【作者】 王耀辉；

【导师】 李新春；

【作者基本信息】 中国矿业大学 ， 管理科学与工程， 2021， 博士

【摘要】 我国医疗卫生事业存在医疗费用不断增长、医疗风险居高不下现象。导致医患关系紧张、医患矛盾突出。一方面患者看病难、看病贵,成为阻碍我国民生和经济发展的一大障碍;另一方面医患纠纷演变成恶性暴力伤医事件,导致医生的执业体验也不断恶化。医疗服务行业存在典型的供需双方信息不对称特征,作为代理人的医生由于具有信息不对称优势,客观上在诊疗过程中会发生医生道德风险行为。对此,在宏观层面的体制政策和中观层面的管理制度已有一定的研究,但是立足于医生个体视角,对其行为心理层面的微观机制还缺乏深入的研究。本研究采用质性研究和量化研究相结合的方法。首先通过文献研究和理论分析,科学界定了医生道德风险的概念内涵,深入比较了医生道德风险和医生诱导需求、过度医疗、防御性医疗等概念的区别。然后,运用扎根方法开展了医生道德风险行为类型和影响因素的质性研究,获得了各个类型及其具体内涵。通过理论分析获得了各影响因素的相互关系,构建了概念模型,在对各影响因素进行操作化定义后,形成了各个变量的初始测量条款。随后按照问卷编制的原则和流程形成了初始测评问卷。通过前测,在经过效度信度检验后,建立了科学的测评问卷。随后采用问卷调查的方法获得数据,进行了信度、效度分析,并通过结构方程模型等方法对研究假设进行了检验。最后结合概念模型和实证结果提出了相应的防范机制,得到了一系列的研究结论。首先,本研究科学界定了医生道德风险的内涵和维度。对于医疗领域的道德风险问题,现有研究大多从医疗保险中的道德风险、医生诱导需求、防御性医疗、过度医疗等视角研究,基本上以作为型的道德风险行为为主。本研究从道德风险的根本属性出发,将不作为的道德风险行为纳入讨论,科学界定了医生道德风险的内涵,并将医生道德风险按主被动方式、损害后果程度进行区分。本研究通过扎根分析获得了医生道德风险的6大类和18小类行为类型、具体表现形式及特征,其中6大类行为包括:渎职行为、过度手术、过度检查、过度用药、过度使用耗材、过度住院治疗。本研究尤其是识别了不作为型的医生道德风险行为,补充了医生道德风险中渎职行为的具体内容。其次,本研究深入分析了医生道德风险行为的影响因素及相互关系。基于医生个人而言,医生道德风险行为的影响因素可以通过六个方面解析,包括:动机维度、机会维度、合理化维度、能力维度、暴露维度和惩罚维度。运用质性研究方法获得了各个变量的具体项目,通过探索性因子分析发现,六个影响因素的条款各自归为了一个独立的因子;通过内部一致性分析、相关性分析和验证性因子分析,开发的测量量表具有较好的收敛效度、区分效度、聚合信度和内部信度。再次,本研究揭示了医生道德风险行为影响因素的作用机制和传导路径。动机、机会、合理化和能力分别正向影响意向,医生道德风险意向正向影响医生道德风险行为。意向的中介效应显著,意向在动机、合理化、机会、能力和行为之间起中介作用。相比而言,意向对机会到行为的中介效应最为明显,意向对能力到行为的中介效应最不明显。暴露的调节效应显著。医院级别、医生年龄、医生职务和医生职称对医生道德风险行为具有干扰作用。最后,本研究建立了医生道德风险行为的防范机制。针对现有防范缺乏系统性并易产生漏洞、扯皮等问题,基于本文建立的医生道德风险行为发生机理理论框架进行了系统分析,并对各个影响因素的因子载荷进行了排序。研究表明:其中来自漏诊误诊压力成为医生道德风险行为的首要动机,医患知识转移程度低下是医生道德风险行为机会的主要原因,安全代价成为医生道德风险行为的首要理由,医生对患者的强势说服能力是其主要优势,医院监督检查是对医生最有影响的暴露手段,行业处罚对医生的震慑作用最大。并综合提出医生道德风险行为的“1+3+6”防范机制:以行为类型及后果严重程度确定防范目标;构建宏观、中观、微观三个层面的防范体系;形成动机、机会、能力、合理化、暴露和惩罚六个视角的防范措施,形成了一体化的防范新思路。综上所述,本研究科学界定了医生道德风险概念内涵,基于医生个人视角构建了医生道德风险行为发生机理概念模型,并为理论研究提供了实证支持,丰富了医疗行为和道德风险的理论研究,并为医生道德风险行为的防范提供了决策参考。更多还原

