【文章】血汗醫院與醫療商品化陷醫病於不義（英文刊載於《國際醫學生》）

作者：

醫師勞動條件改革小組　長庚醫學二　林毅

醫師勞動條件改革小組　陽明醫學三　陳帛威

台灣血汗醫院現況與醫病健康權益受損

台灣目前尚無相關法律規範醫師或住院醫師每周工作時數，雖然衛生福利部醫事司2014年頒布的行政命令《教學醫院評鑑基準及評量項目》中明文列入執勤時數，其中將住院醫師的工時分為A、B、C三個等第，內容如下：

C	1. 住院醫師每週正常值勤時間連同延長值勤時間不得超過88小時。 2. 住院醫師每日正常值勤時間不得超過12小時，連同延長值勤時間不得超過32小時。 3. 住院醫師生理、精神狀況允許時，且符合下列情況，可以超時值勤繼續照護某特定病人。但連續值勤時間仍不得超過36小時。 4. 住院醫師兩次值勤時間中間至少應有10小時以上休息時間。 5. 住院醫師每7日中至少應有完整24小時之休息，作為例假，但因天災、事變、重大突發事件或病人病情危急致住院醫師無法完整休息者，不在此限，惟醫療機構應於事後給予補假休息。
B	1. 住院醫師每日正常值勤時間不得超過12小時，連同延長值勤時間不得超過28小時。 2. 住院醫師生理、精神狀況允許時，且符合下列情況，可以超時值勤繼續照護某特定病人。但連續值勤時間仍不得超過32小時。
A	符合B項，且 1. 住院醫師每日正常值勤時間不得超過12小時，連同延長值勤時間不得超過24小時。 2. 住院醫師生理、精神狀況允許時，且符合下列情況，可以超時值勤繼續照護某特定病人。但連續值勤時間仍不得超過30小時。

另外，實習醫學生在同樣的評鑑基準中完全沒有值勤時間的相關規定。相較於其他國家住院醫師的執勤時間規範，台灣的規範對於醫生而言仍然是過於嚴苛，舉例而言，歐盟執行委員會勞資協議中規定每週工作最大平均工作時數為48小時，每週最大連續工作時數為13小時；法國前項48小時、後項10小時；，英國前項56-64小時、後項14-24小時；丹麥前項37小時，後項13-16小時。比較完國外例子之後，再比較台灣的勞基法(醫師尚未納入)，其中規定工作時數為雙週84小時。由此可以看出台灣評鑑中的每週88小時與連續工時36小時，實際上仍然有改進空間。
   

然而最嚴重的是，這個醫院評鑑實乃空有其表，值勤時間的基準僅為試評項目，不無任何實質效力。即使醫院違規，仍然不會受到法律強制力的處罰。而這項評鑑更存在著先天上的缺陷，這個評鑑中的平均工時88小時，是將醫院中所有科別的醫師的工時加總後再做平均，而醫院的各科別間本來就存在著工作時數不平均的狀況，所以很多合格的醫院中都存在著醫師工作時數超過88小時的情形，更有甚者，受測編號15的醫學中心的整形外科更出現每週工作150小時的超人醫生，但只要其他的醫生工作時數少一點，全院平均下來就可以造成合格的假象。實在讓人很難想像，一週7天的總時數才168小時，其中休息的時間竟然只佔18小時，工時之長，實在令人匪夷所思！實際上台灣目前的工作狀況，根據醫勞小組對於內外婦兒四大科的調查，實習醫學生平均單週工時是八十九小時；至於住院醫師部分平均每週工時是一○四小時。此外調查中發現，有極高比率的實習醫學生及住院醫師，最長連續工作時間超過三十四小時，等於是在二十四小時的白班加上夜間值班後，在精神委靡的情況下，又連續工作了十個小時以上。

血汗醫院已經是台灣醫界中存在已久的問題，推敲其原因為財團資本壟斷醫療經營、健保公共性的不彰以及政府的失能漠視。而在這樣高工作強度的環境下工作，醫師們必定在生理與心理上累積大量因勞動帶來的疲憊感，國內外實證研究早已證明，連續工時、跨夜值班對醫護人員的心血管等健康機能有一定的傷害。此種現象的產生，對病人而言絕非好事。醫事人員過勞絕對會影響病人受到照護的品質，2002年，《美國醫學會期刊JAMA》刊登一份有關「護理師過勞與病人生命」的研究報告，針對168家醫院，1萬多名護理人員和23萬多名病患，進行大型研究發現，護理人員數和病人死亡率兩者有絕對關係。以護理人員照顧4位病人為基準，每增加照顧1人，病患在30天之內的死亡率增加7％；若增加至8位，病患的死亡率更會增加到31％。研究單位依據所的數據估計，以現狀來說，美國護理人員承受過高病人照護負荷，將可能造成每年2萬名不必要的病人死亡。而2011年美國《新英格蘭醫學期刊NEJM》也有一份研究指出，護理人力不足、超時工作與住院患者死亡率相關。如果護理人員連續工作超過八小時，會使住院病人死亡風險提高2％。由此可見，同為醫院中提供醫療服務的醫師，如果過勞勢必會造成病患權益受損。

