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研究生:李修豪
研究生(外文):Hsiu-Hao Lee
論文名稱:值班負荷對內科醫師壓力反應的影響評估
論文名稱(外文):The relationship between duty loading and the stress responses in physicians
指導教授:郭育良郭育良引用關係陳保中陳保中引用關係
口試委員:鄭尊仁蘇大成蕭淑銖羅士翔
口試日期:2016-07-22
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:職業醫學與工業衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2016
畢業學年度:104
語文別:英文
論文頁數:75
中文關鍵詞:醫師值班負荷壓力反應心血管疾病恢復預測
外文關鍵詞:PhysicianDuty loadingStress responseCardiovascular diseaseRecoveryPrediction
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壓力不但影響內分泌系統以及神經系統,更對不同的生理性反應扮演重要的角色,壓力也可能在生理病理學上會造成心血管疾病的起始、發展、或惡化,越來越多人相信壓力越大,心血管疾病的機率越高。
長期工作壓力以及工時過長可能引起粥狀動脈硬化以及心血管疾病,同時短期極度壓力可能引起急性心肌梗塞或腦血管中風。越來越多人想了解壓力源以及壓力反應之間是否有劑量反應效應,對於預防壓力致病的有效對策需求也越來越高。
主動型職業像是醫師,工作壓力可以是兩倍或是三倍,例如醫師可能在相同時間照顧兩倍或是三倍的病人,我們的研究問題是醫師的值班負荷跟壓力反應的關係,這個研究的目的是要評估內科主治醫師的工作負擔,以及評估值班負荷如何影響血壓、心律變異、以及其他壓力指標。這個觀察性研究要探討內科值班負荷對於內科醫師的壓力反應是否有“劑量反應效應”,同時也探討夜間值班事件對血壓、心律變異的效應,此外此研究也測試“運動後心率恢復值”以及“夜間血壓下降值”,是否可以預測值班造成的壓力反應變化。
我們發現內科值班負荷對於內科醫師的壓力反應有“劑量反應效應”,長期沉重值班負荷可能對醫師可能是有害,“睡眠剝奪”以及“值班時新住院病人數目”可能是內科醫師值班時最危險的因子,更多針對值班負荷對心血管效應的大規模研究是需要的。
在內科醫師值夜班時,臨床值班事件的確會造成血壓上升以及交感神經活化,臨床值班事件的影響效應可以持續三十分鐘,這個效應也許可以解釋為何醫師值班後工作表現不佳,同時這個效應對醫師健康可能會有負面效應。
“運動後心率恢復值”跟“夜間收縮壓下降值”可能可以預測醫師值班造成的血壓上升。只有“夜間舒張壓下降值”可能可以同時預測醫師值班造成的血壓上升以及交感神經活化。

Stress not only influences our endocrine systems and neural systems but also plays an important role in various physiological responses. Stress could result in onset, development, or progression of pathophysiological cardiovascular disease. It’s generally accepted that the more the stress, the more the cardiovascular disease.
The working stress and long working hours may lead to atherosclerosis and cardiovascular diseases, while short term extreme stress maybe lead to acute myocardial infarction or cerebrovascular attack. Interest in dose response effect between stressor and stress response is growing, and more effective strategies for prevention of stressor related diseases are needed.
It seems that the stress of active job, such as physicians, could be double or triple. For example, physicians could care twofold or threefold of patients at the same time. We are interested in “the relationship between the duty loading and the stress response of physicians”. The aim of this study is to evaluate the work burden of physicians of internal medicine and how duty loading stress inference heart rate variability, blood pressure and other stress indicators. This study would also explore if there dose response effect between different duty loading in an observational method. We also exam the effects of night duty events on blood pressure and autonomic tone in physicians. Moreover, we also exam whether treadmill heart rate recovery and circadian blood pressure drop predict elevated BP and sympathetic parameters during duty period.
We identified dose-dependent stress responses of the cardiovascular system that were caused by the duty load of physicians. These results indicate that heavy duty loads might be hazardous to physicians in the long run. Sleep deprivation and the number of new patients admitted during duty nights were probably the most critical factors for the observed stress markers. Additional studies with a large sample are warranted for determining adverse cardiovascular effects at the recovery phase of duty load by comparing intensive and less-intensive duties.
Among physicians on night duty, sympathetic tone and blood pressure were elevated by clinical events and these effects lasted for 30 minutes. The effect of duty loading on circadian change and autonomic tone modulations for up to 30 minutes shows that nighttime shifts for physicians may cause impaired performance and adverse effects on their subjective health.
Higher treadmill heart rate recovery within first minute right after stopping running and higher circadian SBP drop were significantly associated with lower difference of blood pressure change caused by duty load. Higher circadian DBP drop was significantly associated with lower difference of blood pressure change and autonomic tone caused by duty load.

博士學位論文口試委員會審定書............................I
謝辭....................................................V
摘要............................................ ......VII
Abstract...............................................IX
TABLE OF CONTENTS....................................XIII
LIST OF FIGURES........................................XV
LIST OF TABLES........................................XVI
Chapter I. Introduction.................................1
Chapter II. Literature review...........................5
2.1 The concept of stress...............................5
2.2 The paradox effect and mechanism of stress response.6
Chapter III. Material and methods.......................9
3.1 The effects of duty loading on physicians of internal medicine................................................9
3.2 The Effects of night duty events on blood pressure and autonomic tone in physicians...........................15
3.3 Treadmill heart rate recovery and circadian blood pressure drop predict elevated BP and sympathetic parameters during duty period..........................17
Chapter IV. Results....................................19
4.1 The effects of duty loading on physicians of internal medicine...............................................19
4.2 The Effects of night duty events on blood pressure and autonomic tone in physicians...........................21
4.3 Treadmill heart rate recovery and circadian blood pressure drop predict elevated BP and sympathetic parameters during duty period..........................22
Chapter V. Discussion..................................25
5.1 The effects of duty loading on physicians of internal medicine...............................................25
5.2 The Effects of night duty events on blood pressure and autonomic tone in physicians...........................32
5.3 Treadmill heart rate recovery and circadian blood pressure drop predict elevated BP and sympathetic parameters during duty period..........................36
Chapter VI. Conclusions and suggestions................41
6.1 Conclusion and suggestions for future studies......41
6.2 Suggestions of stress coping for physicians........42
Figures................................................43
Tables.................................................49
Reference..............................................65
Appendix...............................................75

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