Impact of the 2024 Resident Physician Strike on National Cancer Surgery Volumes in South Korea

Impact of the 2024 Resident Physician Strike on National Cancer Surgery Volumes in South Korea | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of the 2024 Resident Physician Strike on National Cancer Surgery Volumes in South Korea Seunghyeon Lee, Taegu Kim, Eun Woo Lee, Nina Yoo, Sheikh Taslim Ali, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7287193/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background In South Korea, a mass resignation of resident physicians has been ongoing since February 2024 and continues as of June 2025. This study aimed to evaluate the impact of the 2024 resident physicians’ strike on nationwide cancer surgery volumes in Korea. Methods We analyzed nationwide administrative data on reimbursed cancer surgeries from January 2019 to July 2024, using data from the Korean Health Insurance Review and Assessment Service. A multivariable log-linear regression model was used to estimate changes in surgery volume by comparing observed and counterfactual estimates, adjusting for outpatient consultations by cancer type. We focused on common cancers in Korea: thyroid, stomach, lung, and colorectal. Results The number of overall cancer surgeries at tertiary hospitals declined by 24% (95% Confidence Interval (CI): 19–30%) following the strike. Cancer-specific reductions included 27% for thyroid, 31% for lung, 27% for gastric, and 25% for colorectal cancers. In contrast, surgery volumes in secondary hospitals increased overall by 8% (95% CI: 2–14%), with thyroid and gastric cancer surgeries increasing by 14%. Conclusions These findings suggest that clinical workforce instability can rapidly disrupt access to essential surgical services, even in health systems with universal coverage. strike disruption cancer operation surgery Korea Figures Figure 1 Background South Korea has faced challenges due to shortages of physicians in essential medical services. 1 To respond to this, in February 2024, the Korean Ministry of Health and Welfare introduced the Essential Healthcare Policy, which included increasing the number of physicians. Following this announcement, over 90% of resident physicians resigned, primarily those working in teaching hospitals (i.e., tertiary hospitals). 2 A workforce strike in essential medical services is known as critical as it affects the nationwide healthcare system, not only in resource-limited countries but also in high-income ones. 3 Delays or cancellations in cancer surgeries have been reported following the mass resignation (i.e., strike), 4 , 5 which has continued as of July 2025. However, the long-term strike’s impact on changes in nationwide cancer surgery volume, which often serves as an indicator of changes in essential medical service capacity, 3 has not been assessed before. Here, we examined the impact of the 2024 resident physicians’ strike on nationwide cancer surgery volumes in Korea. Methods To evaluate the impact of the strike, we analyzed nationwide data on reimbursements for cancer surgeries from January 2019 to July 2024, the latest period available at the time of analysis. 6 The data were obtained from the Korean Health Insurance Review and Assessment Service, which covers around 97% of the Korean population under public health insurance. 7 We included data from tertiary and secondary hospitals, focusing on the four common cancers in Korea (i.e., thyroid, stomach, lung, and colorectal), using codes from the International Classification of Diseases, Tenth Revision (Supplementary Table 1). Using a regression model, 7 , 8 we estimated the changes in surgery volume by comparing the observed and counterfactually predicted number of surgeries, adjusted for the patient visits (i.e., number of consultations) for each cancer type (Supplement Fig. 1 ). Consider, \(\:{O}_{t}\) is the number of operations performed for cancers (by types) at time \(\:t\) (month). \(\:{H}_{t}\) is the number of consultations (per 100,000 population) at the time \(\:t\) , and \(\:{I}_{t}\) is the indicator variable demonstrating the timing of the strike. We formulated a multivariable regression model as \(\:{O}_{t}={{H}_{t}}^{\beta\:}{e}^{\lambda\:{I}_{t}}\) . Where \(\:\beta\:\) and \(\:\lambda\:\) are the regression coefficients that quantify the number of surgeries and the effect of the strike on the operation ( \(\:{O}_{t}\) ), respectively. Simplifying the model, we further constructed a log-linear multivariable regression model as \(\:{ln}{(O}_{t})=constant+{\beta\:ln}{(H}_{t})+\lambda\:{I}_{t}\) , where \(\:\beta\:\) and \(\:\lambda\:\) were estimated, and the overall reduction in \(\:{O}_{t}\) was estimated using these parameters. Setting \(\:\lambda\:=\) 0, we predicted the counterfactual number of surgery volume since February 2024, while the estimated \(\:\widehat{\lambda\:}\) was used to estimate the % reduction in the number of surgeries by (1- \(\:{e}^{\lambda\:})\times\:100\%\) with an associated 95% confidence interval (CI). All statistical analyses were performed in R version 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria). Results We identified a 24% (95% CI: 19–30%) decrease in the overall number of cancer surgeries at tertiary hospitals. Cancer-type specific reductions were 27% (21%– 33%) for thyroid, 31% (24–38%) for lung, 27% (20–34%) for gastric, and 25% (17–32%) for colorectal (Fig. 1 and Table 1 ). In contrast, overall surgery volume at secondary hospitals increased by 8% (2%-14%), with thyroid and gastric cancer surgery both increased by 14% (Fig. 1 and Table 1 ). Table 1 Estimated changes in the number of cancer surgeries associated with the 2024 resident physicians’ strike in South Korea, by hospital and cancer type Tertiary hospital a Secondary hospital b Unadjusted % (95% CI), (Univariate Regression Model) Adjusted % (95% CI) (Multivariable Regression Model) Unadjusted % (95% CI), (Univariate Regression Model) Adjusted % (95% CI) (Multivariable Regression Model) Overall -21.0 (-28.2 – -13.7) -24.4 (-30.0 – -18.8) 7.4 (-2.3–17.0) 8.2 (2.4–14.0) Thyroid cancer -27.9 (-36.6 – -19.2) -27.0 (-33.1 – -20.9) 13.8 (4.1–23.4) 13.9 (6.2–21.6) Gastric cancer -29.7 (-39.9 – -19.6) -26.9 (-34.2 – -19.5) 6.8 (-5.8–19.4) 14.0 (3.3–21.7) Lung cancer -18.0 (-27.6 – -8.4) -31.0 (-37.8 – -24.2) 25.6 (3.0–38.2) 15.7 (-5.7–25.6) Colorectal cancer -22.0 (-30.1 – -13.9) -24.6 (-32.2 – -17.0) 5.2 (-2.3–12.6) 5.1 (-2.1–12.2) Note: Data represent percentage change in surgery volume with 95% confidence intervals (CIs), estimated using univariate and multivariable interrupted time series regression models. Multivariable models were adjusted for the number of cancer-specific outpatient consultations. a Tertiary hospitals were defined as hospitals designated by the Korean Ministry of Health and Welfare with ≥ 100 beds that provide complex treatments for severe illnesses. b Secondary hospitals were defined as hospitals with ≥ 30 beds that provide general inpatient and outpatient care Discussion Our findings indicate a fragility in providing cancer treatment during the early period of the resident physicians' strike in Korea. The increased rates of cancer surgeries in secondary hospitals were likely due to the changes in patient health-seeking behavior or referral patterns. This suggests the Korean healthcare system has likely adapted to maintain access to some cancer surgeries. However, the overall reduction in surgeries, particularly in tertiary, highlights the significant disruption caused by the strike. Notably, while the compensatory increase in surgeries at secondary hospitals reflects a degree of health system resilience, it also raises concerns about whether these facilities have sufficient capacity and expertise to safely manage complex oncologic cases. Further research is needed to assess the impact of such redistribution on surgical outcomes and quality of care. A previous study demonstrated that the medical workforce crisis is a major contributor to ‘quiet quitting’ in current medical practice. 9 Our findings add quantitative evidence to this narrative, demonstrating that workforce instability can lead to measurable declines in access to life-saving procedures, such as cancer surgeries. Furthermore, the reduction in tertiary hospital cancer surgeries highlights how centralized dependence on resident physicians for surgical care delivery makes the health system vulnerable to labor disruptions. The Korean strike serves as a sentinel event for health systems worldwide. A recent policy analysis outlined striking parallels between Korea and the United States, particularly with regard to rural physician shortages, and increasing resident burnout. 10 Our findings reinforce the need for comprehensive workforce planning that not only increases the number of medical trainees but also expands training infrastructure, improves working conditions, and ensures equitable distribution of personnel across urban and rural areas. 