeon. The evaluated variables comprised patient demographics (age and sex), comorbidities, and the American Society of Anesthesiologists physical status classification to assess preoperative risk. Hemoglobin and albumin levels were included as indicators of nutritional status, while surgical factors such as the type of surgery (emergency surgery was defined as surgery performed within 48 hours, whereas elective surgery was defined as surgery scheduled in advance following a comprehensive preoperative evaluation), surgical approach, concurrent procedures, and operative type (right, left, or rectal resection) were also recorded. In cases of synchronous malignancies, the operative name was determined based on the more advanced lesion. Additional variables included pathological stage (classified by the TNM system, Union for International Cancer Control) and residual tumor status (R0, R1, or R2).
The primary surgical outcomes analyzed included the procedure performed, mean length of hospital stay, reoperation rate (≤30 days), postoperative morbidity, and 30-day mortality. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of Pusan National University Hospital (IRB No. 2407-010-140). The Institutional Review Board waived the requirement for informed consent.
Statistical analysis
The normality of data distribution was assessed using the Shapiro-Wilk test. Continuous variables were expressed as means with standard deviations or medians with interquartile ranges based on distribution. Categorical variables were presented as frequencies and percentages. Between-group comparisons were performed using independent samples t-tests or Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher exact tests for categorical variables. Statistical analyses were conducted using R software (version 4.3.3; R Core Team, 2024). A two-tailed P-value of <0.05 was considered statistically significant.
RESULTS
Pre-surgical variables
Preoperative demographic and clinical characteristics, along with logistic regression analyses, are detailed in Table 1. No significant differences in baseline characteristics were observed between the two groups.
Pre-surgical variables
Surgical variables
In Group B, a lower incidence of emergency and open surgeries was observed compared to Group A. Additionally, Group A had a higher proportion of patients with advanced-stage (stage III–IV) cancers (Table 2).
Surgical variables
Postoperative morbidity
The median length of hospital stay was longer in Group B. While there was no significant difference in the overall complication rates between the groups, specific postoperative complications, including anastomotic leakage and surgical site infections, occurred more frequently in Group A (Table 3).
Postoperative morbidity
Total surgeries and ER visits by year
The annual volume of surgical procedures performed under general anesthesia, as well as the number of emergency room (ER) visits within the department of surgery, are summarized. Colorectal cancer resections and other surgical interventions were categorized as either elective or emergency. Using 2018 as the baseline (100%) for both surgical procedures and ER visits, trends from 2018 to 2024 were analyzed. Elective and emergency surgeries remained relatively stable until 2022; however, a marked decline was observed between 2023 and 2024, with a sharper reduction in emergency surgeries (2024 elective surgeries: 77.1%; emergency surgeries: 49.9%) (Figs. 2, 3).
Annual elective surgeries performed from 2018 to 2024, expressed as a percentage relative to the baseline year of 2018 (100%).
Annual emergency surgeries performed from 2018 to 2024, depicted as a percentage with the average for 2018 as the baseline (100%). (A) Annual averages. (B) Monthly breakdown for each year.
DISCUSSION
South Korea’s healthcare system is internationally regarded for its cost-effectiveness and high-quality patient outcomes. The cost of major surgical procedures in South Korea is approximately one-tenth that in the United States, while clinical outcomes remain comparable to those achieved in other developed healthcare systems. However, relatively lower compensation and increased medico-legal liabilities have contributed to the declining interest in essential specialties, exacerbating healthcare disparities, particularly in rural and underserved regions [6]. Since 2023, surgical procedures at our institution have primarily been performed by attending surgeons due to shortage of residents [7]. Over the past 18 months, 191 colorectal cancer surgeries were conducted under this adjusted staffing model. Contrary to initial expectations, the absence of residents did not result in a marked increase in perioperative complications. These outcomes can be attributed to the continuity of a stable surgical team, coupled with augmented training and the recruitment of experienced surgical assistants. Consequently, the overall quality of surgical care remained largely unaffected. Nonetheless, emergency surgical interventions for acute abdomen cases were often deferred when abdominal surgeons were unavailable, contributing to a decline in emergency procedures and a lower proportion of patients presenting with advanced-stage disease (stages III–IV). This reduction in surgical acuity may explain the observed decrease in major complications, such as anastomotic leakage [8]. Despite stable postoperative complication rates, the mean length of hospital stay increased by approximately 2 days, likely reflecting more intensive postoperative monitoring and diagnostic testing. The shortage of resident and nursing staff has amplified the workload, particularly in perioperative management. Elective surgeries, which are more amenable to comprehensive preoperative planning, were less disrupted, while emergency surgical interventions experienced a reduction of approximately 50%, highlighting the greater strain on available surgical personnel.
