How do we heal medicine? | Atul Gawande

Translator: Anders Finn Jørgensen Reviewer: Niels Justus

I got my start

Jeg begyndte

in writing and research

på skrivning og forskning

as a surgical trainee,

som kirurgisk praktikant,

as someone who was a long ways away

som én, der var lang vej

from becoming any kind of an expert at anything.

fra at blive ekspert inden for noget som helst.

So the natural question you ask then at that point

Det spørgsmål du helt naturligt så vil stille

is, how do I get good at what I'm trying to do?

er, hvordan bliver jeg godt til det, jeg forsøger at gøre?

And it became a question of,

Og det blev til et et spørgsmål om

how do we all get good

hvordan bliver vi alle gode

at what we're trying to do?

til det vi prøver at gøre?

It's hard enough to learn to get the skills,

Det er svært nok at lære færdighederne,

try to learn all the material you have to absorb

prøve at lære alt det materiale, du skal læse

at any task you're taking on.

inden for en hvilken som helst opgave.

I had to think about how I sew and how I cut,

Jeg skulle tænke over, hvordan jeg syede og skar,

but then also how I pick the right person

men derudover også hvordan jeg skal vælge den rette person

to come to an operating room.

til at være på en operationsstue.

And then in the midst of all this

Og så, midt i alt dette,

came this new context

kom denne nye kontekst

for thinking about what it meant to be good.

med at tænke over, hvad det vil sige at være dygtig.

In the last few years

Inden for de sidste par år

we realized we were in the deepest crisis

har vi indset, at vi befinder os i den største krise

of medicine's existence

lægekunsten har oplevet,

due to something you don't normally think about

på grund af noget, du normalt ikke tænker over

when you're a doctor

når du er en læge,

concerned with how you do good for people,

som bekymrer sig om at gøre godt for andre mennesker,

which is the cost

og det er prisen

of health care.

på sundhedssystemet.

There's not a country in the world

Der er ikke det land i verden

that now is not asking

som i dag ikke spørger sig

whether we can afford what doctors do.

om vi kan betaler for det som lægerne gør.

The political fight that we've developed

Den politiske kamp som har udviklet sig

has become one around

handler om

whether it's the government that's the problem

hvorvidt det er regeringen som er problemet

or is it insurance companies that are the problem.

eller det er forsikringsselskaberne som er problemet.

And the answer is yes and no;

Svaret er ja og nej.

it's deeper than all of that.

Det ligger dybere end alt dette.

The cause of our troubles

Grunden til vores besvær

is actually the complexity that science has given us.

er faktisk kompleksiteten som videnskaben har givet os.

And in order to understand this,

Og for at forstå dette,

I'm going to take you back a couple of generations.

Vil jeg tage jer et par generationer tilbage i tiden.

I want to take you back

Jeg vil tage jer tilbage

to a time when Lewis Thomas was writing in his book, "The Youngest Science."

til en tid hvor Lewis Thomas skrev sin bog: "Den yngste videnskab."

Lewis Thomas was a physician-writer,

Lewis Thomas var en læge-forfatter,

one of my favorite writers.

en af mine favorit forfattere.

And he wrote this book to explain, among other things,

Og har skrev denne bog for at forklare, blandt mange ting,

what it was like to be a medical intern

hvordan det var at være intern mediciner

at the Boston City Hospital

på Boston City Hospital

in the pre-penicillin year

i årene før penicillinen

of 1937.

i 1937.

It was a time when medicine was cheap

Det var en tid hvor medicin var billig

and very ineffective.

og meget ineffektiv.

If you were in a hospital, he said,

Hvis du var på et hospital, skrev han,

it was going to do you good

ville det gøre dig godt

only because it offered you

men kun fordi det tilbød dig

some warmth, some food, shelter,

noget varme, noget mad, ly,

and maybe the caring attention

og måske medfølende opmærksomhed

of a nurse.

fra en sygeplejerske.

Doctors and medicine

Læger og medicin

made no difference at all.

gjorde ingen forskel overhovedet.

That didn't seem to prevent the doctors

Dette forhindrede ikke lægerne

from being frantically busy in their days,

fra at være afsindigt travle i deres arbejde

as he explained.

som han forklarede.

