臨床醫學生對醫療環境認知與職涯不安全感之質性研究

Abstract

研究目的：隨著人口高齡化，臺灣醫療體系因照護需求增加而面臨挑戰，然而執業醫師年齡結構亦逐漸高齡化，五 大核心專科（內科、外科、婦產科、小兒科、急診科）長期招收不足，加上醫師人力持續由醫院流向診所，使醫療人力配置失衡問題日益嚴峻。與此同時，年輕世代醫學生帶著更有別於過往世代的工作價值觀，卻即將進入高壓且快速變動的醫療環境發展職涯。臨床見習階段是醫學生職涯探索與決策的重要時期，但目前對其如何理解當前醫療環境、形成職涯不安全感，以及這些感知如何影響未來職涯選擇的研究仍相對有限。因此，本研究透過質性訪談，探討臨床醫學生對醫師職涯的認知、職涯不安全感的來源及其對職涯決策的影響，以作為醫學教育與醫療人力政策之參考。 研究方法：本研究採質性研究設計，以半結構式訪談為資料蒐集方式，於兩所台灣北部的醫學院，透過立意抽樣的方式招募正處於臨床見習階段之醫學系五年級學生，透過自編式訪談綱要進行一對一訪談，並以Spurk等人對職涯不安全感以量表的文獻為參考行採主題分析法進行。 研究結果：本研究共訪談十八位臨床醫學生，發現臨床醫學生透過家庭、生活、媒體、課程及臨床來建立對職涯的認知；儘管同時承受多層次的職涯不安全感並表現出不同的情緒態度，仍對醫師職涯抱有堅持的態度。從訪談資料中共歸納出七大主題：一、個人資源與工作需求間的差距—訪談對象對自身醫療知識是否足以支撐即將到來的角色轉換深感憂慮，同時對研究與教學能力的多重要求感到排斥；二、工作場所的改變—健保制度雖保障職涯穩定性，但其給付結構與制度改革的不確定性使訪談對象感到不安；三、僱傭條件—訪談對象認為薪資報酬未能反映其投入的程度與專業承擔，表達出高度的相對剝奪感；四、勞逸平衡—訪談對象重視休閒時間、社會角色責任與時間自主性，對責任制的工作型態帶來的低自主性深感壓力；五、職涯機會—個人興趣是專科決策的首要依據，但訓練資源的機構及地域落差與內招制度亦引發不確定感；六、聲望降低—醫療知識普及與網路暴力風險加重了訪談對象在醫病溝通上的心理負荷；七、醫療糾紛—為本研究新識別的主題，訪談對象普遍認為糾紛難以完全避免，並已將其納入專科選擇的風險考量。 討論及結論：在職涯不安全感的面向上，本研究從臨床醫學生的在職涯短、中及長期歸納出七類職涯不安全感的來源：對於短期的職涯變化，臨床醫學生表達因專科興趣的探索及個人專業能力不足備感威脅；但對於中長期的職涯發展，臨床醫學生則認為健保制度作為最為核心的不安全感根源。而透過脈絡－機制－結果（CMO）框架分析發現，臨床醫學生的家庭背景對職涯態度具有重要影響，來自醫事人員家庭者具備較高之心理韌性，並且支持在高壓環境中維持正面情緒；因此，對第一代醫學生則得在訓練歷程中更加強化支持網絡，以提供更多職涯發展的情緒與心理資源落差的支持。 此外，另一CMO框架也發現臨床醫學生普遍展現「興趣折衷於現實」的決策模式，即以個人興趣作為職涯探索起點，但最終仍須在可接受的工作條件範圍內進行權衡與調整，反映出對制度環境與專業剝削感而呈現情境適應與情緒權衡交織的歷程。若未能改善薪資結構、工作負荷與醫療法律支持制度，可能持續降低有興趣的當代醫學生投入高需求專科之意願，進一步加劇醫療人力失衡問題。

Purpose: Population aging has intensified healthcare workforce challenges in Tai-wan, including an aging physician workforce, persistent shortages in the five core specialties, and the migration of physicians from hospitals to private clinics. Meanwhile, new generation medical students enter this profession with different work value inspect. The clinical clerkship stage is critical for career decision-making; however, limited research has examined how students perceive the healthcare environment, develop career insecurity, and integrate these perceptions into career planning. This study explores clinical medical students’ perceptions of the medical profession, sources of career insecurity, and their influence on career decisions. Methods: A qualitative design was adopted using semi-structured interviews with 18 fifth-year medical students in clinical clerkships from two medical schools in northern Taiwan, recruited through purposive sampling. Data were analyzed using thematic analysis, involving open coding, constant comparison, and theme development. Results: A total of 18 clinical medical students were interviewed. Participants expressed four types of emotional attitudes toward a medical career: optimistic, neutral, helpless, and pessimistic. Guided by Spurk et al.’s framework of career insecurity, seven major themes were identified: (1) Discrepancy between individual resources/work demands—participants expressed concerns about whether their medical knowledge was sufficient to support the upcoming transition into professional roles and felt burdened by expectations related to research and teaching; (2) Changes of the workplace—while the National Health Insurance system provides career stability, uncertainties regarding its reimbursement structure and ongoing reforms contributed to insecurity; (3) Contractual employment conditions—participants perceived that compensation did not adequately reflect their level of investment and professional responsibility, leading to a strong sense of relative deprivation; (4) Work–nonwork interactions—participants valued leisure time, social roles, and time autonomy, and reported stress related to low autonomy under responsibility-based work systems; (5) Career opportunities—although personal interest remained the primary determinant of specialty choice, regional disparities in training resources and internal recruitment systems generated uncertainty; (6) Decreased prestige—the widespread accessibility of medical knowledge and risks of online hostility increased psychological burdens in physician–patient communication; (7) Medical disputes—identified as a novel theme in this study, participants widely perceived disputes as unavoidable and incorporated them into their risk considerations when choosing specialties. Discussion and Conclusion: This study found that clinical medical students experienced multiple forms of career insecurity across their short-, medium-, and long-term career planning. Through a Context–Mechanism–Outcome (CMO) framework analysis, family background emerged as a significant factor shaping career attitudes. Students from healthcare professional families demonstrated greater psychological resilience and were better able to maintain positive emotions when confronting the challenges of clinical training. These findings suggest the need to strengthen support networks for first-generation medical students by providing additional emotional and psychological resources for career development. Furthermore, a second CMO analysis revealed a prevailing pattern of “interest-compromised-by-reality” career decision-making. While personal interests served as the starting point for career exploration, students ultimately adjusted their choices according to acceptable working conditions. This process reflects an ongoing interaction between contextual adaptation and emotional compromise in response to perceived institutional constraints and professional exploitation. These findings highlight the importance of strengthening support systems for first-generation medical students and improving working conditions within the healthcare system. Addressing compensation, workload, and medico-legal concerns may be essential for attracting future physicians to high-demand specialties and mitigating workforce shortages.