The decline in the number of emergency surgeries is not solely attributable to a shortage of surgeons but rather reflects a broader deficiency of specialized medical personnel required for the management of critically ill patients in tertiary hospitals. Emergency surgical care in university hospitals depends on a multidisciplinary team (MDT), including emergency medicine physicians for initial evaluation, gastroenterologists for endoscopic decompression of bowel obstructions, and anesthesiologists for perioperative management. However, the availability of these specialists has progressively declined, reducing the hospital’s capacity to admit and treat emergency surgical patients. Following the resignation of surgical residents in February 2024, the availability of key personnel—including surgeons, anesthesiologists, emergency medicine specialists, and gastroenterologists—has further diminished, restricting the treatment options for critically ill patients. Previously, emergency surgical candidates underwent rapid assessment in the emergency department, received temporary decompression procedures such as endoscopic stenting, or were promptly scheduled for surgery with anesthetic support. However, with declining specialist availability across multiple disciplines, delays in emergency care and surgical interventions have become increasingly frequent. Thus, the reduction in emergency surgical procedures should not be attributed solely to the shortage of surgical residents but rather to a systemic shortfall of key specialists required for the management of high-acuity patients in tertiary hospitals. The limited availability of professionals capable of handling complex surgical emergencies has further burdened the healthcare system, diminishing its ability to deliver timely and comprehensive care to critically ill patients. This workforce shortage is a complex issue that cannot be addressed simply by increasing the number of physicians. Essential specialties remain underfunded, and the substantial workload and legal risks associated with high-risk surgeries have contributed to declining interest among both residents and specialists. This issue is severe for anesthesiologists who provide general anesthesia for high-risk patients in tertiary hospitals, where the demand for specialized expertise is high but staffing shortages persist. In these institutions, where complex surgical cases require highly skilled anesthesiologists, the shortage of trained professionals has led to surgical delays, increased workload for existing staff, and a growing reliance on a limited number of specialists. Additionally, the high legal liability associated with complex surgical procedures further discourages specialists from entering these fields, ultimately limiting access to essential surgical care. The combination of low financial incentives and high medico-legal risks has created a cycle in which fewer physicians choose to specialize in these critical areas, exacerbating workforce shortages and further straining essential medical services. These factors have further exacerbated the avoidance of essential specialties, ultimately threatening the sustainability of essential medical services and fostering an environment where remaining specialists are compelled to practice defensively. As a result, this shift has led to longer hospital stays, increased preoperative diagnostic testing, and a growing preference for elective surgeries that allow for more thorough preoperative preparation. Consequently, surgeons and other specialists have become more inclined to practice defensively in their clinical decision-making.
Defensive medicine, first defined in 1978, refers to clinical behaviors that exceed the standard of care [9]. It is categorized into “positive” defensive medicine, characterized by excessive diagnostic testing, referrals, and procedures, and “negative” defensive medicine, involving the avoidance of high-risk interventions [10]. The current practice of defensive medicine is evidenced by prolonged hospitalization, increased diagnostic testing frequency, and reduced surgical interventions for high-risk patients, exacerbating emergency department congestion. In a healthcare system where individual providers bear disproportionate legal responsibilities for high-risk patient management, these challenges are likely to escalate [11–14]. To ensure the sustainability of the healthcare system, it is imperative to implement legal safeguards for high-risk procedures and adopt a team-based, integrated approach to perioperative care rather than placing the burden solely on individual providers. Optimizing workforce allocation through strategic recruitment and establishing specialized MDTs can mitigate the impact of staffing shortages [15–17].
