國際醫學畢業生與醫事人力政策之互動： 以台籍波蘭醫學生為例

Abstract

隨著東歐諸國加入歐盟，我國前往就讀醫學系人數逐年攀升，尤以波蘭醫學生為主。近年來，《醫師法》修法更著重國際醫學畢業生返台參加國家考試的審查與認證。然而，現有資料主要以臺灣醫學生和醫師的立場為主，描述我國與他國醫師養成體制或實習訓練之差異，或指稱波蘭醫學生醫療品質不佳，少有自波蘭醫學生視角出發之觀點。至於我國現有的醫事人力政策相關研究，多著墨於供需數量和醫療品質的探討，對於國際畢業醫學生的研究相對較少，尤其是他們返台就業的現況，以及他們的醫療品質和適應情況，鮮有人深入探討。 於此，本研究以波蘭醫學生為例進行質性研究，基於扎根理論，以「國際醫學畢業生」與「臺灣醫事人力政策」切入，探索國際醫學畢業生以及臺灣醫事人力政策是如何相互影響、牽引。首先，透過蒐集PTT Medstudent板上有關該議題之言論，呈現第一次波蘭醫學生爭議時的討論焦點以及論述，進行內容分析。接著進行深度訪談，對象包含波蘭醫學生以及臺灣醫學生與醫療從業人員，以了解國際醫學畢業生欲返台執業可能或曾經面臨的阻礙，以及臺灣醫學生與醫療從業人員對相關議題的想法。最後，結合兩種資料進行主題分析，比較兩者的差異，探索這些話語背後所真正包裹的意涵，希望能釐清醫事人力政策與波蘭醫學生之間的互動性。 本研究採取兩種資料蒐集方式，主因為波蘭醫學生爭議時間長達十五年，所招募的現任臺灣醫學生與波蘭醫學生並未經歷過2009年的531遊行，曾參與過的醫療從業人員也可能因為時隔多年記憶模糊。雖然目前PTT Medstudent板的使用人數不如以往，許多有關波蘭醫學生的討論也已經轉移到其他社群媒體上，但由於這些新興社群媒體的資訊並未能完整涵蓋波蘭醫學生爭議的討論，我還是選擇使用PTT Medstudent板的資料來進行內容分析。希望能透過使用兩種資料交叉比對，來補足各自的不足。 研究結果發現，內容分析之資料著重於「醫療品質」以及「公平性」的論述。資料顯示，當時大多數網友對波蘭醫學生抱持負面觀感，主要與他們跳過大學聯考直接出國讀醫學系有關，對許多重考進入醫學系的臺灣醫學生來說，這是一種「不公平」的行為。此外，PTT Medstudent板在531遊行中扮演了關鍵角色，促成了臺灣有史以來罕見的大規模醫學生運動。 訪談資料中的討論更為豐富，除了「醫療品質」與「公平性」外，論述還進一步擴展至「個人利益」。透過與受訪者的深度交流，我得以反思醫師養成之路上的政策與機制是否合理完善；社會對於醫師一職的崇拜與期待，對醫學生、醫師乃至整個社會帶來了什麼樣的影響；醫學場域中不同的團體與階級可能存在的角力等等議題，這些都使我意識到醫事人力政策面向的多元。在與波蘭醫學生的訪談中，我還發現，他們大多在出國就讀醫學系前，就對未來可能會面對的刻板印象與偏見有所準備，有些人會將批評轉為奮發向上的力量，另一些人則透過自嘲避免批評帶來的衝擊，多元的應對模式也展現了他們的能動性（agency）。 進一步分析兩種資料後，我確認波蘭醫學生爭議實際上是由「醫療品質」、「公平性」與「個人利益」共同構成，不同群體的論述雖然有所差異，但核心理念皆與「文憑主義」相關。許多人會刻意避免談及個人利益，可能與華人文化中避諱談錢的態度有關，而社會大眾對於醫師高度尊敬與崇拜，又加深了醫師不可以「有銅臭味」的形象。 綜合上述，有別於過往與醫事人力政策相關之研究，本研究發現，當討論到醫事人力政策，公平性、收入、醫學教育之實用性等因素也是利益關係人十分關心的議題。制定政策時不應僅以品質和數量的角度著手，否則可能面臨政策「不夠接地氣」或無法說服利益關係人之情況，進而演變為醫學場域中的衝突。必須注意的是，各國醫療體系與社會文化皆有其獨特性，本研究之發現僅適用於臺灣社會中，難以外推到其他的國家。

With the accession of Eastern European countries to the European Union, the number of Taiwanese students pursuing medical education abroad has steadily increased, particularly with a significant influx of students studying medicine in Poland (PL-IMGs). Recent amendments to the Physician Act in Taiwan have intensified scrutiny and certification procedures for PL-IMGs returning to participate in national examinations. Existing literature primarily reflects perspectives from Taiwanese medical students and physicians, highlighting differences in physician training systems, internship experiences, and occasionally expressing concerns about the perceived lower medical quality of PL-IMGs. This research focuses on qualitative investigations using PL-IMGs as a case study. Based on the principles of grounded theory, the study explores the reciprocal influence between international medical graduates and Taiwan''s physician workforce policies. Initially, discussions and arguments during the first controversy involving PL-IMGs are presented through the analysis of discussions on the PTT Medstudent forum. Subsequently, in-depth interviews involving PL-IMGs and Taiwanese medical students and professionals are conducted to understand the obstacles faced by international medical graduates returning to Taiwan for practice and to gather perspectives on relevant issues from local stakeholders. Finally, combining both data sources, thematic analysis is employed to elucidate the underlying meanings behind the discourse and explore the interaction between physician workforce policies and PL-IMGs. This dual-data collection approach is adopted due to the protracted nature of the PL-IMG controversy over fifteen years. Although the usage of PTT Medstudent forum has declined, the data from this platform are still selected for content analysis, supplementing the limitations of other emerging social media platforms in covering the complete discussion of the PL-IMG controversy. Results from content analysis highlight discussions emphasizing “medical quality” and “fairness”. The data indicates negative sentiments among netizens towards PL-IMGs, primarily associated with the perception of bypassing the national university entrance exam. Furthermore, PTT Medstudent forum played a crucial role during the 531 protests, facilitating an unprecedented large-scale movement among Taiwanese medical students. In-depth interview discussions extend beyond “medical quality” and “fairness” to include a more comprehensive exploration of “interests”. Through interactions with interviewees, reflections on the rationality and completeness of policies and mechanisms in the physician training pathway are considered. Societal reverence and expectations for the medical profession, along with power dynamics among different groups and classes within the medical field, are also examined. Interviews with PL-IMGs reveal their preparedness for stereotypes and prejudices before studying medicine abroad, showcasing diverse coping mechanisms. Further analysis confirms that the core of the PL-IMG controversy revolves around “medical quality”, “fairness”, and “interests”. Many deliberately avoid discussing “interests”, fearing potential damage to the sacred image of physicians. Moreover, the core concepts of these discussions are all related to “credentialism”. This reluctance may be influenced by cultural tendencies within the Chinese context to avoid discussing financial matters, amplifying the idealized image of physicians. In summary, departing from previous studies on physician workforce policies, this research emphasizes that discussions about fairness, income, and the practicality of medical education are crucial concerns for stakeholders. Policymaking should consider these multifaceted aspects rather than focusing solely on quantity and quality, preventing conflicts within the medical field. It is imperative to note that the findings of this study are applicable to Taiwanese society and may not be readily extrapolated to other countries due to variations in healthcare systems and societal cultures.