千山響杜鵑：台灣精神科診所的發展

Rebels Gone 'Cuckoo' with Institutional Causes: The Case of Taiwan's Psychiatric Clinics

在全民健保的總額預算支付制度影響下，台灣的各大醫院競相追逐規模經濟，醫院的各個醫療科別，都有明顯成長。在這大者恆大的普遍現象裡，精神科卻是一個例外；伴隨著大醫院裡精神科別發展的停滯，是各地基層精神醫療診所的蓬勃發展。本研究援引制度創業理論，採用質性的研究方法，來解釋精神科發展的異象，本文探究精神科場域樣貌的變遷，並聚焦在三個問題以分析造成變遷的脈絡：精神診所為何興起？誰是促成精神科診所發展的制度創業家？以及這些制度創業家如何運用策略行動來改變場域？我們的研究指出，法規推力與市場拉力是造成精神科醫師出走的主要因素；在精神醫療場域之中，位於中間結構位置的醫師是精神科診所發展的制度創業家，他們採取了社群與協會的建構、資源的連結與引入，以及新活動的論述傳播等三種制度策略，創建新的制度場域。

Under the prevailing regulation of global budget payment, hospitals in Taiwan have been expanding in scale to increase market share. Consequently, the big hospitals get bigger, with their various medical departments growing in parallel. However, psychiatrics departments in hospitals have not expanded; instead, it is the number of psychiatric clinics that has been growing dramatically. Using qualitative research procedures, we draw on the institutional entrepreneurship perspective to explain this anomaly. We focus on three research questions: First, why have psychiatric clinics proliferated? Second, who were most likely to become institutional entrepreneurs leading changes in the psychiatric field? Third, what kind of strategies did the institutional entrepreneurs employ to deal with institutional pressures? Our findings show that the main factors that led psychiatrists to engage in entrepreneurial activity were 'regulation-push force' and 'market-pull force'. The chiefs of psychiatric departments, and specifically those within regional hospitals, have a tendency to become leading institutional entrepreneurs. We also found that, in responding to institutional pressures, these entrepreneurs mainly deployed three strategies: the formation of associations and coalitions of various kinds; the drawing and linking of external resources, and the engagement with discursive and pedagogic practices.