【作者】 杨謦伊；

【导师】 罗颂平；

【作者基本信息】 广州中医药大学 ， 中医妇科学， 2009， 博士

【摘要】 研究目的本研究目的有三:了解台湾中医师专业教育历史发展与现况:探讨台湾中医师执业资格历史发展与现况;讨论台湾中医专科医师制度建立之可行性。并根据研究结果,提出建议,供相关单位及人员改进及发展中医之参考。研究方法为达成研究目的,在历史研究法架构下,以文献探讨、文件分析、比较研究、半结构性访谈及德怀术专家咨询问卷等方式作为数据搜集与汇整方式,偏属于质性研究方法,同时兼具专家意见量化分析。研究成果1.台湾中医师专业地位随历史发展不断提升台湾中医发展至今日,已走向独立发展之路。从业者由早期巫师、儒医、跟师或自学者,演变为国家立法规范经考试及格受社会认可之中医师,中医教育也由传统家传、师承、自学、私塾等形式发展至现代学校教育。其间历经西方医学传入冲击与日据时期中医学几近毁灭之危机,与台湾中医界先进筚路蓝缕设立中医院校,和透过各类中医师执业资格考试培养台湾中医人才,同时藉由政府立法,强制中医师参加公会办理执业登记,及透过中医师公会与各中医医学会等专业团体实施中医师继续教育。整个台湾中医师专业化动态过程与专业性可由历史发展演进来建构分析。检视专业知能、专业资格、专业组织、专业成长、专业伦理等多项专业特征,台湾中医师已然具备,现更要努力者是追求专业权威之不可取代性。2.中医师执业资格考试与专业院校教育造就台湾中医人才台湾中医师之考选,因应历史背景、社会需求、教育及医疗水平等因素,区分为正规医学教育和非正规医学教育两大类。经由考试评量拔擢各类或经师承或经学校教育培养之中医人才,促进中医事业之发展。1943年公布之《医师法》明定中西医师地位平等,将中医、西医并于一法规范,条文第3条规定中医师检核考试资格,其中一项应试资格规定为中医专科以上学校毕业,但当时医药行政与教育部门仍以西医为主,中医界人士屡向政府要求成立中医学校或允许成立私立中医学校,均未获准,故全国无人能符合此一条件,此法形同虚设。1945年台湾脱离日本殖民地统治,回归国民政府接管,初期中医师养成方式,只有考试院举办之中医师考试。由于中医学校阙如,为甄拔中医人才以供社会所需,考试院于1946年举办第一次特种考试中医师考试,其应考资格宽松,当时台北考区录取2人。医师执业资格认定制度乃国家法治之体现,其所规定之应考资格应与人才培养制度密切配合,教、考、用始能合一。1949年国民政府撤退到台湾,原本在中国本土之中西医论争与互动也延伸至台湾,几经波折,1958年中国医药学院成立(后改名为中国医药大学),在创建者中西医师法律地位和教育平等之主张下,以“恢复传统中国医学;吸收西方医学新知,融入中国传统医学”与“促使中西医融会贯通,进而建立新医学体系”为创校宗旨,其在1966年以前仅开设中西合一之医学系;1966年教育部核准该校成立中医科(后改名为中医学系),培养中医专业人才,此为台湾以正规专业教育培养中医师之滥觞,1972年第一届中医学系毕业生为申请中医师检核考试之主要来源。然而当时中医正规专业教育未见普及(1972年第1届毕业生仅43人),而民间不乏师承自修有得之士,因为不具备相当之学历,无法参加中医师检核及特种考试,取得中医师执业资格;且原制定之特种考试中医师考试应考资格规定,以曾担任公立学校或乡镇公所以上之医疗职务为应考试资格之一,难脱密医漂白之嫌,极为社会诟病,各方建议应予修正;在社会对中医师仍有殷切需求下,考试院数次邀请有关人员举行座谈会,咸认为在中医学校尚未普遍设立之前,应举办中医师检定考试,以为中医师进身之阶,弥补台湾中医人才不足,满足社会对中医医疗之需求。故1968年4月2日修正公布《特种考试中医师考试规则》,删除“在机关团体担任中医治疗工作3年以上,有证明文件者”之应试资格,增列“经中医师检定考试及格者”,使自修研习中医有成者,取得中医师特考之应试资格。又鉴于中医师特考及格人员多系自修苦读,缺乏临床训练,考试院1988年《特种考试中医师考试笔试及格人员训练办法》规定:自1989年起,凡以中医师检定考试及格报考中医师特考并经笔试及格者,均应接受为期1年6个月之基础医学及临床诊疗训练,训练期满核定成绩及格者,始完成考试程序,发给考试及格证书。早年《考试法施行细则》即已明订中医师为专门职业及技术人员。1998年台湾司法院大法官释字第453号解释:“各类专门职业及技术人员之执业,攸关人民生命、身体、财产安全至巨,因此其执业资格之授予,应视各类科性质及其专业领域所应具备之专业知识为考虑,自应循完整之正规专业教育及实习养成方为正途,以确保人民之生命财产安全。”加上医事技术日新月异,医疗伦理更有赖教育熏陶,台湾中医师培养走向正规学术化。同年(1998年),长庚大学在创办人王永庆“研究中医以补西医之不足”指示下,于医学院中成立中医学系,每年招生50名,中西医双主修修业8年。1999年12月29日《专门职业及技术人员考试法》修正公布全文27条,并自2001年1月1日起施行,该律法取消检核制度,将检核精神融入考试;其后2000年6月14日修正之《专门职业及技术人员考试法》,也为中医师检定考试订出“落日条款”。因此2001年1月1日起不再受理中医师检核,而于2000年12月31日前申请中医师检核并经核定准予笔试有案者,得于2001年至2005年内继续参加中医师检核笔试,2006年中医师检核考废止停考;至于中医师检定考试则规定2005年为最后一次受理新案报考,2008年旧案补考划下句点,2009年停办。为此考试院特于2000年12月30日订定发布《专门职业及技术人员高等考试中医师考试规则》,其应试资格规定均为接受正规医学专业教育者;另2002年1月16日也修正公布《医师法》全文43条,其第3条第3项规定中医师特考于2011年办理最后一次考试,因此2012年以后中医师高考将成为取得台湾中医师执业资格唯一管道,即必须具备完整之正规专业教育及实习养成方可成为执业中医师。同时《医师法》第8条第1、2项规定:“医师应向执业所在地直辖市、县(市)主管机关申请执业登记,领有执业执照,始得执业;医师执业,应接受继续教育,并每六年提出完成继续教育证明文件,办理执业执照更新。2009年4月22日之前,执业超过6年之中医师必须提出修毕继续教育180学分之证明檔,始可办理执业执照更新,否则无法再执业。台湾藉由立法执行中医师继续教育并与执业执照更新换证结合已具体落实。3.台湾中医师专业教育精致化发展取向台湾中医教育改革在课程设计、教材教法、师资精进与教学评鉴上,不断追求卓越与高质量之教育产出,所培养学生参加中医师资格考试及格率年创新高,并采用计算机辅助教学及运用视听媒体等强化教育质量,且创新将中医经典医籍融入现代基础医学理念规划出新课程,引进问题导向学习、临床技能教学等提高学习动机之教学法。精致教育(betterness education)卓越性、绩效性、科技性和创新性等四个主要特征,印证台湾中医师专业教育发展现况。4.台湾建立中医专科医师制度在中医专业团体与卫生行政部门结合规划下可行(1)关于制度设计原则:中医师分专科执业为专家认同;专科医师培养质量监控应由中医专业团体与卫生行政部门共同执行,且应为开放系统,接受各方监督。(2)关于专科医师培训制度:专科划分应本着突出中医特色、发挥中医优势原则进行;专科医师培训可采取双轨制及2+X培训模式。(3)关于专科医师准入制度:台湾中医专科医师之甄审,各科每年至少办理一次,且不能限制医师执业只能从事某一项专科:卫生署不宜依专科医师人力供需作名额增减管控:专科医师之申请资格、甄审程序步骤、甄审方式、测验科目、范围、时间,计分及合格标准等由各专科医学会拟定甄审办法报请卫生署公告施行:甄审以笔试为之,并得实施口试、测验或实地考试;外国之中医专科医师资格经审查该外国专科医师制度、训练过程与台湾相当者,仍需实施笔试、口试、测验或实地考试。(4)关于专科医师管理制度:台湾中医专科医师制度施行前应建立种子医师制度;已领有专科医学会所发给之专科医师证书并经卫生署审查合格者,仍需接受2+X年教学医院训练,惟三年内申请专科医师甄审,得免笔试、口试、测验或实地考试;台湾中医专科医师训练医院评鉴应由卫生署中医药委员会规划办理;培训经费采政府补助、培训中医院所出资及个人适当负担之方式。5.台湾中医师专业教育、专科医师培训与继续教育制度应形成连续与完整之医学教育体系。建议根据研究研究结果、文献探讨及专家访谈意见,对台湾中医师专业教育、执业资格及中医专科医师制度,提出建议。1.中医师专业教育方面:实施中医学专业认证;创新师承教育融入院校教育体系,并结合毕业后医学教育、继续教育等多元传承,形成连续与完整之中医学教育,成就高级中医临床人才;重视临床学习经验,争取中医住院制度。2.中医师执业资格方面:重视临床技能,采取三阶段国家中医师证照考试:结合中医教育改革,继续优化试题内容质量。3.在中医专科医师制度方面:制度实施前加强宣导并修订相关法令;教育部认可之教学医院评鉴;中医专业团体也应接受评鉴认可。4.后续研究者之思路:中医专科医师问卷对象可扩及病患;可探讨中医教育中西医结合、中医学课程比率、及全科或专精分化之相关议题。更多还原

