台灣醫師面對醫療糾紛的困境與教育需求

The Plight and Educational Needs of Physicians in Taiwan regarding Medical Disputes

林欣慧(Hsin-Hui Lin)

指導教授 ： 吳建昌

國立臺灣大學/醫學院/醫學教育暨生醫倫理研究所/碩士(2017年)

https://doi.org/10.6342/NTU201703304

摘要

本研究目的有二：一、探索國內醫師在面對醫療糾紛時所遭遇的困境；二、對醫療糾紛相關教育的需求。

本研究在困境的探討方面，採用質性研究、半結構式面對面訪談方法進行。在民國106年3月至6月間，透過立意取樣(purposive sampling)之方式，訪談來自不同地區、科系、年齡層、性別，共16位曾有醫療糾紛經驗之醫師，以紮根理論((grounded theory)之方式，對訪談所得之文本作開放式編碼與軸心編碼分析；在國內醫師對醫療糾紛相關教育需求之部分，採用混和研究(mixed-methods research)之方式。除以前述困境探討之研究方法，收集與分析同一群受訪者對醫療糾紛相關教育需求之看法，同時間以立意取樣之方式，針對全國醫師，進行半結構式問卷調查，收集國內不同地區、層級、年齡層、科系之醫師對醫療糾紛相關教育的需求之量性資料，以敘述性統計及推論性統計之方法分析，最後將質性與量性資料整合討論，達到多重檢核(triangulation)與資料互補之目的。

研究結果顯示，台灣醫師面對醫療糾紛，有24項核心困境，包括訴訟程序與法律邏輯相關6項：1. 還原當時事發經過 2. 釐清責任歸屬 3.不懂法律邏輯或訴訟程序 4. 需配合法院隨傳隨到 5. 冗長之審判期 6. 刑事濫訴現象；自我認同危機相關2項：1. 第一次面臨刑法審判與究責之心理衝擊 2.行醫信念受到挑戰；人際網絡與社會互動相關15項： 1. 人身安全威脅2. 被原本關係良好的病家指責拿其當實驗品 3. 病家可能有人格特質疾患，不知如何與其溝通互動 4. 走入訴訟後被建議不再接觸病家，因此無法了解對方想法 5. 無法幫助病家6. 同儕在病家面前指責 7. 同事間推諉責任 8. 提供第二意見之醫師不同意原醫師看法 9. 主治醫師責任制10. 法官或檢察官之庭上斥責 11. 法律專業人士難了解醫療專業內容12. 疑似有鼓勵病人提告之掮客或律師 13. 醫院無協助人員與組織 14. 醫院協助人員負荷過重或專業不足 15. 病家透過媒體發言，造成對醫師名譽與醫病關係之損害；金錢賠償造成之壓力1項。國內醫師對醫療糾紛相關教育有其需求，超過九成填答者同意將相關課程納入醫師養成教育中。受國內醫師重視的授課主題為「醫療傷害訴訟」相關法規認識(56.7%)、「醫療糾紛」發生案例與處理經驗分享(73.7%)、「醫病溝通」：支持病人與家屬之相關溝通技巧，如傾聽、表達同理心、給予病人或家屬情緒支持、告知壞消息、了解病人或家屬之期望等(58.9%)、「醫療傷害」發生時，應如何告知病人及其家屬、如何告知同儕、遺憾或道歉之表示(59.3%)等，其中又以「醫療糾紛」發生案例與處理經驗分享最為重要。有約七成的醫師有上過醫療糾紛相關課程，最常上到的主題為「醫病溝通」、「醫學倫理」、「醫療品質」；在問卷所列的課程中，最少被上到又令醫師最有興趣的課程主題是「模擬法庭」、「醫療傷害訴訟裁判文」、「醫療糾紛」發生案例與處理經驗分享。八成以上醫師認為在醫學系畢業前即應開始接觸醫療糾紛相關課程，占必修課程裡3學分以下即可。授課單位部分，醫學中心之醫師偏好在自己醫院上課；基層院所執業之醫師偏好醫師公會所舉辦的課程，約有三成醫師最有意願參與各專科醫學會所辦之課程；影響醫師是否參與課程的考量包括方便性、以及是否有依專科特性的授課內容或醫療糾紛案例分享。未能修習課程的原因最多為「訓練或繼續教育過程沒有舉辦這類課程」，其次為「沒有時間去上課」、「上課地點太遠」。

