請教各醫學院院長

[Einstein]

◎ 廖偉翔

由於謝炎堯教授的大作，使醫師／實習醫師納入勞基法的議題又再度受到注目。週一（二十八日）正好是成大醫學院院長與學生座談時間，筆者提問：「是否認同醫師／實習醫師納入勞基法？」院長回應：「之前去開全國醫學院院長會議，大家都反對醫師納入勞基法的。」而其主要理由或許也代表了各醫學院院長的意見，主要有兩點：醫學教育的連續性（不可能時間一到就下班）、人力缺口無法補上（工時限制後人力不足）。然而乍聽之下合理的推斷，卻是必須經過檢驗的。在此提出未來可供各醫學院校參酌的方向。

醫師／實習醫師納入勞基法，代表的不只有工時的合理限制，還有勞工身分的認定以及隨之而來的各種職業保障，更在後續基層醫療人員組工會爭取權益等方面有重大意義。醫學教育的連續性和人力缺口，這都需要有實證來支持，目前已有的研究顯示，連續工作過長的時間，反而是提高了病患的風險。前述兩點看法必須要提出院內的研究報告才能討論。而且研究不是只為了保障工時，還要搭配值班制度的重新設計等等，這也要一併納入，否則是不能直接如此宣稱的。

除此之外，醫學院扮演的角色更應該要有示範作用。各醫學院院長宣稱反對醫師納入勞基法，其中有任何實證研究嗎？如果有，請提出供各界公開檢驗；如果沒有，更應該從各校內部的調查做起，提出可能改變的方案，這才是醫學院應有的教育功能。醫學院應該扮演整體醫學教育、乃至於社會大眾的領頭羊，研議醫療社會政策，而不只是在醫學知識上教育自己學校的學生而已。

（作者為成大醫學院醫學系七年級學生）

[Necropsy]

老闆當然不希望員工適用勞基法

[image]

錢從哪裡來?如果是自費的醫院 完全贊成醫護跟所有員工納入勞基法

看看自費的醫美診所 東區上百家....醫美老闆一般也都很愛錢....可是有聽說哪家老闆讓醫師過勞?每個受雇醫師工時都嘛"超勞基法"

健保很惡霸的把訂價權整個拿走 讓很多必須要花錢的好措施無法實行 奸商至少還有訂價權 也可以公開講要釀造的醬油先拿40元來....健保就像一瓶10元不准漲的醬油 要不不賣(可是不賣政府又不准) 哪有可能升級成釀造的呢?

把矛頭對準(幾乎所有的!)醫院 那是廢文吧 PO一百篇也無解....

[gary]

有多少錢 做多少事
不要沒錢 卻打腫臉 充胖子

[lupin]

人再少一點，要什麼法都給你過
不做最大

[lupin]

醫學教育的連續性（不可能時間一到就下班）、人力缺口無法補上（工時限制後人力不足）

這兩點如果願意公開辯論，敢提出的人應該會被羞辱得很難看吧！

[vsdog]

後悔讀醫學系了嗎
醫師納入勞基法遙遙無期

[image]

人再少一點，要什麼法都給你過
不做最大

床再少一點，要什麼人都給你過
不做最好...

施壓是必要的 可是不要搞成零和 彼此讓一步 積極找財源把總額弄大最優先...

[LCL]

看來醫師勞工的思考邏輯已成形
大家已經往醫勞方向走

[kwojohn]

後悔讀醫學系了嗎
醫師納入勞基法遙遙無期

[min]

既得利益者，是不會輕易放棄的。

[newshine]

醫學系七年級
嗯

不錯有反思與提出來的能力


不過醫學系七年級這個已經快要消失了吧

[hjh]

不要小看這些院長
到時候真的弄個研究掰出實證給你看
取樣統計分析.... 看要怎麼「變化」.... just do it.... he can make it...

[李誠民]

住院醫師(Trainee)每個月多一萬還留不住人?!....美國健保改革需要增加的住院(包過實習醫師-PGY-1)醫師訓練費有多少,衛生部官員知道嗎???......Med-care 實施(自1965年)以來,住院醫師保險(包括醫療糾紛保險)都是參院預算中心編列的.......不是都要學美國嗎?!.....醫學院要七年才能畢業(打工(?)都要加入勞保,否則犯法!!...;實習醫師是實際血汗工作,還沒勞保,只有學保!!!
大學畢業只有23K,只有醫學院學生(實習醫師....還沒當醫師就被抹黑?Bumbler先生,哈佛法學博士畢業,多清苦--要靠美青姐資助,才能完成學業?!--國民黨中山獎學金,怎不強調了!!!)102-9-3

