금연정책에 대한 의사들의 정책 정향성 고찰 -심층 인터뷰 결과를 중심으로-

유현재,유명순 한국헬스커뮤니케이션학회 2019 헬스커뮤니케이션연구 Vol.18 No.2

Among diverse medical professionals, physicians have been very important agent in terms of planning and executing many types public health policies in every society. Even though the government is the main agent that plan, execute, and manage every single health policy, we absolutely cannot ignore the important roles and responsibilities of the physicians for making the policies successful. However, researchers have pointed out that there have not been enough academic studies not only dealing with diverse issues related with physicians, but also using physicians as the subjects. Using in-depth interviews with physicians as a data gathering method, this study identified the physicians’ perspectives toward diverse public health policies including antismoking policies and the suggestions for more effective management of health policies. As a specific case, the present study used one of the major antismoking policies in Korea “Smoking treatment by medical professionals” in which the government encourages smokers to go to see physicians for quitting smoking. This policy was initiated in 2015 right after a big price increase of cigarette products in Korea. The goal of this exploratory study is to get meaningful insights supposedly helpful for successful execution of diverse healthcare policies in Korea including the antismoking policy through hearing the physicians’ policy orientations which are their opinions and basic perspectives toward specific policy. As research questions applied in this study, the authors tried to mainly answer following questions: 1) What, and how much accountabilities do the physicians feel regarding public healthcare policies in general? 2) What kind of governance do the physicians suggest regarding the effective management of public healthcare policies including the antismoking policy introduced? 3) What type(s) of specific strategies do the physicians recommend as the tools for better execution of the policy? As the results, the authors found that the physicians’ answers were actually talking about the accountability, governance, and the strategies which were assumed by the researchers as major theoretical concepts for this study in the first place. Some physicians pointed out that there have been less active interactions not only between physicians and government, but also among the physician groups themselves were seen which surely were not helpful at all for successful management of healthcare policies in this society. 의사는 우리나라에서 수행되는 보건의료 정책에 있어 매우 중요한 위치를 차지한다. 정책의 실행 주체는 정부기관이지만, 다수 보건의료 정책의 실현과 효과적 운영이라는 차원에서는 의사의 역할과 참여, 책임은 결코 간과될 수 없기 때문이다. 그럼에도 불구하고, 보건의료 관련 연구 가운데 의사를 활용하거나 의사에 관한 사안을 다루는 사례는 중요성에 비해 많지 않았던 것도 사실이다. 의사를 활용한 설문조사, 인터뷰 등이 여타 대상자들에 비해 쉽지 않다는 현실도 있으며, 더불어 구체적 정책들의 입안과 실현, 발전 등 일련의 과정에서 의사들이 효과적 또는 적극적으로 의견을 개진하였는지, 여타 주체와의 시각을 교환하려는 노력은 충분했는지 등에 대한 견해도 상이할 수 있다는 판단이다. 이 같은 배경을 근거로, 본 연구는 의사들과의 심층 인터뷰를 통해 금연과 관련된 정책 정향성(Policy Orientation) 즉 우리나라에서 수행되는 금연 정책에 대해 의사들이 보유한 다양한 시각들, 즉 정책 수립 과정에 대한 의견과 정책의 효율성에 대한 측면, 효과적 정책 실현을 위한 제언 등을 심층적으로 파악하고자 하였다. 인터뷰의 주요 주제이자, 구체적 사례는 지난 2015년 담배 가격의 인상과 함께 시행되어 2020년 현재까지 시행되고 있는 ‘의사중심의 금연치료’정책을 선택하였으며, 현재 우리나라에서 중요한 보건의료 사안 중 하나라고 판단되었다. 본 연구는 금연정책, 특히 의사 중심의 금연치료 정책을 대상으로, 기존에 충분히 논의되지 않았던 의사들의 견해 및 정책 정향성(Policy Orientation)을 고찰함으로써, 향후 성공적인 정책수행을 위한 시사점을 도출하려는 목적을 가진다. 연구자는 인터뷰를 통해 파악될 내용들이 의사가 건강 자체 혹은 보건의료정책과 관련하여 어떠한 1) 전문가 책무성(Accountability)을 느끼고 있는지, 또한 보건의료 정책의 시행과 관련하여 어떠한 형태의 2) 거버넌스(Governance)를 제안하는지, 그리고 정책의 성공을 위한 3) 구체적인 전략(Strategies)으로서 어떠한 요소들을 언급하는지 등의 소주제로 구조화될 것을 예상하며 연구목표와 연구문제를 설정하였다. 연구결과, 위에 설정한 개념들(책무성, 거버넌스, 전략)에 직간접적으로 해당되는 사안들이 인터뷰를 통해 다수 도출되었으며, 여타 본 주제와 관련하여 추가적 논의가 필요한 항목들 또한 관찰되었다.

