臺灣博碩士論文加值系統

病人對醫師的信任在不斷減少中。許多人懷疑，醫療商品化可能是造成此現象的因素之一。此外，缺乏病人的信任也可能導致醫師覺得自己不被病人信任，換句話說，缺乏病人的信任導致醫師的「被病人信任感」低落。「被病人信任感」低落，是一種情緒負荷的來源，因此理論上可能導致醫師產生職業倦怠。
本研究的目標，是提供實證證據，以支持「醫療商品化對病人對醫師的信任感有負面影響」這樣的假說。此外，本研究也檢測了醫師自覺被病人信任感與住院醫師職業倦怠的相關性。
本研究首先量化各個國家醫療商品化的程度，並使用「國際社會調查項目」在2011年所做，包含二十三個國家的橫斷性調查，來檢驗醫療商品化對病人對醫師的信任感的影響。總共包含34,968位受測者。主要評估的結果指標是一題直接詢問民眾對醫師的一般信任感的試題；次要結果指標則是一份由四個題目所組成的衡量民眾對醫師的一般信任感的量表。本研究結果顯示，醫療比較商品化的國家的受測者，信任醫師的可能性，只有一般國家受測者的一半（勝算比0.47，百分之95信賴區間0.31至0.72）；且對醫師信任感的量表分數也低了1.13分（百分之95信賴區間0.37至1.89）。然而，比起一般國家，對醫師的信任感在醫療去商品化的國家，並不會比較低。
此外，本研究也在2015年11月至2016年五月之間，調查了台灣的住院醫師。本研究使用中文職業倦怠量表來衡量職業倦怠，並製作了包含四個題目的「醫師自覺被病人信任感量表」，用來衡量醫師自覺被病人信任感。本研究使用廣義線性模型加上廣義估計方程式，以職業倦怠作為依變項，估計醫師自覺被病人信任感與職業倦怠的關係，並同時校正潛在的干擾因子。結果總共有1,016位受測者繳回問卷（回應率百分之67.8）。研究結果顯示，個人職業倦怠的盛行率為百分之44.0，顧客相關職業倦怠的盛行率則為百分之14.8。醫師自覺被病人信任感量表具有足夠的內在一致性（Cronbach’s α 0.68），以及良好的建構效度。本研究也顯示，那些自覺不被病人所信任的住院醫師，職業倦怠的程度較高，特別是顧客相關職業倦怠；且這樣的相關性具有劑量反應模式。
本研究的結論是，醫療商品化可能造成民眾不信任醫師；台灣住院醫師的職業倦怠盛行率高，特別是個人職業倦怠；醫師自覺被病人信任感量表具有良好的效度；最後，若住院醫師自覺不被病人信任，則可能導致職業倦怠的程度上升，特別是顧客相關職業倦怠。

Trust in physicians has declined. Commodification of health care has been speculated as a plausible driving force. Besides, lack of patient trust may make physicians feel not being trusted by patients, and thus brings lack of “felt trust from patients” of physicians. As a source of emotional load, lack of felt trust from patients may also contributes to physician burnout theoretically.
The aims of my study are to provide empirical evidence to support the negative effect of health care commodification on patient trust in physicians, and to explore the relationship between felt trust from patients and resident burnout.
I quantified health care commodification, and used cross-national data of 23 countries from the International Social Survey Programme 2011, to study the role of health care commodification in the trust that patients generally place in physicians. A modified health care index was used to quantify health care commodification. There were 34,968 respondents. A question about the level of general trust in physicians, and a four-item “general trust in physicians” scale were used as the major and minor outcomes. The results were that compared with those in the reference countries, the respondents in the health care commodified countries were approximately half as likely to trust physicians (odds ratio: 0.47, 95% confidence interval [CI]: 0.31–0.72) and scored 1.13 (95% CI: 0.37–1.89) less on the general trust scale. However, trust in physicians in the health care decommodified countries did not differ from that in the reference countries.
