陳端容臺灣大學：醫療機構管理研究所李翔Lee, HsiangHsiangLee2007-11-282018-06-292007-11-282018-06-292004http://ntur.lib.ntu.edu.tw//handle/246246/60163中文摘要 世界衛生組織擬定全民健康的目的, 期望能藉由落實基層醫療保健來促進民眾健康, 因此, 基層醫療, 已被視為維護大眾健康極重要的一環; 台灣社會經過各個階段的變遷影響, 醫師的執業選擇也趨近於先進已開發的國家, 尤其最近全民健保的實施, 更對醫師的生涯規劃, 有著極其重要的影響; 近年台灣的醫療市場發展, 財團爲求多角經營牟利, 大力介入醫療產業, 台灣醫師的就業趨勢, 也愈來愈受到外在環境的干擾. 再看台灣整體的封閉式醫療結構仍未改變, 使得醫師一但選擇診所執業, 便不易與醫院取得聯繫, 醫院享有的最新醫療資訊與技術, 無法甚至不願移轉至基層醫師, 使得基層醫師的醫療品質受到民眾質疑, 醫師的專業發展亦受到阻礙難以與時俱進; 不能有效的利用基層醫療資源, 不僅增加醫療成本, 更讓基層醫師人力無法得到妥善的運用, 病患在醫院間流轉, 卻仍得不到完整的醫療照顧,醫院也視病患為衝量的財源, 不斷的安排檢驗與重複門診, 如此失衡的醫療生態, 如何降低醫療費用的支出? 因此, 健全的基層醫療才是維護大眾健康及降低醫療成本的有效工具. 醫師在其職業生涯中, 會在醫院繼續服務, 或是走向基層執業, 其間的選擇決定因素, 國內外已有許多理論與實證研究, 但選擇到基層執業的醫師, 其專業滿意度及身心狀況, 在卻少有研究深入探討. 在現況眾多不利基層診所執業的因素影響下, 正在基層診所的醫師面對如此複雜的競爭環境, 其身心狀況是否有足夠的抗壓性來面對這些挑戰? 執業醫師對本身工作的滿意度是否符合當初選擇基層的期許? 本研究以民國91年衛生署登記基層西醫診所之資料, 篩減後的8925間診所為對象, 將診所醫師個人背景, 執業前經歷, 執業現況與健康狀況為自變項, 執業生涯滿意度為依變項, 郵寄設計問卷, 回收1132份, 粗估無法寄達者5%, 回收率13.4%, 研究結果發現, 個人背景裡的執業型態單獨執業及聯合診所要比受僱醫師生涯滿意度高, 年齡輕的組群較年長者滿意度高; 執業前在醫院裡曾擔任科部主管的經驗者有較佳的執業滿意度; 執業現況中, 非為經濟因素選擇基層執業者以及持續與醫院受訓時相同科別執業者的滿意度較高; 而健康狀況三個構面分數較高較健康者的職業生涯滿意度比分數較低較不健康者為佳. 由本研究最終分析結果, 女性或是健康狀態較佳的醫師, 曾在醫院有行政主管經歷, 持續原來的科別, 沒有經濟壓力, 年齡較輕且是在聯合診所型態較短的工作時間, 這些條件下, 基層執業生涯滿意度會較高.ABSTRACT The World Health Organization (WHO) draws up the Chapter of All-Person Health in an attempt to enhance public health by thoroughly materializing the medical care at the grass-roots level. The office-based level medical care has been, as a result, deemed to play a important role in safeguarding public health. In Taiwan in the wake of the significant transformation in various phases, doctors and physicians in practice are at the level of that in advanced developed countries in terms of the choice available to them in the professional practice. The National Health Insurance policy, which has been put into enforcement recently, has cast an extremely significant impact upon doctors in their career prospects. In recent years in Taiwan, the consortium have been trying hard to give a hand in the medical care industry in an attempt to gain profits. The doctors in Taiwan must be increasingly subject to the interference by the external environments. On the other hand, nevertheless, the overall closed type medical treatment structure remains unchanged. As a result, once a doctor chooses to practice in the clinic, he/she can hardly get in touch with hospitals. In fact, hospitals enjoy the most up-to-date medical resources and technology which those people in hospital management are reluctant to get down to the office-based level doctors. As a discouraging result, the office-based level doctors can hardly win public trust in terms of the quality of their services and, in turn, can hardly get their professionalism upgraded in line with the times. That means a rise of the medical care costs on the one hand and a waste of office-based level doctor resources, leaving patients puzzled amidst hospitals without comprehensive overall care. In the eyes of the hospital management, patients mean the very sources of their revenues. Patients are arranged to receive repeated and repeated diagnoses and outpatient treatments. Under such environment