진료를 받는 고혈압 환자의 혈압 조절과 관련된 의사 요인

김소영,조인숙,이재호,김지현,이은정,박종혁,이진석,김윤,Kim, So-Young,Cho, In-Sook,Lee, Jae-Ho,Kim, Ji-Hyun,Lee, Eun-Jung,Park, Jong-Hyock,Lee, Jin-Seok,Kim, Yoon 대한예방의학회 2007 예방의학회지 Vol.40 No.6

Objectives : Little is known about the physician-related factors that are associated with the management of Hypertension. The purpose of this study was to determine the physician-related factors associated with blood pressure control in hypertensive patients. Methods : We surveyed 154 physicians at 117 public health (subhealth) centers in Gyeonggi-do, Forty-one physicians completed the survey (response rates : 26.6%) and 31 physicians were finally included as the study subjects. Using the information obtained from the self-reported survey, we measured the physician-related factors associated with hypertension control, including their perception of hypertension, prescription patterns (combination prescription rates, specific antihypertensives prescription rates among patients with diabetes mellitus), and sociodemographic factors. We then collected data on blood pressure and medication use in patients seen by these physicians from the health center#s information system. We compared the physicians# perceived hypertension control rates with the actual rates, and then evaluated the rate of high overestimation (overestimation by more than 25% of the median degree of hypertension control rate overestimation) among the physicians. The physicians# antihypertensive prescription patterns were also evaluated. Multiple logistic regression analysis was used to evaluate the independent association between hypertension control and physician-related factors. Results : The physicians tended to overestimate the proportion of their patients with controlled blood pressure (79.5% perceived vs. 57.8% actual). The percentage of physicians with high overestimation was 35.5% (11 physicians). The physicians with lower control rates were more likely to highly overestimate their patients# control rates. Physicians with below-median actual control rates tended to prescribe fewer combination treatments for patients with uncontrolled blood pressure and angiotensin-converting enzyme inhibitors or fewer angiotensin receptor blockers for patients with diabetes mellitus. The rate of high overestimation by physicians was 1.31 times higher in patients with uncontrolled blood pressure than in patients with other conditions (OR=1.31, 95% CI : 1.17-1.48). Conclusions : Physicians have a tendency to overestimate the rates of hypertension control in their patients. Because physicians have a direct role in treatment outcomes, physicians# overestimation about hypertension management contributes to inadequate blood pressure control. Thus, interventions for improving physician# awareness regarding the management of patients with hypertension are needed.

부산시 개원 의사와 개국 약사의 의약분업 정책목적 달성도와 손익에 대한 인식도

박재성,남은우,권영철 한국보건행정학회 2001 보건행정학회지 Vol.11 No.4

The purpose of this study was to identify health care providers' perceptions about the goal achievement and benefit/loss caused by the separation policy of drug prescribing and dispensing after the policy implemented on July 1, 2001. Uslng stratified sampling method based on the administration area, Ku, 315 physicians and pharmacists were sampled from the rosters of physician and pharmacist association in the city of Busan on 2001. There were 122 and 115 responses from physician and pharmacist sample, respectively. 78.3% of physicians and 50.4% of pharmacists evaluated that the goal of the policy was not achieved. Moreover, 75.3% of physicians and 40.7% of pharmacists did not support the policy. Most physicians and pharmacists considered preventing the citizens with drug abuse and misuses as the most important benefit derived from the policy. However, physicians and pharmacists concerned over raising health care cost that could be patients' burden. The most important physicians' benefit derived from the policy was free choice of all possible medicine that might result in effectiveness of medication. In physicians' the most important loss, most physicians worried about that breaking traditional patient and physician relationship might cause physicians' authority in treating diseases to be damaged. Pharmacists considered the most important policy benefit as hiked social status resulted from enforcement of profession due to the policy whereas they considered the most significant loss as expected financial problems of small pharmacies compared to that of large pharmacies or pharmacies adjacent to hospitals. In the current problems of the policy, physician and pharmacists blamed the government for inadequate preparations of the policy implementation. Physicians and pharmacists also considered citizens' mature attitudes toward the policy as a crucial success factor.

