韩国传统医生的医疗纠纷案件外文文献

Available online at ScienceDirect European Journal of Integrative Medicine 6 2014 497 501 Original article Medical dispute cases involving traditional Korean medical doctors A survey Hyeun Kyoo Shina Soo Jin Jeonga Byoung Kab Kangb Myeong Soo Leeb aHerbal Medicine Research Division Korea Institute of Oriental Medicine Daejeon Republic of Korea bMedical Research Division Korea Institute of Oriental Medicine Daejeon Republic of Korea Received 26 September 2013 received in revised form 20 May 2014 accepted 20 May 2014 Abstract Introduction Medical dispute cases have increased worldwide as patients become more aware and able to access medical information The aim of this survey was assessing the frequency and resolution of medical dispute cases involving traditional Korean medicine TKM Methods A total of 501 TKM clinics were randomly selected from throughout South Korea and stratifi ed by region and contacted by mail The clinics were asked about the frequency and resolution of any medical dispute cases between June 1 and December 9 2008 Results Response rates were 4 0 for TKM private clinics and 40 1 for TKM hospitals Out of a total of 501 clinics 64 12 7 reported having at least one medical dispute case The rates of medical disputes for each TKM therapy in proportion to the 112 respondents were as follows acupuncture 38 34 herbal medicine 31 28 moxibustion 13 17 physical therapy 11 10 herbal medicine injection 7 6 chiropractic 7 6 and misdiagnosis 5 4 Of the 97 disputes 71 73 were resolved by mutual agreement 15 15 were resolved by insurance claims 3 3 went to civil suits and 8 cases 8 were resolved using other methods Conclusions A method to record medical disputes would be necessary to further clarify this process if accurate information on frequency and resolution is to be achieved The standardisation of TKM and the establishment of evidence based medicine should continue to improve this situation Furthermore legal guidelines and regulations of TKM should be established for the resolution of medical disputes This article belongs to the Special Issue Ensuring and Improving Patients Safety in Integrative Health Care 2014 Elsevier GmbH All rights reserved Keywords Traditional Korean medicine Medical dispute Complementary and alternative medicine Adverse events Introduction Medical disputes have increased dramatically worldwide in recent decades 1 5 In South Korea medical disputes have increased rapidly since the late 1980s due to patients rising awareness of their rights and greater access to medical informa tion 3 6 A medical dispute is defi ned as a patient proposal in return for the argument which may or may not correlate medical mal This article belongs to the Special Issue Ensuring and Improving Patients Safety in Integrative Health Care Corresponding author at Medicine Research Division Korea Institute of Oriental Medicine 483 Expo ro Yusung gu Daejeon 305 811 Republic of Korea Tel 82 42 868 9266 fax 82 42 868 9299 E mail addresses drmslee mslee kiom re kr M S Lee practice 1 Usually a medical dispute is started once patient claims that doctors fail in their care and obligations in medical practice and the patient s symptoms is worsened or death as a result of their neglect 7 The medical system in South Korea is regulated by the gov ernment and comprises two systems one based on Western medicine and the other based on traditional Korean medicine TKM Only traditional Korean medical doctors TKMDs can prescribe herbal formulas acupuncture moxibustion cupping physical and chiropractic therapies based on the TKM theory These TKM therapies are unavailable to Western medical doc tors because medical laws restrict their practice 8 TKM is an integral part of the national medical insurance system Western medicine has been part of the national insurance system since July 1 1977 whereas TKM has been part of this system since February 1 1987 9 10 In 2008 14 818 TKMDs http dx doi org 10 1016 j eujim 2014 05 004 1876 3820 2014 Elsevier GmbH All rights reserved 498 H K Shin et al European Journal of Integrative Medicine 6 2014 497 501 provided TKM prescriptions to a total of 12 128 657 patients that were reimbursable by the national health insurance system This represents 