臺灣地區醫師繼續教育接受者之調查研究

Research from the Perspective of Continuing Medical Education Participating Physicians in Taiwan

林介山(Jesun Lin)

指導教授 ： 王俊文

中山醫學大學/醫學院/醫學研究所/碩士(2006年)

摘要

研究目的
醫師繼續教育( Continuing Medical Education, CME )之定義，即是醫師在取得醫師資格之後的醫療生涯，仍然須要繼續接受教育，以維持因時代進步而日新月異的醫療水準，改善醫師之醫療專業能力以維護病人的健康，這些教育的活動都稱為醫師繼續教育。醫師繼續教育可能直接或間接影響醫師的醫療行為，進而影響治療效果與醫療品質，由此可知醫師繼續教育的重要。
本研究乃針對臺灣地區在醫院與診所從事醫療工作的醫師，其接受醫學繼續之後的迴響進行調查，參考國內外文獻和專家意見，由接受者的滿意度提出之回饋，期許整理出適合臺灣當代的醫師繼續教育之模式。尤其在2003年3月至6月國內發生SARS疫情肆虐，曝露出我國醫學繼續教育體系，醫療與公共衛生的許多缺失，SARS疫情穩定之後，醫療品質策進會、臺灣醫學教育會等醫學教育之學者專家，更向醫療衛生主管單位—行政院衛生署，建議充實醫學系畢業生的核心醫療專業技能，並強化醫學人文、醫學倫理，配合以可行性高的臨床醫學、預防醫學、公共衛生學，建構以社區為基礎的完整醫療照護。
研究方法
採用文獻回顧及探討我們從2002年到2004年臺灣中區醫療網所做的兩次資料分析之後，再擴大針對臺灣醫師繼續教育接受者(服務於醫院、診所醫療工作的醫師)做實際調查，其內容採結構式「問卷調查」之設計，利用系統性分層隨機抽樣方式，將相關結果運用「敘述性分析」、「因素分析」、「差異性分析」以及「迴歸性分析」得以解析各構面的結果與關聯性。
研究結果
調查醫師繼續教育接受者及提供者之間各構面結果，顯示除了師資之構面具有較一致的看法，其餘的構面則具有明顯的差異，這些構面分別是：教育內容與主題、辦理教育的方式、教育達成目標、教育成效、辦理教育的理由、教育法令之規定及對醫療政策或生態之影響等。然而，較低工作時數之醫學繼續教育接受者，其對各構面之看法較為傾向支持與重視，不但對繼續教育有較高的滿意度而且較重視醫療政策之影響；接受者具有專科醫師資格者，對於各構面的之滿意度與反應和不具專科醫師資格者，呈現顯著差異。經過迴歸性分析，發現繼續教育內容主題與辦理理由乃是影響接受者對滿意度的最主要因素。
結論與建議
我國政府對於醫師繼續教育之政策方針與醫師法之醫師繼續教育規範，和美國、歐盟、日本、韓國比較起來，尚屬完備。本篇研究臺灣所有的專科醫學繼續教育六年的總學分點數都會超過臺灣醫學會所規定的180學分，只要臺灣醫學會能承認專科醫學會所辦的繼續教育學分，則六年積分無問題，可以更換執業執照。一般科醫師之臨床工作性質與家庭醫學科醫師極為類似，實際上可和家醫同時舉辦，故衛生署可授權由各專科去辦理醫學繼續教育，省略臺灣醫學會認證工作，彼此可以節省許多時間、費用並且減少糾紛。辦理醫學繼續教育的內容與型式應採取多元發展，在經過專業篩選後由醫師自行選擇所需，以配合實際從事醫療工作的接受者期待的教育內容主題與辦理理由，更能合乎醫療政策及臨床醫學實務之需求。因此須要多元化積極開放相關醫學團體創造受教育者參加繼續醫學教育的誘因。並且成立立場客觀的醫師繼續教育監督聯盟(Continuing Medical Education Audit League, CMEAL)，不受任何提供財務、經濟或政治協助單位之影響、以促進醫學繼續教育之品質及成效。雖然醫學繼續教育在臺灣是強制性的，然而，不應以醫師未參與醫學繼續教育之理由而剝奪其醫師執業資格，因為這麼做是違憲的剝奪醫師之工作權。同時醫師不應因參加繼續教育而遭受財務損失，因為繼續教育能讓醫師扮演健康維護者的角色，促進被保險人的健康且節省健保費用。

