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專 專業 專業者 專業素養

醫. Expertise Profession Professional Professionalism. 專 專業 專業者 專業素養. 商. 法. 工. Does your doctor have professional knowhow?. 力能業專. Does your doctor have the proper professional behavior?. 專業風範. “ The reflex seems to be somewhat over-active; you kept him waiting for two hours! “.

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專 專業 專業者 專業素養

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  1. Expertise Profession Professional Professionalism 專 專業 專業者 專業素養 商 法 工

  2. Does your doctor have professional knowhow? 力能業專

  3. Does your doctor have the proper professional behavior? 專業風範 “The reflex seems to be somewhat over-active; you kept him waiting for two hours! “

  4. 職業倫理 商業倫理 生命倫理 家庭倫理 社會倫理 群體, 行為, 生活 Population, Behavior, Living exp. The fundamental basis for the stability of the society

  5. 倫理是一從種心態 一個觀點也是 一個角度導致的行為 而不是 一種學科 應沒有基礎醫學倫理及 臨床倫理的分野

  6. 實虛 虛實

  7. 理倫 德醫 Medical ethicsis a form of Professionalisman art, attitude, behavioral,conceptual problem,not solely a scientific problemA learning experience rather than a teaching subject 中華民族為禮儀之邦,中華文化以倫理為重。中華民族文化教育源自以孔子為首的先秦儒家思想。 由正心、誠意、修身而到齊家、治國、平天下之「以己及人」精神何在? 以下這種高尚且簡單的教育精神何在? 「大學之道在明明德,在親民,在止於至善」「知之為知之者,不知為不知者,是知也」 「窮其理而致其知」 子曰,「吾非生而知之者,好古,敏而求之者」「不耻下問」 「切問而近思」「學而不思則罔,思而不學則殆」 「三人行必有我師焉」「温故而知新,可為師矣」

  8. 可是…我們的現代高等教育會注重並改善學生及家長的心態嗎?可是…我們的現代高等教育會注重並改善學生及家長的心態嗎? 急功近利 貪腐作弊 治標棄本 道高魔漲 家庭 社會 文化 學校 政府

  9. 名醫涉收天價打禁藥 〔記者林慶川、林相美綜合報導〕 台北市立萬芳醫院血管中心主任張耀中利用病患家屬求醫心切心理,以廉價禁藥充當「高科技新藥」,收取天價為病童在院外注射,張及其秘書陳雅玲昨被台北地檢署依涉刑法詐欺、違反藥事法罪嫌起訴,建議法官對兩人判處重刑。 被害人邱小妹的母親馮梅蕊昨天下午得知張被起訴,直斥張:「向錢看齊、毫無醫德」,並透露至少還有一對夫妻被騙五、六百萬元。 萬芳醫院暫停其職務 萬芳醫院也緊急召開醫學倫理委員會,決議暫時停止張耀中所有醫療業務及行政主管職務,張耀中本人並未出面說明。台北市衛生局解釋,張耀中的行為涉嫌違反醫師法第廿五條第二項,利用業務機會執行犯罪行為。最嚴重的處分可廢止醫師證書、廢止執業執照,其餘處分包括警告、修習學分及停業。 邱小妹是在九十四年暑假赴泰國參加一場國際數學比賽,得了心算組第一名,但返台後卻發現境外感染病毒,昏迷一星期,醫生查出是「急性腦脊髓病變」,雖撿回一命,卻有癲癇、智能不足等發展延遲後遺症。就讀高一的邱小妹昨晚下課後受訪表示,現在上體育課,汗都流不出來,只有頭皮會稍出汗,很難受。 病童母錄影揭發騙行 馮梅蕊說,女兒從小就讀資優班,學過鋼琴、小提琴、直笛,昏迷醒過來後,什麼都記不起來,還問:「為什麼我變笨了?」父母當然要盡力為女兒找良醫。張耀中向馮表示,自己自瑞士藥廠進口新科技產品,可以修復腦細胞,但一個療程注射二十次要四十五萬元,前後在邱小妹就讀的國中音樂教室或是邱家為邱小妹注射四十次。馮梅蕊有一次向醫生朋友提及女兒在進行此療程後,朋友提醒可能受騙,於是以針孔錄下張的醫療行為向台北市衛生局檢舉。