7 3 of the total medical treatment and 3 5 of the medical cost compared with Western medicine 11 However the use of TKM therapies has continuously increased as has complementary and alternative medicine CAM and traditional Chinese medicine TCM use 12 13 Recently TKM has faced diffi culties regarding the lack of a suffi ciently robust scientifi c evidence basis for establishing effi cacy Furthermore questions have arisen regarding the safety of increasingly used TKM Medical dispute cases have been a major social issue in West ern medicine Medical accidents and disputes in the Korean medical system have increased since the late 1980s but exact fi g ures are diffi cult to determine 3 Medical dispute cases related to TKM are very similar to Western medicine A few cases of medical disputes between patients and TKMDs have been reported by governmental agency the Korean Consumer Agency KCA and a non governmental organisation the Association of Traditional Korean Medicine ATKM 14 To address the increasing interest in both traditional therapies and their med ical complaints among the public this survey aimed to assess the frequency and resolution of medical dispute cases related to TKM by TKMDs Methods Study design This study presents a survey of medical dispute cases related to TKM practices in TKM private clinics and hospitals carried out between June 1 and December 9 2008 The survey was sent out to TKMDs on the directory of the Association of Traditional Korean Medicine ATKM by mail Setting There are 11 001 TKM clinics in South Korea 10 859 TKM private clinics and 142 TKM hospitals Our study was conducted in TKM private clinics and hospitals There are many TKM private clinics which are medical insti tutions that use general TKM therapies and treat minor ailments A total of 10 859 TKM private clinics were iden tifi ed and stratifi ed by region including one capital Seoul six large cities Busan Daegu Incheon Gwangju Daejeon and Ulsan and nine local regions Gyeonggi do Gangwan do Chungcheongnam do Chungcheongbuk do Jeollanam do Jeollabuk do Gyeongsangnam do Gyeongsangbuk do Jeju do using a stratifi ed sampling method Table 1 Through the directory of the ATKM we selected 4200 TKM private clinics according to stratifi ed by region using a propor tionate probability sampling method and randomly sent out 4200 TKM private clinics in each region with return envelopes In contrast there are fewer TKM hospitals and these are medical institutions that use professional TKM therapies and treat serious diseases All 142 TKM hospitals were contacted because of the high likelihood of them having medical disputes Table 1 Distribution of TKM private clinics by regional blocks in South Korea Total region no No of total TKM private clinics No of responding TKM private clinics N 10 859 453 4 2 Seoul 3052 94 3 1 Busan city905 28 3 1 Daegu city 685 29 4 2 Incheon city 453 14 3 1 Gwangju city 263 11 4 2 Daejeon city 393 45 11 5 Ulsan city 233 19 8 2 Gyeonggi do 2041 63 3 1 Gangwan do 285 10 3 5 Chungcheongbuk do 287 18 6 3 Chungcheongnam do 375 25 6 7 Jeollabuk do 389 30 7 71 Jeollanam do 269 12 4 5 Gyeongsangbuk do 510 27 5 3 Gyeongsangnam do 606 21 3 5 Jeju do 113 7 6 2 Participants Traditional Korean Medical Doctors TKMDs who provided medical treatment to patients regardless of gender age career period or number of patients were included In the event of nonresponse we randomly chose and added new samples from the sampling frame Variables The survey items were as follows Appendix A Gender and age Number and type of medical disputes during the intervention period The main cause of medical disputes in TKM treatment e g acupuncture moxibustion chiropractic and physical therapy and herbal medicine The resolution methods for medical disputes Statistical analysis A frequency analysis was conducted for all questions Anal ysis of the survey results was performed using Microsoft Excel and SPSS WIN 12 0K SPSS Inc Chicago IL USA Ethical considerations The ethical review committee of the Korea Institute of Ori ental Medicine provided their agreement for the study to take place The survey was conducted on a voluntary basis with agree ment from the participants for the use of the collected data for scientifi c purposes