of the medical care being out of balance, how can the expenditures for medical care costs possibly come down? In fact, only wholesome office-based level medical care will be the very tool to safeguard public health and bring the medical care cost down. In their professional careers, will doctors choose to continually serve with hospitals or choose to serve patients at the office-based level? To answer this question, there have been many theoretical and empirical studies conducted either in Taiwan and the world over. To doctors who choose to serve patients at the office-based level, are they satisfied with their profession? What is their physical and mental status amidst the profession? There have been rare studies to answer such questions. With numerous factors against practice at office-based level clinics, are doctors serving with the office-based level clinics healthy enough to deal with all those pressures and to tackle such challenges? Are the doctors satisfied enough with the profession to live up to the expectation when they chose such kind of practice? The Study takes 8,925 clinics selected out of the office-based level clinics (excluding Chinese herbal clinics and older than 70 years old clinic in charge doctors) accredited with the Department of Health (DOH) in 2002 as the samples. The questionnaire was designed to be aimed at the individual backgrounds, experiences accumulated before they practiced as a doctor, status quo of the professional practice and health conditions as the independent variables and level of satisfaction in the profession as the dependent variables. A total of 1,132 copies of the questions were successfully retrieved. The rough estimate indicates that 5% of the questionnaires failed to reach the target samples. The questionnaires indicate a successful retrieval rate of 13.4%. The findings yielded through the study indicate that in personal backgrounds, doctors serving at their own individual clinics and serving in concerted clinics responded with higher satisfaction level than doctors being hired. Doctors of younger age groups show higher satisfaction levels than their senior counterparts. Doctors who had headed the hospitals’ departments or sections before the professional practice responded with a higher satisfaction level. In their current professional practice, those who chose to serve in the office based level not in financial income consideration and those who are serving in the departments the same as the specialists in the resident training respond with a higher satisfaction level. In the scores rated in the three aspects, those doctors that are healthier, with higher scores respond with higher satisfaction level than their counterparts with lower scores and that are less healthy. The final analysis of the study indicates that doctors in healthier physical conditions, having headed departments or sections in hospitals, serving in the categories the same as their previous internship training, free of financial pressure, serving in concerted clinics, still as a junior show a higher satisfaction level at the office-based services.