台灣民眾的就醫第二意見行為之探討

Abstract

在醫療資源有限的情況下，民眾的逛醫師（doctor shopping）行為始終是被撻伐的對象，而忽略了民眾也能對醫療品質作監督。本研究以面臨重大疾病時，所出現的就醫第二意見行為（second opinion behavior）為例，了解民眾如何對就醫安全及醫療品質作自我把關及監督。 為了解民眾就醫第二意見行為的樣貌以及驗證其中重要發現在人群中的分佈，故採質量性兼具的混合型研究設計（Mixed-method design）質性研究的資料收集期間自94年11月到95年4月共訪得18位重大疾病的患者，整理質性研究的發現，於95年5月10日至13日進行全國性電話訪問調查，共收集1057名18歲以上成人的資料，完訪率為93.7％。 研究結果有以下重要發現： 1. 就醫第二意見行為是一種對醫療品質的追求及就醫安全自我把關的策略，其動機來自於因應醫療的不確定性和醫療諮詢之不足，以及對醫師的不信任。 2. 透過尋求專業第二意見或是常民諮詢的社會比較的過程，民眾將綜合這些意見來增進對疾病的了解以及作治療地點的選擇。 3. 民眾在選定就醫地點前分成確定診斷和治療方式以及選定治療地點兩個階段，第一階段重視醫療診斷的確認和醫療知識的了解，屬於醫療品質過程面的監督；第二階段則會考量醫院名聲、醫師醫術等屬於醫療品質結構和結果面的監督，消費意識也在此階段最為突顯。 4. 對於整體醫療照護體系的負面觀感將會影響醫病之間的信任，使民眾傾向於多重確認的方式來對就醫安全作自我把關。

整體而言，就醫第二意見行為是一種理性的行動策略，反映了民眾能對醫療品質作多元的監督，以及積極參與醫療過程、追求知的權利和重視消費者自由選擇的權益之現象，但這樣的行動策略僅限於「出走」，若缺乏有效的「發聲」管道，無法提供體制面改革的有效性。而今後政府在醫療品質促進方面應考量提供民眾對醫療品質不滿的有效發聲管道。

The limited medical care resources has made “doctor-shopping” behavior among the general public a target for criticism, yet the possible function of safeguarding against undesirable outcomes that may be inherent in this commonly practiced precautions has long been overlooked. This study aims to understand how the laypersons themselves assure patient safety and quality of care by examining the “second opinion behavior” (SOB) in the health seeking process. A mixed-method design combing qualitative and quantitative data collection approaches was employed to explore the nature of the SOB and its distribution and determinants. In-depth interviewing with 18 patients who were facing life-and death decisions for the treatment of their illness was carried out from November 2004 thought April 2005. Based on the findings of the qualitative data, structured items to measure SOB and its correlates were constructed. Through a nation-wide telephone survey, valid responses from 1057 adults aged 18 years and older were collected, with a response rate of 93.7%. The major findings are: 1. The SOB is a strategy for pursuing health care and self-assuring patient safty, which is motivated by coping with medical uncertainty and the deficit of medical information, and a distrust in physicians. 2. By means of seeking second opinions form professionals and making lay consultations within one’s own social network, i.e., a social comparison process, the laypersons integrate the information they acquired to enhance their understanding of the nature and the prognosis of the disease and, furthermore, to choose the best institution for the on-going treatment. 3. Basically two stages can be differentiated in the health seeking process before the institution for treatment was chosen finally. The task of the first stage is confirming the diagnosis and taking in related knowledge and information, which means to safeguard against the process aspect of quality. Once the diagnosis was confirmed, in the second stage, the main task is finding a competent doctor in a renowned medical care institution, which pinpoints to the structure and outcome aspects of the quality. It is in the second stage that the consumerism was in operation obviously. 4. The overall negative outlook on the health care system may bring about the general distrust between patients and physicians. As a result, the gereral public themselves may initiate precautious strategies by multiple consultations and confirmations. In conclusion, the SOB is a rational action, which reflects that the gereral public are capable of supervising the quality of care and actively participate in the medical care process, and that they express their awareness of their rights of being informed and making decision. However, all actions taken by the general public characterize merely “exit” (going out) but without “voice,” which hardly poses any opportunity for health care reforming or re-structuring. It is therefore suggested that the government should provide channels for the general public to voice their discontents to the quality of care.