臺灣博碩士論文加值系統

中 文 摘 要
目的：
職業世代研究的進行，可幫助我們瞭解不同職業世代之健康特性及可能危害。目前有關醫師職業群體的研究，大多著墨於西醫師之職業群體，鮮少文獻資料針對醫師群體中較為特別、且在東方民族社會仍扮演相當重要地位的中醫師做描述。中醫師與西醫師同樣具有高學歷、高社經地位且擁有豐富健康知識，但具不同醫療特性，而且中醫師在職業上有中草藥與針灸暴露的特殊性，其所呈現的健康狀態、罹病與死亡情形應有所不同。目前臺灣仍無醫師世代之相關研究。期本研究所探討中醫執業人員之特質與健康結果，能建立完善之中醫師世代資料庫以為後續研究之準備，並提供未來相關健康照護人員研究資料之參考。

材料與方法：
本研究研究對象之資料取自衛生署中醫師證照登記系統，共獲得9,981位中醫師資料。為確保中醫師世代之死因資料完整性，本研究扣除民國74年前超過85歲或未滿25歲者，餘7,675位研究對象，即為本研究之研究族群。將研究族群分別去串聯1985-2005年衛生署死亡登記擋、1998-2002年全民健保檔、及1985-2004年國健局癌症登記系統，取得796位死亡中醫師資料、269位罹癌中醫師資料6,951位存活之中醫，進一步將所串聯而得之研究族群資料與一般族群資料進行死因分布與探討、平均餘命之分析、疾病型態與罹病風險、醫療利用率及癌症發生率等分析與探討。

結果：
本研究結果顯示，中醫師之生活型態有較為健康的情況，在全死因分析部份，其SMR <1且有長於國人的平均餘命、疾病盛行率也低於國人、全癌症之SIR<1，由本研究之結果可得知中醫師職業可能有保護作用，也有比國人較為健康之事實，但本研究無法排除醫師本身自我治療及帶病工作的情況，這一部分值得進一步去關注及探討。此外，本研究中也同時顯示，中醫師在肝癌、泌尿系統惡性腫瘤SIR與泌尿系統疾病SMR皆略高於一般國人，此危險因子可能與中醫師職業暴露有關，例如中草藥重金屬污染、藥源性疾病以及醫療業務相關因素等等，顯示其可能為此職業世代的特殊職業疾病，值得我們加以重視，並進一步深入研究其相關危險因子。

結論：
醫師的健康與病人的照護息息相關，健康的醫師才能提供病人良好的照護與安全。在本研究呈現出中醫師較國人來的健康的事實，未來宜加以探討使中醫師較為健康的因子，以增進國人健康，但在中醫師特殊疾病與暴露上亦需多加重視，以其增進中醫師的整體健康。本研究結果亦可提供日後中醫師相關研究及其它相關健康照護職業世代之參考依據。

Abstract
Objectives:
Occupational studies can help us know the characteristics of different jobs. The features affecting physicians’ health, including high education, high socioeconomic status, and rich healthy knowledge would give us a concept that physicians are healthier than are general population. An important form of medications by Chinese medical physicians is very popular in Asia, including in Taiwan. Chinese medicine physicians who master traditional Chinese medicine are a special group of physicians and are critical to the quality of medical care. There are few studies related to physicians’ health and no study associated with Chinese medicine physicians in Taiwan. Through this research, we can observe the Chinese medicine physicians’ health status.

Method:
Based on the medical personnel register system with the Taiwan Department of Health, we have established a cohort of 7675 physicians in Chinese medicine between 25 years and 85 years of age since 1985. Data sources come from data of Taiwan’s death register systems, National Health Insurance Research database and Cancer Register System of Bureau of Health Promotion. In this study, we calculated the mortality, morbidity rate, medical utilization and the differences of life expectancies between physicians of Chinese medicine and the general population in Taiwan.

Result:
Our study found Chinese medicine physicians are a healthier occupational group who have lower standardized mortality ratios (SMRs), lower morbidity rates, lower standardized incidence rates (SIRs) of cancers and longer life expectancies compared to general population. However, the SIRs in urinary system and liver caner and SMRs in urinary system diseases were higher than the reference group. It maybe associated with their job exposure, such as heavy metal contaminations in herbal, drug induced diseases and medicine factors. It is necessary to investigate the risk factors of specific diseases mentioning above factors for these practitioners. We also can not exclude biases about physicians treated themselves and working illnesses which further studies should focused on.