Defensive medicine, driven by the fear of malpractice litigation, complex legal frameworks, and insurance liabilities, not only inflates healthcare costs but also undermines the quality of patient-physician relationships [18,19]. Physician-friendly legal frameworks, such as those in Spain, report lower incidences of defensive medical practices [20]. Moreover, due to its association with increased healthcare expenditures, diminished care quality, and potential patient harm, mitigating defensive medicine is imperative in modern healthcare [16]. Effective policy interventions, including capping non-economic damages, streamlining litigation processes, and integrating mediation for medical malpractice disputes, have successfully curtailed defensive medicine in several U.S. states [21,22]. Addressing these concerns necessitates collaborative initiatives between governmental agencies and healthcare leaders, including public education campaigns that elucidate the complexities of clinical practice and establish realistic patient expectations, thereby reducing dissatisfaction and the risk of malpractice litigations [22].
Advancements in surgical techniques have expanded the eligibility criteria for surgical interventions to encompass elderly and frail patients with multiple comorbidities [6]. This paradigm shift underscores the need for co-management strategies integrating both surgical planning and postoperative care, which have become the standard in hospital-based medicine. The MDT model, in particular, is highly beneficial for the management of high-risk surgical patients, who have a disproportionately elevated risk of adverse outcomes and increased healthcare resource utilization [16]. In a study by Pearse et al. [23], over 80% of postoperative mortalities occurred in a 12.5% subset of high-risk patients among 4.1 million non-cardiac surgeries. Similarly, Stephens et al. [24] demonstrated that patients with esophageal cancer managed by an MDT had significantly lower surgical mortality (5.7% vs. 26.0%, P=0.004) and improved 5-year survival rates (52% vs. 10%, P=0.0001) compared to those managed by individual surgeons. In South Korea, the hospitalist system, introduced in 2017 to address these challenges, has had limited adoption, with only 326 hospitalists currently practicing nationwide [25].
A viable solution involves establishing regional specialized centers dedicated to complex critical care. Concentrating personnel within these centers, coupled with adequate compensation, would enhance the delivery of specialized care. MDTs composed of surgical and medical specialists focused on emergency care could improve surgical outcomes and mitigate the current shortage of surgical personnel [26,27]. The issue of “emergency room bouncing” could be alleviated by identifying on-calls surgeons available for emergent procedures within each region, ensuring prompt dispatch to handle critical cases. Establishing acute abdominal centers, similar to cardiovascular centers, would enable surgeons to operate at facilities with the requisite resources rather than relying exclusively on their primary hospital, thereby optimizing resource allocation [27,28]. Ensuring adequate work-life balance for healthcare professionals is essential to prevent burnout. Although there is interest among physicians in becoming critical care surgeons, barriers such as inadequate compensation and high medico-legal risk deter many potential candidates. The focus should be on improving remuneration and providing institutional support rather than merely increasing the number of trainees [29,30].
This study had some limitations. First, its retrospective design, conducted at a single center, may introduce selection bias, potentially limiting the generalizability of the findings to other hospitals in Korea or countries with comparable healthcare challenges. Second, the study did not propose specific, actionable strategies for the implementation of MDT or hospitalist systems. Nevertheless, discussions with peer surgeons from multiple institutions suggest that similar challenges are widespread across hospitals. Despite the absence of formal recommendations, the inclusion of all surgical patients in the statistical analysis minimizes the risk of selection bias, enhancing the internal validity of our findings. Although detailed implementation strategies were not provided, this study holds clinical significance by offering valuable data that highlights the practical issues currently confronting the surgical field in South Korea and suggests insights into potential solutions.
In conclusion, our findings revealed that despite the absence of surgical residents, overall complication rates remained stable. However, the increased reliance on attending surgeons led to a more defensive clinical approach and a tendency towards conservative management. Addressing these challenges will require systemic policy interventions, such as promoting multidisciplinary collaboration and implementing legal reforms to mitigate malpractice concerns and optimize surgical care.
Notes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING
This study was supported by a Biomedical Research Institute Grant from the Busan National University Hospital (grant number: 20240066).
ACKNOWLEDGMENTS
We thank the Department of Biostatistics at the Biomedical Research Institute of Busan National University Hospital.
DATA AVAILABILITY
The datasets generated and/or analyzed during the current study are not publicly available because the data contain the personal information of patients. These will be made available by the corresponding author upon request.