  10. Privacy act The right to know

  11. Hospital: is $$$ the culprit? • 商業 • 學術 • 服務 醫院,護士,病患,保險業者齊來騙

  12. 全國7醫院9醫師 販賣不實巴氏量表 〔記者蔡彰盛、洪素卿2007-12-25〕新竹憲兵 隊與海巡署、新竹市警第一分局日前發現人蛇 集團引進越南女子來台賣淫,發現集團勾結人 力仲介公司,向全國各大醫院醫師施賄,安排 人頭病患向醫師要求開立不實的巴氏量表,以 便向勞工局申請外籍看護工來台。新竹地檢署 昨天指揮搜索拘提全國七所醫院九名醫師到案 ,這些包括副院長、主任級在內的醫師,涉嫌 收賄開具不實的巴氏量表給仲介公司,檢方發 現他們每件收取兩萬五千元到六萬元不等金額,以圖利人力仲介業者申請外籍看護工來台,實際大都從事賣淫。 檢方查出,涉案醫師們近一兩年中,至少開出超過一百張以上的不實巴氏量表,昨天搜索過程中,還扣到連醫院大印、院長章都蓋好的空白巴氏量表。監控過程中也發現,收賄醫師主動發手機簡訊向業者索賄、談價碼,囂張的程度讓檢方搖頭,全案將向上全面擴展調查。 巴氏量表又稱巴氏指數(Barthel Index),最早是美國醫師發展用於評估住院復健病患進展狀況,在台灣,長期照護上最常用來評估個案的身體功能。除了醫療專業用途,全民健保居家護理申請作業上的收案標準,今年元旦之前,外籍看護工申請標準也用巴氏量表。

  13. 痔瘡變癌詐上億 5醫遭拘提2009/05/26 02:34 刑事局廿五日查獲五名涉案主治醫師,揭開白色巨塔黑幕,部分醫師坦承收錢辦事,也有人推稱是盛情難卻才「情義相挺」! 警方發現,該集團是把痔瘡變成直腸癌;乳房囊腫當成乳癌,並煞有其事地替病患化學治療,其中人頭徐國安以直腸癌請領兩千五百萬元保險金後,還常住院把請領保險給付當成賺錢,吃定保險公司。刑事局偵四隊去年偵辦傅建森詐領保險金集團,查出傅嫌利用過去從事醫療廢棄物的機會,認識不少醫院醫師,也容易取得醫院丟棄的癌症檢體,再以一到兩百萬元不等的代價,勾串醫師出具不實癌症報告。 由於檢體調包,涉及醫師專業,檢警難窺其中問題 檢警全面過濾九十二年到九十六年間傅建森經手的保險案件,並透過粒腺體DNA比對原檢體,始讓案情曝光,更讓部分涉案醫師無言以對。 警方查出,傅嫌透過獵人頭公司尋找家境困難的人頭向安泰、南山、國華等保險公司重複投保、並給予數十萬元不等的代價,佯裝成病患,由醫師施以手術後,詐領保險金。 不過警方發現,這些病患許多人都沒有工作,連吃飯都有問題,卻有能力負擔每個月十幾萬元的保險費。罹癌後,還可四處玩樂,正常作息,根本不像癌症病患。 警方借提在監服刑的傅建森後,昨天凌晨六點分別前往五名醫師住處拘提他們到案。 警方調查,該集團向保險公司共請領一億八千多萬元的保險理賠;保險公司依診斷書已理賠了一億元,健保局也給付相當數額的癌症醫療保險金。警訊後,依詐欺、偽造文書等罪嫌移送法辦