11 This study has several limitations. First, changes in health-seeking behavior during the strike period may have influenced our estimates. However, we adjusted for outpatient consultation volumes (Supplementary Fig. 1) in our models to account for this potential confounder. Second, our estimate is based on the counterfactual scenario, which may influence the accuracy of our findings. However, in the sensitivity analysis using an interrupted time series analysis (Supplementary Materials), we found no significant difference in our estimates (22% reduction and 8% increase in overall surgery rates since the strike in tertiary and secondary hospitals, respectively). In conclusion, our findings indicated that the resident physicians’ strike significantly reduced the nationwide cancer surgery volumes at the tertiary hospital in Korea. This study underscores the need for strategic workforce planning for medical trainees. Furthermore, it highlights that the national policies aimed at expanding the physician workforce must be coupled with efforts to ensure clinical training capacity, improve working conditions, and retain essential personnel. Additional research is warranted for the long-term impact of such disruptions on cancer patient outcomes, including mortality and economic burden. Abbreviations CI confidence interval Declarations Ethics approval and consent to participate Ethics approval was waived by the institutional review board at the Catholic University of Korea (IRB No. MC25ZISI0049). Consent for publication Not applicable Consent to participate Not applicable Availability of data and materials Data will be available upon request from the corresponding author. Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors wish to acknowledge the financial support of the Catholic Medical Center Research Foundation made in the program year of 2024. Authors' contributions RS designed the study. SL and TK collected data. SL, TK, EWL, and STA analyzed data. RS, SL, and TK wrote the first draft, which all authors substantively revised. SL and TK prepared figures and tables. All authors reviewed the final version of the manuscript. Acknowledgements None References The Chosun Daily. Rural Areas Suffer Severe Shortage of Doctors, https://www.chosun.com/english/national-en/2023/07/22/KV7WBL26 CUWLLFKGPJUQS56FHU/ (accessed 4 August 2025). The Lancet Regional Health-Western P. Junior doctor strikes in South Korea: more doctors are needed? Lancet Reg Health West Pac 2024; 44: 101056. 20240328. DOI: 10.1016/j.lanwpc.2024.101056 . Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16: 1193–1224. DOI: 10.1016/S1470-2045(15)00223-5 . Yoo C. Patients hit by canceled or postponed surgeries as doctors resign collectively, https://en.yna.co.kr/view/AEN20240219006800315 (accessed 4 August 2025). Lee S, Kim T and Ryu S. Quiet quitting and medical education disruption: lessons from South Korea. J R Soc Med 2025: 1410768251352668. 20250626. DOI: 10.1177/01410768251352668 . Korean Health Insurance Review and Assessment Service. Open data portal system, https://opendata.hira.or.kr/op/opc/olapDiagBhvInfoTab1.do (accessed 4 August 2025). Ryu S, Hwang Y, Ali ST, et al. Decreased Use of Broad-Spectrum Antibiotics During the Coronavirus Disease 2019 Epidemic in South Korea. J Infect Dis 2021; 224: 949–955. DOI: 10.1093/infdis/jiab208 . Ali ST, Cowling BJ, Lau EHY, et al. Mitigation of Influenza B Epidemic with School Closures, Hong Kong, 2018. Emerg Infect Dis 2018; 24: 2071–2073. DOI: 10.3201/eid2411.180612 . Ng IK, Goh WG, Thong C, et al. 'Quiet quitting' among medical practitioners: a hallmark of burnout, disillusionment and cynicism. J R Soc Med 2025; 118: 73–77. 20250213. DOI: 10.1177/01410768241311059 . Kim S, Waters JP and Hong YK. South Korea’s Physician Shortage Crisis: Lessons For US Policy Makers, https://www.healthaffairs.org/content/forefront/south-korea-s-physician-shortage-crisis-lessons-us-policy-makers (accessed 4 August 2025). Abbasi K. Will four-year medical degrees solve the crisis in medical education? J R Soc Med 2024; 117: 359. DOI: 10.1177/01410768241306006 . Additional Declarations No competing interests reported. Supplementary Files Supplementary4Aug2025.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 09 Dec, 2025 Editor assigned by journal 04 Aug, 2025 Submission checks completed at journal 04 Aug, 2025 First submitted to journal 04 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7287193","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558651008,"identity":"57f08f8a-5fc9-4641-a086-4b5db4fa36eb","order_by":0,"name":"Seunghyeon Lee","email":"","orcid":"","institution":"Konyang University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Seunghyeon","middleName":"","lastName":"Lee","suffix":""},{"id":558651009,"identity":"ffc94565-9f6d-4678-b282-c2f9d679f251","order_by":1,"name":"Taegu Kim","email":"","orcid":"","institution":"Konyang University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Taegu","middleName":"","lastName":"Kim","suffix":""},{"id":558651010,"identity":"69ab7f0f-bf14-4000-9269-07ffcaa06077","order_by":2,"name":"Eun Woo Lee","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Eun","middleName":"Woo","lastName":"Lee","suffix":""},{"id":558651011,"identity":"42ebde97-89db-48dc-8776-b509800e6ad6","order_by":3,"name":"Nina Yoo","email":"","orcid":"","institution":"St. Vincent's Hospital, The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Nina","middleName":"","lastName":"Yoo","suffix":""},{"id":558651012,"identity":"a8a4337d-7842-43ec-b336-243eb12b69a8","order_by":4,"name":"Sheikh Taslim Ali","email":"","orcid":"","institution":"The University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Sheikh","middleName":"Taslim","lastName":"Ali","suffix":""},{"id":558651013,"identity":"52e7aebf-b3a9-473e-9523-474cc68e7285","order_by":5,"name":"Benjamin J. 