關鍵字

醫學繼續教育 ； 教育接受者 ； 滿意度 ； 醫療政策

並列摘要

Objective
Continuing medical education (CME) fulfills the need to continually educate a practicing physician in order to meet the demands of evolving modern medicine and to enhance physician professionalism. All activities toward such ends are considered continuing medical education. CME may directly or indirectly affect patient care, which eventually influences treatment results. Thus one can see the importance of providing quality continuing medical education for physicians.
By surveying physicians working in hospitals and clinics, we collected comments on their personal experiences with CME courses. By using domestic and foreign journals in addition to experts’ opinions, we inferred participating physician approval levels, positive or negative feedbacks from physicians who attended CME courses. It is the objective of this study to provide a working model for the providers and recipients of the CME. It might ensure that Taiwanese physicians attend adequate continuing medical education in clinical practice and medical behavior in order to achieve a holistic approach to patient-centered care. The importance of CME became especially evident during the SARS outbreak in 2003. Between March and June 2003 SARS ravaged Taiwan, it also revealed the serious deficiencies in medical education, clinical medicine, epidemiology and public health in Taiwan. After the SARS outbreak was controlled, the Medical Quality Improvement Association, Taiwan Medical Education Association and other organizations and medical education experts made a few policy recommendations to the Department of Health of the Executive Yuan. The recommendations called for bolstering core medical skills of medical school graduates and strengthening medical ethics in addition to improving the standard of clinical medicine, preventive medicine, epidemiology, public health and ultimately, creating a community-based medical treatment system.

Materials and Methods
First, we reviewed existing medical literature and analyzed the data received our studies from 2002 to 2004 through Taiwan’s Central Region Medical Network. Then we expanded the survey of Taiwanese physicians (hospitals and clinics) using a systematic cross-sectional sampling method. The results were then processed through “descriptive analysis”, “factor analysis”, “differential analysis” and “regression analysis” to explain the results in each area and the relationships thereof.

Results
The results show that other than “qualifications of instructors”, the subjects’ comments show clear disparities. These areas include: course content, subject matter, method of course administration, course objectives, results, reasons for the program, medical education regulations, impacts on medical practice environment and policies. The results show that attendees consistently expressed lower approval ratings than the instructors. However, physicians who work fewer hours tend to support and value the CME programs more. Not only do they express higher approval, they also show higher regard to potential health policy impacts. Finally, the comments from specialists and those of general practitioners show clear disparities.
According to regression analysis, the “subject matter of the course” and “reasons for the program” is the two areas that impacted attendee approval levels of CME the most. According to the survey results “Continuing medical education” are the most important factor in attendee’s cooperation in medical policies.

Conclusion and Suggestions
In comparison with CME policies and regulations in the United States, the European Union, Japan and South Korea, Taiwan’s policies and regulations are adequate. However, many general CME curricula overlap with the curricula for specialists. Additionally, courses dealing with medical ethics should be included in medical specialty field in order to promote thorough understanding. Currently medically societies of almost all disciplines embrace this notion. Therefore, other than specialized CME courses there are increasing number of medical ethic courses in their specialties. All specialized CME programs in Taiwan surveyed in this study exceed the national requirement of 180 credits in every 6 years as long as the courses are approved by the national medical board. The practices of a generalist and a family physician are very similar in nature. The two CME programs may be combined into one, and allow other specialized medical societies to design their own programs. This will eliminate unnecessary certification, save time, expenses and disputes. CME courses should not be attended simply for the sake of accumulating required credits for license renewal.

CME courses should be developed to include more variety in content and programming. Practicing physicians should select courses relevant to the needs of medical policies and practice. Therefore, there is a need to open up the administration of CME to related medical organizations such as medical associations, physicians’ associations, medical schools, medical education associations and the Department of Health. Additionally, an impartial Continuing Medical Education Audit League (CMEAL) should be established to ensure the quality and successful results of continuing medical education.

Although CME is required by the Taiwanese government, a physician’s license may not be revoked simply because of inadequate-participation. Such is an unconstitutional act taking away a physician’s right to practice. The best way to avoid inadequate-participation is for the national and local medical boards to notify the physician of insufficient credits at least one year prior to renewal to allow them enough time to fulfill the requirement. Finally, physicians should not feel their attendance of CME courses will result in financial loss because the attendance of CME courses will make them better physicians provide a higher level of care.

並列關鍵字

Continuing medical education ； CME provider ； CME participating physician ； approval levels ； medical policies

參考文獻

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