Sometimes there are news reports about Taiwanese physicians collapsing or suddenly dying at work, making it clear that they are victims of overwork. Many mistakes that occur in Taiwan’s hospitals are the result of doctors being overworked.
Advanced countries like the US, those in Europe, Japan and so on, have labor laws regulating the number of hours doctors are allowed to work. These laws protect doctors’ health and their patients’ safety.
One of President Tsai Ing-wen’s (蔡英文) election pledges was for physicians to be covered by the Labor Standards Act (勞動基準法). This pledge received widespread support among physicians. When Minister of Health and Welfare Lin Tzou-yien (林奏延) took over at the ministry, as well as when he addressed the World Health Assembly, he announced that he would push for the policy’s implementation.
Since there is a consensus behind the idea that physicians should be covered by the Labor Standards Act, the next step should be to discuss what complementary measures should be implemented in connection with the act, as well as the advantages and shortcomings of those measures.
First, the ministry is concerned that the inclusion of physicians in the Labor Standards Act would result in a shortage of doctors, but it does not have to. The government must not estimate the need for physicians without first changing the public’s habits in seeking medical advice.
Currently, the National Health Insurance system is all-inclusive: It tolerates the fact that people with minor ailments fill medical centers to the point of overflowing, places no restrictions on how it is used and does not attempt to apply any kind of efficient distribution of medical resources.
Unless the government stratifies medical services and finds ways to reduce medical treatment for pseudo-ailments, there will be a permanent shortage of medical staff and it will not be because of the Labor Standards Act.
According to the ministry’s definition of personnel shortages, it generally only occurs in connection to patient care at large hospitals and the reason is the lack of a medical stratification system. Big hospitals assign a lot of staff to treat patients with minor ailments, in particular outpatient services. If the volume of outpatients and patients visiting for the first time could be reduced, doctors would automatically return to the ward to care for inpatients and fulfill the stipulations of Article 43 of the National Health Insurance Act (全民健康保險法).
This is the only way to stop healthcare from collapsing, as it will keep patients with minor ailments at primary care clinics and community hospitals, allowing major hospitals to deal with seriously ill patients and patients requiring more difficult treatments.
If the government ignores the continuous medical care cost reductions and tolerates the fact that large hospitals are run as trusts, a small number of large hospitals owned by big corporations will remain big, and perhaps become so big that the government will not be able to touch them, while smaller hospitals and clinics will have to close down because they can no longer remain competitive or lose the ability to protect the health of their local communities. As time passes, medical resource distribution will become imbalanced and physicians will become money-making tools for businesses, which is a threat to their dignity and value.
According to Article 58 of the Medical Care Act (醫療法), “medical care institutions shall not establish clinical assistants to conduct medical practices,” but the ministry uses a lack of staff as a reason to flout the law and allow clinical assistants. This is tantamount to replacing physicians with clinical assistants — at a much lower cost — and it ignores patient safety.
When the water in an aquarium is dirty, it should be changed to improve the quality, but the ministry is in effect constantly adding more fish, resulting in an ever-deteriorating environment.
Once physicians are covered by the Labor Standards Act, the working conditions for medical staff will improve and that will lead to a natural increase in staff. In addition, improving and expanding the implementation of the nurse practitioner and hospitalist — physicians whose primary professional focus is the general medical care of hospitalized patients — systems will resolve the lack of resident doctors in critical care wards and remote areas.
Major changes to the medical care system might have an impact on the medical care environment and international competitiveness 10 or 20 years from now. Whether the inclusion of physicians in the Labor Standards Act will lead to a shortage of doctors will still have to be studied. Even if that is the result, the correct complementary measures required are still the implementation of a stratified medical care system and the reduction of the need for pseudo-medical treatment, such as futile medical care — continued medical care or treatment of a patient when there is no reasonable hope of a cure or benefit — and not the increase of low-cost medical assistants.
To protect medical safety for patients and the interests and rights of medical staff, the government should promptly implement a stratified medical care system and stop the introduction of clinical assistants. The public should also help monitor the government and demand that it implements Tsai’s election pledge to include physicians in the Labor Standards Act.
Chong Chee-fah is an emergency attending physician at Shin Kong Wu Ho-Su Memorial Hospital and chairman of the Taiwan Medical Alliance for Labor Justice and Patient Safety.
Translated by Perry Svensson
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