Besides, residents in Taiwan were surveyed between November 2015 and May 2016. The Chinese version occupational burnout inventory and the four-item ‘physician-felt-trust-from-patient’ (PFTFP) scale I made were used to measure burnout and physician felt trust. Generalized linear model with generalized estimating equation with burnout as the dependent variable was employed to estimate the association between physician felt trust and burnout while adjusting other potential confounders. There were 1,016 questionnaires returned (response rate 67.8%). The prevalence of personal burnout and client-related burnout were 44.0% and 14.8%, respectively. The PFTFP scale demonstrated adequate internal consistency (Cronbach’s α 0.68) and favorable construct validity. Residents feeling less trusted from patients had significantly more burnout, especially client-related burnout, which showed a strong dose-response pattern.
In conclusion, health care commodification may play a meaningful role in the deterioration of public trust in physicians. The prevalence of burnout among residents in Taiwan was high, especially personal burnout. The validity of the PFTFP scale is satisfactory. Feeling less trust from patients may lead to a higher level of burnout among residents, especially client-related burnout.

TABLE OF CONTENTS
中文摘要......i
Abstract......iii
TABLE OF CONTENTS......v
LIST OF TABLES......vii
LIST OF FIGURES......viii
CHAPTER 1 INTRODUCTION......1
CHAPTER 2 LITERATURE REVIEW......2
2.1 Trust in Medical Care Settings......2
2.2 Health Care Commodification and Decommodification......2
2.3 Patient General Trust in Physicians and Health Care Commodification......4
2.4 Physician Felt Trust from Patients......7
2.5 Physician Burnout......8
2.6 Association between Physician Felt Trust and Burnout......8
CHAPTER 3 MATERIAL AND METHODS......10
3.1 Aim 1: To explore the influence of country-level health care commodification on people’s general trust in physicians.......10
3.1.1 Study Design and Data Source......10
3.1.2 Quantify Health Care Commodification......10
3.1.3 Outcomes......12
3.1.4 Study Sample, Explanatory Variables, and Processing of Missing Data......14
3.1.5 Statistical Analysis......15
3.2 Aim 2: To verify the association between physician felt trust and burnout.......15
3.2.1 Study Design and Sample......15
3.2.2 Physician-felt-trust-from-patient Scale......16
3.2.3 Measurement of Burnout......17
3.2.4 Other Variables Measured......19
3.2.5 Statistical Analysis......21
CHAPTER 4 RESULTS......23
4.1 Aim 1: To explore the influence of country-level health care commodification on people’s general trust in physicians.......23
4.2 Aim 2: To verify the association between physician felt trust and burnout.......28
CHAPTER 5 DISCUSSION......36
5.1 Aim 1: To explore the influence of country-level health care commodification on people’s general trust in physicians.......36
5.2 Aim 2: To verify the association between physician felt trust and burnout.......41
CHAPTER 6 CONCLUSION......45
REFERENCE......46
APPENDIX. PUBLISHED PAPERS......56

LIST OF TABLES
Table 1. Items Used to Construct “General Trust in Physician” Scale and the Comparison to Validated Scales......13
Table 2. Items to Represent Physician Felt Trust from Patients and the Original Items......16
Table 3. Modified Health Care Index Data (2011)......23
Table 4. Adjusted odds ratio (OR) of higher agreement on “doctors in [your country] can be trusted”......26
Table 5. Demographics and Other Characteristics of Surveyed Residents in Taiwan between November 2015 and May 2016......29
Table 6. Basic Statistics and Internal Consistency of Items of the Physician-Felt-Trust-from-Patients Scale (n = 996)......30
Table 7. Promax rotated factor pattern from exploratory factor analysis of five scales (n = 896)a......31
Table 8. Convergent and discriminant validity: Pearson correlation coefficients of physician felt trust from patients and other varialbes (n = 873)......32
Table 9. ß estimates of the generalized linear model with generalized estimating equation (n = 793)a......33

LIST OF FIGURES
Figure 1. The conceptual framework to explain how commodification may affect multiple dimension of trust through three intermediate factors (consumerism, conflict of interest, and risk of unmet care needs.)......7
Figure 2. Possible mechanism of the association between low physician felt trust from patients and physician burnout......9
Figure 3. Scatter plot and regression line of average score of patient trust and health care index......25
Figure 4. Estimated adjusted odds ratio (OR) of higher trust in physicians for health care commodified countries compared to reference and decommodified countries conditioning on each level of household income. The overall interaction effect of health care commodification (dichotomized into commodified and reference/decommodified countries) and household income were nonsignificant (P=0.36). Bars represent 95% confidence intervals.......27
Figure 5. Effect estimates of resident physician felt trust on resident burnout......34

1. Bonds DE, Camacho F, Bell RA, Duren-Winfield VT, Anderson RT, Goff DC. The association of patient trust and self-care among patients with diabetes mellitus. BMC family practice 2004;5:26.
