【作者】 孙杨；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2008， 硕士

【摘要】 目的:通过对武汉市3年医疗事故技术鉴定案例的了解与分析,揭示目前医患纠纷处理模式的特点,同时结合目前我国医患纠纷处理立法情况与司法导向现状,力求通过引入博弈理论的观点和模型构建对医患纠纷中的现象进行分析,提出当前情况下医患双方在纠纷处理中选择策略时所需要注意的问题,并进一步对缓解医患纠纷的制度建设提出建议。方法:本研究主要采用文献研究、理论与实证研究相结合的方式;运用文献分析、知情人访谈等定性研究方法,结合实证资料量化处理,并运用统计分析方法对指标分析比较并分析相关因素,同时根据博弈理论构建初步的医患纠纷博弈模型,寻求医患纠纷现象的合理解释。研究资料主要来源于武汉市医学会和国内外有关医患纠纷与博弈相关理论书籍及文献。分析结果:1、医疗事故技术鉴定每年受理的案例数量基本保持平稳,主要委托进行鉴定的机构是卫生行政部门(53.4%)与法院(45.7%),三级医疗机构是医疗事故鉴定中医方的主要构成部分(67.8%)。患方的年龄构成除不足5岁的婴幼儿比例偏高(9.2%)外,基本符合人群正态分布的特征。医疗事故的等级与医方承担的责任呈现负相关关系。2、2004～2006年的医疗事故认定率逐年的升高,分别为25%、36%、44%。经过分析发现医疗事故技术鉴定结果中医疗事故认定率上,三级医疗机构明显低于非三级医疗机构(χ2=23.841,P<0.001);法院委托的鉴定案例其事故认定率要明显低于由卫生行政部门委托的案例(χ2=6.257,P=0.012),卫生行政部门委托鉴定的案例其医疗事故认定率逐年提高(χ2=13.076,P=0.001),分别为2004年26%,2005年41%,2006年58%,而法院委托的案例,其医疗事故认定率无明显变化(χ2=0.676,P=0.713)。3、时间指标分析指出,由法院委托的鉴定案例其患方“就诊——受理”平均时间要长于非法院委托的案例;而出现死亡结果的鉴定案例其患方“就诊——受理”平均时间要短于非死亡结果的鉴定案例;对于法院委托的鉴定案例来看,医疗事故中的患方“就诊——受理”平均时间间隔要短于非医疗事故;对于患方死亡的鉴定案例来看,医疗事故中的患方“就诊——死亡”平均时间间隔要短于非医疗事故;4、结合博弈理论,医患纠纷符合不完全信息条件下的动态博弈过程,最终根据信号博弈模型构建医患纠纷博弈模型的初步框架。患方在博弈模型中不能确且的知晓医方是否有责任,只对此有一个信念,然后患方通过观察医方对待医患纠纷的态度,患方修正自身的信念,并选择处理医患纠纷方式的策略。主要结论1、根据医疗事故认定率的分析以及近年来我国医患纠纷处理法律规范和司法导向的分析,发现医疗事故技术鉴定可能对医方存在一定的偏移和保护,这一现象在2005年后是得到国家法律和司法部门一定程度上的默许和认可的。这一现象体现了司法部门运用国家规定的法律法规寻求促进医疗行业和技术发展与保护患方利益这一对矛盾间的平衡所作出的努力。2、医患纠纷产生的主要因素可能来源于患方对损伤性后果的直观感受,这一感受同时决定了患方认为医方在诊疗过程中因过错存在责任的信念强度,以及患方所将会采取的策略选择。越是严重的损伤性诊疗后果,导致患方对医方存在责任的信念越是强烈,同时也使患方采取的策略更倾向于尽快的验证自身信念的正确性。建议1、根据国家的宏观导向,希望医患纠纷尽量在医疗事故的范畴内进行解决,在这一背景下医方和患方在具体的纠纷博弈需要更多的理性来选择策略,引导和谐社会中医患纠纷的尽快合理的解决。卫生行政部门可以作为促进双方理性的调解角色,而不仅仅是力求在行政调解中尽快令医患双方达成协议。2、在短时期内,法院作为最有权威和体现公正性的第三方机构,在医患纠纷博弈中作为最后的策略,需要在医患纠纷的处理中体现更多的价值。司法部门对于医患纠纷案件的审理上可以充分利用司法调解等手段,同时在一定程度上探索简化医患纠纷民事案件的审理程序,提高审理效率。3、长远来看,我国应该重视医疗机构医疗责任的分散机制的设计和建设,逐步建立健全以医疗责任险为代表的医疗机构医疗责任的分散机制。更多还原

【Abstract】 Object: Analysis the Wuhan medical accident checkup cases, find out the character of the medical dispute resolution, and combine with legislation of China medical dispute actuality. We want to analyze the phenomenons of the medical dispute by Game Theory,and give the recommendation for both sides’strategy choosing. Finially find out how to reduce the medical dispute.Methods: This research mainly adopts literature and theory study, and demonstration investigation. It uses qualitative research approach, such as document analysis, expert consultation, etc and quantitative research approach, such as demonstration investigation. It also uses statistical analysis methods to analyze and compare about the statistical indexes and the analysis of the relevant factors. At the same time, we build the primary former of medical dispute by Game Theory, find out explanation of phenomenons of the medical dispute. The study data mainly come from Wuhan Medcine academy, and the literature mainly come from medical dispute and Game Theory book at home and aboard.Analysis:1. The count of medical accident checkup cases every year is calm. The cases mainly come from the health administration (53.4%) and court (45.7%). The hospital in the cases mainly build by third level hospital (67.8%). The patient’s age structure nearly accord with normal distributing,except the count of baby whose age smaller than 5 years has a high proportion (9.2%). The leve of the medcial accident have a negative correlativity with the duty of hospital.2. 