探究台灣血汗醫院成因

近年來，台灣醫療院所規模有M型化的趨勢，中型醫院逐漸消失，醫師人力流入大型醫院，七成以上的醫師受雇於大型醫院，成為領取醫院薪水的受薪階級。為了在維持醫院營運，由資深醫師構成的決策圈的醫院，加上不當的健保體制，往往促使醫院一味追求績效、向商品化偏斜，例如：鼓勵自費醫療、高階健檢、衝高服務量等，在誘發需求的同時，為了壓低成本，醫院內龐大繁雜的工作重擔往往落在醫療階級中基層的醫師如Intern、PGY，造成基層醫師過勞、危害病人安全的情況。

醫療專業由於其封閉性與階級隨年資向上流動的特性，使得資深醫師扮演醫院營運的決策者，而基層醫師由於醫療體系崇尚階級的特性，對於醫院決策沒有發言權，最後淪為醫療體系下的小螺絲釘，只能受制於營利導向的經營模式，縱使有意見，也只能默默吞下，期待自己隨著年資漸長，階級提升、擺脫血汗剝削的那一天。

台灣醫界規模最大的組織為醫師公會全國聯合會，其對於衛福部與立法院有舉足輕重的地位，對國家醫療政策的影響十分深遠，儼然是醫界代表。然而細查其組成，成員不乏私立醫院院所經營者、醫界大老，對於應當維持公共性的醫療來說，醫師公會全國聯合會所扮演的角色，往往令人懷疑。舉例來說，為了維護病人安全、保障醫師勞動權益，由一群青年醫師、醫學生組成的醫師勞動條件改革小組，致力於將醫師納入勞基法，然而醫師公會全聯會為了壓低醫院經營成本、追求利潤，總是百般阻撓醫師納入勞基法。此外，大型財團醫院往往利用關係人交易、土地資賃等方式，將帳面盈餘減到最低，藉此作為無法提供基層人員合理待遇的藉口。

第三部分，拒絕過勞，維護醫療公共性

在財團醫院橫行、基層備受剝削的現狀下，政府今年拋出了國際醫療專區大餅，宣稱能夠藉此吸引國外顧客，藉由自費醫療，將台灣醫療打造成國際級產業，盈餘用以改善醫事人員待遇。然而弔詭的是，過往基層在抗議血和剝削時，資方總是強調人力不足，希望大家共體時艱，但是對於國際醫療專區，政府卻表是台灣醫療人力過剩，可向外發展，且已有多家醫院磨刀霍霍，準備大賺一筆。我們可以預見，可以進入國際醫療專區內的醫師，必定不是目前受到剝削最嚴重的基層醫師，而是享有一定待遇的資深醫師，當資深醫師流入國際醫療專區，在區外的基層醫師工作量勢必大增、更加過勞，必定會衝擊台灣本土醫療。

在目前政府和財團醫院共謀的狀況下，台灣醫療商品化勢不可檔，醫療階級化的景況日漸清晰。然而還是有許多基層醫師、醫學生，抱持著維護醫療公共性的理想，因此我們組織草根性的組織，指正台灣醫療的缺失，希望能夠集結基層醫事人員的力量以抗衡由資方主導的醫界，並喚起社會大眾的關注，其許有一天，「病人的利益為我首要顧念」能夠真正的實踐！

Sweat Hospital and Medical Commercialization Cause Doctor Burnout and Patient Deprivation

Author： Yi Lin & Po-Wei Chen (members of Medical Labor Condition Group)

The Labor Environment of Taiwan Doctors

So far, there hasn’t been any legitimate concerning the average working hours for intern and resident. In 2013, Ministry of Health and Welfare issued an executive order, Teaching Hospital Accreditation Benchmarks and Assessment Project《教學醫院評鑑基準及評量項目》, mentioned working hours and ranked working hours for residents as A, B and C three levels. Besides, the assessment doesn’t contain related working hours for interns. Compared to the regulation of working hours for residents in Taiwan, the situation is way too harsh for doctors in Taiwan. For instance, European Commission states that the maximum average working hours goes up to 48 hours with the maximum continuous working hours is 13hours.While in French, the former one is 48 hours and the latter one is 10 hours. In the UK, it would be 56 to 64 hours and 14 to 24 hours. As for Denmark, the former counterpart is 37 hours and the latter is 13 to 16 hours. In the LABOR STANDARDS LAW in Taiwan, exclusive of doctor, the working hours are 84 hours every two weeks. In Taiwan, the maximum average working hours is 88 hours with the maximum continuous working hours is 36hours in Teaching Hospital Accreditation Benchmarks and Assessment Project《教學醫院評鑑基準及評量項目》, implying that the situation still leaves a lot to be desired.

