[Life] “The death of a 19-year-old with terminal cancer… I had to accept it as a doctor.”

[※ Editor's note = The article on the interview with Professor Kim Hyun-ah of Hallym University Sacred Heart Hospital has a lot of content, so it is being sent in five parts. This is the fourth time we have dealt with attitudes toward death and the medical-industrial complex. The first article, submitted on September 8, included Professor Kim's growth story and the dangers of narcotic painkillers. The second article on September 23rd mainly dealt with the '3-minute treatment' issue, and the third article on September 28th mainly dealt with the commerciality of medical care. The fifth article, which will be published after next week, will include information on autoimmune diseases, arthritis, mental illness, and how to use hospitals. [Life] is an autobiographical interview, so it includes many personal stories and photos.]

(Seoul = Yonhap News) Senior Reporter Geunyoung Yoon = "When I was working as an oncology resident at Seoul National University Hospital, there was a 19-year-old young patient. He was now transitioning from a child to a young adult. This young man had terminal lymphoma and the cancer had spread throughout his body. There was nothing more the hospital could do. It was difficult for me to watch the young patient's pain and despair from the sidelines. One weekend, this patient's condition worsened. I saw him struggling to breathe in pain. “As a doctor, I thought I should do something, but no matter how much I looked, I called the professor in charge and he told me it was time to quit.”

This is what Kim Hyun-ah, a professor at Hallym University Sacred Heart Hospital (rheumatology department), said in an interview with Yonhap News. The interviews were conducted five times at the hospital office starting on August 26th.

Professor Kim said in an interview, "There are many cases where terminal cancer patients continue to receive unreasonable treatment," adding, "From the patient's perspective, not only do they have to spend a lot of additional money even though it has little effect on prolonging life, but it can also cause the problem of not having time to organize their lives."

He said, “In the current medical environment, it is difficult for doctors to stop treatment, so patients and their guardians must make good judgments. We must also think about whether it is right to prolong life pointlessly in the intensive care unit.”

Professor Kim was born in Seoul in 1964, graduated summa cum laude from Seoul National University College of Medicine, and received a master's and doctoral degree in medicine from the same university. After working as an oncology resident and rheumatology resident at Seoul National University Hospital, he has been working as a professor (rheumatology) at Hallym University Sacred Heart Hospital since 2000.

Professor Kim, an expert in autoimmune diseases and osteoarthritis, received attention for publishing a series of books criticizing the state of the Korean medical community and honestly expressing his personal experiences in addition to his research activities in his field. The books include ‘A Time to Learn to Die’ (2020), ‘The Age of Medical Business’ (2023), ‘My Daughter Collapsed Quietly’ (2023), and ‘Fake Patients’ (2026).

Next is the 4th article of the interview, Q&A

-- It is said that a good doctor is one who knows when to do his best and when to quit. What does this mean?

▲ There was a female arthritis patient, Ms. A, who came to me regularly for treatment. Her husband was in the terminal stage of cancer and was being treated at the hematology and oncology department of 00 University Hospital. It was a university hospital that was not included in the Big 4 hospitals (Seoul National University Hospital, Severance Hospital, Samsung Seoul Hospital, and Hyundai Asan Medical Center). One day, a professor at the university hospital said this. “At this point, treatment may be meaningless. You don’t have much time left to live.” Mr. A, who could not accept this, is said to have kicked out the door of the clinic.

-- What happened after that?

▲ Ms. A said she took her husband to one of the Big 4 hospitals and continued receiving chemotherapy. As a result, the husband is said to have been unable to come home and died after spending six months in the hospital. Mr. A said he regretted it. This is because the cost of treatment increases and the patient's pain increases. However, it is difficult to say anything to the Big 4 hospitals that accepted this patient and continued to administer anticancer drugs. I even went so far as to kick down the door of my previous hospital because it is not easy for a doctor to do nothing.

-- You said that even death has a quality.

▲ I do not think it is desirable to die in an unconscious state, with a respirator attached and multiple tubes inserted. Of course, there is no such thing as a comfortable death. But I think I should know that I will die. And I think it's better to die peacefully, if possible, with your family watching.

-- They said you should prepare for death in advance.

▲ You should think about this on a daily basis. Is it desirable for me to become a patient, lose my autonomy, and artificially prolong my life? If I get sick, how long will I stay in the hospital? In which place will I die? If I die at home, when will I go home and face my deathbed? Who will take care of me? How will the related costs be financed? But it seems that not many people think like this.

-- Isn't it because of the fear of death?

▲ No one likes thinking about death. However, you must prepare what you need to prepare. Some people think that preparing for death is as simple as putting together a 2 million won shroud. People think about many things when buying a car, but they don't seem to think much about their own death.

-- You said that property issues are also important in preparing for death.

▲ Writing a will regarding inheritance is also an important part of preparing for death. This is because if you do not do so, disputes will arise between your children. However, you should not control your children with your property. It is not wise to act like you have to be good to me to give me wealth.