What they were trying to do

Hvad de prøvede at gøre

was figure out whether you might have one of the diagnoses

var at finde ud af om du havde en af de diagnoser

for which they could do something.

som man kunne gøre noget ved.

And there were a few.

Og der var få.

You might have a lobar pneumonia, for example,

Du kunne for eksempel have lungebetændelse

and they could give you an antiserum,

og de kunne give dig et antiserum,

an injection of rabid antibodies

og injektioner af kanin antistoffer

to the bacterium streptococcus,

mod bakterien streptococcus

if the intern sub-typed it correctly.

hvis lægen kunne bestemme undertypen rigtigt.

If you had an acute congestive heart failure,

Hvis du havde akut hjertesvigt,

they could bleed a pint of blood from you

kunne de tape en halv liter blod fra dig,

by opening up an arm vein,

ved at åbne en pulsåre på armen

giving you a crude leaf preparation of digitalis

og give dig knuste blade fra planten fingerbøl

and then giving you oxygen by tent.

og lægge dig i et ilttelt.

If you had early signs of paralysis

Hvis du havde tidlige tegn på lammelse

and you were really good at asking personal questions,

og var du virkelig god til at spørge om personlige spørgsmål,

you might figure out

kunne du finde ud af

that this paralysis someone has is from syphilis,

at lammelsen skyldes syfilis,

in which case you could give this nice concoction

hvorefter du kunne ordinere en hyggelig blanding

of mercury and arsenic --

af kviksølv og arsenik --

as long as you didn't overdose them and kill them.

så længe de ikke overdoserede og slog patienten ihjel.

Beyond these sorts of things,

Udover denne slags ting

a medical doctor didn't have a lot that they could do.

var der ikke meget en læge kunne gøre.

This was when the core structure of medicine

Det var dengang kernestrukturen af lægeverden

was created --

blev skabt --

what it meant to be good at what we did

hvad det var at være god til, hvad vi ville

and how we wanted to build medicine to be.

og hvad vi ønskede hvad lægekunsten skulle udvikle sig til.

It was at a time

Det var en tid

when what was known you could know,

hvor hvad der var kendt vidste du,

you could hold it all in your head, and you could do it all.

du kunne have det hele i dit hovede og du kunne det hele.

If you had a prescription pad,

Hvis du havde en receptblok,

if you had a nurse,

hvis du havde en sygeplejerske,

if you had a hospital

hvis du havde et hospital

that would give you a place to convalesce, maybe some basic tools,

kunne det give dig et sted hvor folk kunne komme sig, måske nogle simple redskaber,

you really could do it all.

Så kunne du gøre det hele.

You set the fracture, you drew the blood,

Du rettede benbruddet, du tappede blodet,

you spun the blood,

præparerede det

looked at it under the microscope,

og kiggede på det under mikroskopet,

you plated the culture, you injected the antiserum.

du dyrkede kulturer, du indsprøjtede antiserum.

This was a life as a craftsman.

Det var en håndværkers liv.

As a result, we built it around

Som resultat, opbyggede vi

a culture and set of values

en kultur og et sæt af værdier

that said what you were good at

som siger hvad du var god til

was being daring,

var at at være dristig,

at being courageous,

at være modig,

at being independent and self-sufficient.

at være uafhængig og selvtilstrækkelig.

Autonomy was our highest value.

Autonomi var vores højeste værdi.

Go a couple generations forward

Gå et par generationer frem

to where we are, though,

til hvor vi er nu

and it looks like a completely different world.

og det ligner en fuldstændig anden verden.

We have now found treatments

Vi har nu fundet behandlinger

for nearly all of the tens of thousands of conditions

for næsten alle de titusinder af tilstande

that a human being can have.

som et menneske kan have.

We can't cure it all.

Vi kan ikke kurere alt.

We can't guarantee that everybody will live a long and healthy life.

Vi kan ikke garantere at alle vil leve et langt og sundt liv.

But we can make it possible

Men vi kan gøre det muligt

for most.

for de fleste.

But what does it take?

Hvordan er det muligt?

Well, we've now discovered

Vi har nu udformet

4,000 medical and surgical procedures.

4.000 medicinske og kirurgiske procedure.

We've discovered 6,000 drugs

Vi har opfundet 6.000 medikamenter

that I'm now licensed to prescribe.

som jeg nu har tilladelse til at ordinere.