2. Gupta S, Brenner AT, Ratanawongsa N, Inadomi JM. Patient trust in physician influences colorectal cancer screening in low-income patients. Am J Prev Med 2014;47:417-23.
3. Jones DE, Carson KA, Bleich SN, Cooper LA. Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure. Patient Educ Couns 2012;89:57-62.
4. Lee YY, Lin JL. How much does trust really matter? A study of the longitudinal effects of trust and decision-making preferences on diabetic patient outcomes. Patient Educ Couns 2011;85:406-12.
5. Mancuso JM. Impact of health literacy and patient trust on glycemic control in an urban USA population. Nurs Health Sci 2010;12:94-104.
6. Nguyen GC, LaVeist TA, Harris ML, Datta LW, Bayless TM, Brant SR. Patient trust-in-physician and race are predictors of adherence to medical management in inflammatory bowel disease. Inflamm Bowel Dis 2009;15:1233-9.
7. Thom DH, Kravitz RL, Bell RA, Krupat E, Azari R. Patient trust in the physician: relationship to patient requests. Fam Pract 2002;19:476-83.
8. Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen Burnout Inventory: A new tool for the assessment of burnout. Work Stress 2005;19:192-207.
9. Kakiashvili T, Leszek J, Rutkowski K. The medical perspective on burnout. Int J Occup Med Environ Health 2013;26:401-12.
10. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015;90:1600-13.
11. Blendon RJ, Benson JM, Hero JO. Public trust in physicians--U.S. medicine in international perspective. The New England journal of medicine 2014;371:1570-2.
12. DeCamp MW. Ethics and the physician-patient relationship: Medico-moral consequences of commodification. Einstein Quart J Biol Med 2002;19:135-8.
13. Churchill LR. The United States health care system under managed care. How the commodification of health care distorts ethics and threatens equity. Health Care Anal 1999;7:393-411.
14. Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Serv Res 2002;37:1419-39.
15. Arrow KJ. Uncertainty and the welfare economics of medical care. The American economic review 1963;53:941-73.
16. Barton JL, Trupin L, Tonner C, et al. English language proficiency, health literacy, and trust in physician are associated with shared decision making in rheumatoid arthritis. J Rheumatol 2014;41:1290-7.
17. Meyer S, Ward P, Coveney J, Rogers W. Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann. Health Sociology Review 2008;17:177-86.
18. Williams CC. Beyond commodification: re-reading the future of work. Foresight 2004;6:329-37.
19. Room G. Commodification and decommodification: a developmental critique. Policy & Politics 2000;28:331-51.
20. Polanyi K. The great transformation: the political and economic origins of our time. Boston: Beacon Press; 2007.
21. Esping-Andersen G. The Three Worlds of Welfare Capitalism. Princeton: Princeton University Press; 1990.
22. Mackintosh M, Kovalev S. Commercialisation, inequality and transition in health care: the policy challenges in developing and transitional countries. Journal of International Development 2006;18:387-91.