의사의 커뮤니케이션 스타일과 질, 의사-환자관계 유형에 따른 환자만족 요인

임지혜 ( Jee Hye Im ),이기효 ( Key Hyo Lee ),백수경 ( Soo Kyeong Paik ) 한국병원경영학회 2009 병원경영학회지 Vol.14 No.3

The main objective of this study is to investigate the influence of physician`s communication styles and quality, and physician-patient relationship on patient satisfaction for improving physician`s communication which is one of factors determining service quality in health care services, and providing the suggestion for building the positive physician-patient relationship. Data were collected from 341 inpatients in 13 general hospitals and university hospitals located in Busan Metropolitan City and Kyeongsang-do area using structured self-administered questionnaires. Major results of the empirical analysis are as follows; First, mutual-opened-cooperative physician-patient relationship, patient`s communication receptive attitude, patient-oriented physician`s communication style, and quality were significantly varied by respondents` characteristics such as age, consensual, job, and income. Second, empathy, patient`s communication receptive attitude, physician-patient relationship, and patient satisfaction were significantly varied by respondents` medical-related conditions. Third, there was a significant correlation between active communication receptive attitude of patient and mutual-opened-cooperative physician-patient relationship. Fourth, patient-oriented physician`s communication style and physician-patient relationship were found to have positive influence on total communication quality and effectiveness and empathy facet of communication quality both. Finally, patient-oriented physician`s communication style, empathy, active communication receptive attitude of patient, and mutual-opened-cooperative physician-patient relationship were found to have positive influence on patient satisfaction. This research findings suggest that putting emphasis on effective physician`s communication and enhancing positive physician-patient relationship are crucial for marketing activities and customer satisfaction management in health care settings.

의사와 간호사의 복장에 대한 의사, 간호사 및 환자의 견해

김석범,강복수,정연희 영남대학교 의과대학 1996 Yeungnam University Journal of Medicine Vol.13 No.2

의사와 간호사의 복장에 대한 견해를 파악하기 위하여 1996년 3월 1일부터 1996년 3월 31일까지 영남대학교 의료원에 근무하는 의사 130명, 간호사 147명과 입원환자 211명을 대상으로 자기기입식 설문조사를 실시하였다. 의사의 복장에서는 의사와 간호사 모두 기존 코트 형태ㅡ이 가운보다 다른 형태의 가운을 선호하였고, 특히, 의사보다 간호사들이 더 선호하였다. 환자에서 전체적으로 기존 형태와 다른 형태의 가운에 대한 선호도의 차이는 없었으나 학력이 높을수록 다른 형태의 가운을 더 선호하였다.(p<0.01) 의사의 가운 색상에 있어 의사와 간호사의 73.6%는 흰색을 선호하였으며, 환자는 86.3%가 흰색을 선호하였다. 남자의사가 여자의사와 간호사에 비해 흰색을 더 산호하였고 (p<0.01), 환자에서는 색상선호도에 대한 유의한 차이는 없었다. 진료시 넥타이를 착용해야 한다라는 응답률이 남자의사, 40세 이상 의사, 내과계 근무의사, 그리고 ㄱ됴수에서 다른 군보다 유의하게 높았다. (p<0.01). 환자에서는 여자가 남자보다, 60세 이상군이 다른 연령군보다, 초등졸 이하군이 다른 학력군보다, 기타 시지역 거주자와 군 지역 거주자가 대구시 거주자보다 더 높았다(p<0.01). 주말 및 휴일 진료시 의사의 캐쥬얼 복장에 대해서는 전체적으로 찬성하는 편이었고, 의사의 연령이 젊을수록 유의하게 선호도가 높았다(p<0.05). 간호사 복장에 대해서는 의사와 간호사 전체의 78%가 바지 착용을 선호하였고 간호사는 96%가 바지 착용을 선호하였으며, 특히, 40세 이상군과 외래, 지원 및 행정부서에 근무하는 간호사들은 100% 선호하였다. 환자들은 학력이 낮을수록 스커트를 선호하였고, 고학력군일수록 바지 착용을 선호하였다. 간호사의 가운 색상에 대해서는 의사와 간호사 전체의 46.7%가 흰색을 선호하였고, 의사들은 흰색을, 간호사들은 다른 색을 더 선호하였다(p<0.01) 환자들은 79.1%가 흰색을 선호하였다. 캡 착용에 대한 문항에서 간호사들은 95.9%가 착용하지 않아도 좋다라고 응답하였으며, 특히, 40세 이상군과 외래 및 특수부서에 근무하는 간호사들은 전원캡을 착용하지 않아도 좋다라고 응답하였다. 반면에 환자들은 77.7%가 캡을 착용하여야 한다라고 응답하였다. 이상의 결과로 보아 의사와 간호사의 복장은 기존의 전통적인 형태와 색상만을 고집할 것이 아니라, 의사와 간호사 본인들과 환자들의 의견을 만족시킬 뿐만 아니라 시대적 흐름과 현실감각에 맞게 가운의 형태와 색상에 변화를 주는 것을 고려하는 것이 좋을 것이라고 사료되었다. A survey was conducted to study attitudes of physician, nurse and patient towards physician's and nurse's uniform, from March 1 to March 31, 1996. The study population was 130 physicians and 147 nurses engaged in Yeungnam University Medical Center and 211 inpatients of Yeungnam University Medical Center. A questionnaire method was used to collect data. The following are summaries of findings: In the respect of physician's uniform, both physicians and nurses preferred other type of gown to the traditional coat-typed one and especially, nurses preferred more than physicians. Patients showed no difference in the preference of the traditional one and other form of gown as a whole but those who had higher educational level preferred other form of gown(p<0.01). Regarding the color of physician's gown, 73.6% of physicians and nurses liked white color, and 86.3% of the patients also liked the white color. Male physicians preferred the white color more than female physicians and nurses(p<0.01). Patients showed no meaningful difference for the color. The opinion of insisting on wearing a necktie when physician see patients was given by male physicians, physicians of fifty or more, physicians working in the field of medicine and professors, which showed significantly higher percentage than other group(p<0.01). In the group of patients, the same opinion was given by female, the group of sixty or more, the group of elementary school graduates or less and people residing in other cities and counties more than male, the group of other ages, the group of having higher educational level and people of Taegu city(p<0.01). It tended to agree wearing casual wear of physician during the working time of weekend and holiday as a whole. Younger physicians showed significantly higher preference for it(p<0.05). Regarding the nurse's uniform, both physicians and nurses preferred trousers, and 96% of the nurses did. Especially, nurses who were forty years old or more and who served at outpatient department and administrative and aid parts expressed 100 percent partiality to trousers. For the patients, those who had lower educational level preferred skirt and those who had higher educational level preferred trousers. As to the color of nurse's gown, 46.7% of the physicians and nurses liked white color. The physicians preferred white and nurses preferred other color(p<0.01). Of the patients, 79.1% liked white color. Regarding the wearing cap, 95.9% of the nurses replied it didn't have to wear the cap. The nurses who were fifty or more and who served at outpatient department and special parts gave whole answers of not having to wear the cap. On the other hand, 77.7% of the patients answered nurse had to wear the cap. From the above findings, it would be advisable to give a change to the forms and colors of the gowns to match with the trend and sense of the time instead of insisting on the traditional typical ones.

