臺灣博碩士論文加值系統

隨著時代的改變，消費主義的興起、醫院企業化經營，醫學專業已經歷了幾十年的變遷。雖然媒體對醫師的報導越趨醫療疏失等負面形象，社會學也有相關醫學專業等論述產出，並帶著批判和懷疑的眼光。然而關於醫學專業的探討，有太多的論述但實證研究較為缺乏，並且缺少醫師自身的觀點。
因此，本研究目的在探討並呈現當代重要之醫學專業價值，並以此專業價值作為出發點，了解不同的醫師所持的專業價值是否會影響其對於目前醫師專業表現的評量，以及如果醫師認為醫學專業目前表現不佳，他們又會認為是何種原因造成的。
本研究是以全國西醫師為研究對象，以2007年醫事處的執業醫師資料為準，並採取系統抽樣選出8000名醫師郵寄問卷。於2008年一月寄發第一次問卷，並經過一次催收後，至三月回收有效問卷1679份，回覆率達21%。
研究結果發現：(1)醫師所持專業價值的部份：64.4%醫師認為即使目前的健保資源有限，醫師的臨床專業自主也不應受到限制；67.1%的醫師即使在面對健保的限制之下，也會盡力爭取民眾的優先利益；約80%的醫師強調無論如何處方診療時絕不可以考量利潤。而有52.5%的醫師在醫療決策時傾向以民眾的選擇為主體。(2)就專業表現評量的部份：當代的醫師對於目前同儕的專業表現多為正向，但就傾聽、解釋告知的部份較差強人意。(3)就責難歸因而言：大部分的醫師都將目前專業表現不佳的原因指向健保制度，其次則為民眾自主強勢，再來為社會價值的變遷。(4)而認為由於健保資源有限，醫師專業自主應受到限制者，有較高的傾向將目前醫學專業表現不佳歸因於醫院的經營管理策略。(5)此外，年齡世代是ㄧ個很重要的因子，我們發現越老的醫師則其持有的專業價值就越高，並且對當代醫學專業表現的評價就越好。
由以上結果可知，目前的台灣醫師仍持有較傳統的專業價值，整體來說他們對於目前的專業表現評價皆為正向，但認為醫病溝通的技巧較差。另外，健保對於醫師的執業也造成了很大的影響，尤其是他們對於醫療照護組織的管制也間接的影響了醫學專業價值的形塑。然而，除了對於外在體制的責難，部分醫師也認為，由於醫界本身的自我控管機制失靈，因此醫師本身對於現狀也難辭其咎。

With the rise of managed care, medical consumerism, and the corporatization of hospitals, medical professionalism has experienced drastic transition in the past few decades. Although the image of medical profession become more and more negative, as reflected in the media and illustrated by the accumulated criticism from sociologists, very few empirical research have been done to tap the perceptions and observations that come from the physicians themselves.
The purposes of this study, therefore, are to describe the physicians’ attitudes towards medical professionalism, i.e., their professional values, and then examine how the values they hold influence their assessment of current state of medical performance, and, if any deficiency in professionalism was indicated, for which what factors did they attribute the blame.
Data on which this study was based came from a nation-wide mail survey. Through a systematic sampling, about 8000 physicians who were practicing in biomedicine (so-called Western physicians) and having memberships in Taiwan Medical Association in the year 2007 were selected as potential participants for this study. Started in January 2008 and after one follow-up mailing, a total of 1679 valid questionnaires were collected in March 2008, resulting in a response rate of 21%.
The major findings of this study are: (1) The professional values held by this sample of physicians are presented in the following aspects of professionalism: 64.4% physicians did not agree that their clinical autonomy should be regulated by the National Health Insurance (NHI) even under the situation of limited health care resources; 67.1% said that the patients’ welfare will be their top priority even in face of NHI restrictions; about 80% emphasized that profit should not be taken into account while providing clinical services; and 52.5% supported the idea that patients should have more autonomy in the process of medical care decision making, (2) With regard to their assessment of current performance among their professional members, most of them made an overall positive assessment, although the aspects of listening, and informing and advising during patient-physician interactions were considered relatively unsatisfactory, and (3) In response to deficiency in professionalism or poorer professional performance, NHI, consumerism, and societal values were three blames most often attributed by the participants, and (4) Physicians who made justification on the restriction of clinical autonomy under stringent resources were more likely to attribute current poor performance to the managerialism adopted by hospitals, and (5) Physicians’ age (cohort) is the most powerful factor in relation to professional value and self-assessment of performance. The older the age the more strong the professional values they held, and more positive their assessment of current professional performance.
Contemporary physicians in Taiwan still hold conventional medical professionalism, and their assessment of current performance of their professional members is positive overall, with the communicative skill the poorest competency. Although NHI, as a national health policy, has exerted much impact on their practices in general, in particular managerial interventions applied in health care organizations are considered the ultimate menace to their professionalism. Yet beyond blaming, some physicians also argue that medical professionals must be responsible for the status quo because of the failure of self-regulation.

致謝 I
摘要 II
Abstract IV
目錄 VII
圖表目錄 IX
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 4
第三節 研究預期貢獻與重要性 5
第二章 文獻探討 6
第一節 醫學專業價值與倫理 6
第二節 醫師們對醫學專業的觀感 15
第三節 醫師對健保、民眾、醫院經營策略的看法 21
第四節 責難歸因(blme attribution)在醫療場域的應用 25
第五節 結論 30
第三章 研究方法 32
第一節 研究架構 32
第二節 測量工具 34
第三節 資料收集與分析 39

第四章 研究結果 43
第一節 樣本特質 43
第二節 醫師所持專業價值及醫學專業評量 46
第三節 專業價值與專業形象及其相關因子 53
第四節 整體專業不佳的歸因及其相關因子 60
第五節 專業自評之相關影響因素 65
第六節 整體專業評量不佳的歸因 69
第五章 討論 73
第一節 醫師所持專業價值之變遷 73
第二節 醫師所知覺得當代專業形象 77
第三節 醫師之利潤觀 79
第四節 醫師們對醫院經營策略的責難歸因 81
第五節 研究限制 85
第六章 結論與建議 86
參考文獻 89
附錄ㄧ 96
附錄二 98

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