Conclusion:
Under special occupational setting, health status of Chinese medical physicians is critical to the quality of medical care. Physicians of Chinese medicine are considered to be a healthier occupational group compared with the general population in Taiwan. Our results can provide detail data for other cohort studies associated with health care workers.

Contents

Chinese abstract ……………………………………………………………………….I
English abstract …………………………………………………………………...…III
Contents ………………………………………………………………………………V
List of figures ……………………………………………………………………….VII
List of tables ……………………………………………………………………….VIII
Chapter 1. Introduction…………………………………………………………….….1
1.1 Background…………………………………………………………………..1
1.2 Objectives…………………………………………………………………….4
1.3 Literature review……………………………………………………………..6
1.3.1 Physicians’ health characteristics………………………………………..6
1.3.2 Mortality and morbidity among physicians……………………………..8
1.3.3 Risk factors related physicians’ health…………………………………11
1.3.4 Chinese medicine physicians’ characteristics and potential risk……….13
Chapter 2. Material and methods…………………………..………………………...16
2.1 Mortality pattern and life expectancy research……………….…………….16
2.1.1 Study population………………………………………………………..16
2.1.2 Statistical analysis……………………………………………………...17
2.2 Morbidity pattern and medical utilization…………………………………..19
2.2.1 Study population………………………………………………………..19
2.2.2 Statistical analysis……………………………………………………...20
2.3 Cancer incidence research…………………………………………………..23
2.3.1 Study population………………………………………………………..23
2.3.2 Statistical analysis……………………………………………………...25
Chapter 3. Result……………………………………………………………………..26
3.1 Mortality pattern and life expectancy research results…………………..….26
3.2 Morbidity pattern and medical utilization analysis………………..………..28
3.3 Cancer incidence research results…………………………………………..31
Chapter 4. Discussion…………………………………………………………...……32
4.1 Mortality pattern and life expectancy research…………………..…………33
4.2 Morbidity pattern and medical utilization…………………………………..40
4.3 Cancer incidence research…………………………………………………..47
Chapter 5. Conclusions………………………………………………………………52
References……………………………………………………………………………53
Appendices…………………………………………………………………………...63
Appendix 1. Publications in refereed journals………………………………….63
Appendix 2. Conference papers………………………………………………...71