【Abstract】 Aim:This thesis carries three purposes which are to introduce the historical development and current situation of Taiwan Chinese Medicine（CM） doctors’ medical education,explore the history and present condition of Taiwan CM doctors’ practice qualifications and discuss the feasibility of establishing the Taiwan CM specialist system.Based on research results, suggestions will be proposed as reference for related departments and staff to improve and develop CM.Methods:Under the frame of history research methodologies,literature review,document analysis,comparative research,semi-structured interviews, Delphi Technique expert consultancy questionnaire,etc.are adopted as data collection and pooling methods whicharemostly qualitative in nature and at the same time carry out the quantitative analysis of experts’ opinions.Result:1.Taiwan CM Doctors’ Professional Status Rises with History DevelopmentUp to now,Taiwan CM has taken the road of independent development. Practitioners have transformed from the early-stage witches,Confucian doctors,master-followers or self-learners to CM doctors who have passed the examinations according to the legislation of Taiwan and are recognized by the society.CM education also develops from traditional family inheritance, masters’ instruction,self-study or home learning,etc.to modern school education.During the development period,CM once was nearly ruined by the impact of the introduction of Western Medicine and the Japanese invasion.Taiwan CM ancestors tried their best to establish the CM colleges,educated CM staff through various CM practice qualification exams,demanded CM doctors to attend the CM Doctors’ Society and register relying on government legislation,and provided CM doctors’ advanced education through CM Doctors’ Society and various CM associations.The dynamic process of Taiwan CM doctors’ professionalization and specialization can be taken into constructive analysis from the angle of historical development.Taiwan CM doctors have the professional features in specialized knowledge,qualifications, organizations,professional development and ethics,etc.What they need to seek at present is the irreplaceable professional authority.2.CM Doctor Practice Qualification Examination and Specialty Colleges Bring About Taiwan CM PersonnelFor historical background,social requirement,education and medical care level and other factors,Taiwan CM doctors’ examinations fall into two categories:regular medical education and irregular medical education. Examinations can evaluate and select various CM personnet learning from school or masters which impel the development of CM.Law of Doctors issued in 1943 prescribes clearly that CM and Western Medicine doctors enjoys equal status and the two kinds of medicine are regulated by the same law.The third item of this law concerning CM doctors’ Qualification Examination states one qualification is to graduate from CM specialty school or above.However,medical administration and education were mostly about Western Medicine at that time.CM personnel asked the government to set up CM schools or allow setting up private CM schools but failed. Therefore no one in Taiwan met this requirement.The law existed in name only. In 1945,Taiwan severed the colonial reign of Japan and returned to Republic of China（R.O.C.）