台灣醫院骨科專科醫師人力評估

在醫療專業中，醫師為醫療團隊之主要領導者，醫師人力直接影響醫療資源及醫療生態。而專科醫師之醫療乃是時勢所趨，其人力結構牽涉就醫可近性，醫療品質及醫療費用等，故專科醫師人力需作合適規劃，才能提供適當的醫療服務來保障民眾健康。台灣自1977年成立骨科醫學會至今已產生1618名骨科專科醫師，而在2005年亦有1472名執業中，平均每一名服務1.56萬人口。若根據郭耿南等之研究美國骨科醫師人力需求為每1.5萬人口一名，則反証台灣骨科人力已趨飽和。然台灣醫療制度與生態均和美國不同，此骨科醫師人力在未來發展是否能滿足需求尚未可知，且近年骨科醫師年增加率逐年遞減，而其年齡結構亦趨老化，為因應未來避免醫師人力供給不足或過剩，以維持適當之骨科醫療品質，推估未來醫師人力需求以資調控乃是重要之課題。本研究以醫院骨科醫師為對象，採用健保資料檔，以住院醫令數代表醫療耗用量，以行政院經建會及內政部戶政司之人口數及結構，做分析探討骨科醫療及醫師人力需求。假設醫師生產力不變而民眾之就醫習慣亦不變，則以推估之預期年醫療使用除以基準年之醫師平均生產力可以得人力需求預估數，並加上據現有醫師年齡結構推計之屆時退休預計人數，以之推估至預期年所需補充增加之醫師人力。另參考Miller法則推估人力之自然耗損，並以骨科醫師人力問卷調查實際了解其工作現況，生涯規劃等，以修正人力需求推估。假設目前之人力供給得以維持平衡供需，評估推至預期年其供需結果之落差。另外以骨科手術及執行醫師回溯性探討骨科各次專科之發展。將手術項目區分至各次專科，以健保資料檔分析歷年手術量變化，再以各次專科代表性手術之執行醫師數分析歷年醫師人力投入變化，以1998為基準年至2005年逐年手術量和執行醫師數之成長幅度比較各次分科間發展之差異。結果以2005為基準年，則可推估出醫令數至目標年2020年將成長1.34倍，而其中尤以50歲以上年齡層之醫令數呈顯著增加。以回朔分析2000到2005年，則得出骨科醫療耗用之平均年成長倍數為1.026833。2005年領有骨科專科醫師執照者有1,472名，但在醫院執業者有879名(佔59.71%)，若維持目前醫療供需狀態，則至目標年2020年以平均生產力除之而得所需供給之骨科醫師數1178名，故理論上自2005至2020年基本須增加299名骨科專科醫師在醫院執業，則為供給符合與目前水準相當之骨科醫療，平均每年約需增加20名，而以屆齡退休醫師之補充計，每年須增中推估之17名(65歲退休)至高推估之27名(60歲退休)。若參考Miller法則推算，且假設新增醫師按醫院醫師占率現狀投入，需年增30名則2005年之879名以2020年增加幅度36%推估為1195名，共增加316名，則平均年得21名之補充，僅及補充醫療耗用成長所需。由於目前執業之平均工作量尚在合理範圍，故不予調整，然投入意願影響之生力投入雖無法預估，但卻有降低之勢。故每年須增加之37~47 名醫院骨科醫師人力與1998~2005年平均年增加22名之落差極大，依此推估則至2020年人力供給恐呈現嚴重不足。至於骨科各次分科之發展不同，以醫療服務量之變化觀察，雖總體是呈成長，但各次分科細分之成長幅度卻與次分科手術執行醫師之人數成長不盡配合。其中手術量成長幅度大於執行醫師成長幅度者，依次為足踝外科、骨腫瘤、脊椎外科及骨折，反之執行醫師成長幅度大於手術量成長幅度者，則依次為手外科、關節重建、運動醫學及肩肘關節，呈現各次分科之發展變化具有落差。另外，在自1998到2005年之資料發現，醫院骨科醫師之人力分佈以醫學中心最為穩定，而區域醫院有逐年增加之趨勢，反之地區醫院則為逐年減少，且其變化點均在2000年發生。這種人力板塊推移之現象，必和台灣健保制度、醫院生態有關。醫師人力之供需影響醫師生態及醫療品質甚巨，實須建立一套有系統之骨科資料庫，藉此資料庫之持續觀察分析及公開，乃能提供衛生政策，醫療保險，學會調控，醫院運作，乃至於醫師個人生涯規劃之參考。