2004~2005 the medical accident rate of checkup case hoist by years, 2004-25%,2005-36%,2006-44%. Third level hospital’s medical accident rate obvisly lower than non-third level hospital (χ2=23.841,P<0.001);Medical accident rate of the court case obvisly lower than health administration case (χ2=6.257,P=0.012). Medical accident rate of the health administration case hoist by years(χ2=13.076,P=0.001),2004-26%,2005-41%,2006-58%. At the same time medical accident rate of the court case has no obviously change (χ2=0.676,P=0.713). 3. Time index analysis find out that the mean“treat to commission”time of court case longer than non-court case (health administration case); the mean“treat to commission”time of dead case shorter than non-dead case.In the court case, the mean“treat to commission”time of medical accident case shorter than non-accident case.In the dead case, the mean“treat to dead”time of medical accident case shorter than non-accident case.4. Combining with Game Theory, the medcial dispute fit the dynamic Game of incomplete information, and the primary medcial dispute former came from the signaling Game former.The patient can not know whether hospital has duty in beginning of the Game, but have a faith , patient can amend the faith by observe the hospital’s attitude to medical dispute, and then patient choose the strategy of resolution.Results:1. By analysis of medcial accident rate of checkup case and china medical dispute law, we find out that medical accident checkup has nepotism to hospital, and from 2005,the nepotism has recognized by the low and court. This phenomenon is the balance of the conflict between health vocation development and protecrion patient’s behalf.2.Medical dispute caused by the responsibility of patient for the treat hurt outcome, the responesibiliy decide the degree of faith that hospital has duty for the treat hurt outcome, and then patient will choose the strategy. The more serious outcome ,the high degree faith and the patient will be more inclined to choose the strategy which will check the faith. Suggestions:1. Following the national macroscopical guide, the medical dispute should resolute in the ground of medical accident. Hospital and patient in the dispute game should choose strategy more nous, guide the dispute resoluted more effective in the harmonious society.2. In the near future, court to be the third side is the most authority and equity. To be the final strategy ,court can show more value in medical dispute resolution.3. In long-range future, national design and build for decentralization of hospital’s duty mechanism should be the most important resolution of medcial dispute. The example of the mechanism is medical duty care system, the system should be work up.更多还原