  14. 診所勾安養院詐健保 收押6醫 更新日期:2009/01/09 04:34 黃文博/台南報導 台南地檢署再查獲診所勾結安養機構詐領健保費案,有十九家安養機構、十家診所及藥局涉嫌,近五年來以假看診、真詐財方式,共詐得五萬多筆、三千多萬元;診所的老醫師竟找來森林系畢業的充當,並到安養機構看病多年,五醫師和一密醫訊後收押,六藥師交保。 這十九家安養機構為台南平安、大愛、保健、民族、開元、友廉、人慈、崇善、南臺、大同、揚明、華恩、長榮、中華、如新、愛惠、長恩、愛心和維康,他們涉嫌勾結台南市的蔡朝榮、高茂、許仁智診所及台南縣歸仁鄉的松愛、信德診所詐領保費,五位醫師李喬智、廖述發、蔡朝榮、蘇君毅、許仁智及密醫李國明,因否認犯罪,檢方昨天凌晨向法官聲請羈押獲准。 森林系畢扮密醫 幫老人看病 令檢調驚訝的是,屏東某技術學院森林系畢業的李國明,竟然充當密醫,以李喬智、廖述發兩名老醫師的身分,到安養機構替老人看病;而四十多歲的許仁智,雖然詐領巨額的健保費,但因投資股票失利,積欠地下錢莊債務而被迫歇業,檢調人員大嘆「簡直就是現世報!」。 台南地檢署去年偵辦安平診所醫師勾結安養機構詐領健保費,懷疑台南地區應該還有很多診所也有問題,經健保局南區分局調閱九十二至九十七年資料,發現上述五家診所都有問題。 五診所、十九安養機構涉案 前天下午,檢察官陳建弘、廖曉萍、蔡佩容率台南縣市調查員,鎖定台南地區十九家安養機構、五家診所及倍安、高明、詠承、健昇等四家藥局進行搜索,除查扣資料廿箱外,並傳喚李喬智、廖述發、蔡朝榮、蘇君毅、許仁智及密醫李國明、六名藥師和兩名護士證人。 初步調查,被告十二人,在最近五年內,分別以假看診、真刷卡、換藥、換現金及醫療器材方式,共向健保局詐領五萬一千多筆、三千一百五十二萬元,有安養老人一年刷卡一百卅多次,五名醫師及密醫均否認犯案,檢方則認為有串證之虞,聲押獲准。

  15. 付不出醫藥費 重症患遭棄醫院更新日期:2009/01/19 15:56 不景氣之下,不少急重症患者的家屬因為付不出醫藥費一走了之,醫院無奈之下只好為病患募款。在苗栗醫院的急重症病房,吳先生永遠躺在最後一床、最角落的地方,身體整個捲曲一起,因為從工地摔落,從此癱瘓,甚至得靠呼吸器維生,吳先生今年45歲,還算是壯年,不過一病不起,只有看護陪著他,太太和三個小孩已經很久沒有出現在病房,連醫藥費都沒人付。  同樣高齡70歲的徐先生誤食農藥,積欠了六年看護費用,從來沒有一個親人來探望過他,這兩個案例都是醫院的冰山一角,因為現在越來越多沒錢繳健保,把病人滯留在醫院等著被安置的例子從去年開始倍數成長。 經濟不景氣,健保局統計,兩年來申請疏困貸款案的人數增加許多,從96年2400件共1.6億元,到97年已經成長到8700件,金額高達5億元,數字非常可觀,長期臥病者遭到 棄養的病患大部分都是被丟在公立醫院,院方不能拒絕病人,現在只好動用社會資源募款或轉介慈善團體代繳保費。

  16. G;4 上樑不正 下樑歪 政軍警 經醫教 2009-0529

  17. 神聖使命

  18. Why? What? How? When? Why & What 已經不是個 問題,而是How & When 多加倫理課程並考試 包含在PBL教案中 應可用OSCE測試 在五六年級最適合 愈早養成習慣愈好 應可用在一二年級

  19. What should students be learning in medical schools? B 行為 倫理 Relevance to humanity 人 L P 生命 科學 群體 社區 Life sciences knowledge Significance To society

  20. Traditional 強調歸納觀念 Categorization 倫理 倫理 倫理 倫理 倫理 倫理 倫理 PBL 倫理 強調演譯觀念 Critical thinking

  21. 辯論 故事書籍 醫學影視 應用 圖3 PBL醫學教育以教案來整合課程的理念 圖2 傳統醫學教育的線性專業學科組合流程 討論 釐清 大體解剖 專業授課 如何將倫理融入醫學課程 ? 傳授 接受 內化

  22. 中國醫藥大學 醫學倫理教育 醫學系一、二年級:醫學電影欣賞與討論,PBL 四年級:醫學社會學模組 (整合課程4205) lectures, 影片欣賞、小組討論,PBL 六、七年級:醫學倫理演講與實例小組討論,PBL 辛幸珍

  23. Small Group Tutorial 互動 自主 整合 循證 以人為本 以學生為中心 以病人為中心 Tutor Case problem • Professional behavior • Self-directed learning • Team-work spirit • Communication skills Students

  24. Charlie Whittaker: rejected for a promising cureLos Angeles Times, Oct. 29, 2002 • Jayson and Michelle Whittaker sought permission of Britain’s embryo panel of HFEA (Human Fertrilizagtion and Embyology Authority) for a procedure that might cure their son, Charlie, who has had a blood disorder since birth. Charlie is now 3 yrs old. Their application was rejected by the panel.