Reference
Baird, N., Fish, JS., Dworkind, M., et al. (1995) Physician, heal thyself. Developing a hospital-based physician well-being committee. Can. Fam. Physician., 41, 259-263.
Barger, LK., Ayas, NT., Cade, BE., et al. (2006) Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS. Med., 3, e487.
Bortz, WM. (1992) Health behavior and experiences of physicians. Results of a
survey of Palo Alto Medical Clinic physicians (review). The West. J. Med., 156, 50-51.
Breslow, NE., and Day, NE. (1987) Statistical methods in cancer research. IARC Workshop 25-27 May 1983. IARC Sci. Publ., 82, 1-406.
Breslow, NE., and Day, NE. (1994) Statistical Methods in Cancer Research. vol 1., IARC Sci. Publ., Lyon, France.
Buddeberg-Fischer, B., Klaghofer, R., Stamm, M., et al. (2008) Work stress and reduced health in young physicians: prospective evidence from Swiss residents. Int. Arch. Occup. Environ. Health., 82, 31-38.
Bureau of Health Promotion. (2002) Taiwan National Health Interview Survey,The ROC Department of Health, Taipei.
Caplan, RP. (1994) Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. Br. Med. J., 309, 1261-1263.
Carpenter, LM., Swerdlow, AJ., and Fear, NT. (1997) Mortality of doctors in different specialties: findings from a cohort of 20000 NHS hospital consultants. Occup. Environ. Med., 54, 388-395.
Chang, LK. (2002) The Role of Demographics and Behavior Pattern in Stress Perception and Approach-Avoidance Intention. Master’s thesis, National Sun Yat-sen University, Kaohsiung, Taiwan.
Chiou, HY., Hsueh, YM., Liaw, KF., et al. (1995) Incidence of internal cancers and ingested inorganic arsenic: a seven-year follow-up study in Taiwan. Cancer Res., 55, 1296-1300.
Chiou, HY., Chiou, ST., Hsu, YH., et al. (2001) Incidence of transitional cell carcinoma and arsenic in drinking water: a follow-up study of 8,102 residents in an arseniasis-endemic area in northeastern Taiwan. Am. J. Epidemiol., 153, 411-418.
Davanzo, E., Frasson, C., Morandin, M., et al. (2008) Occupational blood and body fluid exposure of university health care workers. Am. J. Infect. Control., 36, 753-756.
Davidson, SK., and Schattner, PL. (2003) Doctors' health-seeking behaviour: a questionnaire survey. Med. J. Aust., 179, 302-305.
Division of Health Statistics. (2002) Statistical Annual Report of Medical Care, National Health Insurance, The ROC Department of Health, Taipei.
Division of Health Statistics. (2003) Statistical Annual Report of Medical Care, National Health Insurance, The ROC Department of Health, Taipei.
Division of Health Statistics. (2006) Statistical Annual Report of Medical Care, National Health Insurance, The ROC Department of Health, Taipei.
Division of Health Statistics. (2007) Statistical Annual Report of Medical Care, National Health Insurance, The ROC Department of Health, Taipei.
Doll, R., and Hill, A.B. (2004) The mortality of doctors in relation to their smoking habits: a preliminary report. Br. Med. J., 328, 1529-1533.
Doll, R., and Peto, R. (1976) Mortality in relation to smoking: observation on male British doctors. Br. Med. J., 2, 1525-1536.
Doll, R., and Peto, R. (2000) Boreham J and Sutherland I: Smoking and dementia in male British doctors: Prospective study. Br. Med. J., 320, 1097-1102.
Erica, F., Holly, B., and Carol AB. (2000) Mortality rates and causes among U.S. physicians. Am. J. Prev. Med., 19, 155-159.
Eriksson, M., Hardell, L., Malker, H., et al. (1998) Increased cancer incidence in physicians, dentists, and health care workers. Oncol. Rep., 5, 1413-1418.
Ernst, E. (2000) Prevalence of use of complementary/alternative medicine; a systematic review. Bull. World Health Organ., 78, 252-257.
Firth-Cozens, J., and Greenhalgh, J. (1997) Doctors’ perceptions of the links between stress and lowered clinical care. Soc. Sci. Med., 44, 1017-1022.
Forsythe, M., Calnan, M., and Wall. (1999) Doctors as patients:postal survey examining consultants and general practitioners adherence to guidelines. Br. Med. J., 319, 605-608.
Frank, E., Brogan, DJ., Mokdad, AH., et al. (1998) Health-related behaviors of women physicians vs. other women in the United States. Arch. Intern. Med., 158, 342-348.
Frank, E., Biola, H., and Burnett, CA. (2000) Mortality rates and causes among U.S. physicians. Am. J. Prev. Med., 19, 155-159.
Gijsbers van Wijk, C.M., Kolk, A.M., van den Bosch, W.J., & van den Hoogen, H.J. (1992) Male and Female Morbidity in General Practice: The Nature of Sex Differences. Soc. Sci. Med., 35, 665-678.
Goodman, LJ. (1975) The longevity and mortality of American physicians, 1969-1973. Health and Soc., Summer, 353-375.