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Panels show the monthly number of cancer surgeries per 100,000 population for thyroid (A), gastric (B), lung (C), and colorectal (D) cancer in tertiary (teaching) and secondary (general) hospitals. Brown and orange dots represent observed monthly surgery rates in tertiary and secondary hospitals, respectively. Solid lines indicate fitted regression estimates, and dashed lines show counterfactual projections assuming the resident physician strike had not occurred. The vertical dashed line denotes February 2024, when the strike began. The shaded blue region indicates the post-intervention period used to estimate strike-associated changes in surgery rates.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7287193/v1/51d753504160fc4b9010c80c.png"},{"id":98444657,"identity":"f15e9ab2-7bc6-44f9-a5ca-c50f2a086fd3","added_by":"auto","created_at":"2025-12-17 17:16:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":471811,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7287193/v1/2976ce4b-3b42-42cb-91d8-5b2917a8b19d.pdf"},{"id":98072296,"identity":"5858cd42-6a68-44db-b678-14fff19535a5","added_by":"auto","created_at":"2025-12-12 13:12:44","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":145538,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary4Aug2025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7287193/v1/68a3742c825c734f3a3ca650.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of the 2024 Resident Physician Strike on National Cancer Surgery Volumes in South Korea","fulltext":[{"header":"Background","content":"\u003cp\u003eSouth Korea has faced challenges due to shortages of physicians in essential medical services.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e To respond to this, in February 2024, the Korean Ministry of Health and Welfare introduced the Essential Healthcare Policy, which included increasing the number of physicians. Following this announcement, over 90% of resident physicians resigned, primarily those working in teaching hospitals (i.e., tertiary hospitals).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e A workforce strike in essential medical services is known as critical as it affects the nationwide healthcare system, not only in resource-limited countries but also in high-income ones.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Delays or cancellations in cancer surgeries have been reported following the mass resignation (i.e., strike),\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e which has continued as of July 2025. However, the long-term strike’s impact on changes in nationwide cancer surgery volume, which often serves as an indicator of changes in essential medical service capacity,\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e has not been assessed before. Here, we examined the impact of the 2024 resident physicians’ strike on nationwide cancer surgery volumes in Korea.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTo evaluate the impact of the strike, we analyzed nationwide data on reimbursements for cancer surgeries from January 2019 to July 2024, the latest period available at the time of analysis.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The data were obtained from the Korean Health Insurance Review and Assessment Service, which covers around 97% of the Korean population under public health insurance.