醫院評鑑制度的緊箍咒：在學術研究壓力下的急診科醫師

How emergency physicians in Taiwan confront pressures for academic research: Personal interviews and institutional analysis

蔡同堯(Tuna-Yao Tsai)

指導教授 ： 高美英

臺北醫學大學/人文暨社會科學院/醫學人文研究所/碩士(2013年)

https://doi.org/10.6831/TMU.2013.00075

摘要

背景
臺灣自全民健康保險實施後，大部份的醫療院所收入必須仰賴健保給付。醫院評鑑的本意在確保病人得到良好的照護品質，然而政府為推展政策，將評鑑結果與健保給付掛勾，方便以評鑑手段控制醫院行為。現有多種評鑑並行，其中教學醫院評鑑規定，機構內需有至少百分之十的醫師，要有三年內的學術成績，方能在此項評鑑條文中獲得Ａ等。而醫院為能得到較高給付，以在醫療市場中生存，不得不努力達成評鑑要求。急診醫師的工作特別，在臨床工作之中無法抽空進行學術研究。若要達到要求，勢必得犧牲休閒或家庭生活。
醫師為受聘雇的勞工，被要求同時進行臨床服務、教學與研究工作；而學術工作也具備勞動的特性。資本家為榨取更多的勞動，將企圖控制生產過程。Burawoy指出，資本家設計了趕工遊戲、內部勞動市場以及內部國家的機制；一旦勞工參與了趕工遊戲，表示勞工同意了遊戲規則，就此與資本家的利益調合，而自發性地生產更多的勞動。

方法
本研究為質性研究，研究對象為我國具備急診醫學專科證書的醫師。取樣自方便性樣本，由主持人或受訪者推薦，挑選十三位各種不同行政職務、生涯規劃及學術成就的醫師。採用深入訪談的方式，探討急診醫師對於親身參與或不參與學術勞動的想法及做法。

結果
研究發現，來自資本家的要求將產生誘因排擠效應，讓急診醫師對研究失去熱情。而對於較嚴格的要求，可能以離職的方式作為因應，找尋另一個要求較可接受的地方工作。而即使是仍想進行研究的急診醫師，也可能因從未受過研究的訓練，過程備感艱辛而放棄。
然而，適應良好的醫師將成為趕工遊戲的勝利者，升任更高的職位，得到較好的報償，且進一步加強類似的控制。

結論
本研究發現了基層急診醫師不願參與學術研究的現象，並探討其原因；以及急診醫師對於學術競賽的批評。要鼓勵年輕醫師參與學術研究，獎懲制度並不如想像中有效。如何為醫師進行合理的工時分配、提供足夠的學術研究教育訓練、以及建立導師制度，可能才是有效的做法。急診醫師承認學術研究有其價值。但受到學術資本主義的影響，使急診醫師對學術研究失去了原有的初衷，反而破壞了原本的意義。對於強迫醫師進行學術研究，我們應有更深刻的反省與討論。

關鍵字

急診 ； 全民健保 ； 醫院評鑑 ； 趕工遊戲 ； 誘因排擠 ； 學術研究

並列摘要

Background
Since the National Health Insurance program (NHI) was put into practice in Taiwan in 1995, most hospital and clinics’ income comes from the payments from the NHI. Hospital evaluation was implemented to ensure the quality of medical care. Moreover, the government has linked the evaluation ratings to the payment scale to control the behavior of hospitals. Ranking as a teaching hospital requires that at least 10% of the doctors in the institution must demonstrate research achievements attained within three years prior to the evaluation. Hospitals want to obtain a grade A in evaluation to rate a high payment scale, so they will enforce the doctors do research. Emergency physicians can’t find time to do research during their daily work. If they want to achieve the requirement, they had to take their own family time.
Doctors though supposedly professionals are increasingly tied to service to hospitals under the NHI system. Their standard condition of work are as salaried personnel with at
least sixty hours of work time per week. In effect, they are hired labor. They are requested to do clinical service, teaching, and research at the same time. Under the global demand for advances in medical technology and pharmacology, academic activity also has the character of labor. The capitalist attempt to control the process of production for extracting the labor. Burawoy has pointed out that capitalists designed the making out, internal labor market, and internal state. Once labors joined the making out, Labors agree the rules of the game. Labor’s interest was mediated with the capitalist’s, then labors will subject
themselves to exploitative conditions willingly are held to the same standards for research.

Methodology
This thesis is a qualitative study. The subject is the experience of emergency physician in public and private hospitals in Taiwan. This study seeks to understand the
whole person, including career motives, life trajectory, and family life and meaning. The sampling from convenience sample, according to respondents recommendation. I have
chosen thirteen emergency physicians in different kinds of administrative jobs, career planning, and levels of academic achievement. I have done in-depth interviews to these
emergency physicians to know, how they think and what they do, for academic labor production.

Result
The pressure from hospital administration will bring about a motivation-crowding effect. Extrinsic rewards will undermine intrinsic motivations. The emergency physician will
lose their original passion for research. They may leave from a institution with higher requirement to a lower. Even if the emergency physician still want to do research, he will
feel strange to the research process and give up.
However, if the emergency physicians can do well, they may be promoted, earned more money. Then they will strengthen the similar control system.

Conclusion
Emergency physicians allows the valus of academic medical research. But in the effect of academic capitalism, the emergency physicians loose their passion of academic research. The valus of academic medical research was broken.
We have to do more introspection and discussion about enforcing emergency physician to academic medical research.

並列關鍵字

Emergency physician ； academic

參考文獻

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