Hawton, K., Clements, A., Sakarovitch, C., et al. (2001) Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J. Epidemiol. Community Health., 55, 296-300.
Huang, IC., Yang, CH., Sung, FC., et al. (2009) Risks of ambulatory cares among female nursing staffs in Taiwan. J. Clin. Nursing., 18, 1207-1216.
Hughes, PH., Brandenburg, N., Baldwin, DC., et al. (2001) Prevalence of substance use among US physicians. JAMA., 267, 2333-2339.
Innos, K., Rahu, K., Baburin, A., et al. (2002) Cancer incidence and cause-specific mortality in male and female physicians: a cohort study in Estonia. Scand. J. Public. Health., 30, 133-140.
Juel, K., Mosbech, J., and Hansen, ES. (1997) Mortality and cause of death among Danish physicians 1973-1992. Ugeskr. Laeg., 159, 6512-6518.
Juel, K., Mosbech, J., and Hansen, ES. (1999) Mortality and causes of death among Danish medical doctors 1973-1992. Int. J. Epidemiol., 28, 456-460.
Karasek, R., Baker, D., Marxer, F., et al. (1981) Job decision latitude, job demands and cardiovascular disease: a prospective study of Swedish men. Am. J. Pub. Health., 71, 694-705.
Kariv, D., Offer, I., Notzer, N., et al. (2007) Israeli Physicians’ Performance after Sleep Deprived Situations-Differences among Male and Female Hospital Residents. Ethno-Med., 1, 59-70.
Kivimäki, M., Sutinen, R., Elovainio, M., et al. (2001) Sickness absence in hospital physicians: 2 year follow up study on determinants. Occup. Environ. Med., 58, 361-366.
Lai, MN., Lai, JN., Chen, PC., et al. (2009) Increased risks of chronic kidney disease associated with prescribed Chinese herbal products suspected to contain aristolochic acid. Nephrolgy (Carlton),14, 227-234.
Lai, MS., Chung, KP., Tang, ST., et al. (2007) Assessment of the health care quality among cancer centers in Taiwan, DOH93-HP-1057. Taipei: Bureau of Health Promotion.
Lamberg, L. (2002) Long hours, little sleep: bad medicine for physicians-in-training? JAMA., 287, 303-306.
Landrigan, CP., Rothschild, JM., Cronin, JW., et al. (2004) Effect of reducing interns’ work hours on serious medical errors in intensive care units. New Eng. J. Med., 351, 1838-1848.
Lee, CH., Wang, JD., and Chen, PC. (2008) Case-crossover study of hospitalization for acute hepatitis in Chinese herb users. J. Gastroenterol. Hepato., 23, 1549-1555.
Li, CY., and Sung, FC. (1999) A review of the healthy worker effect in occupational epidemiology. Occu. Med., 49, 225-229.
Li, J., Yang, W. and Cho, SI. (2006) Gender differences in job strain, effort-reward imbalance, and health functioning among Chinese physicians. Soc. Sci. Med., 62, 1066-1077.
Lin, CM., Yang, CH., Sung, FC., et al. (2008) Risks and causes of hospitalizations among physicians in Taiwan. Health. Serv. Res., 43, 675-692.
Lindeman, S., Läärä, E., Hakko, H., et al. (1996) A systematic review on gender-specific suicide mortality in medical doctors. Br. J. Psychiatry., 168, 274-279.
Lindeman, S., Läärä, E., Hirvonen, J., et al. (1997) Suicide mortality among medical doctors in Finland: are females more prone to suicide than their male colleagues? Psychol. Med., 27, 1219-1222.
Liu, SH., Wu, CS., Lin, YL., et al. (2008) Lower mortality in male physicians of Chinese medicine than male population in Taiwan. Tohoku J. Exp. Med., 216, 187-194.
Lotufo, PA., Gaziano, JM., Chae, CU., et al. (2001) Diabetes and all-cause and coronary heart disease mortality among US male physicians. Arch. Intern. Med., 161, 242-247.
Lu, JRF., and Hsiao, WC. (2003) Does universal health insurance make health care unaffordable? lessons from Taiwan. Health. Aff., 22, 77-88.
Lu, TH., Chang, HY., Hwu, CM., et al. (2001) Comparison of official coders versus physician panel in assignment of underlying cause of death. J. Formos. Med. Assoc., 100, 365-369.
McMichael, AJ., Spirats, R., and Kupper, LL. (1986) An epidemiological study of mortality within a cohort of rubber workers, 1964-72. J. Occup. Med., 18, 165-168.
Monson, RR. (1987) Observations on the Healthy Worker Effect. J. Occup. Med., 28, 425-433.
Mori, M., Inutsuka, H., Wada, I., et al. (1998) Factors associated with hepatitis C virus transmission in the area of high incidence of hepatic cancer in Japan. Hepatol. Res., 10, 17-26.
Nelson, DE., Giovino, GA., Emont, SL., et al. (1994) Trends in cigarette smoking among US physicians and nurses. JAMA., 271, 1273-1276.
Nortier, JL., and Vanherweghem, JL. (2002) Renal interstitial fibrosis and urothelial carcinoma associated with the use of a Chinese herb (Aristolochia fangchi). Toxicology., 27, 577-580.