  25. Charlie Whitaker • From birth, Charlie was pale and sleepy, and at 12 weeks, his doctors discovered that Charlie’s body was not making any red blood cells. He has Diamond-Blackfan Anemia Syndrome, which is rare and affects <700 people world-wide. Charlie may not live over 30. • To survive, Charlie needs a blood transfusion every 3 wks, along with Desferal to draw out the excess iron that builds up after transfusion. The only cure is to transplant new blood-making cells from a right-match sibling (to avoid rejection).

  26. “I’m just so angry” said Michelle. “Abortion is legal in the UK. They are protecting a 3-day old embryo, but we could terminate an 18-week old fetus.” Jason and Michelle decided to have another pregnancy and use the cells from the 3-day embryo for transplantation to cure Charlie. They are going to do so in the US.

  27. Learning issues Population What is an embryo panel? Do other countries have a similar regulatory agency? Who sits in this panel? What is embryo screening? How is it done? What are the ethical issues in this technology? Behavior Parents’ emotional response? Charlie’s emotion living with this sickness? and with frequent transfusions? as well as needles for Desferal. Is parents’ behavior ethical? Life sciences How and where are RBC made? Function of RBC? What is transfusion? What are the health risks in transfusion? Why does iron build up after transfusion and why is it bad to the body? What is a stem cell? How do cells differentiate in an embryo in the first few days?

  28. The Hamilton Spectator, December. 27, 2002 • Olivieri, trained at McMaster University and later head of the blood research program in Sick Kid Hospital of the Univ of Toronto, began her study in 1989 on a drug called “deferiprone” for the treatment against accumulation of iron in thalassemia patients. As her research dried up in 1993, a drug company, Apotex, stepped in. The initial studies were promising and Olivieri published a few papers in supporting it. • Yet, within a year, Olivieri found that research on a related drug pointed to accelerated heart and liver damage, and thus there was a possibility that deferiprone may be potentially harmful to patients in the trial. Apotex warned her not to disclose this finding, but Olivieri insisted that the patients, research ethnics board and drug regulators must be told. • Apotex immediately stopped funding her study and in 1996, Olivieri published her results. This led to a bitter legal fight with Apotex and a demotion by the hospital. Nancy Olivieri A whistleblower stirring up long pending problems inmedical ethics & academic freedom

  29. Nancy Olivieri Today • Olivieri filed a grievance against the hospital for demoting her for medical misconduct. Her demotion at the Sick Kid Hospital was revoked. • Olivieri launched a grievance against U of T for failing to protect her academic freedom. This issue was resolved and she is claiming a victory. • Apotex sued Olivieri for $10 million for breach of contract and publishing incorrect information about the drug. Olivieri file a countersuit against Apotex for libel. This is still an on-going and expensive issue to be resolved. • Apotex’s drug is used in 25 countries (*many 3rd world countries). Olivieri is trying to get the drug’s conditional approval in Europe revoked. * Thalassemia is an inherited blood disorder found in children across the Mediterranean region, the Middle East, India and throughout southeast Asia.

  30. P opulation B ehaviour L ife Sciences • How is medical research being funded generally? • How does a drug get approved for commercialization ? • What is a clinical trial and how is it done ? • What is the role of a academic institute in which its research is funded by private sectors ? • Is Olivieri paying too high a price for her actions ? • Is this an issue of medical misconduct evoked by Olivieri’s personal ego? • Should Olivieri’s academic freedom be protected by U of T ? • What is thalassemia and what are its complications ? • What is the treatment for thalassemia ? • Why does Apotex invest so much in deferiprone, when an alternative drug with similar action of mechanism, deferoxamine, is already in existence for years.

