醫師開立疾病診斷證明書之困擾――以中部某醫學中心為例之初步研究

A Preliminary Study of Dilemmas in Writing Sickness Certification among Physicians at a Medical Center in Central Taiwan

近年來風險意識提昇，民眾逐漸有購買保險的習慣，由於申請保險給付時須具醫師開立之疾病診斷證明書，但因為「鑑識」工作非醫師職責，所以醫師僅只能在診斷書內描述醫療狀況，不能做非醫療的判斷。但是病患或家屬為了增加保險給付，常對醫師在診斷書內所使用的文字有所要求，不僅增加醫師的工作負荷也產生困擾，甚而影響醫病關係。為瞭解醫師開立診斷書時，曾經遇到的困擾、困擾程度及對病患或家屬要求的配合程度，本研究以自擬結構式問卷進行自陳問卷調查。結構式問卷乃根據29位PGY（Post Graduate Year，畢業後一般醫學訓練）住院醫師提供之意見、訪談主治醫師、法律專家、參考相關文獻，綜合歸納後完成。問卷內容含：基本資料、開立診斷書曾經遇到的困擾頻率及程度、對病人或家屬要求配合度、醫師感受、病歷寫作教育需求五部份，採李克特四尺度量表法計分。以中部某醫學中心自願填寫研究問卷的醫師為研究對象，共完成有效問卷247份。研究結果發現：申請診斷書的主要原因為「申請保險給付」（32%）及「請假證明」（18%）。只有24%的醫師認為開立診斷書「沒有困難」。當病人或家屬要求修改診斷書中的文字或內容時，有三成（31%）醫師拒絕配合。醫師開立診斷書頻率最高的困擾是：「被要求不要寫出會影響保險給付的字眼」，其次是「被要求修改疾病診斷證明書中的文字或內容」，再次是「沒有統一的中文疾病診斷」。醫師開立診斷書困擾程度最高的是「被要求寫與事實不相符的診斷」，其次是「病人或家屬態度強硬、不講理」。只有三成（32%）醫師認為自己有充足的能力勝任開立診斷書業務，有近六成（58%）醫師有中、高程度願意接受相關在職教育訓練。研究最後提出對醫師、病人、保險機構及PGY教育訓練計劃之建議。

Lately, with growing awareness of dangers and risks, people gradually become accustomed to buying insurances. When a patient is applying for insurance benefits, a physician’s diagnosis is called for. Since the “forensic” work isn’t the responsibility of the physician, the latter may only diagnosis the disease within the medical conditions and add no non-medical judgments. However, in order to get more insurance payments, words written in the diagnosis are often criticized by the patients or/and their families. It definitely troubles and causes problems for the physician, and sometime even affects the physician-patient relationship seriously. To understand what sort of disturbances that physicians are facing, the affecting level of them, and the cooperation a physician might give as writing a diagnosis, this study is through a self-structured questionnaire survey, and it is an open one which was originally put together based on 29 PGY residents’ opinions. After that we have interviewed some concerned attending physicians, legal issue specialists, and looked into relevant literatures before its completion. Content of the questionnaire includes basic information, disturbance frequency and its severity in the physicians’ experiences of issuing diagnostic statements, cooperation level given under the demands of the patient or the patient’s family, what the physician felt during the process, and the needed education of writing up proper medical records. Four-Scale mining Liker Scale scoring method was used in this study. Willing physicians working at a certain medical center in Central Taiwan are our research objects, and a total of 247 questionnaires were completed and returned. The results showed that the main reasons for people to get a medical diagnosis were applying for insurance payments (32%), and leave certificate (18%). Only 24% of the respondents did not feel annoyed at writing a diagnosis. When the patient or his/her family asked for amending the content of the diagnosis, 31% of the respondents said no and refused to do it. Among those listed problems of writing up the diagnosis, “being asked not to write words that would affect the insurance benefits” turned out to be the most annoying item, followed by “being asked to modify the text in the certificate of diagnosis,” and “facing patients or their family members’ tough and unreasonable attitudes.” Only 32% of the physicians thought themselves having adequate capability to cope with writing diagnosis statements, while 58% of them are willing to accept additional job-related education and training. Finally, according to the results, we made some recommendations in the study on training programs aiming at physicians, patients, insurance agencies, as well as PGY.