臺灣醫師專業形象的變遷-媒體內容分析

Abstract

背景與目的：一連串醫界醜聞事件，讓醫師蒙上陰影。原本應是割瘤去病的手術刀，卻揮向健康人身上，以詐領保險金。醫界大老直斥「醫德淪喪！」、「把整個醫界形象破壞殆盡！」醫師不再是單純的醫療工作者，「名醫」名號滿天飛，卻盡在媒體社會新聞裡領風騷。社會充斥著醫師的負面新聞，原本被期待應是「助人專業或道德事業」的純淨白袍，被染黑、惹紅，甚至沾黃，而至色彩繽紛。 到底目前社會如何看待醫師的專業形象？醫師深植在民眾心中，還是濟世救人嗎？本研究的目為：(一)臺灣現今的醫師專業形象是否有變遷？(二)臺灣醫師的專業形象是否受全民健康保險的全面開辦而受影響？ 方法：本研究首先透過文獻分析整理出八類醫師專業形象要素，包含能力、自主、支配、權威、利他、去專業化、公司化與商業化，並以內容分析法分析醫師在不同屬性的媒體訊息，不同階段及全民健保開辦前後，所呈現的專業形象變遷。 本論文依據研究設計，資料來源可分為兩大部份： 一、報紙部分：以《聯合報》、《中國時報》、《自由時報》與《蘋果日報》為主要分析對象，並以實體報紙為樣本，以瞭解報導所佔篇幅與位置。總計抽取民國43年至民國98年間1372筆有效樣本。 二、雜誌部分：普查中華民國醫師公會全國聯合會所出版的期刊《臺灣醫界》。範圍從民國47年創刊至98年底，共52卷的社論或「專論」為研究對象。 上述兩種媒體的內容分析，除統計露出頻率、新聞主題、消息來源、篇幅相關外，並就專業形象八大要素在媒體的表現，予以負10至正10的評分。 結果：利他、自主、權威與能力的專業要素，都在《臺灣醫界》或報紙的個別調查中居八要素的前四位；這四項也是「專業」傳統定義的核心。亦即作為醫師，不論是社會大眾或醫師自我認知的專業形象本質，大體上均還是以傳統專業核心為外界所認知。但是，其中能力、權威與利他等在報紙上的露出頻率卻一路滑落。 全民健保實施後，醫師專業形象也隨之變遷。比較八個形象要素在媒體上的討論頻率。在報紙報導上，除商業化外，其他專業形象包含能力、自主、支配、權威、利他、去專業化與公司化等七項要素的報導比率都下滑，商業化形象要素則略微上升；並以利他與能力的下滑程度最為明顯，顯見全民健康保險對於傳統醫師形象的衝擊。 但在《臺灣醫界》方面，全民健康保險實施後，包含能力、優勢支配與權威等三項要素的文章比率都下滑，自主性、利他、機構化及商業化形象要素則上升，去專業化則無改變，其中能力的下滑程度最為明顯。全民健保對於醫師的自主性、利他或利己、商業化，及醫療機構大型化的影響很大，使得醫師在這四個面向的議題討論頻率均大幅增加。 結論：在民眾心目中，醫師還是救治、幫助病患，具充分醫療能力，且帶著些許權威的「父親」般形象的專業角色。但是，這些傳統醫師認知卻為商業色彩等負面形象而淡化，也添幾抹營利、自私的灰暈；全民健保的開辦，或許是個觸媒；這些疑慮值得未來醫學教育、醫療政策執行者深思。

Background Public attitudes to doctors are changing. The professional image of physicians has been overshadowed by a series of scandals of malpractice and fraud. Leaders in medicine denounced these wrongdoings as examples of “deterioration in medical ethics” and “a destructive force that has shattered the reputation of physicians”. Physicians are no longer just health care workers as many aspired celebrity physicians strive to gain visibility and media exposure. In the meantime, the press is filled with negative stories about self-interest driven physicians. The white coat that symbolizes humanism and professionalism has seemingly been tainted. How have the people’s perceptions of doctors have changed? Are doctors still well-respected life-saving professionals? The objective of this dissertation is to understand the change of professional image of physicians over time in Taiwan and whether it has been affected by the establishment of the National Health Insurance (NHI) program? Method Based on literature review, this thesis first identifies eight essential factors of physicians’ professional image, including competence, autonomy, dominance, authority, altruism, de-professionalization, corporatization and commercialization. Content analysis technique is then deployed to assess any change in physicians’ professional image over time, as well as before and after the inception of the NHI program, through examination of two types of media: 1. Newspapers: newspapers reflect the attitudes of the general public. Subjects of analysis include United Daily News, China Times, Liberty Times and Apple Daily. A sample of 1,372 reported stories between 1954 and 2009 was selected. 2. Medical Journal: Taiwan Medical Journal, published by the Taiwan Medical Association, was chosen to reflect physicians’ perspectives. A total of 52 articles of editorials or special reports between 1958 and 2009 were elected. In addition to reporting descriptive statistics of frequency, topics, sources and length of the reports, a score between -10 to +10 is also given to each report based on its ratings on the eight factors of professional image. Results Altruism, autonomy, authority and competence are four of the most commonly identified factors of professional image among articles in the Taiwan Medical Journal. These four factors are also the key elements in the traditional definition of medical professionalism, which is typically recognized and associated with physicians’ professional image by both the public and physicians themselves. However, in contrast, competence, authority and altruism became less frequently mentioned in the newspapers. Since the inception of the NHI, physicians’ professional image had drastically transformed. With respect to the frequency of discussion of the eight factors in the newspaper, except commercialization which had experienced a slight increase, the numbers of reports on other factors—competence, autonomy, dominance, authority, altruism, de-professionalization and corporatization were all declining, especially for altruism and competence. This suggests a significant impact of the NHI on the professional image of physicians. On the other hand, the numbers of articles on competence, dominance and authority in the Taiwan Medical Journal had reduced after the implementation of the NHI, with competence having the most decrease. On the contrary, the numbers for autonomy, altruism, corporatization and commercialization had increased while that of de-professionalization remained the same. It has been suggested that the NHI has a critical effect on physicians’ professional autonomy, altruistic behavior, and commercialization, as well as the market concentration of medical institutions. Consequently, the numbers of related articles on these four factors also increased substantially in the medical journals. Conclusion For the general public, physicians are still very much competent, authoritative, life-saving professionals and the image has not shifted too much away from paternalism. However, the attitudes are changing as a result of the growing commercialization of health care, which raises concerns over the ethical implications of profit-seeking and self-interest driven medical practice. The NHI program may have also catalyzed the transformation of physicians’ professional image through its effect on the overall market. Medical educators and policy-makers must carefully consider these changes and their implications in their future planning of the health systems.