And we're trying to deploy this capability,

Vi prøver at udbrede denne formåen,

town by town,

by efter by,

to every person alive --

til alle personer i live --

in our own country,

i vores eget land,

let alone around the world.

samt i resten af verden.

And we've reached the point where we've realized,

Og vi har nået det punkt hvor vi har erkendt,

as doctors,

som læger,

we can't know it all.

at vi ikke kan vide det hele.

We can't do it all

Vi kan ikke selv

by ourselves.

gøre alt.

There was a study where they looked

Det var en undersøgelse hvor de kiggede

at how many clinicians it took to take care of you

på hvor mange klinikere som skulle til at tage sig af dig

if you came into a hospital,

hvis du kom på hospitalet,

as it changed over time.

som det har ændret sig over tid.

And in the year 1970,

Og i året 1970

it took just over two full-time equivalents of clinicians.

tog det hvad der svarer til to fuldtidsklinikere.

That is to say,

Det vil sige

it took basically the nursing time

at det tog noget tid til pleje

and then just a little bit of time for a doctor

og så en lille smule tid for lægen

who more or less checked in on you

som kom forbi dig

once a day.

en gang om dagen.

By the end of the 20th century,

I slutningen af det 20'ende århundrede

it had become more than 15 clinicians

kræver det nu mere end 15 klinikere

for the same typical hospital patient --

for den samme type hospitalspatient --

specialists, physical therapists,

specialister, fysioterapeuter,

the nurses.

sygeplejerskerne.

We're all specialists now,

Vi er alle specialister nu

even the primary care physicians.

selv de praktiserende læger.

Everyone just has

Alle har kun

a piece of the care.

en lille del af plejen.

But holding onto that structure we built

Men at holde fast i strukturen vi byggede

around the daring, independence,

omkring den frygtløshed, uafhængighed,

self-sufficiency

selvtilstrækkelighed

of each of those people

hos hver at disse mennesker

has become a disaster.

er blevet en katastrofe.

We have trained, hired and rewarded people

Vi har uddannet, ansat og belønnet folk

to be cowboys.

til at være cowboys.

But it's pit crews that we need,

Men det er mekanikere, vi har brug for,

pit crews for patients.

mekanikere for patienter.

There's evidence all around us:

Der er beviser nok omkring os:

40 percent of our coronary artery disease patients

40 procent af patienter med blodpropper i kranspulsåren

in our communities

i vores samfund

receive incomplete or inappropriate care.

modtager mangelfuld eller forkert behandling.

60 percent

60 procent

of our asthma, stroke patients

af vores astma- og hjerteslagspatienter

receive incomplete or inappropriate care.

modtager mangelfuld eller forkert behandling.

Two million people come into hospitals

to millioner kommer på hospitalet

and pick up an infection

og pådrager sig en infektion

they didn't have

som de ikke havde før

because someone failed to follow

fordi nogle ikke fulgte

the basic practices of hygiene.

de basal principper for hygiejne.

Our experience

Vores erfaring

as people who get sick,

med folk som bliver syge,

need help from other people,

har behov for hjælp fra andre folk,

is that we have amazing clinicians

er at vi har forbløffende klinikere

that we can turn to --

som vi kan henvende os til --

hardworking, incredibly well-trained and very smart --

hårdtarbejdende, utroligt veltrænede og meget kloge --

that we have access to incredible technologies

at vi har adgang til fantastiske teknologier

that give us great hope,

som giver os meget håb.

but little sense

Men lidt fornemmelse

that it consistently all comes together for you

for at det forenes på pålidelig vis for dig

from start to finish

fra start til slut

in a successful way.

på en succesfuld måde.

There's another sign

Det er et andet tegn

that we need pit crews,

på at vi skal bruge mekanikere,

and that's the unmanageable cost

og det er de uhåndterlige udgifter

of our care.

for sundhedsvæsnet.

Now we in medicine, I think,

Vi indenfor lægevidenskab, tror jeg,

are baffled by this question of cost.

er ligeglade med dette spørgsmål om pris.

We want to say, "This is just the way it is.

Vi ønsker bare at sige: "Sådan er det bare.

This is just what medicine requires."

Det er hvad behandling koster."