의사 특성에 따른 외래 진료내용의 변이

정은경,문옥륜,김창엽,Jeong, Eun-Kyeong,Moon, Ok-Ryun,Kim, Chang-Yup 대한예방의학회 1993 예방의학회지 Vol.26 No.4

It is well known that a physician's personal characteristic affects his practice pattern. Furthermore, a physician's specialty has powerful influences on his practice pattern. However, despite the fact that specialization has received the most attention for its influence on physician's service behavior, few studies have been conducted on the variations of contents and volume of physician's services. This study has intended to identify factors influencing the practice variations according to various physician characteristics. There are some other evidences that medical care providers are different in using of health services and resources in Korea. Four physician characteristics were selected for the analysis, two demographical factors, age and sex, and two practice factors, place of practice and medical specialty. Also, three indicators of service amount (total amount of insurance claim bill, number of visits per case, number of prescriptions per case) were selected. From the pool of insurance claims for ambulatory care received by the Korean National Federation of Medical Insurance(NFMI), 84,898 cases were randomly sampled. In the meantime using physician database of NFMI, 613 general practitioners (GP), 107 regular family physicians (FP), 483 'grandfather' family physicians(GFP), and 1,157 specialist practitioners(SP) were randomly sampled. Their different practice contents were compared concerning the specialty, age groups, sex, and practice sites (urban-rural) Specialist physicians tend to provide more costly care than do generalists. General practitioners and family physicians usually make fewer following visits and prescriptions. Age is also the important factor in determining the amount of services, which is highest at the physician's age group of 40's. Female doctors and urban practitioners use much more resources than their counterparts respectively. Research findings suggest that physician's characteristics particularly the specialty can affect practice patterns and resource utilizations. Other characteristics such as age and sex are not controllable but physician's specialty is relatively easily controllable during the entire phases of policy implementation. This is all the more true in the individual's initial decision of his specialty. Specialization therefore should receive policymaker's attention for its potential influence on medical care utilization and health care expenditure.