23. Mackintosh M. Commercialisation, inequality and the limits to transition in health care: a Polanyian framework for policy analysis. Journal of International Development 2006;18:393-406.
24. Bambra C. Worlds of welfare and the health care discrepancy. Social Policy and Society 2005;4:31-41.
25. Mechanic D. Changing medical organization and the erosion of trust. Milbank Q 1996;74:171-89.
26. Havighurst CC. Starr on the corporatization and commodification of health care: the sequel. Journal of health politics, policy and law 2004;29:947-67; discussion 1005-19.
27. Reich AD. Selling our souls: the commodification of hospital care in the United States: Princeton University Press; 2014.
28. Bambra C. Cash Versus Services: ‘Worlds of Welfare’ and the Decommodification of Cash Benefits and Health Care Services. Journal of Social Policy 2005;34:195-213.
29. Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J Med Philos 1999;24:243-66.
30. March JG. Primer on Decision Making: How Decisions Happen: Free Press; 1994.
31. Messick DM. Alternative logics for decision making in social settings. Journal of Economic Behavior & Organization 1999;39:11-28.
32. Tenbrunsel AE, Messick DM. Sanctioning systems, decision frames, and cooperation. Adm Sci Q 1999;44:684-707.
33. Ward PR, Rokkas P, Cenko C, et al. ‘Waiting for’ and ‘waiting in’ public and private hospitals: a qualitative study of patient trust in South Australia. BMC Health Serv Res 2017;17:333.
34. Ward PR, Rokkas P, Cenko C, et al. A qualitative study of patient (dis)trust in public and private hospitals: the importance of choice and pragmatic acceptance for trust considerations in South Australia. BMC Health Serv Res 2015;15:297.
35. Cunningham PJ. High medical cost burdens, patient trust, and perceived quality of care. J Gen Intern Med 2009;24:415-20.
36. Rodwin MA. Conflicts of interest and the future of medicine: the United States, France, and Japan: Oxford University Press, USA; 2011.
37. O’Dowd A. Doctors’ worry about NHS “privatisation” is growing, says BMA. BMJ (Clinical research ed) 2016;353.
38. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients' trust in their physicians: effects of choice, continuity, and payment method. J Gen Intern Med 1998;13:681-6.
39. Kao AC, Green DC, Zaslavsky AM, Koplan JP, Cleary PD. The relationship between method of physician payment and patient trust. JAMA 1998;280:1708-14.
40. Cammett M, Lynch J, Bilev G. The Influence of Private Health Care Financing on Citizen Trust in Government. Perspectives on Politics 2015;13:938-57.
41. Lester SW, Brower HH. In the eyes of the beholder: The relationship between subordinates' felt trustworthiness and their work attitudes and behaviors. J Leadersh Org Stud 2003;10:17-33.
42. Salamon SD, Robinson SL. Trust that binds: the impact of collective felt trust on organizational performance. J Appl Psychol 2008;93:593.
43. Brennan N, Barnes R, Calnan M, Corrigan O, Dieppe P, Entwistle V. Trust in the health-care provider–patient relationship: a systematic mapping review of the evidence base. Int J Qual Health Care 2013;25:682-8.
44. Oskrochi Y, Maruthappu M, Henriksson M, Davies AH, Shalhoub J. Beyond the body: A systematic review of the nonphysical effects of a surgical career. Surgery 2015.
45. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-85.
46. Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National Survey of Burnout among US General Surgery Residents. J Am Coll Surg 2016;223:440-51.
47. Mahan JD. Burnout in Pediatric Residents and Physicians: A Call to Action. Pediatrics 2017;139.
48. Baer TE, Feraco AM, Tuysuzoglu Sagalowsky S, Williams D, Litman HJ, Vinci RJ. Pediatric Resident Burnout and Attitudes Toward Patients. Pediatrics 2017.
49. Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res 2014;14:325.
50. Zubairi AJ, Noordin S. Factors associated with burnout among residents in a developing country. Ann Med Surg (Lond) 2016;6:60-3.
51. De Silva MJ, McKenzie K, Harpham T, Huttly SRA. Social capital and mental illness: a systematic review. J Epidemiol Community Health 2005;59:619-27.
52. De Silva MJ, Huttly SR, Harpham T, Kenward MG. Social capital and mental health: A comparative analysis of four low income countries. Soc Sci Med 2007;64:5-20.
53. International Social Survey Programme: Health and Health Care - ISSP 2011. International Social Survey Programme Research Group, 2013. (Accessed December 7, 2014, at http://www.issp.org/.)
54. OECD Health Data 2011. 2011. (Accessed June 6, 2015, at http://stats.oecd.org/.)
55. Ministry of Health and Welfare, Executive Yuan R.O.C. Taiwan. 2011. (Accessed June 6, 2015, at http://www.mohw.gov.tw/cht/Ministry/.)
56. Hospital beds by hospital ownership. Eurostat, 2011. (Accessed July 6, 2015, at http://ec.europa.eu/eurostat.)
57. The hospitals in the 27 European countries: country profile Sweden. European Hospital and Healthcare Federation, 2012. (Accessed June 7, 2015, at http://www.hope.be/03activities/quality_eu-hospitals/eu_country_profiles/sweden-eu_hospitals-profile.pdf.)
58. Mazag J. PHIS Hospital Pharma Report: Slovakia. Bratislava, Slovakia: Pharmaceutical Health Information System; 2009 April.
59. Farsi M, Filippini M. An analysis of efficiency and productivity in Swiss hospitals. Swiss Journal of Economics and Statistics 2006;142:1-37.
60. OECD. Health insurance coverage for a core set of services, 2011, in Health at a Glance 2013. Paris: OECD Publishing; 2013.
61. OECD Health Division. Guidelines for the Implementation of the SHA 2011 Framework for Accounting Health Care Financing. 2014.
62. Bayindir EE. Hospital ownership type and treatment choices. Journal of health economics 2012;31:359-70.
63. Horwitz JR, Nichols A. Rural hospital ownership: medical service provision, market mix, and spillover effects. Health Serv Res 2011;46:1452-72.
64. Horwitz JR. Making profits and providing care: comparing nonprofit, for-profit, and government hospitals. Health affairs (Project Hope) 2005;24:790-801.
65. Dugan E, Trachtenberg F, Hall MA. Development of abbreviated measures to assess patient trust in a physician, a health insurer, and the medical profession. BMC Health Serv Res 2005;5:64.
66. Meyer SB, Ward PR, Jiwa M. Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patients with coronary disease in South Australia. BMJ open 2012;2.
67. Yeh W-Y, Cheng Y, Chen M-J, Chiu AW-H. Development and validation of an occupational burnout inventory. Taiwan J Public Health 2008;27:349-64.
68. Shang L, Liu P, Fan L, Gu H, Li J. Psychometric properties of the Chinese version of Copenhagen Psychosocial Questionnaire. Journal of Environmental and Occupational Medicine 2008;25:572-6.
69. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav 1981;2:99-113.
70. Yeh W-Y, Cheng Y, Chen C-J, Hu P-Y, Kristensen TS. Psychometric properties of the Chinese version of Copenhagen burnout inventory among employees in two companies in Taiwan. Int J Behav Med 2007;14:126-33.
71. Stassen W, Van Nugteren B, Stein C. Burnout among advanced life support paramedics in Johannesburg, South Africa. Emerg Med J 2013;30:331-4.
72. Muzafar Y, Khan HH, Ashraf H, et al. Burnout and its Associated Factors in Medical Students of Lahore, Pakistan. Cureus 2015;7:e390.