關鍵字

醫師人力；專科醫師；供給量；需求量

並列摘要

In the medical profession, physicians (surgeons) are the main leaders of medical teams. Their manpower and its distributions directly affect the medical resources as well as the medical environment. Practice of medicine transferred from general physician to professional specialist is a trend of medical care and its quality, fees and convenience will be greatly influenced by the physician manpower structure. Therefore, planning of manpower should be set up so as to provide appropriate service and to ensure the health of people. Taiwanese Orthopedic Association has been established in 1977. Up to now, it has already developed to 1,618 orthopedists, and 1,472 were practicing in 2005, while each of them serves 15.6 thousand people on average. Comparing the American orthopedist manpower demand is one per 15 thousand populations. It seems that the demand for Taiwan orthopedist has been saturated. Yet, the Taiwanese medical system and environment are different from the U.S. It is unknown whether future advancement for orthopedists is already saturated. Moreover, in recent years, the yearly increasing amount of orthopedists is declining. The age structure among orthopedists also tends to be older. In order to balance the future supply and demand of orthopedic surgeons to maintain healthcare quality, it is crucial to estimate the demand for the future manpower. This research is for the study of orthopedists manpower in hospitals. Base on the health insurance databases, using hospital care orders to represent the medical care consumption. In addition, this study analyzes orthopedics treatment and care demand of people by using the data of population and its structure from the Executive Yuan and Interior Department. The hypothesis is that if the productivity of orthopedist and the service demands of people remain the same, then the estimate orthopedics treatment and care demand of expected years divided by surgeon’s productivity of base years, results in the manpower demand of the expected years. In addition, we can find out the possible recruiting totals for doctors by analyzing the age structure for present practicing doctors and the future-retiring doctors. On the other hand, to use Miller’s Law as reference, we can find out the natural manpower consumption, and further revise the manpower demand by investigating doctors’ working status and future planning from the questionnaires. In addition, there is a retrospective study about the developmental trends in each orthopedic subspecialty according to the amounts of orthopedics subspecialty surgeries and their executive surgeons. Different kinds of surgery are divided into each subspecialty to allow analysis of the changes in surgery amount with health insurance data. Executed surgeons of these surgeries are analyzed to estimate the quantity change in surgeons of different subspecialty. The relative quantity changes of surgeries and surgeons of each subspecialty from1998 to 2005 are compared for valid developing trends. The year 2005 is set as the base year, the estimated quantity of hospital care orders is going to rise approximately 1.34 times by year 2020 and obviously will be an increase for patients over 50 years old. While retrospective analysis from 2000 to 2005, orthopedics medical consumption has been growing at an average rate of 1.026833 per year. In 2005, there were 1472 orthopedists licensed and 879 (59.71%) working in hospitals. If the current status remains, there should be 1178 hospital orthopedists demanded in 2020. Thus, during 2005 and projected for 2020, the basic demand is to add 299 orthopedists that equal to increase 20 in average every year. As for substitution of the retiring doctors, we anticipate average 17 (retire age of 65) to 27 (retire age of 60) of each year should be added to the basic demand. Refer to Miller’s Law: to recruit new doctors at the current rate, there will have to be 30 more in each year; which is 879 in 2005 and 1195 (36% increase) in 2020. In total, there will be 316 more, which means 21 more in each year to complement the needs of hospital care consumption. Due to the average working load for practicing is still in a feasible range so it will not be adjusted. Yet, the aspiration to be orthopedist of graduated medical student is declining. Therefore, an average hospital needs 37 to 47 more orthopedists each year, which is a huge difference when comparing average increase 22 per year from 1998 to 2005. It will result in a serious shortage of hospital orthopedist manpower demand by 2020. As for the development of each orthopedic subspecialty, although the ultimate result is growing by observing changes in surgical services, the total of surgeons of each subspecialty do not match-up in every way. Those subspecialty that the amount (in percentage) of growth in surgery are more than that of the executive surgeons are foot surgery, bone tumor, spine surgery, and bone fracture. On the centrally, those subspecialty that the amount (in percentage) of growth in surgery are less than that of the executive surgeons are hand surgery, joint reconstruction, sports medicine, and shoulder elbow. It shows that each orthopedist subspecialty has a different developmental trend. An unexpected discovery from reviewing the data between 1998 and 2005 is that hospital orthopedics manpower are stable in medical centers, while there is an increase in district hospitals and decline in area hospitals. Also, the changing point is all in 2000. This situation of manpower transposition must have been related to the Taiwanese health insurance system and hospital ecology. Medical doctor manpower demands influences medical ecology and quality tremendously. It is essential and crucial to establish a system of orthopedics database. Through this database, the observation, analysis and publicity can be continuous, which can also provide references for further sanitation policies, medical insurance, association adjustment, hospital functions, and also doctors’ personal career and life scheme.