H K Shin et al European Journal of Integrative Medicine 6 2014 497 501 499 Table 2 Dispute cases and resolution methods among traditional Korean medical doctors Total N 501 TKM private clinic N 444 TKM hospital N 57 p Valuea Experience of medical disputes 0 240 Yes64 13 58 13 6 11 No 416 83 365 82 51 89 No response 21 4 21 5 0 No of disputes experienced 0 099 1 time 49 77 46 79 3 50 2 times 9 14 8 14 1 17 3 times 4 6 3 5 1 17 More than 4 times 2 3 1 2 1 17 Main cause of disputeb0 492 Acupuncture 38 34 34 33 4 40 Herbal medicine 31 28 30 29 1 10 Moxibustion 13 17 11 11 2 20 Physical therapy11 10 9 9 2 20 Herbal medicine injection7 6 7 7 0 Chiropractic 7 6 6 6 1 10 Misdiagnosis 5 4 5 5 0 Total 112 100 102 100 10 100 Dispute resolution methods 0 0001 Insurance claim 15 15 15 18 0 Mutual agreement 71 73 65 77 6 50 Civil suit 3 3 3 4 0 Other 8 8 2 2 6 50 Total97 100 85 100 12 100 All data are expressed as N a Calculated by Fisher s exact test b Multiple statements are considered TKM traditional Korean medicine Results The total number of TKM clinics in Korea in 2008 was 11 001 A total of 10 859 TKM private clinics were selected according to region using a proportionate probability sampling method and randomly and investigated all 142 TKM hospi tals Finally 453 TKM private clinics responded to questions nine incomplete answers were excluded Responses from TKM private clinics were as follows 444 were received from TKM private clinics response rate 4 0 and 57 from TKM hospitals response rate 40 1 The respondents from the TKM private clinics include 404 91 male and 40 9 female and nine 2 respondents were in their 20s 174 40 in their 30s 194 44 in their 40s 46 10 aged in their 50s 18 4 over 60 and three did not provide their age Of the 501 TKM private clinics and hospital respondents surveyed in South Korea only 64 12 7 reported having a medical dispute experience 58 private clinics and six hospi tals In terms of the frequency of medical dispute experiences two respondents had more than four experiences four had three experiences nine had two experiences and 49 had one experi ence The rates of medical dispute experiences for each type of TKM were as follows acupuncture 38 34 herbal medicine 31 28 moxibustion 13 17 physical therapy 11 10 herbal medicine injection seven 6 chiropractic seven 6 and misdiagnosis fi ve 4 Of the 97 medical dispute resolu tion methods 71 73 were resolved by mutual agreement 15 15 were resolved by insurance claims three 3 went to civil suits and other methods were used in eight cases 8 There was a statistically signifi cant difference between TKM clinics and TKM hospitals only in dispute resolution methods p 0 001 but not for other questions Table 2 Discussion This study is the fi rst nationwide survey to assess medical dispute cases associated with licenced TKM practitioners and their dispute resolution methods We found that severe medical disputes do occur and are most likely to be associated with the use of acupuncture 34 and herbal medicine 31 Previous studies have consistently demonstrated that the most frequent medical disputes and adverse events are related to acupuncture and herbal medicine in TKM and TCM 13 17 In consumer research a recent paper showed that 167 371 cases of consumer complaints related to medical treatments and drugs were received from 1999 to 2010 and 7532 4 5 of these were due to TKM The number of total complaints increased from 5670 in 1999 to 27 344 in 2010 TKM complaints also increased from 198 in 1999 to 859 in 2010 14 Adverse experiences do not always lead to medical disputes but in an investigation of patients who visited TKM clinics 8 2 of indi viduals had certain types of adverse experiences resulting from TKM 15 At the TKMD level our study showed that 97 cases of medical disputes occurred in 64 TKM clinics The survey reported that medical disputes in China gradually increased In 500 H K Shin et al European Journal of Integrative Medicine 6 2014 497 501 38 TCM clinics there were 345 medical disputes in 2001 692 in 2003 and 1018 in 2004 In 114 TCM clinics there were 30 medical disputes in 2005 and 66 in 2006 16 18 Dispute resolution methods are important in the study of medical disputes In the present study 73 of disputes were