73. Chambers CN, Frampton CM, Barclay M, McKee M. Burnout prevalence in New Zealand's public hospital senior medical workforce: a cross-sectional mixed methods study. BMJ open 2016;6:e013947.
74. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study. JAMA 2006;296:1071-8.
75. Frequently Asked Questions: ACGME Common Duty Hour Requirements. 2014. (Accessed Oct 26, 2015, at https://www.acgme.org/acgmeweb/tabid/271/GraduateMedicalEducation/DutyHours.aspx.)
76. Christino MA, Matson AP, Fischer SA, Reinert SE, Digiovanni CW, Fadale PD. Paperwork versus patient care: a nationwide survey of residents' perceptions of clinical documentation requirements and patient care. J Grad Med Educ 2013;5:600-4.
77. Cheng Y, Luh W-M, Guo Y-L. Reliability and validity of the Chinese version of the Job Content Questionnaire in Taiwanese workers. Int J Behav Med 2003;10:15-30.
78. Hurrell Jr JJ, Nelson DL, Simmons BL. Measuring job stressors and strains: where we have been, where we are, and where we need to go. J Occup Health Psychol 1998;3:368.
79. Locke DE, Decker PA, Sloan JA, et al. Validation of single-item linear analog scale assessment of quality of life in neuro-oncology patients. J Pain Symptom Manage 2007;34:628-38.
80. Radloff L. Center for epidemiological studies—Depression scale. Actualisation de la base de données BeST & Inclusion de nouvelles échelles dans la base de données existante BeST 1977.
81. Lee K, Ou Y, Chen S, Weng L. The psychometric properties of a short form of the CES-D used in the Taiwan longitudinal study on aging. J Formosa Ment Health 2009;22:383-410.
82. Yu S. Contribution of health care decommodification index to the analysis of the marginalisation of east asian countries in comparative welfare studies. Development and Society 2012;41:253-70.
83. Everitt BS, Skrondal A. The Cambridge dictionary of Statistics, Fourth Edition. New York: Cambridge University Press; 2010.
84. Kawiorska D. Healthcare in the Light of the Concept of Welfare State Regimes-Comparative Analysis of EU Member States. Oeconomia Copernicana 2016;7:187.
85. Farrants K, Bambra C, Nylen L, Kasim A, Burström B, Hunter D. The recommodification of healthcare? A case study of user charges and inequalities in access to healthcare in Sweden 1980–2005. Health policy (Amsterdam, Netherlands) 2017;121:42-9.
86. Quercioli C, Messina G, Basu S, McKee M, Nante N, Stuckler D. The effect of healthcare delivery privatisation on avoidable mortality: longitudinal cross-regional results from Italy, 1993-2003. J Epidemiol Community Health 2013;67:132-8.
87. Arora M, Asha S, Chinnappa J, Diwan AD. Review article: burnout in emergency medicine physicians. Emergency medicine Australasia : EMA 2013;25:491-5.
88. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. The New England journal of medicine 2004;351:1838-48.
89. Schumacher DJ, Frintner MP, Winn A, Cull W. Graduating Pediatrics Residents' Reports on the Impact of Fatigue Over the Past Decade of Duty Hour Changes. Acad Pediatr 2015;15:362-6.
90. Gohar A, Adams A, Gertner E, et al. Working memory capacity is decreased in sleep-deprived internal medicine residents. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2009;5:191-7.
91. Lenzner T, Kaczmirek L, Lenzner A. Cognitive burden of survey questions and response times: A psycholinguistic experiment. Appl Cogn Psychol 2010;24:1003-20.
92. Stoop IA, Billiet J, Koch A, Fitzgerald R. Improving survey response: Lessons learned from the European Social Survey: John Wiley & Sons; 2010.
93. Tourangeau R, Rips LJ, Rasinski K. The psychology of survey response: Cambridge University Press; 2000.