我是傷心老爸.!!兒子差0.7分無緣上北醫牙.只好南下讀高醫牙!讓我不捨.擔心睡不好.記得指考考完兒子信心滿滿. 說不用重考[建中應屆]高中從不補習.兒子目標陽明牙.離我家不到5公里!一切天意.想到他9月6日高醫報到.現心有如刀割!想高中3年每天早上戴他到建中.三年級晚自習帶他回家!唉!這一切讓我好心痛.想到他在高雄6年.我今年已53歲.人生有幾個6 年.他不重考.牙醫是他了第二興趣[第一是音樂]祝福他平安.順利!"....
……..
傷心老爸!應該高興!!!...否則社會,家庭等壓力,他畢業後,只好拼醫美賺錢?!....您不見小S她老公,胡瓜她老公.....搞醫美是要有能力的(我不是說您!)....先要帥,會拼酒....最後是能上夜店"把妹",恭喜您! 您兒子考上了高醫,而不是台大!!!102-9-3…..

這是我個人在此網站最近發言:;;;......我兩年前曾參加民進黨不分區立委的公聽會--有關台南奇美醫院(總醫師?);;您成大醫院實習醫師過勞死(高醫實習醫生--Graduate student);在場發問多次,時間有限,教育部代表與衛生署醫政處長臨時脫逃!!!---問到大學生到7-11打工,若沒加勞 健保,是要處罰的!!!;您醫院副院長(A madem)確答覆說::實習醫師要不要加勞健保,需要雇主是否願意加保?!.....甚麼怪論調!!!!--成大會爭取教育部增加學保?!(勞保都是騙人的!! 學保有哪些保障?!)....

我是傷心老爸.!!兒子差0.7分無緣上北醫牙.只好南下讀高醫牙!讓我不捨.擔心睡不好.記得指考考完兒子信心滿滿. 說不用重考[建中應屆]高中從不補習.兒子目標陽明牙.離我家不到5公里!一切天意.想到他9月6日高醫報到.現心有如刀割!想高中3年每天早上戴他到建中.三年級晚自習帶他回家!唉!這一切讓我好心痛.想到他在高雄6年.我今年已53歲.人生有幾個6 年.他不重考.牙醫是他了第二興趣[第一是音樂]祝福他平安.順利!"....
……..
傷心老爸!應該高興!!!...否則社會,家庭等壓力,他畢業後,只好拼醫美賺錢?!....您不見小S她老公,胡瓜她老公.....搞醫美是要有能力的(我不是說您!)....先要帥,會拼酒....最後是能上夜店"把妹",恭喜您! 您兒子考上了高醫,而不是台大!!!102-9-3…..

這是我個人在此網站最近發言:;;;......我兩年前曾參加民進黨不分區立委的公聽會--有關台南奇美醫院(總醫師?);;您成大醫院實習醫師過勞死(高醫實習醫生--Graduate student);在場發問多次,時間有限,教育部代表與衛生署醫政處長臨時脫逃!!!---問到大學生到7-11打工,若沒加勞 健保,是要處罰的!!!;您醫院副院長(A madem)的答覆說::實習醫師要不要加勞健保,需要雇主是否願意加保?!.....甚麼怪論調!!!!--成大會爭取教育部增加學保?!(勞保都是騙人的!! 學保有哪些保障?!)....

[李誠民]

台大醫科的心得文
http://mypaper.pchome.com.tw/skindoctor/post/1247118438
這篇文章被瘋狂轉載
9洪浩雲
https://www.facebook.com/Dr.AAATP?fref=ts
洪浩雲醫師自稱台大外科總醫師,回台大—10萬/月薪,轉身改行走醫美—30萬/月薪,那為甚麼熬了5-6年(?)—包括Intern&Residency training
台大醫科的心得文_--每天工作15-6hrs.—大七生—Internship,台大不是說:--Residency(PGY1-3)每週工作不超過60hrs?
聯合報╱記者張錦弘／即時報導】 2013.02.20 11:55 pm (102-2-21Newshine)

今年學測有163人滿級分，和往年一樣，很多滿級分考生都說想申請台大醫學系，不過台大醫院副院長、醫學系系主任張上淳提醒，社會大環境及醫療體系改變，醫生已不像早年那麼受大家尊崇，要面對越來越多醫療紛爭，待遇也不再那麼好。從讀醫學系到當醫生，都很辛苦，真正有愛心、耐心、想服務人群，才來讀醫學系，將來較不會後悔。

張上淳說，今年醫學系新生改為6年制，畢業後考上醫生證照，還要接受1-2年的不分科住院醫師訓練，再接受3-5年的專科住院醫師訓練，從早忙到晚，但在公立醫院的月薪，只有6-8萬元，要熬到30幾歲當主治醫師，才能領10多萬薪水，不像大家想像的那麼好。
......洪浩雲當時是亞東外科總醫師,回大沒成功(還不是薪資而已,還要熬到副教授 教授!!),;當然就轉作醫美了!!!!......現在是羅東 教授!!),;當然就轉作醫美了!!!!......現在是羅東醫院外科醫師(主治醫師?!,or fellow?!)