【Abstract】 There are some problems in China’s medical services,such as the increasing medical expenses and emerging medical risks,which lead to the tense relationship and the prominent contradiction between doctors and patients.On the one hand,it is difficult and expensive for patients to seek for medical services,which has become a major obstacle to the people’s livelihood and economic development in China;on the other hand,the doctor-patient disputes have evolved into vicious incidents,which has led to the deterioration of doctors’ vocational experience.Asymmetric information between supply and demand features medical industry,and therefore doctors,as the agents,are prone to moral hazard behavior in the process of diagnosis and treatment.In this regard,there has been some research on the macro level of institutional mechanism and the meso level of management system,but there is still destitution of research on its occurrence mechanism at the micro level based on the perspective of individual doctors.This study amalgamated methods of qualitative research and quantitative research.Firstly,through literature research and theoretical analysis,the concept of doctor moral hazard was defined,and the differences among doctors’ moral hazard,induced demand in medical services,excessive treatment and defensive medical treatment were compared.Then,the paper utilized grounded theory to gain the types and influencing factors of doctors’ moral hazard behavior,and obtained the specific connotation of each type.Through theoretical analysis,the relationship between the influencing factors has been obtained,and the concept model constructed.After the operational definition of each influencing factor,the initial measurement items of each variable were formed.Then,according to the principle and process of questionnaire preparation,the initial questionnaire was formed.After the pre-test and the validity reliability test,a scientific questionnaire was established.Finally,the data were obtained by questionnaire survey,reliability and validity analysis were conducted,the hypothesis of which was tested by structural equation model to obtain a series of research conclusions.First,the study defined the connotation and dimensions of doctors’ moral hazard.For the moral hazard in medical services,most of the antecedent researches are from the perspectives of moral hazard in medical insurance,induced demand in medical services,defensive medical behavior,and excessive medical behavior,basically behavioral moral hazard behavior.This study,based on the fundamental attribute of moral hazard,introduced non-behavioral moral hazard,defined the concept of doctor moral hazard,and distinguished the moral hazard of doctors as passive or active way,and different degrees of damage.Grounded theory was utilized to obtain six types with specific manifestations and characteristics and eighteen sub-types of moral hazard behavior,especially the non-behavioral doctors’ moral hazard,and complemented the specific content of the malpractice in doctors’ moral hazard.Secondly,this study deeply analyzes the influencing factors of doctors’ moral hazard behavior and the relationship among them.Through theoretical research and grounded research,the influencing factors of doctors’ moral hazard behavior could be analyzed from six aspects: motivation dimension,opportunity dimension,rationalization dimension,ability dimension,exposure dimension and punishment dimension.Through exploratory factor analysis,it is found that the terms of the six influencing factors are classified as an independent factor;through internal consistency analysis,correlation analysis and confirmatory factor analysis,the developed scale has good convergence validity,discriminant validity,aggregate reliability and internal reliability.Thirdly,this study revealed the mechanism of the moral hazard behavior of doctors.Motivation,opportunity,rationalization and ability have positive impact on intention,and doctor’s moral hazard intention has a positive impact on doctor’s moral hazard behavior.The mediating effect of intention is significant,and intention plays a mediating role among motivation,rationalization,opportunity,ability and behavior.Comparatively speaking,the mediating effect of intention on opportunity to behavior is the most obvious,and the mediating effect of intention on ability to behavior is the least obvious.The regulatory effect of exposure was significant.Hospital level,doctor’s age,doctor’s position and doctor’s title have interference effect on doctor’s moral hazard behavior.Finally,this study established the prevention mechanism of doctors’ moral hazard behavior.In view of the lack of systematic prevention and prone to loopholes,wrangling and other problems,this paper makes a systematic analysis based on the theoretical framework of the occurrence mechanism of doctor’s moral hazard behavior established in this paper,and sorts the factor loads of various influencing factors.The research shows that: the pressure from missed diagnosis and misdiagnosis is the primary motivation of doctors’ moral hazard behavior,the low degree of knowledge transfer between doctors and patients is the main reason for doctors’ moral hazard behavior opportunity,the safety cost is the primary reason for doctors’ moral hazard behavior,the strong persuasive ability of doctors to patients is the main advantage,and the hospital supervision and inspection is the most influential exposure means for doctors Professional punishment has the greatest deterrent effect on doctors.The“1+3+6” prevention mechanism of doctor’s moral hazard behavior was put forward synthetically: the prevention target is determined by the type of behavior and the severity of the consequences;the prevention system is constructed from three levels of macro,meso and micro;the prevention measures are formed from six perspectives of motivation,opportunity,ability,rationalization,exposure and punishment,forming a new integrated prevention network.To sum up,this study scientifically defined the concept of doctors’ moral hazard,constructed the conceptual model of the occurrence mechanism of moral hazard behavior of individual doctors,and provides empirical support for theoretical research,has enriched the theoretical research of medical behavior,and serves as practical guidance for prevention of moral hazard behavior of doctors.更多还原