resolved by mutual agreement 15 were resolved by insur ance claims and 3 were resolved by civil suits These results were consistent with other research data In the case of Western medicine in South Korea 85 9 of disputes were resolved by mutual agreement and 9 3 1116 cases resulted in malprac tice claims submitted to courts in 2008 19 20 In comparison in 2005 95 of events were resolved through mutual agree ment 1 5 were resolved through insurance claims and 3 3 were resolved through civil suits The rate of mutual agreement decreased whereas the use of insurance claims increased 20 Medical dispute resolution methods in TCM were similar to those in South Korea Of 2055 cases 85 2 1752 cases were resolved by mutual agreement 7 9 162 cases were resolved by medical dispute mediation committees 6 9 141 cases were resolved in court and 42 7 877 cases were resolved through reimbursement 18 In South Korea and China where traditional and Western medicines co exist 85 of medical dis putes were resolved by mutual agreement and less than 10 were resolved by law In both traditional medicine and CAM dispute resolution through the legal system requires complex processes Western medicine has standards and ranges for practice and diagnosis and it is easy to defi ne medical disputes In contrast the lack of standards of care and assumption of risk theories makes it diffi cult to identify medical disputes in TKM TCM and CAM 2 21 23 In particular it is not appropriate to apply the medical dispute resolution guidelines of Western medicine to the reso lution of medical disputes in TKM or CAM The investigation of TKM medical disputes by TKMDs is also diffi cult 23 25 Thus traditional medical experts are required to establish defi nitions classifi cations rules and evidence for medical dispute resolution 26 Limitation of this study is that the target for medical dispute investigation was only TKMDs but not included consumers To understand the current situation of TKM medical dispute in South Korea the survey should have targeted both TKMDs and consumers We were also unable to determine the root causes and effects of medical disputes Our survey method was not as accurate or detailed as other research on medical disputes because of possible recall bias and selection bias Furthermore we did not consider the total treatment frequency or the number of TKMDs in the surveyed clinics or hospitals This omission means that we cannot determine the exact rate of malpractice in the dispute claim process In conclusion since most medical disputes are resolved by the agreement between medical doctors and patients it is diffi cult to investigate their accurate frequency and resolution Thus a method of collecting data is necessary to further clarify this pro cess in medical treatment system The standardisation of TKM and the establishment of evidence based medicine should con tinue to aid in the resolution of these disputes Furthermore legal guidelines and regulations for TKM characteristics should be established for the resolution of medical disputes related to TKM rather than relying on mutual agreement between doctors and patients Confl ict of interest statement The authors declare that they have no potential confl ict of interest Acknowledgments This research was supported by a grant Construction of Scientifi c Evidence for Herbal Medicine Formulae Grant No K14030 from the Korea Institute of Oriental Medicine KIOM Appendix A Questionnaire A Question a bout exper ience o f medical dispute 1 Do you have any experi ence of a medical dispute in previous year 1 Yes 2 No 2 How many t imes have you experi ence d such a medical dispute 1 1 time 2 2 times 3 3 times 4 More than 4 times 3 What is the main cause of dispute 1 Acupunctu re 2 Herbal medicine 3 Moxibustion 4 Physi cal therapy 5 Herb al medicine injection 6 Chiroprac tic 7 M isdia gnosis 4 What method did you use for the dispute resolutio n 1 Insurance claim 2 Mutual agree ment 3 Civ il suit 4 Other please explain B Th ese a re qu estions about you 1 Where is your place o f work 1 Private clinic 2 Hospital 2 How old are you 1 20 29 2 30 39 3 40 49 4 50 59 5 60 3 What is your gender 1 Male 2 Female References 1 Wu CY 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