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e We included data from tertiary and secondary hospitals, focusing on the four common cancers in Korea (i.e., thyroid, stomach, lung, and colorectal), using codes from the International Classification of Diseases, Tenth Revision (Supplementary Table\u0026nbsp;1). Using a regression model,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e we estimated the changes in surgery volume by comparing the observed and counterfactually predicted number of surgeries, adjusted for the patient visits (i.e., number of consultations) for each cancer type (Supplement Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConsider, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{O}_{t}\\)\u003c/span\u003e\u003c/span\u003e is the number of operations performed for cancers (by types) at time \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:t\\)\u003c/span\u003e\u003c/span\u003e (month). \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{H}_{t}\\)\u003c/span\u003e\u003c/span\u003e is the number of consultations (per 100,000 population) at the time \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:t\\)\u003c/span\u003e\u003c/span\u003e, and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{I}_{t}\\)\u003c/span\u003e\u003c/span\u003e is the indicator variable demonstrating the timing of the strike. We formulated a multivariable regression model as \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{O}_{t}={{H}_{t}}^{\\beta\\:}{e}^{\\lambda\\:{I}_{t}}\\)\u003c/span\u003e\u003c/span\u003e. Where \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\lambda\\:\\)\u003c/span\u003e\u003c/span\u003e are the regression coefficients that quantify the number of surgeries and the effect of the strike on the operation (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{O}_{t}\\)\u003c/span\u003e\u003c/span\u003e), respectively. Simplifying the model, we further constructed a log-linear multivariable regression model as \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{ln}{(O}_{t})=constant+{\\beta\\:ln}{(H}_{t})+\\lambda\\:{I}_{t}\\)\u003c/span\u003e\u003c/span\u003e, where \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\lambda\\:\\)\u003c/span\u003e\u003c/span\u003e were estimated, and the overall reduction in \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{O}_{t}\\)\u003c/span\u003e\u003c/span\u003e was estimated using these parameters. Setting \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\lambda\\:=\\)\u003c/span\u003e\u003c/span\u003e0, we predicted the counterfactual number of surgery volume since February 2024, while the estimated \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\lambda\\:}\\)\u003c/span\u003e\u003c/span\u003e was used to estimate the % reduction in the number of surgeries by (1-\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{e}^{\\lambda\\:})\\times\\:100\\%\\)\u003c/span\u003e\u003c/span\u003e with an associated 95% confidence interval (CI). All statistical analyses were performed in R version 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified a 24% (95% CI: 19\u0026ndash;30%) decrease in the overall number of cancer surgeries at tertiary hospitals. Cancer-type specific reductions were 27% (21%\u0026ndash; 33%) for thyroid, 31% (24\u0026ndash;38%) for lung, 27% (20\u0026ndash;34%) for gastric, and 25% (17\u0026ndash;32%) for colorectal (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In contrast, overall surgery volume at secondary hospitals increased by 8% (2%-14%), with thyroid and gastric cancer surgery both increased by 14% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEstimated changes in the number of cancer surgeries associated with the 2024 resident physicians\u0026rsquo; strike in South Korea, by hospital and cancer type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTertiary hospital\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eSecondary hospital\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eUnadjusted % (95% CI), (Univariate Regression Model)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdjusted % (95% CI)\u0026nbsp;(Multivariable Regression Model)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUnadjusted % (95% CI), (Univariate Regression Model)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdjusted % (95% CI)\u0026nbsp;(Multivariable Regression Model)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-21.0 (-28.2 \u0026ndash; -13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-24.4 (-30.0 \u0026ndash; -18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.4 (-2.3\u0026ndash;17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.2 (2.4\u0026ndash;14.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThyroid cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-27.9 (-36.6 \u0026ndash; -19.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-27.0 (-33.1 \u0026ndash; -20.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.8 (4.1\u0026ndash;23.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.9 (6.2\u0026ndash;21.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastric cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-29.7 (-39.9 \u0026ndash; -19.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-26.9 (-34.2 \u0026ndash; -19.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.8 (-5.8\u0026ndash;19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.0 (3.3\u0026ndash;21.