.In the early period,there’ s only one way of educating CM doctors,the CM doctor examination given by the Examination Board.Since lack of CM schools and considering the social demand,the Examination Board offered the Special Examinations of CM Doctors for the first time and the qualification requirement is loosened.In that year,2 people passed the exams in Taipei.Doctor practice qualification identification system is the demonstration of the legal administration of the country and the examination qualification should meet with the personnel education system closely,therefore teaching, examination and application can be integrated.In 1949 when R.O.C.withdrew to Taiwan,the struggle and interaction between CM and Western Medicine in China’s mainland also expanded to Taiwan.After twists and turns,China Medical College,later named China Medical University was founded in 1958.The founders proposed that the legal status and education of CM and Western Medicine doctors and held the following as the education principles:recovering CM,absorbing new knowledge of Western Medicine,and building new medical system by assimilating the two medicine systems.Before 1966,only Integrated CM and Western Medicine Department was offered.In 1966,CM Specialty was established with the permission of the Ministry of Education and later it changed to CM Department to educate the CM specialists.It’ s the beginning of CM doctors’ regular specialist education in Taiwan.In 1972,among those taking the Qualification Examination for CM Practitioner Examination,most are the first session of CM Department graduates.However,the regular specialist education was not popular at that time（only 43 graduates of the first session in 1972）. Many experienced specialists having learned by themselves or from masters in the society didn’t have the equivalent education background and couldn’t take the examinations to get the practice qualifications.One qualification for Special Examination of CM Doctors was to take the medical care position in public schools,town administrations or above.This might offer chances to those false doctors:therefore people from different fields suggested correcting this qualification condition.With the urgent need for CM doctors, the Examination Board invited related personnel to discuss several times.All the attendants suggested it necessary to hold Qualification Examination for CM Practitioner Examination which would educate more CM personnel and meet the social requirement for CMcare.Therefore,on April 2^nd,1968,the amended Regulations of Special Examination of CM Doctors was issued.It deleted the qualification requirement of working as CM doctors for three years or above in government or institutes and holding the related proof.It included those passing the Qualification Examination for CM Practitioner Examination, offering opportunities for those learning by themselves.Considering those passing the Special Examination of CM Doctors mainly learned by themselves and didn’t have enough clinical training,the Examination prescribed in 1988 in Training for Passers of the Special Examination of CM Doctors that since 1989,all those who have passed the Special Examination of CM Doctors with the qualification of Qualification Examination for CM Practitioner Examination must receive basic medical and clinical diagnosis and treatment training which lasts from 6 months to 1 year.When they pass at the end of the training period,the examination procedure finishes and certificates will be issued.Examination Law Enforcement Regulations issued earlier has stated that CM doctors are professional and technical staff.No.453 judicial interpretation of the Justice of the Constitutional Court of Taiwan says that all kinds of professionals’ and technicians’ practice concerns people’s life, health and property safety.The conferment of the practice qualification