台灣急診醫師醫療糾紛的現況與探討—「以屏東縣市急診醫師為例」

Abstract

前言 台灣急診醫師的醫療糾紛正急速增加中。近年來全國急診室常常擁塞，醫療糾紛與急診暴力越來越多，醫病關係越趨緊張。台灣急診醫師醫療糾紛，法院判決急診醫師敗訴率17.6%，若發生民事訴訟，法院判決急診醫師敗訴率35.3%，平均急診醫師敗訴賠償金額約440萬元。探討急診醫師醫療糾紛的因素刻不容緩。 目的 台灣醫療糾紛越來越多，研究醫療糾紛的文章也很多，但是專門研究急診醫師醫療糾紛的文章卻甚少。本研究因研究生本身為台灣急診醫學會醫病關係委員會委員暨南部某區域醫院急診醫學科主任的立場，試著收集委員會專家的意見，制定問卷內容，於急救責任醫院訪查時進行問卷調查與回收分析。希望能從改善控管急診的流程，探討急診醫師醫療糾紛的原因與需求，以期減少急診醫師的醫療糾紛。進一步於委員會中報告及提出建言，並回饋給會員。 方法 本研究主要使用因果比較研究法為基本研究類型。研究對象為屏東縣市執業中的急診醫師，採樣方式為屏東縣市全部急診醫師發放問卷與回收。回收樣本分成「曾發生過醫療糾紛」與「不曾發生過醫療糾紛」兩大類別變項，以委員會專家的意見產生問卷內容為基數變項。資料收集乃以此問卷調查為主要工具，最後使用 One Way ANOVA 推論統計得出結果。另外，急診醫師醫療糾紛其他現況的推論，使用其他類別變項與醫療糾紛因素的推論統計得出結果。 結果 屏東縣市本次問卷調查共回收有效問卷46份。曾發生過醫療糾紛的急診醫師佔屏東縣市急診醫師高達41%。男性急診醫師佔百分比96%。72%急診醫師的年齡落在31-50歲，屬於青壯年期。31-40歲佔29%，比41-50歲 (佔43%) 還少，顯示剛取得專科的年輕主治醫師不願意下鄉服務。各家急救責任醫院的急診專科醫師目前仍嚴重不足。我們發現「是否曾發生過醫療糾紛」兩大類別在「急診轉院的風險」變項有顯著差異情形(相對於其它流程、發生與需求因素變項)。「急診職等」在問診與理學檢查的錯誤、急診診斷的錯誤、急診治療的錯誤有顯著差異情形。「急診年資」在急診診斷的錯誤、急診侵入性治療的錯誤、醫院的危機處理制度未完善有顯著差異情形。 討論 我們發現曾經發生過醫療糾紛的屏東縣市急診醫師認為急診轉院的風險較高，可以解釋成高高屏急診壅塞中，屏東縣市急診病患跨過高屏溪轉入高雄的高風險，可能是造成急診醫師醫療糾紛的元凶之一。有趣的是，急診年資越高醫師的急診診斷錯誤的平均數較低，可能自恃較不會誤診。急診年資較少醫師的急診侵入性治療錯誤的平均數較高，可能對侵入性治療較沒把握。急診年資16~20年的急診醫師認為醫院的醫療糾紛危機處理機制未完善。急診主任較重視問診與理學檢查的錯誤、急診診斷的錯誤與急診治療的錯誤等流程因素的風險控管(相對住院醫師、主治醫師其他職等)。急診醫師認為急診診斷、治療、檢傷等候期、家屬的態度、不當的醫病關係與社會環境的變遷是與引起醫療糾紛之間關係很重要的；意即醫療糾紛乃肇始於急診診斷錯誤、治療錯誤和家屬的過高期待。在研究中，反而急診醫師的個人因素排在最後。醫院高層與急診主任須改善控管相關流程。 結論 每當有醫療糾紛發生，社會大眾總是怪醫師，媒體用放大鏡檢視醫師，但本研究顯示急診醫師的個人因素反而排在最後。研究中可發現其實急診醫師醫療糾紛的因素是複雜且都很重要的。這份研究也道出急診醫師的無奈心聲:家屬要求急診醫師提供快又準的急診診斷與治療。對於年輕急診醫師的侵入性治療，醫院應該提供更多的急診專業訓練。未來，待全國問卷回收後，可比較各區域急診醫師的醫療糾紛，期能挖掘各區域的急診生態。最後，也請衛生主管機關重視高高屏急診壅塞與轉院風險。

Introduction Medical disputes of emergency physicians in Taiwan are growing rapidly. Due to overcrowded emergency rooms, and more and more medical disputes, the doctor-patient relationship is getting more nervous throughout our country in recent years. Up to 85% of emergency physicians thought that 'medical disputes could break out at any time' is the main source of pressure. Discussion of medical disputes of emergency physicians is without delay. Purposes Up to now, there have been only a few studies of discussion of medical disputes of emergency physicians in Taiwan. Therefore, the purpose of this research is to explore and discuss the causes of medical disputes of emergency physicians, and to give forward suggestions and feedback to emergency physicians.

Methods This research utilized casual-comparative research as a basic study. Objects are emergency physicians in the practice in Pingtung County. Sampling methods are for all emergency physicians in Pingtung County, issued questionnaires. Opinions of the committee of experts are as the base of the questionnaire, and then data are collected by means of this questionnaire. Furthermore, the key factors of medical dispute are scored and then analyzed by statistical methods.. Results Medical disputes of emergency physicians were up to 41%, occurred in Pingtung County. We discovered that 'medical dispute ever occurred if or not' had significant differences ( relative to other process and demand factors ) in the ' risk of emergency transfer '. It is interesting, senior emergency physicians had lower means of “error of emergency diagnosis”, and junior emergency physicians had higher means of “error of emergency invasive treatment”. Senior emergency physicians believed that hospital medical dispute crisis management system is not perfect. Emergency directors put more importance to 'error of history taking and physiological examination', 'error of emergency diagnosis ', and 'error of emergency treatment'. Emergency physicians believed that emergency diagnosis, treatment, triage, improper family’s attitude, physician-patient relationship and social environment were important. Hospital manager and director of the emergency must improve related processes. Personal factor of emergency physician was sorted finally. Conclusions Whenever there is a medical dispute, people always blame emergency physicians. However, this research showed that personal factor of emergency physician was sorted finally. This research revealed that the causes of medical dispute of emergency physicians were complicated and very important. More professional training programs, such as invasive procedures, should be provided for junior emergency physicians. After all regional questionnaires collected in the future, we can mine the regional medical disputes of emergency physicians throughout our country. Finally, the Department of Health should put importance to the overcrowded emergency room and the risk of emergency transfer.