-- People spend a lot of money on treating diseases before they die, and anticancer drugs in particular cost 100 million won per year.

▲ A drug worth 100 million won is not that expensive. Gene therapy can cost 600 to 800 million won, but such drugs have not yet arrived in Korea. Treatments worth about 300 to 400 million won are already being supplied to Korea. Among these, there are many medications that are not covered by health insurance. Even in cases where health insurance is applied, subscribers pay jointly, so the burden on the public is the same.

-- What is gene therapy?

▲ To be precise, it is gene and cell therapy. It is made by inserting genetic information that attacks problem cells (cancer cells, etc.) into immune cells. These drugs are used to treat not only cancer but also other diseases. Of course, these drugs are not without any improvements over previous drugs. Side effects have been slightly reduced and the survival rate may slightly increase. However, you should consider whether it is effective enough to justify such a high price.

-- They say that the reason new drugs are expensive is because they have to reflect numerous challenges, failures, and astronomical clinical trial costs.

▲ That is the logic of pharmaceutical companies. The process of completing the medicine is as follows. First, experiments are conducted on cells. The method is to administer a candidate drug to cancer cells. As a result, candidate drugs that are judged to be promising are tested on animals, and if they pass, they enter clinical trials on humans. In this way, some drugs are ultimately approved by the authorities, but the pharmaceutical company is not in charge of this entire process.

-- What is that story about?

▲ I acknowledge that pharmaceutical companies invest a lot of money into developing new drugs. However, I think there is some exaggeration. For example, let's assume that among the first 100 drug candidates, about 2 have advanced to the clinical trial stage. By filtering out 98, two basic promising substances were discovered, and this process is usually handled by university research institutes, not pharmaceutical companies. And the costs are often covered with public funds, not pharmaceutical company money. In this respect, pharmaceutical companies' logic that high drug prices are inevitable to cover the costs of failed drugs is somewhat unconvincing. And pharmaceutical companies have never properly disclosed the costs of each stage of new drug development. This means that drug price calculation is not transparent.

-- There is also a saying that it is a medical-industrial complex, like the military-industrial complex.

▲ The military-industrial complex is where the military and industry combine to share profits. A medical-industrial complex is a combination of medicine and industry, where ‘medical’ refers to pharmaceutical companies and medical device companies. I believe that the fact that hospitals administer anticancer drugs worth hundreds of millions of won, which are not cost-effective, to patients, and the fact that low-priced drugs are being pushed out by high-priced drugs is not unrelated to the medical-industrial complex.

-- What does it mean to say that low-priced drugs are being pushed out?

▲ I have chronic skin disease on my palms. Sometimes it itches so much that you can't sleep, and even with medication, it doesn't go away. At this time, I take steroids. It is very convenient to cut the 5mg tablet in half and take only 2.5mg. That's how effective it is. This drug is sometimes prescribed to patients with rheumatoid arthritis. Common medications are used to calm the waves (inflammation), but sometimes there are storms. At that time, if steroids are administered, the storm calms down. If a patient keeps steroids on hand and takes them in an emergency, the number of cases where they have to rush to the emergency room is reduced.

-- Are steroids expensive?

▲ It’s cheap. The insurance price of one 5mg tablet is only 16 won. Of these, only a portion is borne by patients. This is because health insurance applies. Although it is such a cost-effective drug, it is unfortunate that it is gradually disappearing from hospital prescriptions.

-- Aren't steroids excluded from prescriptions because of their severe side effects?

▲ There is no drug with zero side effects. Rather, I believe that pharmaceutical companies are reducing the presence of this drug in terms of income and expanding the number of expensive biological products. Pharmaceutical companies advertise that “if you use this biological agent, you do not need to use steroids.” However, such drugs also cause side effects, including tuberculosis. Although it has not been revealed yet because it has only recently been released, more side effects may occur if it is used for 10, 20, or 30 years.

-- How much do biological products cost?

▲ It is sometimes 10,000 times more powerful than steroids. Enbrel injection, which is prescribed for rheumatoid arthritis patients, is administered once a week and costs about 150,000 won under insurance. It is 600,000 won per month. I believe that the prescription of these expensive drugs has nothing to do with the medical-academic complex.

-- Are there any other cases related to this?

▲ Belimumab is a drug used for patients with lupus, an autoimmune disease. The price for one month of this drug is about 790,000 won. It is extremely expensive compared to steroids, which cost 16 won per tablet. I'm not sure how this drug is any better than steroids in treating swelling and inflammation. However, there are quite a few cases where patients ask to be prescribed this drug because they do not want to take steroids.

-- Should we say that many doctors are participating in pharmaceutical companies' high-priced drug strategies?

▲ A few years ago, an incident occurred at the European Society of Rheumatology. While creating treatment guidelines, a professor left, saying, “I can no longer participate.” There was a rumor that this was because the academic society was trying to create guidelines to encourage the use of expensive drugs.