should take into consideration the nature and required expertise of different subjects.Regular professional education and internship are demanded to ensure the life and property safety of people.With the ever-changing medical techniques,the medical ethics relies more on education.CM doctor education in Taiwan is more standard and academic.In 1998,Department of Chinese Medicine was set up in the Medical College of Chang Gung University under the guidance of its founder,Mr.Wang Yung-ching,to study CM to make up for the defects of Western Medicine.50 students are recruited each year and the dual major of CM and Western Medicine Program lasts for 8 years.27 items of Professionals and Technologists Examination Act were amended and announced on December 29th 1999 and enacted since January 1st 2001.This law deletes the qualification review system and integrates its spirit into examinations. Professionals and Technologists Examination Act amended on June 14th 2000 also make sunset clause for CMdoctor qualification examinations.Therefore no CM doctor qualification review is accepted after January 1st 2001.Those who applied for the qualification review and were allowed to take the written examinations before December 31st 2000 would continue taking the examinations from 2001 to 2005.The qualification examination was deleted since 2006.The CM doctor qualification examination regulations prescribe that the accepted new applications in 2005 are the last ones and the make-up examinations for old cases stop in 2008 and the examination ends in 2009.On December 30th 2000, the Examination Board issued Regulations for Senior Qualification Examination for Professional and Technical Personnel in the category of Chinese Medicine Practitioner which prescribes the qualification is receiving regular medical specialty education.On January 16th 2002,43 items of Law of Doctors were amended and announced.The third regulation of Item 3 prescribes that the Special Examination for CM Doctors in 2011 is the last one.After 2012,the only way to get the CM practitioner qualification is to attend the Senior Qualification Examination for CM doctors.That is to say only attending regular medical education and internship can one become registered CM doctor.At the same time,the No.1 and No.2 regulations of Item 8 of Law of Doctors prescribes that doctors should apply to the city or country they belong to for registration of practice.Only after getting the license can one practice medicine.Those medical practitioners need to receive advanced educationand renew licenses by providing the advanced education proof every 6 years.Before April 22nd 2009,those CM doctors who practiced more than 6 years should provide proof of 180 credits’ advanced education to renew the license;otherwise they can’t practice any more.By legislation,Taiwan realizes the combination of CM doctors’ advanced education and the renewal of practice licenses.3.Tendency of Betterness Education in Taiwan CM Doctor Specialist EducationIn course design,teaching material and methodologies,the advancement of teaching staff and evaluation,Taiwan CM educational reform seeks for the excellent and high quality output.The passing rate of CMdoctor qualification examination rises year by year.Computer Aided Instruction and multimedia are introduced to improve the teaching quality.New courses are designed by initiatively integrating the CM classic works into modern medical concepts. New teaching methodologies are adopted to enhance the learning motives like question-oriented teaching and clinical skill teaching.Betterness Education has four major features:excellence,efficiency,scientific and innovativeness which reflects the current development of Taiwan CM doctor specialist education.4.The Feasibility ofEstablishingCMSpecialist System in Taiwan under the Planning of CM Professional Societies and Health Administrations（1） System Designing Principles:the specialist practice of CM doctors is recognized by experts;the quality control of specialist education should be undertaken by CM professional societiesand health administrations together which should be open for inspection.