[李誠民]

Service: An Essential Component of Graduate Medical Education
Jennifer C. Kesselheim, M.D., M.Ed., and Christine K. Cassel, M.D., M.A.C.P.
N Engl J Med 2013; 368:500-501February 7, 2013DOI: 10.1056/NEJMp1214850
住院醫師(&/orIIntern)到底是訓練(Training)&/or服務(Survice)?!,請看下列文章::

Medicine is a service profession, and commitment to service is a hallmark of humanistic人性的人文主義 physicians. Despite the importance of service, there are few widely disseminated definitions of it. One comes from the Arnold P. Gold Foundation, an organization whose programs on humanism in medicine have been integrated into 93% of U.S. medical schools; the Gold Foundation defines service as “the sharing of one's talent天才天資, time, and resources with those in need; giving beyond what is required.”1 Though fundamental to physicians' professional role, service is being harmfully undermined within the medical profession and within graduate medical education (GME) in particular.
Service and education have been set in conflict ever since the original GME infrastructure emerged in the early 20th century. Whereas medical students pay tuition教學學費 for their education, residents continue to learn while becoming an invaluable part of an institution's workforce. Residents are trainees who are evolving into autonomous practicing physicians — a process that requires balancing the responsibility of educating oneself with responsibility for direct patient care. During this evolution, residents must focus on both education and service.
To protect residents from such transgressions and provide oversight to residency programs, the Accreditation Council for Graduate Medical Education (ACGME) conducts an annual survey in which residents evaluate their training environments. Rather than probing residents for evidence of excessive scut work, however, the ACGME asks, “How often has your clinical education been compromised by excessive service obligations?,” with responses on a scale ranging from “not at all/never” to “extremely often.” The ACGME reports that on the 2007–2008 resident survey, this item had the highest rate of responses considered to indicate a program's noncompliance with council expectations.3 The council's chosen phrasing casts service in clear opposition to education. The survey is important because the data contribute to training programs' evaluations, and negative reviews regarding service can affect the ACGME's assessment of program quality……

But the ACGME survey raises numerous unanswered questions. Is it appropriate to focus on residents' personal interpretations of the terms “service” and “education”? How do residents define service? Does their definition align with those used by practicing clinicians and experienced educators (or by the Arnold P. Gold Foundation)? What happens if trainees and those responsible for their training have incongruent expectations for the role of service in medical training?.......
• A hematology resident is asked to consult about a patient scheduled for elective surgery who was incidentally found to have mild coagulation abnormalities. The resident has performed several other consultations this month for similar indications.
• A surgical resident is asked to dictate命令口授指定 a letter to a referring physician about a patient seen in the surgical clinic. The attending surgeon asks the resident to modify the letter's recommendations, and the resident must revise the dictation.
• After participating in a cardiac resuscitation on an inpatient unit, a pediatrics resident is asked to enter into the patient record orders for the various medications used.
• A family practice resident misses a teaching conference in order to see her last clinic patient, who arrives late because of transportation problems……..
How can we ensure that medical trainees view service as an avenue to enhancing their learning, rather than a threat to it? First, we recommend that medical educators openly and frequently reaffirm that service is an explicit aim of GME….
….. Over the past decade, many medical educators have worked to optimize the educational value of residency and protect trainees from engaging in menial奴僕的 activities from which they do not learn. As such reform continues, however, it risks going too far and sacrificing certain essential educational experiences that can emerge from service activities, as well as the opportunity to teach trainees about service's importance to the profession. As we train future physicians, we should convey the message that service to patients is fundamental to our professional role and an invaluable mechanism for learning.


The 2011 Duty-Hour Requirements — A Survey of Residency Program Directors
N Engl J Med 2013; 368:694-697February 21, 2013DOI: 10.1056/NEJMp1214483
美國IOM(Institute Of Medicine)在2009年公布ACGME的調查報告,重點在要求有"Fatigue"的課程安排,至於縮減駐院醫師工時(Duty hrs.),是否有關病人安全,要在2014年可能有結果?!........

