2003~2013年台灣主治醫師人力與服務量分佈之長期資料研究 －以產科、兒科、外科住院服務為主

Abstract

研究背景：「內外婦兒四大皆空」問題，除了四大專科現任醫師人力的流失，還有醫學生選擇意願的下降，許多醫院的四大科幾乎每年都有住院醫師招收不足的問題，並以外科及婦產科與兒科的情況最為嚴重。然而過去醫師人力流失問題多關注於醫師人數的多與寡，比較少以分佈作探討，且多以領證人數做統計，故本研究希望能以有提供住院服務之外科、產科與兒科實際服務與覆蓋的分佈與數量做探討。 研究目的；探討台灣不同地區，有提供住院服務之外科、產科、兒科主治醫師的服務量與醫師人力的分佈與關係。 研究方法：本研究利用2003~2013年全民健康保險研究資料庫進行，針對2003~2013年間有提供住院服務之產科、兒科與外科的醫師為對象進行分析。使用成長曲線(growth curve)函數，分析不同都市化程度之次醫療區，每萬人口醫師數、平均每位醫師服務量、每位醫師年平均申報點數與醫師平均年齡是否有差異。 研究結果：本研究結果發現(1.)有提供住院服務之外科與產科醫師人力明顯下降(2.)有提供住院服務之小兒科醫師人力整體增加，但年輕醫師佔比逐年遞減(3.)外科醫師人力與服務量呈現反向變動，外科醫師平均負擔加重(4.)有提供住院服務之外科、產科與兒科醫師有區域分佈不均的現象(5.)有提供住院服務之外科、產科與兒科醫師平均年齡逐年上升(6.)低都市化程度地區有提供住院服務之外科醫師平均年齡有年輕化的現象。 結論： 2003至2013年間，有提供住院服務之外科、產科與小兒科實際執業的醫師人力逐年遞減，並且有醫師人力地理分佈不平均的現象，多數的醫師僅集中於少數高都市化程度的地區。目前醫師人力組成主要為中壯年醫師，四十歲以下的年輕醫師人力逐年遞減，導致醫師平均年齡的上升。欲解決外科、產科與兒科醫師人力分佈問題，政策干預是必要的。

Background： Currently, the 4 major medical disciplines in Taiwan (internal medicine, general surgery, pediatrics, and obstetrics and gynecology) suffer from a shortage of specialized physicians, which could lead to a crisis in health care system. This shortage can be attributed to an insufficient number of specialized physicians opting to work in hospitals and a declining number of medical students that are willing to enter a specialized discipline. Previous research that investigated physician manpower focused on overall decline, rather than the distribution of physicians by specialty. The current study aims to elucidate the geographic distribution of physicians and the relationship between patient volume and the number of attending physicians in different regions of Taiwan between 2003 and 2013. In so doing, we focused on general surgery, obstetrics, and pediatric inpatient services. Methods：This study analyzed data from the National Health Insurance Research Database (NHIRD) that had been recorded between 2003 and 2013. Specifically, we developed multilevel growth curve models; performed one-way analysis of variance (one way ANOVA) for bivariate analysis; and used the growth curve function for multivariate analysis. The primary goal of this analysis was to elucidate relationships between level of urbanization, number of doctors per million people, average patient volume per physician, average number of payment dots, and average age of physician. Results： There were a number of key findings in this study. (1) The number of obstetricians providing obstetric inpatient surgical services decreased between 2003 and 2013. (2) The number of pediatricians working in hospitals increased; however, the proportion of young pediatricians decreased. (3) There was an inverse relationship between the number of surgeons who work in a given area and patient volume, which increased the average patient burden of some surgeons. (4) There was disparity in the geographic distribution of attending physicians who provided general surgery, obstetric, and pediatric inpatient services. (5) The average age of obstetricians, pediatricians, and general surgeons increased. (6)Surgeon who worked in hospital tended to be young in low urbanized areas. Conclusion：Between 2003 and 2013, the number of obstetricians, pediatricians, and general surgeons who provided inpatient service decreased. Furthermore, there was disparity in the geographic distribution of these specialized physicians. Specifically, our findings indicate that most doctors were clustered in highly urbanized areas. Currently, most physicians are middle-aged. Indeed, the number of younger physicians decreased throughout the study period, leading to an increase in average physician age. Given these findings, we suggest that policy interventions are necessary to resolve physician manpower issues in surgery, obstetrics, and pediatrics.