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-18.0 (-27.6 \u0026ndash; -8.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-31.0 (-37.8 \u0026ndash; -24.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.6 (3.0\u0026ndash;38.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.7 (-5.7\u0026ndash;25.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColorectal cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-22.0 (-30.1 \u0026ndash; -13.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-24.6 (-32.2 \u0026ndash; -17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.2 (-2.3\u0026ndash;12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.1 (-2.1\u0026ndash;12.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: Data represent percentage change in surgery volume with 95% confidence intervals (CIs), estimated using univariate and multivariable interrupted time series regression models. Multivariable models were adjusted for the number of cancer-specific outpatient consultations.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003eTertiary hospitals were defined as hospitals designated by the Korean Ministry of Health and Welfare with \u0026ge;\u0026thinsp;100 beds that provide complex treatments for severe illnesses.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003eSecondary hospitals were defined as hospitals with \u0026ge;\u0026thinsp;30 beds that provide general inpatient and outpatient care\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings indicate a fragility in providing cancer treatment during the early period of the resident physicians' strike in Korea. The increased rates of cancer surgeries in secondary hospitals were likely due to the changes in patient health-seeking behavior or referral patterns. This suggests the Korean healthcare system has likely adapted to maintain access to some cancer surgeries. However, the overall reduction in surgeries, particularly in tertiary, highlights the significant disruption caused by the strike. Notably, while the compensatory increase in surgeries at secondary hospitals reflects a degree of health system resilience, it also raises concerns about whether these facilities have sufficient capacity and expertise to safely manage complex oncologic cases. Further research is needed to assess the impact of such redistribution on surgical outcomes and quality of care.\u003c/p\u003e\u003cp\u003eA previous study demonstrated that the medical workforce crisis is a major contributor to \u0026lsquo;quiet quitting\u0026rsquo; in current medical practice.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Our findings add quantitative evidence to this narrative, demonstrating that workforce instability can lead to measurable declines in access to life-saving procedures, such as cancer surgeries. Furthermore, the reduction in tertiary hospital cancer surgeries highlights how centralized dependence on resident physicians for surgical care delivery makes the health system vulnerable to labor disruptions.\u003c/p\u003e\u003cp\u003eThe Korean strike serves as a sentinel event for health systems worldwide. A recent policy analysis outlined striking parallels between Korea and the United States, particularly with regard to rural physician shortages, and increasing resident burnout.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Our findings reinforce the need for comprehensive workforce planning that not only increases the number of medical trainees but also expands training infrastructure, improves working conditions, and ensures equitable distribution of personnel across urban and rural areas.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, changes in health-seeking behavior during the strike period may have influenced our estimates. However, we adjusted for outpatient consultation volumes (Supplementary Fig.\u0026nbsp;1) in our models to account for this potential confounder. Second, our estimate is based on the counterfactual scenario, which may influence the accuracy of our findings. However, in the sensitivity analysis using an interrupted time series analysis (Supplementary Materials), we found no significant difference in our estimates (22% reduction and 8% increase in overall surgery rates since the strike in tertiary and secondary hospitals, respectively).\u003c/p\u003e\u003cp\u003eIn conclusion, our findings indicated that the resident physicians\u0026rsquo; strike significantly reduced the nationwide cancer surgery volumes at the tertiary hospital in Korea. This study underscores the need for strategic workforce planning for medical trainees. Furthermore, it highlights that the national policies aimed at expanding the physician workforce must be coupled with efforts to ensure clinical training capacity, improve working conditions, and retain essential personnel. Additional research is warranted for the long-term impact of such disruptions on cancer patient outcomes, including mortality and economic burden.