從系絡觀點檢視策略執行對醫師同理心之衝擊。方法：針對參加總額自主管理方案245家醫院，便利取樣區域層級以上醫院，於2008年6月至12月以自陳報告調查84家1,280位醫師，回收51家醫院有效樣本441份，代表醫院和醫師的回收率為60.71%和34.45%。低層次解釋變項(策略執行感受)透過群內聚合產生相同測量內容的系絡變項，且納入高分析層次解釋變項(機構特性)，應用層級線性模式(Hierarchical Linear Modeling, HLM)進行分析。結果：醫院同時執行競比的策略，意指「成本抑制」和「收入提增」，同理心突現三構面且命名為「熱心照護」、「自動自發」和「站在病人立場」。HLM分析顯示，收入提增策略(系絡變項)對醫師熱心照護、自動自發有正向的系絡直接影響(γ＝0.249, 0.150, p＜.05)，成本抑制策略(系絡變項)對同理心三構面的負向影響(γ＝-0.054~ -0.109)未達0.05顯著水準；權屬別對醫師自動自發(γ＝0.208, p＜.05)、評鑑等級對醫師熱心照護(γ＝0.200, p＜.05)有系絡的直接影響，而宗教屬性對醫師同理心不具系絡效果(γ＝0.019~0.202, p＞.05)。個體解釋變項中，年齡對熱心照護(γ＝0.070, p＜.05)有正向影響，專科別(內科vs.外科)對同理心的影響(γ＝-0.057~ 0.051, p＞.05)未達顯著水準。簡言之，個體層次變項解釋醫師同理心26.77%~32.93%群內變異，醫院層次變項解釋45.49%~59.33% 群間變異。結論：台灣導入健保總額下，當醫院管理重點愈強調收入創造，而較不強調成本抑制，則醫師愈能展現熱心照護、真正瞭解病人情緒。本文藉由階層資料和跨層次分析，實證組織系絡會形塑醫師同理心，也不應忽視個人特徵的影響.

Objectives: This study explored the contextual effects of a perceived emphasis on cost and revenue on physicians’ empathy in hospitals participating in the global budget program. Methods:We selected 84 teaching hospitals and surveyed 1,280 physicians with structured questionnaires.A total of 441 usable questionnaires from 51 hospitals were returned. This represented response rates of 60.71 percent for the hospitals and 34.45 percent for the physicians. We conducted hierarchical
linear modeling using individual physician-evaluated empathy as the outcome variable.The perceptions of strategic implementation at the physician level were aggregated at the hospital level to serve as a contextual variable. We also included rank, ownership and religious type as hospital-level variables. Results: The strategy of revenue-generation led to increases in physicians’compassionate care and perspective taking (γ= 0.249, 0.150, p<.05), but unit management’s emphases on cost containment did not significantly reduce physicians’ empathy (γ=-0.054~
0.109,p>.05). The contextual effects of hospital rank (medical centers vs. regional hospital) on physicians’compassionate care (γ=0.20, p<.05) as well as ownership (public vs. private) on physicians’perspective taking (γ=0.208, p<.05) showed significant differences, although the contextual effects of religious type were not significant (γ=0.019~0.202, p>.05). Physician age positively influenced physician empathy in compassionate care (γ=0.070, p<.05); however, data revealed no significant
differences among medical specialties (γ=-0.057~0.051, p>.05). The individual-level factors explained 26.77%~32.93% of within-hospital variance on empathy and hospital-level factors explained 45.49%~59.33% of between-hospital variance. Conclusions: Results indicated that organization context could shape the physicians’ empathy, while the impact of personal characteristics should not be ignored. (Taiwan J Public Health.