目錄 誌謝………………………………………………………………….I 中文摘要……………………………………………………………II 英文摘要……………………………………………………………IV 目錄…………………………………………………………………VI 表目錄………………………………………………………………IX 圖目錄……………………………………………………………XIII 第一章 緒論 第一節 前言……………………………………………………..2 第二節 研究目的………………………………………………..6 第三節 期望貢獻……………………………………………….6 第二章 文獻探討 第一節 基層醫療的定義、服務內容與特質…………………..8 第二節 專業生涯規劃的抉擇………………………………..10 第三節 基層醫療現況………………………………………..12 第四節 影響基層醫師工作滿意度的理論與實證研究 …….22 第三章 研究方法 第一節 硏究架構………………………………………………30 第二節 研究假說……………………………………………… 32 第三節 樣本及資源……………………………………………. 32 第四節 問卷設計………………………………………………..33 第五節 變項名稱及操作定義…………………………………..34 第六節 分析方法………………………………………………..49 第四章 研究結果 第一節 描述性分析…………………………………………….50 第二節 雙變項分析…………………………………………….66 第三節 迴歸分析……………………………………………….87 第五章 討論及研究限制 第一節 描述性分析結果之討論……………………………….93 第二節 雙變相分析及多類變項分析, 以及 兩連續變項間的相關程度分析結果之討論…………98 第三節 迴歸分析結果之論…………………………………..102 第六章 結論及研究限制與建議 第一節 研究結論………………………………………………104 第二節 研究限制與建議……………………………………..105 參考文獻 中文部份……………………………………………………….106 英文部分……………………………………………………….108 問卷………………………………………………………………….112 表目錄 表1-1 台灣地區醫療院所醫事人員數醫師部分…………………4 表2-1 美國不同科醫師每週看診量及收入比較……………….16 表2-2 美國歷年選擇家庭醫學專科醫師比例………………….16 表2-3 診所醫師比例逐年降低— 北市醫師公會會員人數統計為例………………………19 表2-4 歷年醫療機構健保門診費用申請狀況………………….20 表2-5 台灣地區歷年公私立醫療院所統計表………………….21 表3 變項名稱及操作表格…………………………………….34 表4-1.1　基層醫師個人基本資料描述…………………………….50 表4-1.2　基層醫師個人基本資料描述…………………………….52 表4-1.3　基層醫師個人基本資料描述…………………………….53 表4-1.4　基層醫師執業前經歷描述……………………………….54 表4-1.5　基層醫師執業前經歷描述……………………………….55 表4-1.6　基層醫師執業前經歷描述……………………………….56 表4-1.7　基層醫師執業現況描述………………………………….57 表4-1.8　基層醫師執業現況描述………………………………….58 表4-1.9　基層醫師執業現況描述………………………………….59 表4-1.10　基層醫師執業現況描述………………………………..60 表4-1.11　基層醫師執業現況描述………………………………..60 表4-1.12　自覺健康狀態填答分析………………………………..61 表4-1.13　自覺健康狀態填答分析………………………………..62 表4-1.14　自覺健康狀態填答分析………………………………..62 表4-1.15　各健康構面常模轉換後分數描述分析………………..63 表4-1.16　工作滿意度狀態描述…………………………………..63 表4-1.17　工作滿意度題目因素分析結果描述…………………..65 表4-1.18　各滿意度構面分數描述分析…………………………..66 表4-2.1　基層醫師個人特質與健康狀況之t檢定……………….67 表4-2.2　基層醫師執業前經歷與健康狀況之t檢定…………….67 表4-2.3　基層醫師執業現況與健康狀況之t檢定……………….68 表4-2.4　基層醫師個人特質與滿意度之t檢定………………….69 表4-2.5　基層醫師執業前經歷與滿意度之t檢定……………….70 表4-2.6　基層醫師執業現況與滿意度之t檢定………………….72 表4-2.7　基層醫師個人特質與一般健康狀況之變異數分析…….72 表4-2.8　基層醫師執業前經歷與一般健康狀態之變異數分析….73 表4-2.8　基層醫師執業前經歷與一般健康狀態之變異數分析….74 表4-2.10　基層醫師個人特質與活力狀態之變異數分析…………75 表4-2.11　基層醫師執業前經歷與活力狀態之變異數分析………76 表4-2.12　基層醫師執業現況與活力狀態之變異數分析………….77 表4-2.13　基層醫師個人特質與心理健康狀況之變異數分析…….77 表4-2.14　基層醫師執業前經歷與心理健康狀態之變異數分析….78 表4-2.14　基層醫師執業前經歷與心理健康狀態之變異數分析….79 表4-2.16　基層醫師個人特質與專業工作滿足之變異數分析…….80 表4-2.17　基層醫師執業前經歷與專業工作滿足之變異數析…….81 表4-2.18　基層醫師執業現況與專業工作滿足之變異數分析…….82 表4-2.19　基層醫師個人特質與診所客觀環境之變異數分析…….82 表4-2.20　基層醫師執業前經歷與診所客觀環境之變異數分析….83 表4-2.21　基層醫師執業現況與診所客觀環境之變異數分析…….84 表4-2.22　基層醫師個人特質與自我成就感之變異數分析……….84 表4-2.23　基層醫師執業前經歷與自我成就感之變異數分析…….85 表4-2.24　基層醫師執業現況與自我成就感之變異數分析……….86 表4-2.25　基層醫師健康狀態間相關性分析……………………….87 表4-2.26　基層醫師健康狀態間相關性分析……………………….87 表4-2.27　基層醫師健康狀態與滿意度間相關性分析…………….87 表4-3.1專業工作滿足羅吉斯迴歸分析結果………………………..88 表4-3.2診所客觀環境羅吉斯迴歸分析結果……………………….89 表4-3.3自我成就感羅吉斯迴歸分析結果………………………….90 表4-3.4　滿意度羅吉斯迴歸分析結果………………………………91 圖目錄 圖2-1 醫策會醫療體系評鑑區分圖………………………………..13 架構圖………………………………………………………………….311720901 bytesapplication/pdfen-US基層診所醫師生涯滿意度Office-based physiciancareer satisfaction[SDGs]SDG3thesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/60163/1/ntu-93-P91843013-1.pdf