「動作專家」還是「儀器操作員」？物理治療師的專業自主與照護實作

為什麼物理治療會有「動作專家」與「儀器操作員」這個極端的實作圖像落差？本研究透過檔案資料分析、深度訪談與田野觀察來分析物理治療師的專業實作。本文的研究發現有以下三點：首先，《物理治療師法》與全民健康保險制度構成了物理治療師在醫療分工中的從屬地位。醫師在制度上的主導性地位，源自於診治分工中診斷的優先性。其次，物理治療評估是一種功能性診斷，而有別於醫師的病理性診斷。透過評估工作，物理治療師將患者的病理性問題轉化成功能性問題。最後，本文提出「編排工作」的概念來描述物理治療師的照護實作。編排工作有三個重要面向：安排治療順序、調整治療內容與規劃治療計劃。有效的物理治療，仰賴治療師充分編排其照護實作。然而，在現實條件下，知識與技術、勞動條件與醫師控制程度，都是影響治療師照護實作的重要因素。透過這個概念，本文主張，必須問題化看似定義明確的「治療」；透過看見照護實作與其他社會條件相互交織的過程，我們才有可能介入療效的討論。在政策建議上，本文認為法規制度上應該給予物理治療師執業自主的空間。同時，健保制度在規劃給付點數與項目時，也亟需納入醫事人員的意見，才能真正反應照護實作的內涵與價值。

關鍵字

物理治療；照護實作；分工；專業自主；編排工作

並列摘要

Why is there a huge gap between “movement expert” and “machine operator” in physical therapists’ practices? To analyze the professional practice of physical therapy, I use a variety of methods, including archival data analysis, in-depth interview, and participant observation. My research has three main points. First, Physical Therapy Act and National Health Insurance constitute the subordinate status in the medical division of labor; and the institutionally dominant position of physicians results from the superiority of diagnosis. Second, physical therapists’ assessment is a functional diagnosis which is different from the pathological diagnosis of physicians. Through the process of assessment, physical therapists can transform the patient’s physical problem into a functional problem. Third, I coin the concept of “choreographing work” to describe the clinical practice of physical therapy. This concept contains three aspects: arranging therapies in a sequence, adjusting the contents of therapies, and organizing therapeutic plans. An effective physical therapy relies on the adequate “choreographing work.” By this token, I argue we should problematize the definition of “therapy” to discover the interweaving process between care practices and social conditions. For policy implications, my findings call for reform of legal and medical systems to strengthen physical therapy. Two especially important changes would be to legitimize autonomy of physical therapists according to paramedical law and to have the payment system of National Health Insurance incorporate other professionals’ input besides the physician’s in the treatment for chronic pain.