本研究提供國內醫師在面對醫療糾紛時，所遭遇的困境，及對醫療糾紛相關教育的需求之探索性結果。醫師在處理醫療糾紛時所面對的困境非常多元化，除個人內在身心思索，亦牽涉到司法、人際、醫療糾紛處理制度、媒體等法學、政策學、醫院管理學或社會學議題，每一困境項目都值得未來研究深入探究。在醫療糾紛教育方面，國內醫師需求甚高，然而何種教育訓練方式與內容能有效幫助到醫師，值得更多實證研究探究。

關鍵字

醫療糾紛 ； 醫師 ； 困境 ； 教育需求 ； 紮根理論 ； 台灣

並列摘要

This research was aimed to explore (1) the plight of physicians in Taiwan regarding medical disputes (2) the educational needs of physicians in Taiwan regarding medical disputes.

To probe the plight of physicians in Taiwan regarding medical disputes, we performed qualitative, semi-structural face-to-face interview to collect our subjects’ opinion. The time of subjects’ recruitment and interview was between March, 2017 and June, 2017. Via purposive sampling, 16 physicians that had been involved in a medical dispute were enrolled in the study. The subjects were from various areas and medical specialties Taiwan. We analyzed and coded the subjects’ opinions openly and axially by grounded theory.

To understand the educational needs of physicians in Taiwan regarding medical disputes, we collected opinions from the above-mentioned 16 subjects in the “plight” part of the study. Meanwhile, via purposive sampling, semi-structural questionnaires were collected from 273 physicians across the island. Descriptive and inferential statistics were both used to analyze the questionnaire data. A discussion was made to incorporate results from qualitative data and quantitative data.

We identified 24 core plights in facing medical disputes by physicians in Taiwan. In the category “difficulty in litigation”, there were 6 plights: (1) difficulty in clarifying the incident (2) difficulty in deciding who to be responsible (3) unfamiliarity about the litigation process and rationale (4) need to cooperate with the court time (5) the lengthy trial period (6) vexatious litigation (especially the criminal procedures). In the category “self-identity crisis”, there were 2 plights: (1) psychological shock during criminal procedures (2) beliefs in medical practice being challenged. In the category “Interpersonal relationship and communications”, there were 15 plights: (1) threatening of personal safety (2) being accused of “doing experiments” on the patients (3) certain personality disorder of the patient-family hindering communication with the physician (4) being advised not to contact with the patient-family after the dispute has occurred (5) could not help the patient anymore (6) being blamed by staffs (7) shirking of responsibility by staffs (8) a second doctor not agreeing the viewpoint of the first doctor (9) the system of “attending physician responsible for all” (10) blame from the judge or the prosecutor (11) difficulty for the judge or the prosecutor to understand medical conditions (12) in some cases, the patient-family were pushed to litigation due to potential benefit of the adviser (13) lack of support from the hospital (14) amateur or overloaded support personals (15) pressure from the media. Another category was the compensation itself too high for the physician to afford.

Need for education about medical dispute was obvious. Over 90% of subjects agreed the incorporation of this education into the training program. Of the 11 listed topics of this field, the most favored topics were: (1) knowing about the regulations (56.7%) (2) medical dispute case sharing (73.7%) (3) communication with the patient-family (58.9%) (4) how to respond to a medical dispute: focus on telling the patient-family, the staff and apologize (59.3%). Seventy percent of the subjects reported having attended any class about medical dispute. The most frequent attended classes were: “communication”, “medical ethics” and “healthcare quality”. The least attended and the most wanted classes were “simulation of the court”, “verdict of medical dispute” and “case sharing”. Over 80% of the subjects voted that the medical dispute classes should be delivered to the undergraduates, and that the credits should be below 3. As for the location of education, physicians in medical centers preferred taking a class in his or her own hospital; physicians in local clinics preferred the class at medical associations. Current hindrance to the classes were “class not available”, “time not available” and “too distant the location of the class”.

In summary, the current study provided information about plights when physicians facing medical disputes, and physicians’ need for related education. The plights were found to be very heterogeneous, due to complex interactions between medical practices, regulations, personal beliefs, and various other personal and social factors. The interactions could be a further direction of research. Physicians’ interests were high in medical dispute education. The effectiveness and efficacy of specific content or method of education regarding medical disputes warrant further research.

並列關鍵字

medical dispute ； medical malpractice ； physician ； plight ； education ； grounded theory ； Taiwan

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