진료보조인력(Physician Assistant)의 법적지위에 관한 고찰: 자격조건과 업무범위를 중심으로

권오탁 한국법제연구원 2021 법제연구 Vol.- No.61

If a person who is not a physician is medical practice as a physician, it is an unlicensed medical practice under the current law. And it's an illegal act. However, due to the lack of physicians now, health professionals other than physicians are engaged in medical practice. And they know that their actions are illegal. However, it is undesirable to allow anyone other than a physician to perform medical practice that deals with the life of a patient for any reason. Therefore, in order for a person other than a physician to medical practice, strict qualifications must be met. In addition, the scope of work must be determined. As a result, it is necessary to give a solid legal status as a new health professionals who can legally assist physicians. Three conditions must be met to clarify the legal status of physician assistants. First, physician assistants must have a certain level of qualification. In order for physician assistants, a new type of health professionals, to perform physician's work, they must go through a reasonable curriculum and strict verification process. Therefore, it is necessary to complete the curriculum of university education or higher, and have at least one year of basic medical education and clinical field practice. In addition, only those who have passed the national examination should be granted a license and perform physician assistance services. Second, the scope of work should be clarified. Physician assistants must be directed and supervised by a Physician. In addition, physician assistants cannot perform essential medical practices such as diagnosis, prescription, and surgery under any circumstances. Third, the scope of responsibility for work must be determined. Physician assistants form a vertical work relationship with physicians. Therefore, physician assistants are implementation assistants. So physicians are responsible for contracts under civil law and for management and supervision under criminal law. In addition, physician assistants and health professionals such as medical resident, nurses, and medical service technologist form a horizontal work relationship. Therefore, their scope of responsibility is determined by the degree of fulfillment of their respective duty of care. The fundamental solution to the problem of physician assistants is to increase the number of physicians. However, increasing the number of physicians is not an easy problem. So it takes a lot of time to solve the problem. Therefore, in order to save the patient's life, it is necessary to improve the system so that qualified physician assistants can work stably. And work is already subdivided in the medical field. Ultimately, legalizing physician assistants reflects the reality of the medical field. And this will be a condition for faithfully fulfilling the duty of the state to save the patient's life. 의사가 수행하는 의료행위를 의사 이외의 자가 수행하면 현행법상 무면허의료행위이며따라서 불법행위이다. 그러나 부족한 의사인력의 공백을 채우기 위해 의사 이외의 보건의료인력이 불법행위임을 알면서도 무면허의료행위를 수행하고 있는 것이 현재 우리 의료현장의현실이다. 그리고 이들을 진료보조인력이라고 명명하고 있다. 그러나 이처럼 검증되지 않은자가 지속적으로 환자의 생명을 다루는 직무를 수행하도록 용인하는 것은 바람직하지 않다. 따라서 의사가 아닌 진료보조인력이 의사업무를 수행할 필요가 있다면 엄격한 자격조건을갖추고 일정한 업무범위 내에서 합법적으로 의사의 업무를 수행하거나 또는 의사의 진료를보조할 수 있도록 새로운 보건의료인력으로서의 명확한 법적지위를 부여할 필요가 있다. 진료보조인력의 법적지위를 명확히 하려면 첫째, 자격조건을 갖춰야 한다. 진료보조인력이 새로운 형태의 보건의료인력으로써 의사만이 수행할 수 있는 업무를 수행하기 위해서는합당한 교육과정과 엄격한 검증과정을 거쳐야 한다. 따라서 대학교육이상의 교육과정을 이수한 자가 최소 1년 이상의 기초의학교육과 임상 현장실습을 이수하고 국가시험을 통해 검증된 경우에만 면허를 부여하고 해당업무를 수행하도록 하는 것이 바람직하다. 둘째, 업무범위를 명확히 해야 한다. 진료보조인력이 의사업무를 수행한다고 하더라도 이는 의사의 지시와 감독권 내에서 수행해야 하며 진단‧처방‧수술과 같은 핵심적이고 필수적인 의사의 고유업무는 이들이 수행할 수 있는 업무범위에서 환자의 안전을 위해 필연적으로 제외시켜야 한다. 셋째, 업무에 대한 책임범위가 확정되어야 한다. 진료보조인력은 수행하는 업무에 대한 지시와 감독을 의사에게 받는다는 점에서 의사와 수직적 업무관계를 형성한다. 따라서 진료보조인력과 의사간의 법률관계에서 진료보조인력은 이행보조자의 지위에 놓이게 되며, 의사는민법상으로는 계약책임을, 형법상으로는 관리감독책임을 진다. 그러나 전문의에게 지시와감독을 받는 전공의, 간호사, 응급구조사 등의 보건의료인력과 진료보조인력은 수평적 업무관계를 형성한다. 따라서 전공의, 간호사 등 보건의료인력과는 각자의 주의의무 이행 여부에따라 책임범위를 판단해야 한다. 이미 의료현장에서는 상당한 역할을 수행하고 있으나 규범적으로는 무면허의료행위를 하는 진료보조인력의 문제를 근본적으로 해결하는 방안은 충분한 의사인력을 확충하는 것이다. 그러나 의사인력 확충 문제는 다양한 이해관계가 복잡하게 얽혀있어 해결되는데 상당한시간이 필요할 것으로 예상된다. 따라서 현재 환자의 생명을 살리기 위해 의료현장에서 무면허의료행위를 하고 있는 진료보조인력이 충분한 자격조건을 갖추고 합법적인 지위에서 안정적으로 근무할 수 있도록 제도를 정비할 필요가 있다. 또한 이미 의료행위가 세분화되면서다양한 형태의 보건의료인력이 협력할 수밖에 없는 것이 임상의료현장의 현실이라는 점에서도 진료보조인력의 합법화를 위한 제도보완이 필요하며 이는 종국적으로 환자의 생명, 더 나아가 국가의 국민건강보장 의무를 충실히 이행하기 위한 전제조건이 될 것이다.