  31. 外籍新娘阿美 阿美是一位由印尼嫁來台之外籍配偶,婚後立即生了一個女兒,與先生恩愛生活。 不過,阿美一直對先生家的幾位親友(大伯、叔叔與堂哥)都有著不等程度的肢體不便感到不解,而且聽說先生過世的爸爸與一位伯父生前也是如此,且皆在行動越來越不便後幾年過世。阿美逐漸意識到先生家族中,隱藏某一嚴重的遺傳疾病,然而先生與婆家人大都不願多談。直到一天,無意間由鄰居口中得知先生家族數代都罹患晚發性遺傳小腦萎縮症。阿美查閱出這種慢性疾病是由於基因缺陷造成,很容易遺傳下一代,而且在未發病時就已將基因傳給了下一代。為了決定要不要生養下一代,阿美主張先生應去醫院做基因檢測。先生竟斷然拒絕,完全避開此話題。 一天,阿美發現自己意外地懷孕了。全家大小都很高興,阿美卻心事重重,她幾次提議要做胎兒基因檢測,卻被先生一再否決,阿美非常氣憤,自己偷偷到醫院做胎兒基因檢測。結果為陽性,阿美堅決墮胎,男方家族對阿美的一意孤行很不諒解,阿美也就毅然決然的離開了先生與夫家回去印尼。事隔年餘,阿美開始懷疑當初這樣做是否值得? 辛幸珍 CMU-CFD

  32. 秀蘭的遺憾 秀蘭73歲的婆婆,被診斷為第四期肺癌且已造成肋膜積水,醫師認為在此階段所有治療皆很難帶來任何效益,勸家屬不要對此治療抱有太大希望,並預測其壽命約在六個月至一年間。秀蘭的先生與其他兄弟一致決議,堅決不讓母親知道實情。一年後婆婆過世。家人雖然傷痛,但對其自始至終沒有經歷惡耗,略感安慰。然而秀蘭卻對整個醫療過程中完全婆婆本人沒有參與意見感到不安,認為婆婆一定有很多事情未交待,卻沒能讓她表達臨終心願。 三年後,秀蘭因便血至醫院檢查發現為胃癌,癌細胞已擴散至腹腔,病情相當不樂觀。秀蘭的先生為了避免其因過度震驚而承受不了打擊,決定暫時不讓她知道病情。秀蘭也沒有追問,只是默默地承擔對病情之疑慮與擔憂。 ㄧ天下午,一位未見過面的腫瘤治療科醫師來醫院會診。單刀直入就說:「陳女士,有關妳的病情妳大致上了解吧?依我們對妳資料的判斷,因為妳的病情已屬第四期,是不應該考慮手術,對化學治療藥物也不敏感,所以目前我們也幫不上忙……」。 夜深人靜,秀蘭望著窗外,回想三年前婆婆自診斷到死亡之前皆處於不知之狀況,秀蘭現在反而覺得婆婆是幸福的…既然被宣佈無法治療,想到自己疾病末期將要承受之痛苦,年幼之子女,努力工作的先生..實在不應拖累他們……。凌晨五點,醫院警衛發現頂樓有物品摔落,原來是ㄧ位想不開的女病患……。 辛幸珍 CMU-CFD

  33. Why do some scientists behave badly? 地位 名譽 利益 權力

  34. How does it happen ? Under pressure… promotion, rewards, achievement Greedy needs……I want more (money, grants, papers, profits, awards) Fame-grasping….I must be no. 1, I want to be famous, on the top Easy way out to acquire the above Not enough training in ethics Lack of good professional role model

  35. Doctors with 正確的醫事行為 are good doctors

  36. 心若改變, 你的態度會跟著改變。態度改變, 你的習慣會跟著改變。習慣改變, 你的性格會跟著改變。性格改變, 你的人生會跟著改變。 Attitude

  37. 正確的醫事行為 來自正確的學習態度 態度要及早培育

  38. Conclusion PBL is the way

  39. 倫理可以用 PBL 來學習身教內化,不用言教授課 It is possible to lean medical ethics under the PBL environment without didactic lectures (learner-centered learning) 倫理案例可以用 日常媒體報導事件來設計,與生活接軌 The design of problems for learning ethical issues can utilize events reported in the public media. (context-oriented learning) 沒有倫理素養及正確價值觀的學生不應受錄為醫學生 Ethical values represent behavioral/attitude awareness; selection of medical students should be based on their attitudes, not their factual knowledge base. (proficiency-based learning)

  40. Thank you for your attention

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