醫師開立診斷書之困擾與相關問題探討

Dilemma of writing sickness certification in the clinical doctors

林素真(Su-Chen Lin)

指導教授 ： 葉季森

中臺科技大學/管理學院/健康產業管理研究所/碩士(2011年)

摘要

背景：「鑑識」工作非醫師職責，醫師僅能在疾病診斷書內描述醫療狀況，不能做非醫療的判斷。但是病患或家屬常為了豁免責任、去除刑責、請病假、補助及特權等原因，對醫師於診斷書內所使用的文字有所要求，造成醫師的困擾。
目的：瞭解醫師開立疾病診斷書之常見困擾、困擾程度及其相關因素。
方法：本研究以自擬結構式問卷進行問卷調查，結構式問卷係先以開放式問卷收集29位PGY住院醫師之意見，經歸納整理後完成。問卷內容含：基本資料、人格特質、常見困擾頻率與程度、常見困擾醫師配合度、病歷寫作教育需求、主觀困難感受及業務困難感受六部份，採李克特四尺度量表法計分。本研究以中部某醫療機構的醫師為研究對象，發出問卷158份，有效問卷回收率為53.8%。
結果：申請診斷書的主要原因為保險用(30.5%)及請假證明(17.6%)。醫師認為開立診斷書時「病人或家屬態度強硬，不講理」、「病人或家屬苦苦哀求，不達目的絕不中止」、「被要求寫與事實不相符的診斷」最感困擾。女醫師之困擾程度顯著高於男醫師，主治醫師之病歷寫作教育需求顯著高於住院醫師。在「醫師配合程度」上，內科系醫師高於其他科醫師，在「業務困難感受」上，內科系醫師高於外科系醫師。就相關性部分，「執業年資」、「年齡」與「業務困擾感受」之間有顯著負相關。「困擾程度」與「主觀困擾感受」之間有顯著正相關。「困擾程度」、「主觀困擾感受」與「業務困擾感受」之間有顯著負相關。
結論：有八成的受訪醫師對開立疾病診斷書感到困擾，近六成的醫師對病歷寫作教育訓練有需求。愈年輕的醫師對開立診斷書之業務困難感受是愈強的。建議將開立疾病診斷書之相關課程列入醫師PGY或在職教育中，以減輕醫師之困擾，並提供標準的書寫規範供醫療院所，落實醫師養成教育。病人應尊重醫師，且避免限制醫師的自主權，以建立良好的醫病關係。另於保險給付認定標準上可用病歷摘要補充診斷書內容之不足。

關鍵字

困擾 ； 疾病診斷書 ； 醫師

並列摘要

Background: The“forensic”work is not the responsibilities of physicians, the doctors can only diagnosis the disease within the medical conditions and can’t do any non-medical judgments. In order to remit the responsibility, to exempt from the penalty, to get a sick leave a grant and a privilege, the words written in the sickness certificate are often requested by the patients and their family, and it also causes the problems for doctors.
Objectives: To understand what disturbances, the affecting level and correlative factors that doctors are facing.
Methods: This study is a self-structured questionnaire survey, and it is an opened one which first collected 29 PGY residents’ opinions, and is completed by collection and analysis. The questionnaire included 6 parts: basic information, personality characteristic, disturbance frequency and its severity, trouble with the cooperation between doctors and patients, the requirements of medical-writing education, the experience of subjective difficulties and operational difficulties. Four-Scale mining Liker Scale scoring method is used. In this study, the willing physicians from a medical institutions in the middle of Taiwan are the research objects, and a total of 158 questionnaires are completed, the response rate was 53.8%.
Results: The main reason to apply for insurance with a medical certificate (30.5%) and leave proof of (17.6%). The physicians believe they are annoyed when they are asked to write sickness certifications, the obsessions are "the attitude of the patients or their families is hard, not unreasonable," "patients or their family’s begging, and do not stop," "be asked to write the diagnosis inconsistent with the facts." the most disturbing. The distress of female physicians is obviously higher than the distress of male physicians. The requirement of medical-writing education is much more needed by the attending physicians then the residents do. On "Physician Compliance", the physicians are higher than other doctors; on "operational difficulties feeling" the physicians are higher than surgeons. According to the relevance, it shows a negative correlation between "years of practice", "age" and "operational difficulties feeling"; one shows a positive correlation between "distress" and "subjective feelings of distress," and the other shows a negative correlation between "distress", "subjective feelings of distress" and "operational difficulties feeling" .
Conclusion: 80% of Physicians respond to have trouble with opening sickness certificates, nearly 60% of physicians require a medical-writing education and training. The younger the doctor is, the more distress of opening a sickness certificate the doctor gets. Suggest by means of including a class of “how to write a sickness certificate” in MD PGY or in in-service training to reduce physicians’ trouble, to provide a standard of written specifications for a medical institutions, and to implement the medical education. Patients should respect doctors, and avoid limiting the autonomy of physicians to establish a good relationship between doctors and patients. And a standard in the insurance benefits presumption can be supplemented by anamnesis digests to benefit the insufficiency of a sickness certificate.

並列關鍵字

Dilemma ； Sickness Certification ； Clinical Doctors

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