공중보건의의 정신장애자 진료실태에 관한 연구

서동우,이부영,문옥륜 大韓神經精神醫學會 1991 신경정신의학 Vol.30 No.5

The authors investigated the current status and problems of care for the mentally ill patients by public health physicians. The subjects were 314 public health physicians, who replied to self reporting questionnaires. The results are as follows; 1) There are few phychiatric facilities near mos of health subcenters, and only 18.5% of Public Health Physicians consult with psychiatrists. 2) The average proportion, of mental illness namely the number of mentally ill patients divided by that of the whole patients, is 2.1%. The number of mentally ill patients per resident population of 100,000 is 172. 3) Most of public health physicians show positive attitude toward his participation in the care for mentally ill patients. 4) The will ingness of participation of public health physicians in care for mental ill patients are significantly different depending on experience of intership, interested field of medicine, and attitude of family member to the psychiatric admission. The proportions of mental illness were significantly different depending on their experience in the psychiatric ward. 5) 71.0% of public health physicians treat mentally ill patients with psychotropic drugs, but many of them dont`s have nor prescribe psychotropic drugs except anxiolytics. 6) Public health physicians refer 35.9% of the mentally ill patients to the psychiatric facilities, and the referral rate of the psychosis is higher than that of the neurosis. 7) Public health physicians reported the difficulties in care of the mentally ill patients as follows; low affordability for medical costs lack of psychiatric knowledge of the public health physicians, deficiency of effectiveness in the delivery and consultation system of mental healthservice. 8) Public health physicians suggested the followings as possible solutions for above problems; providing practical manual for the mental illness, extended support for the mentally ill patients by the government, establishment of the psychiatric consultation system, reinforcement of psychiatric education in medical college, inclusion of psychiatric lectures in the public health physicians`reeducation programs and etc,. 9) The desirable delivery system of mental health service in rural area is that the public health physicians care for the mentally ill patients under the consultation with the psychiatrist. 10) The performance of the public health physicians` roles in mental health as identifier, referral agent, care provider and consultant was insufficient.