-- Is the Korean Medical Society also related to the medical-industrial complex?

▲ Clinical trials for new drugs are mainly conducted by professors at university hospitals. During this process, service fees are exchanged. Pharmaceutical companies also need the help of academic societies to receive approval from the Ministry of Food and Drug Safety for new drugs and to receive health insurance benefits. And when seminars at academic societies are held, pharmaceutical companies set up booths to promote new drugs at the event venue. Instead of allowing it, the society receives donations from pharmaceutical companies. A significant portion of the academic society's operating expenses comes from pharmaceutical companies. Of course, society members also pay membership fees periodically.

-- Should we say that there is also a medical-industrial complex related to medical devices?

▲ As already mentioned earlier, the fact that hospitals recommend robotic surgery, which costs patients 5 to 20 million won, rather than low-cost laparoscopic surgery, is not unrelated to the medical-industrial complex. Recently, a patient at our hospital underwent robotic back surgery, and it is said that the cost was 8.5 million won. It is said that there was no other way to choose surgery other than robotic surgery. He said that his back was very painful and that he had to wait a month for other types of surgery. In this way, hospitals are expanding robotic surgery, which costs patients more than 10 times more than laparoscopy.

-- Why is recommending robotic surgery the result of the medical-industrial complex?

▲ Robotic surgery is not covered by health insurance. Therefore, there is less government control over surgery prices. Therefore, from the hospital's perspective, robotic surgery is inevitably more advantageous in terms of revenue than laparoscopic surgery, which is subject to strong price controls. Medical device manufacturers can also sell robotic surgery machines worth billions of won. In this way, a win-win is achieved for both sides.

--Are there many people who fall into difficulties due to the burden of medical expenses?

▲ Even though Korea’s per capita gross national income (GNI) is $37,000, there are many people who cannot go to the hospital because they do not have money. Due to health insurance, the out-of-pocket cost is usually around 30%, but there are many families who find it difficult to afford this. One of the reasons why the family economy is becoming difficult and why elderly people are bankrupt is the burden of medical expenses.

-- Is there anything you would like to say to the National Assembly and the government?

▲ Medical expenses can stretch like a rubber band. If we are not careful, all of our limited resources could end up in the medical-industrial complex. When making medical policy, I think we should create a space for public discussion and come up with a reasonable plan, rather than just calculating voters' votes.

(Interview 4th article question-answer end)

<Summary of the first interview article>

[Life] “You can fall into drug addiction even with medicine prescribed at the hospital, so be careful” (September 8)

There is no perfectly healthy body. As you live, you are bound to get sick. In particular, diseases caused by aging are difficult to cure. Even if you have some problems with your body, it is important to accept it and live with it.

There are patients who suffer from pain for no particular reason. Fibromyalgia is one such pain. This is because there is a problem with the central nervous system, and since the pain is not caused by inflammation or tissue damage, painkillers do not work well. If possible, pain should be reduced by reducing stress and exercising.

This does not mean that you should do certain exercises at high intensity. The idea is to make exercise a part of your life. And you need to sleep well. It is better to avoid processed foods and cook at home and eat natural foods.

You should be careful about narcotic painkillers in hospitals. This is because you can become addicted by taking just one pill. There are many cases where young people addicted to drugs first encounter drugs at hospitals.

<Summary of the second interview article>

[Life] “A young man chats with his friends on KakaoTalk without knowing that he will die the next day… It’s so heartbreaking” (September 14)

There are too many patients flocking to university hospitals. If many patients with mild symptoms come to tertiary care institutions, patients in critical condition cannot receive treatment in a timely manner. 80-90% of human diseases can be resolved at local hospitals.

In high-level general hospitals, there are quite a few cases where doctors see more than 100 patients a day. In this case, the treatment time per patient may be as little as 3 minutes. If treatment time is short, patients may not be able to properly explain their disease, and doctors may make hasty judgments.

For a doctor to provide proper treatment, I think the minimum required is about 30 minutes per patient for the first visit and 15 minutes for the repeat visit. However, in reality, it is difficult to secure time like this.

<Summary of the 3rd interview article>

[Life] “The salary gap for professors in university hospitals is more than double… The more prescriptions for MRI etc., the higher the salary” (September 28)

If a professor at a university hospital sees a lot of patients and prescribes a lot of expensive tests, his or her salary goes up. As a result, the salary gap between professors within the same university hospital can be more than double.

In Korea, not only local hospitals but also university hospitals focus on making money. This originated from a deformed system in which more than 90% of hospitals and clinics were run by private entities.

The value of medical practice should not be measured by income. In this respect, linking hospital income and professor salaries seems problematic. How can a professor work with a sense of calling in a situation where salary is determined by how many tests are performed, not by whether the patient is treated with sincerity?

These problems are not unrelated to the fact that the medical fee (price) system itself is distorted.