Ostlin, P. (1989) The ‘Healthy-Related Selection Effect’ on Occupational Morbidity Rates. Scand. J. Soc. Med., 17, 265-270.
Peter, R., and Siegrist, J. (2002) Psychosocial work environment and the risk of coronary heart disease. Int. Arch. Occup. Environ. Health., 73, S41-S45.
Rosvold, EO., and Bjertness, E. (2001) Physicians who do not take sick leave: hazardous heroes? Scand. J. Public Health., 29, 70-71.
Rosvold, EO., and Bjertness, E. (2002) Illness behaviour among Norwegian physicians. Scand. J. Public Health., 30, 125-132.
Saper, RB., Kales, SN., Paquin, J., et al. (2004) Heavy metal content of ayurvedic herbal medicine products. JAMA., 292, 2868-2873.
Schlicht, SM., Gordon, IR., Ball, JRB., et al. (1990) Suicide and related deaths in Victorian doctors. Med. J. Aust., 153, 518-521.
Shanafelt, TD., Sloan, JA., and Habermann, TM. (2003) The well-being of physicians. Am. J. Med., 114, 513-519.
Shin, YC., Kang, JH., and Kim, CH. (2005) Mortality among medical doctors based on the registered cause of death in Korea 1992-2002. J. Prev. Med. Pub. Health., 38, 38-44.
Shin, HR., Kim, JY., Ohno, T., et al. (2000) Prevalence and risk factors of hepatitis C virus infection among Koreans in rural area of Korea. Hepatol. Res., 17, 185-196.
Shin HR, Kim JY, Kim JI, et al. (2002) Hepatitis B and C virus prevalence in a rural area of South Korea: the role of acupuncture. Br. J. Cancer., 87, 314-318.
Stavem, K., Hofoss, D., Aasland, OG., et al. (2001) The self-perceived health status of Norwegian physicians compared with a reference population and foreign physicians. Scand. J. Public Health., 29, 194-199.
Stavem, K., Hofoss, D., and Aasland, OG. (2003) Work characteristics and morbidity as predictors of self-perceived health status in Norwegian physicians. Scand. J. Public Health., 31, 375-381.
Steenland, K., Hu, S., and Walker, J. (2004) All-cause and cause-specific mortality by socioeconomic status among employed persons in 27 US States, 1984–1997. Am. J. Public Health., 94, 1037-1042.
Su, FH., Cheng, SH., Li, CY., et al. (2007) Hepatitis B seroprevalence and anamnestic response amongst Taiwanese young adults with full vaccination in infancy, twenty years subsequent to national hepatitis B vaccination. Vaccine., 25, 8085-8090.
Sulaiman, HA., Julitasari, Sie. A., et al. (1995) Prevalence of hepatitis B and C viruses in healthy lndonesian blood donors. Trans. R. Soc. Trop. Med. Hyg., 89, 167-170.
Sun, CA., Chen, HC., Lu, CF., et al. (1999) Transmission of hepatitis C virus in Taiwan: prevalence and risk factors based on a nationwide survey. J. Med. Virol., 59, 290-296.
Sun, WY., Chen, WW., Chen, L., et al. (1995) Difference of lifestyle advice between traditional Chinese medical doctors (TCMDs) and Western-style medical doctors (WSMDs) in People's Republic of China. Patient Edu. Couns., 25, 311-316.
Thompson, WT., Cupples, ME., Sibbett, CH., et al. (2001) Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study. Br. Med. J., 323, 728-731.
Torre, DM., Wang, NY., Meoni, LA., et al. (2005) Suicide compared to other causes of mortality in Physicians. Suicide Life-Threat Behav., 35, 146-153.
Ullmann, D., Phillips, RL., Beeson, WL., et al. (1991) Cause-specific mortality among physicians with differing life-styles. JAMA., 265, 2352-2359.
van Vegchel, N., de Jonge, J., Bosma, H., et al. (2005) Reviewing the eVort–reward imbalance model:drawing up the balance of 45 empirical studies. Soc. Sci. Med., 60, 1117-1131.
Wachtel, TJ., Wilcox, VL., Moulton, AW., et al. (1995) Physicians’ utilization of care. J. Gen. Intern. Med., 10, 261-265.
World Health Organization. (1992) The Victoria Declaration on heart health, The World Health Organization, Geneva
World Health Organization. (2002) WHO traditional medicine strategy 2002-2005. Geneva, Switzerland.
Williams, SV., Munford, RS., Colton, T., et al. (1971) Mortality among physicians: a cohort study. J. Chron. Dis., 24, 393-401.
Wu, AW., Folkman, S., McPhee, SJ., et al. (1991) Do house officers learn from their mistakes? JAMA., 265, 2089-2094.
Yang, HY., Wang, JD., Lo, TC., et al. (2009) Increased mortality risk for cancers of the kidney and other urinary organs among Chinese herbalists. J. Epidemiol., 19, 17-23.
Yeh, JY., Xirasagar, S., Liu, TC., et al. (2008) Does marital status predict the odds of suicidal death in Taiwan? A seven-year population-based study. Suicide Life Threat. Behav., 38, 302-310.
Zhang, M., Wang, H., Miao, J., et al. (2009) Occupational exposure to blood and body fluids among health care workers in a general hospital, China. Am. J. Ind. Med., 52, 89-98.