간호사와 의사의 악성종양성 통증관리 실태

서순림,정복례,박진미 慶北大學校 醫科大學 1996 慶北醫大誌 Vol.37 No.3

목적 : 본 연구는 암환자의 통증사정과 관리에 대한 간호사와 의사의 지식을 파악하고 실제로 통증사정과 관리를 위해 실시한 방법을 분석하므로써 간호사와 의사를 위한 악성종양성 통증관리 교육프로그램 개발의 기초자료를 제공하기 위한 것이다. 대상 및 방법 : 연구대상은 대구시내 2개 종합병원에 근무하는 간호사 136명, 수련의사 46명이었으며 자료수집기간은 1995년 12월부터 1996년 3월까지였고 설문지를 사용하여 조사하였다. 연구도구는 June Dahl, McCaffery 등의 기존도구에 실제 수행하고 있는 통증사정과 관리에 대한 개방식 질문내용을 첨가하여 사용했으며 자료분석은 SAS program에 의해 두 집단간의 X^2 test를 하였다. 결과 : 암환자는 진단초기이던 진행된 상태이던 통증호소율이 상당히 높았다. 악성종양성 통증은 암자체로 인하며 통증을 가장 정확히 판단하는 사람은 환자자신이라고 하면서도 환자의 통증호소를 그대로 믿어야 한다는 관점에서는 간호사/의사 모두 지식정도가 낮았다. 또한 수면이나 안정을 통증완화와 동일시하거나 활력증상의 변화를 심한 통증때문으로 간주하는 등 잘못 알고 있었고 진통제사용에 대해서 간호사와 의사 모두가 어느 정도는 과소투약의 문제를 인식하고 있었으나 구강투여의 적절성이나 부작용, 최대용량 사용 시기 및 심리적 의존심 발생확률 등에 대한지식이 상당히 부족하여 마약성 진통제 사용에 대한 지나친 두려움이 있음을 볼 수 있었다. 현재 실무에서의 통증사정은 간호사와 의사 모두 환자행위 관찰을 위주로 하고 있고 통증관리는 대부분 진통제 사용에 의존하고있었다. 결론 : 악성종양성 통증 사정 및 관리에 대한 지식부족이 나타났으며 이로 인한 간호사 의사의 보수적인 태도와 편견이 있었으므로 이를 개선하기 위한 악성종양성 통증관리교육 프로그램을 실시하여 통증을 호소하는 암환자의 삶의 질을 높여야 할 것이다. The purpose of this study was to identify the knowledge and the parctice of cancer pain management in nurses and physicians. The subjects were 136 nurses and 46 residents working at two hospitals in Taegue from December, 1995 to march. 1996. The survey was done by self-reported method using questionnaires and data analysis by SAS. The results were as follows; 1. The rate of patients with pain was 39% by nurses and 42% by physcians perceived at the time of cancer diagnosis. Nurses and physicians reported that the incidence rate of pain was 90% respectively in the cases of advanced cancer. The rate of patients complaining pain during one month or more was 72% by nurses and 75% by physicians. 2. Nurses and physicians knew well the fact that 'pain is due to cancer itself' and 'patient with pain is the best one who judges accurately its intensity'. However, there was low level of such knowledge as that 'cancer pain with treatment is relieved well' and 'medical professional must believe patient's report of pain'. 3. There was prevailed some misconcept like that 'sleep and sedation can be equated with pain relief', 'observable changes in vital sign must be relied upon to verify a patients's statement that he has severe', and 'giving patient placebo is useful test to determine if the pain is real' in most nurses and physicians. 4. Most nurses and physicians responded that 'cancer pain of hospitalized patient is rarely or never relieved'. 5. 56% of nurses and 79.% of physicians agreed in terms of undermedication of cancer pain management. About 50% or more of nurses and physicians showed that 'pain is better controlled when analgesics are administer around the clock'. In terms of oral route as the preferred administration of analgesics, constipation occurred frequently after repeated administration of narcotics, and prognosis less than 24 months as appropriate time to receive maximal doses of analgesics, nurses and physicians didn't know well. 6. Nurses and physicians knew little about the fact that the incidence of psychological dependence as a result of the legimate use of narcotics in cancer pateints with pain was less than 1%. Most of them knew psychological dependence as one of frequent side effects in cancer patients with pain and concerned it with one of their family who receiving narcotics. 7. Few of nurses and physicians knew accurately having patient's request of increasing amounts of analgesia due to increasing pain. 8. At the current practice for pain management, nurses used to administer analgesics(45%) and listening/psychological support/giving good environment(31%) to patients, physicians used to prescribe analgesics(77%) mainly. 9. The behavioral change of patients due to pain was observed as the assessment of pain patients by nurses923%) and physicians(61%). As the above results, pain was not relieved completely although it was one of frequent symptoms in cancer patients at the clinical setting. Nurses and physicians had lack of knowledge of pain assessment and management. Particularly as the results of knowledge deficit for narcotic medication such as pharmacology, administration, side effect, psychological dependence and prescription about maximal doses, nurses and physicians had misconcepts and did misuse of analgesics besides they had conservative attitudes toward pain assessement and management. Therefore it is necessary for nurses and physicians to be given an appropriate in-service education for pain management in clinical setting. After this education done for them, it is recommanded evaluative research of education program for improving quality care of cancer patient with pain.

대구시 개원의사와 개국약사의 의약분업에 대한 인식과 태도

이무식,윤능기,서석권,박재용,Lee, Moo-Sik,Yoon, Nung-Ki,Suh, Suk-Kwon,Park, Jae-Yong 대한예방의학회 1993 예방의학회지 Vol.26 No.1