（2） Specialist Training System:the classification of specialist departments should focus on exerting the advantages and features of CM.The training can take two-tier system and the training model of 2+X. （3） Specialist Access System:the screening and examination of Taiwan CM specialist should be undertaken at least once a year and it shouldn’t restrict the practitioner to only one specialist department.Ministry of Health shouldn’t add or deduct the number according to the demand and supply of specialist doctors’ manpower situation.Each specialist department society should draft the examination ways and hand in to the Ministry of Health to announce and enact,which include the application qualification,the examination procedure,examination ways,subjects,limit,time,grading and passing standard,etc.Examination is carried out in written and oral tests, quizzes,or field examination.If the examination of the qualification of foreign CM specialists shows that their specialist system and training process are equivalent to those of Taiwan,they still need to take the written and oral examinations,quizzes or filed examination.（4） Specialist Administration System:Seed doctor system should be established prior to Specialist CM System.Those who have obtained the specialist certificates from specialist societies and passed the examination of the Ministry of Health still need to receive 2+X years’ training in teaching hospitals.Written and oral examinations,quizzes or field examinations can be exempted if applying for the specialist examination within 3 years.The training hospitals’ evaluation should be undertaken by CM Committee of the Ministry of Health.About the training expenses,it should be shared by the government,the training CM hospitals and individuals.5.Taiwan CM doctor specialist education,specialists’ training and advanced education should form a continuous and complete medical education system.Suggestions:Based on research results,literature discussion and expert interviews, suggestions are proposed for Taiwan CM doctor specialist education,practice qualification and specialist doctor system. 1.CM Doctor Specialist Education:Conduct the authentification of CM specialty;innovatively combine master inheritance into school education and carry out the advanced study and post-graduation medical education so as to form continuous and complete CM education and educate senior CMclinical staff; emphasize the clinical learning experience and seek for the CM residence system.2.CM Doctor Practice Qualification:Emphasize the clinical skills and take the 3-phase national CM doctor license examination;optimize the examination content,considering the CM education reform.3.CM Specialist System:Before enactment,publicity and amendment of related orders are needed;the evaluation of teaching hospitals should be carried out which are recognized by the Ministry of Education;CM professional societies should also be evaluated.4.Thoughts for Follow-up Researches:the questionnaire of CM specialists can extend to patients;related topics like integrated CM and Western Medicine education,course rate of Program of CM,general doctor or specialty differentiation may be further explored.更多还原