In 2010, the Accreditation Council for Graduate Medical Education (ACGME) released new Common Program Requirements designed to improve patient safety as well as resident education and quality of life.1 These rules, which went into effect in July 2011 and introduced additional regulations related to duty hours and resident supervision, have already inspired considerable debate. In studies conducted before implementation, program directors and residents expressed mixed feelings about the potential effects of the new standards.2,3 Although program directors supported the 80-hour workweek, the maximum frequency of in-house call, and mandatory off-duty time, they opposed limiting first-year residents to 16-hour shifts.2 Residents expressed greater concern than program directors, fearing potential negative effects on quality of care, as well as resident education, experience, and preparedness for senior roles. The quality of life for residents was the only factor that they predicted might improve.3
Perhaps our most important finding is the strongly negative response to the 16-hour shift limitation for first-year residents, which mirrors that of earlier surveys.2-4 As the most junior physicians in the hospital, interns may be the most susceptible to fatigue and errors due to inexperience. Yet residents and program directors do not report that interns are less fatigued or working fewer total hours…..
….Whereas most program directors approved of nearly all individual duty-hours standards, less than half expressed overall approval of the 2011 Common Program Requirements. This discrepancy may be due to the perceived negative effects on residents' education and accountability (“ownership” of patients) and perhaps also due to the increased workload the requirements have produced for program directors. Alternatively, the strong negative response to daily shift limitations, particularly the 16-hour limit for interns, may outweigh the positive response to the other standards, swaying overall sentiment. Finally, program directors may simply believe that there are too many regulations, an opinion expressed by 68.3% of respondents.
Although the ACGME remains committed to self-regulation of residency working conditions,5 our findings highlight the problem of applying a common standard to more than 100,000 resident physicians in the United States. Residents and program directors responding to national surveys since the implementation of the 2011 requirements report that the standards have had a substantial effect on the quality of residency training and residents' preparation to take on more advanced, supervisory roles. They agree that transitions of care have increased while continuity of care has decreased and that there has been no improvement in patient safety or the quality of care provided in U.S. teaching hospitals. Specialty-specific responses, however, suggest that there are fundamental differences in training expectations among disciplines, the most important of which are manifest in the transition from junior to senior resident.
……We believe that individual residency-review committees should develop rules to ensure that graduated responsibility is afforded in a safe and specialty-specific manner, while improving residents' education and quality of life as well as patient care. We also think it would be helpful to survey residents and program directors regularly to assess the effects of ACGME regulations on educational experience, achievement of milestones, competency for independent practice at graduation, life of trainees, and effects on patient care. More detailed study of the effects of fatigue and work hours on patient outcomes, “near misses,” and medical errors is also warranted. The results of these studies should be considered in future revisions of the Common Program Requirements and in the implementation of the Next Accreditation System.


The Step 2 Clinical Skills Exam — A Poor Value Proposition
Elmer Philip Lehman, IV, M.D., M.P.P., and Jason Ross Guercio, M.D., M.B.A.
N Engl J Med 2013; 368:889-891March 7, 2013DOI: 10.1056/NEJMp1213760
為甚麼會有"鮭魚返鄉”—尤奇是”來來—台大,去去去—美國的”--台灣人羨慕的美國?!
Efforts to minimize the regulatory and administrative burden in U.S. health care have never been greater. Stakeholders, including physicians, increasingly focus on eliminating waste and reducing costs in these areas to maximize the value and efficiency of care. One regulatory domain that deserves greater scrutiny in this context is medical licensure………..
For example, the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB) mandate the purchase of four licensing products by medical students and resident physicians over the course of their training. This three-step series of examinations is known as the United States Medical Licensing Examination (USMLE) and is jointly administered by the NBME and FSMB. The second exam, Step 2, is itself a two-part test administered in two sittings. One component, Step 2 Clinical Knowledge, is a multiple-choice exam; the other, Step 2 Clinical Skills (CS), is a day-long evaluation of clinical skills that takes place at one of five standardized-testing centers in the United States. Given the pass rates among examinees and the exam's cost, we believe that Step 2 CS provides a poor return on investment and little appreciable value to the U.S. health care system — and should therefore be eliminated.
The NBME and the FSMB reap impressive revenues from the administration of Step 2 CS. Using the most recent data available, we calculate that the cost of this test to U.S. and Canadian examinees is at least $20.4 million per year, given that 17,852 first-time examinees took the test in 2011 at a per-examinee cost of $1,140 (see tableFinancial Analysis of the USMLE Step 2 Clinical Skills Exam.)……..

再等一下::2014年美國的IOM report將要出刊了!!!.....這事發生在1985年左右的紐約醫學中心的事,....討論到現在還在討論住院醫師(PGY1-3---Ttrainee!!)的工時,但絕對無法符合勞工法的工時,但教育 訓練方是大大的改革了!!!

[旺大]

人再少一點，要什麼法都給你過
不做最大

床再少一點，要什麼人都給你過
不做最好...

施壓是必要的 可是不要搞成零和 彼此讓一步 積極找財源把總額弄大最優先...

不幹最大！

[Funghy]

這位學弟，實証醫學在這案不適用，這只是單純數學問題