Deep-rooted problems push nurses to handle doctors' duties

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Conflict continues over roles of physician assistants

By Jun Ji-hye

One physician assistant said she had to carry out a polypectomy, an operation to remove polyps from the inside of a patient's colon, while another said she was once told to pronounce a patient dead.

These are actual cases contained in reports the Korean Nurses Association received from physician assistants across the country about unlawful orders they received from doctors.

Such procedures and duties should be handled by doctors under the Medical Services Act. But in Korea's medical profession, physician assistants have been tacitly pushed to conduct such procedures, according to the association.

In other countries such as the United States, physician assistants are considered to be licensed medical professionals who examine, diagnose and treat patients under the supervision of physicians. But things are different in Korea, as hospitals appoint skilled nurses with several years of experience as physician assistants. Additional courses or professional licenses are not required to appointment them.

The controversy over the roles of physician assistants in Korea, which dates back years, was reignited amid recent conflicts involving the Nursing Act that was railroaded by the main opposition Democratic Party of Korea in late April, only to be vetoed by President Yoon Suk Yeol on May 16 and eventually scrapped late last month in a National Assembly revote.

The act was aimed at clarifying the scope of nurses' duties to improve their working conditions. Nurses have long wanted their own law, claiming that a lack of clarity regarding their exact roles and duties, as stipulated in the Medical Services Act, has ended up increasing their workload.

In exercising his veto power, Yoon sided with doctors and other medical workers, who claim the act will only divide the medical profession and cause conflict.

In protest, the nurses' association has been supporting physician assistants, rejecting the unlawful orders made by doctors, ironically illustrating that their refusal abides by the current law.

This was a symbolic measure stressing the need to legislate the Nursing Act to clarify the scope of nurses' roles.

Members of the Korean Nurses Association lift pickets calling for the legislation of the Nursing Act during a rally held in central Seoul, May 19, to protest President Yoon Suk Yeol's veto against the act. The vetoed bill was eventually scrapped on May 30 in a National Assembly revote. Korea Times photo by Ahn Dae-eun

According to the Korea Health and Medical Workers' Union, the number of physician assistants is estimated at around 10,000 nationwide.

"Large hospitals have 60 to 100 physician assistants on average," an official from the union said. "Nurses with five to six years of experience are usually appointed as physician assistants without taking additional courses."

The Medical Services Act stipulates that nurses assist medical treatments under the supervision of physicians or dentists.

But because the definition of the assistance of medical treatment is too ambiguous, physician assistants have performed a wide range of roles including assisting doctors in carrying out operations and procedures and prescribing medication, most of which are regarded as procedures performed by medical residents.

Despite the controversy over the violation of the law, the number of physician assistants has increased sharply for over a decade mainly due to shortages of doctors.

The nurses' association created a list of 24 unlawful orders made by doctors that physician assistants are being encouraged to reject as a show of protest.

The 24 orders include performing surgery, the prescription of medication, ultrasonography, electrocardiography, arterial blood collecting, tracheal intubation and sutures.

Kim Young-kyeong, head of the Korean Nurses Association, speaks with tears during a news conference in front of the National Assembly on May 30 after the Nursing Act, vetoed by President Yoon Suk Yeol, was scrapped in a Assembly's revote. Yonhap

Kim Young-kyeong, who heads the nurses' association, said physician assistants will continue to reject unlawful orders by doctors, even though the Nursing Act was scrapped.

"We will continue to push for the legislation of the act within the tenure of the current Assembly," Kim said during a news conference on May 30. "We will also judge unfair lawmakers (who sided with the scrapping of the act) in general elections slated for next year and condemn the health minister and vice minister who made false claims (about the act)."

The Korean Intern Resident Association (KIRA), which represents over 16,000 trainee doctors across the country, shared the concerns that physician assistants have been pushed to fill a shortage of doctors.

It said the shortage of young doctors has become more noticeable, since a law governing the status and working environment of medical residents was enacted in December 2016 capping the maximum weekly working hours to 80 for residents.

"The root cause of physician assistants being pushed to perform surgery or prescribe medication in lieu of doctors was the unwillingness of hospitals to recruit additional doctors," an official at the association said.

The Ministry of Health and Welfare, however, believes that the Nursing Act is not directly linked to the issue of physician assistants. It claims it is improper to posit that a list of 24 orders created by the nurses' association is all illegal.

Health and Welfare Minister Cho Kyoo-hong passes by nurses who hold pickets to denounce President Yoon Suk Yeol's veto against the Nursing Act in front of Korea University Anam Hospital on May 16. The vetoed bill was eventually scrapped on May 30 in a National Assembly revote. Yonhap

"The list was created while nurses have engaged in conflicts with other medical workers," said Lim Gang-sub, who heads the nursing policy department at the ministry. "It is very difficult to tell what doctors should do and what nurses should do, as some cases require the efforts of both."

Still, experts stressed the need for specific rules in managing the work of medical workers.

"The current medical field lacks specific rules and this has resulted in conflicts between medical workers," said Kim Yoon, a professor of health policy and management at Seoul National University College of Medicine. "Rules are necessary to clarify the roles of physician assistants and offer proper education to them."

Amid the growing controversy, the health ministry said it will begin full-fledged discussions this month about the issue involving physician assistants.

"We will form a panel comprised of experts, medical workers and relevant organizations to discuss the issue," a ministry official said.