However, the assessment does come into its expected efficacy. The standards of working hours is in its trial, not having any practical power. Even when the hospitals violate the Teaching Hospital Accreditation Benchmarks and Assessment Project《教學醫院評鑑基準及評量項目》, they are still free of punishment. Moreover, the assessment exhibits an intrinsic defect. The average working hours just mentioned comes from the average total working hours of the summation of all divisions practice, while it can be noticed that working hours of divisions of different practice exist difference. Therefore, doctors working over 88 hours per week can be seen in many hospitals passing the assessment. Furthermore, a plastic surgeon from hospital numbered 15 works a whopping 150 hours a week. It is hard to imagine that with the total of 168 hours a week, this plastic surgeon only have 18 hours to take a rest. It is definitely inconceivable how long the working hour is for this surgeon. According to the research on the Internal medicine, surgery, Obstetrics and gynaecology and Pediatrics from Medical Labor Condition Group (醫勞小組), the average working hours for interns in Taiwan is 89 hours a week while it is 104 hours for residents. The research also unveiled that there is an astonishing high percentage of interns and residents working over 34 hours continuously.

Sweat Hospitals and patients’ right

“Sweat hospitals” is a long-existing problem for medicine in Taiwan. It can be resulted from the financial groups monopolizing the medical service, inefficiency of the publicness of health insurance and the incompetence of our government. Under the highly stressful conditions, doctors must be exhausted physically and mentally because of the tiredness from overworking. Researches conducted around the world have proven that continuous working and night shifts have unneglectable influence on cardiovascular diseases and other body functions. The phenomena described above are far from goodness as far as patients are concerned. The overworking of medical personnel will definitely damage the quality of medical service. In 2002, the journal, JAMA, published a research finding, Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction, which surveyed 168 hospitals, more than 10000 medical personnel and about 230000 patients. This research finding concluded that there is a close relationship between the total number of medical personnel and the mortality of patients. Taking every personnel caring four patients as standard, the mortality of patients within 30 days can increase by 7% if the personnel take care of one extra patient. In 2011, another journal, NEJM, also published an essay, Nurse Staffing and Inpatient Hospital Mortality, insufficient medical personnel and burnout bear relevance to the mortality to hospitalized patients. If their continuous working hours exceed 8 hours, the mortality of hospitalized patients will go up by 2%. Thus, the unexpected burnout of doctors, also as members of medical personnel providing medical service, is likely to jeopardize the rights of patients.  

        Class Oppression Accelerating Medical Collapse

          Since 1980s, distribution of medical facilities scale in Taiwan have moved toward M-shaped form. Regional hospitals vanished quickly while more and more manpower switched into big hospitals. Nowadays, over seventy percent of doctors work in big hospitals and lives on salaries paid by their boss. In order to pursue profit in highly competitive market, hospital managers (usually senior doctors) tend to adopt a interest-oriented strategy such as marketing out-of-pocket service or forcing front-line doctors to boost their service amount. Meanwhile, most of the labor burden have been laid on junior doctors such as interns and residents, which leads to long-term overtoil, putting patients’ safety in danger.

          Due to its high entry threshold and tight class structure, hospitals are usually run by senior doctors, while junior doctors are ruled by seniors and have no voice when suffering from long working hours. The only happiness of the juniors is dreaming that with time flies, one day they might get rid of all the torture and free themselves.

          Taiwan Medical Association is the biggest medical interest group in Taiwan and it plays an important role in health policy making. Nevertheless, many of its members are managers of private sectors, which means that they might prioritize profit other than publicity and lobby the government to implement a more commercializing health policy. In recent years, Medical labor condition reform group, which formed by medical students and junior doctors who pursue medical publicity, urged that doctors should be protected by《Labor Standards Act》because exhausted doctors might do harm to patients. However, Taiwan Medical Association oppose this reform because once doctors covered by《Labor Standards Act》, hospital managers have to recruit more manpower and the cost will rise. In addition, private sectors have multiple tricky means such as related parties transaction to lower book surplus to rationalize its claim that junior workers should share weal and woe with hospitals.

           Commercializing Risk Around The Corner

           This year (2014), the government plans to establish international healthcare industry park, boasting that the park will spur medical care, biotechnology, pharmaceuticals, rehabilitative care, health enhancement and other industries. Paradoxically, there is an existing manpower shortage in Taiwan, which means that the extra manpower need in the park might further worsen the shortage and generate medical inequality. Furthermore, it is senior, skilled doctors who will get the ticket to the park and make a big fortune. On the other hand, burden on junior doctors will become heavier and heavier. Worst of all, healthcare system in Taiwan might lose its original publicity.

          Stand By Patients’ Side, Retrieve Publicity

          Overall, the overwhelming wave of medical commercialization seems unstoppable.  Pre-existing interest-oriented hospitals still make their ways, and the international healthcare industry park is lurking around the corner. However, there are many medical students and doctors who believe that medicine should not be commercialized. Therefore, we organized grassroots group “Medical labor condition reform group” voluntarily. By criticizing current system defects and unite junior doctors and medical students, we hope that we can reverse the worsening situation. We truly believe that one day, we can retrieve the publicity and proudly state that “The health of my patients will be my first consideration”!