Mail questionnaire was administrated to 370 practising physicians and 388 pharmacists in Taegu city selected by systematic sampling to examine utilization states and opinion of pharmacy under medical care insurance programme and the attitude to the functional division between physicians and pharmacists from April to May 1992. Regarding the opinion on the outcome of drug-store under medical insurance, 71.2 percent of practicing physician answered faliure but 13.4 percent of practicing pharmacists answered failure in contrast. Fifty percent of practicing physician asserted introducing functional division between physician and pharmacist while 66.9 percent of practicing pharmacist answered drug-store under medical insurance itself is sucessful programme. Average daily numbers of preparation of medicine was 32.2 case. Percentage of utilization of drug-store under medical issurance to average daily cases of preparing of medicine was 20 percent, percentage of utilization with physician's prescription was 0.7 percent. And 58.7 percent of practicing physician experienced outside the institute prescription. Regarding the opinion on the pros and cons of enforcing functional division between physician and pharmacist, 59.2 percent of practicing physician prefered pros and 17.7 percent cons, but 38 percent of practicing pharmacist prefered pros and 45.5 percent cons. And pharmacist knew better the content of functional division between physician and pharmacist than physician. As a reason for pros of enforcing functional division between physician and pharmacist, practicing physician emphasized to prevent misuse or abuse of medicine but practicing pharmacist emphasized to display physician and pharmacist's professional ability. And as an opinion on implementation style of functional division between physician and pharmacist in pros respondents, practicing physician favored mandatory enforcement (52.3%), while practicing pharmacist favored partial incomplete functional division (81.7%). As the method of prescription if functional division between physician and pharmacist will be enforced, both practicing physician and pharmacist prefered generic name (44.0%, 89%) mostly, but physician prefered brand name (35.3%) secondly. Regarding the reason for not implementing functional division between physician and pharmacist up to date, both physician and pharmacist answered problem of business right between physician and pharmacist, followed by lack of recognition, and interest of people and lack of the govermental willness. Regarding the opinion on prior decision of condition for enforcing functional division between physician and pharmacist, practicing physician and pharmacist named uneven distribution of medical facilities and drug-store between rural and urban, inequality of physician and pharmacist manpower and the problem of manpower demand and supply mostly, and practicing physician pointed out establishing attitude of acceptance on the part of pharmacist and practicing pharmacist favored establishing attitude of acceptance on the part of physician, which was different attitudes between physician and pharmacist. Following conclusion was reached ; 1. Current drug-store under medical insurance program yield insufficient outcome, so we should consider program conversion from drug-store under medical insurance program to functional division between physician and pharmacist. 2. There were problem of business right and conflicts between physician and pharmacist at enforcing functional division between physician and pharmacist, so the goverment should search for formulating plan to resolve the problem and have neutral willness for the protection of the national health. 1989년 10월부터 실시되고 있는 약국의료보험과 의약분업제도에 관한 태도를 조사하기 위하여 대구시내 개원의사 및 재국약사를 계통적 표본추출법(systematic sampling)에 의한 표본을 선정하여 우편설문지법으로 1992년 4월 20일부터 5월 20일까지 조사하여 회신된 개원의사 184명, 개국약사 157명의 설문지를 분석한 결과를 요약하면 다음과 같다. 현재 시행중인 약국의료보험의 성과에 대해 개원의사는 71.2%가 '실패적'이라고 한 반면 개원약사는 13.4%가 '실패적'이라고 하였다. 개원의사의 50%는 약국의료보험을 폐지하고 의약분업을 도입해야 한다고 한 반면, 개국약사는 66.9%가 의약분업제도와는 관계없이 약국의료보험자체만으로도 성공적인 제도라고 하였다. 개국약사의 약국 1일 평균조제건수는 32.2회였으며, 약국의료보험 이용횟수는 6.2회로 조제건수의 20%에 불과했고, 의사처방전을 지참한 약국의료보험이용횟수는 조제건수의 0.7%였다. 그리고 개원의사의 원외처방전 발행경험자는 58.7%였다. 의약분업제도의 실시에 대해 개원의사는 59.2%가 찬성하였으며 27.7%가 반대하였으나 재국약사는 38.0%가 찬성, 45.5%가 반대 하였다. 그리고 약사가 의사보다 의약분업의 내용을 더 많이 안다고 하였다. 의약분업제도 실시의 찬성자중 찬성이유로 개원의사는 '의약품의 남오용 방지' (54.1%)를 많이 지적한 반면 개국약사는 '의사와 약사의 전문직능 발휘'(62.0%)를 많이 제기하였다. 그리고 분업찬성자에서 개원의사는 52.3%가 '완전강제분업'을 원한 반면, 개국약사는 81.7%가 '부분분업'을 원하였다. 의약분업제도 실시시에 처방전의 발행 방법에 대해서는 개원의사와 개국약사 모두 '일반명' 처방을 44.0%, 89.8%로 가장 많이 원하였고 개원의사에서는 '상품명' 처방도 35.3%나 차지하였다. 의약분업제도의 실시가 이루어지지 않은 이유에 대해 개원의사 및 개국약사 모두 '의사 약사단체 상호간의 업권문제'를 가장 많이 지적했으며 '국민들의 인식 및 관심 부족' '정부의 의지력 결여' 순으로 일치된 결과로 나타났다. 의약분업실시를 위한 선결조건으로는 '의료시설과 약국의 도시 농촌간의 균등분포'를 가장 많이 지적하였으며 의사는 '약사들의 수용태세 확립', 약사는 '의사의 수용태세 확립'을 그 다음으로 지적해 서로 상반된 결과가 나타났다. 이상의 결과를 종합해 보면 첫째, 조사대상 개원의사들은 현행 약국의료보험제도에 대해 부정적 견해를 보인 반면 개국약사들은 긍정적 견해를 보였으나 약국의료보험이용은 극히 저조하고 의사의 처방전 발행도 저조한 실정이다. 이에 약국의료보험제도에서 의약분업제도로의 제도적 전환이 고려되어야 할 것으로 생각된다. 둘째, 의사와 약사의 의약분업에 대한 의견이 상이한 점으로 미루어 유추할 수 있지만 의약분업제도 실시의 장애요인으로 의 약사단체 상호간의 업권문제와 의약사간의 갈등이 지적되는 바, 이들 모두를 만족 할 대안을 선택하는 것이 쉬운일 아닐 것이므로 국민의 건강보호차원에서 정부의 중립적 의지가 있어야 할 것으로 생각된다.