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econfidence interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003cem\u003e\u003cbr\u003e\u003c/em\u003eEthics approval was waived by the institutional review board at the Catholic University of Korea (IRB No. MC25ZISI0049).\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003c/em\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eConsent to participate\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003c/em\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eData will be available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003c/em\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003c/em\u003eThe authors wish to acknowledge the financial support of the Catholic Medical Center Research Foundation made in the program year of 2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003cem\u003e\u003cbr\u003e\u003c/em\u003eRS designed the study. SL and TK collected data. SL, TK, EWL, and STA analyzed data. RS, SL, and TK wrote the first draft, which all authors substantively revised. SL and TK prepared figures and tables. All authors reviewed the final version of the manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe Chosun Daily. Rural Areas Suffer Severe Shortage of Doctors, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.chosun.com/english/national-en/2023/07/22/KV7WBL26\u003c/span\u003e\u003cspan address=\"https://www.chosun.com/english/national-en/2023/07/22/KV7WBL26\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eCUWLLFKGPJUQS56FHU/ (accessed 4 August 2025).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Lancet Regional Health-Western P. 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DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/01410768241306006\u003c/span\u003e\u003cspan address=\"10.1177/01410768241306006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"strike, disruption, cancer, operation, surgery, Korea","lastPublishedDoi":"10.21203/rs.3.rs-7287193/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7287193/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn South Korea, a mass resignation of resident physicians has been ongoing since February 2024 and continues as of June 2025. This study aimed to evaluate the impact of the 2024 resident physicians\u0026rsquo; strike on nationwide cancer surgery volumes in Korea.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe analyzed nationwide administrative data on reimbursed cancer surgeries from January 2019 to July 2024, using data from the Korean Health Insurance Review and Assessment Service. A multivariable log-linear regression model was used to estimate changes in surgery volume by comparing observed and counterfactual estimates, adjusting for outpatient consultations by cancer type. We focused on common cancers in Korea: thyroid, stomach, lung, and colorectal.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe number of overall cancer surgeries at tertiary hospitals declined by 24% (95% Confidence Interval (CI): 19\u0026ndash;30%) following the strike. Cancer-specific reductions included 27% for thyroid, 31% for lung, 27% for gastric, and 25% for colorectal cancers. In contrast, surgery volumes in secondary hospitals increased overall by 8% (95% CI: 2\u0026ndash;14%), with thyroid and gastric cancer surgeries increasing by 14%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThese findings suggest that clinical workforce instability can rapidly disrupt access to essential surgical services, even in health systems with universal coverage.\u003c/p\u003e","manuscriptTitle":"Impact of the 2024 Resident Physician Strike on National Cancer Surgery Volumes in South Korea","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 13:12:39","doi":"10.21203/rs.3.rs-7287193/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-09T07:10:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-04T13:24:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-04T13:23:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Human Resources for Health","date":"2025-08-04T05:31:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d650b238-82d9-4ad6-b076-feec79e15d09","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-12T13:12:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 13:12:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7287193","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7287193","identity":"rs-7287193","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}