When you go from a world

Når du går fra en verden

where you treated arthritis with aspirin,

hvor du behandlede gigt med aspirin,

that mostly didn't do the job,

som sjældent virkede,

to one where, if it gets bad enough,

til en hvor, hvis det er slemt nok,

we can do a hip replacement, a knee replacement

kan erstatte hofter eller knæ.

that gives you years, maybe decades,

Hvilket giver dig år, måske årtier

without disability,

uden funktionsnedsættelse,

a dramatic change,

en dramatisk forandring,

well is it any surprise

men er det en overraskelse

that that $40,000 hip replacement

at en hofteoperation til $40.000

replacing the 10-cent aspirin

som erstatning til en 10 cents aspirin

is more expensive?

er meget dyrere?

It's just the way it is.

Sådan er det bare.

But I think we're ignoring certain facts

Men jeg tror at vi ikke kan ignorere nogle sandheder,

that tell us something about what we can do.

som fortæller os noget om hvad vi kan gøre.

As we've looked at the data

Da vi kiggede på data

about the results that have come

for at finde resultater der er kommet

as the complexity has increased,

efter kompleksiteten er steget

we found

fandt vi

that the most expensive care

at de dyreste behandlinger

is not necessarily the best care.

ikke nødvendigvis er de bedste.

And vice versa,

Og omvendt,

the best care

den bedste behandling

often turns out to be the least expensive --

viser sig ofte at være den billigste --

has fewer complications,

har færre komplikationer,

the people get more efficient at what they do.

og folk er mere effektive med hvad de gør.

And what that means

Hvilket betyder

is there's hope.

at der er håb.

Because [if] to have the best results,

Hvis man for at få de bedste resultater

you really needed the most expensive care

virkeligt havde behov for den mest kostbare behandling

in the country, or in the world,

i landet, i verden,

well then we really would be talking about rationing

så havde vi virkeligt behov for at tale om rationering

who we're going to cut off from Medicare.

af hvem som skal dækkes af Medicare.

That would be really our only choice.

Det ville være vores eneste valg.

But when we look at the positive deviants --

Men når vi kigger på de positive afvigelser --

the ones who are getting the best results

dem som får de bedste resultater

at the lowest costs --

til den laveste pris --

we find the ones that look the most like systems

så opdager vi at dem som minder mest om systemer

are the most successful.

er de mest succesfulde.

That is to say, they found ways

Hvilket vil sige, at de fandt veje

to get all of the different pieces,

for at få alle de forskellige dele,

all of the different components,

alle de forskellige komponenter,

to come together into a whole.

samlet til en helhed.

Having great components is not enough,

At have fantastiske komponenter er ikke nok,

and yet we've been obsessed in medicine with components.

og stadigvæk syntes vi at være besat af komponenter indenfor medicin.

We want the best drugs, the best technologies,

Vi vil have de bedste medikamenter, de bedste teknologier,

the best specialists,

de bedste specialister,

but we don't think too much

men vi tænker ikke meget på

about how it all comes together.

hvordan det hele skal fungere sammen.

It's a terrible design strategy actually.

Det er faktisk en forfærdelig designstrategi.

There's a famous thought experiment

Her er et berømt tankeeksperiment,

that touches exactly on this

som rammer plet,

that said, what if you built a car

som siger: "Hvad hvis du byggede en bil

from the very best car parts?

af alle de bedste bildele?"

Well it would lead you to put in Porsche brakes,

Du starter med at bruge Porche bremser,

a Ferrari engine,

en Ferrari motor,

a Volvo body, a BMW chassis.

et Volvo karrosseri, et BMW chassis.

And you put it all together and what do you get?

Og du samle det hele og hvad vil du få ud af det?

A very expensive pile of junk that does not go anywhere.

En meget dyr bunke skrot, som ikke kører nogen steder.

And that is what medicine can feel like sometimes.

Og det er hvad lægeverden nogen gange føles som.

It's not a system.

Det er ikke et system.

Now a system, however,

Nu med systemer,

when things start to come together,

når ting fungere sammen,

you realize it has certain skills

så opdager du at bestemte færdigheder

for acting and looking that way.

for at betragte det sådan.

Skill number one

Færdighed nummer et

is the ability to recognize success

er evnen til at genkende en succes

and the ability to recognize failure.

og evnen til at genkende en fiasko.

When you are a specialist,

Når du er specialist,

you can't see the end result very well.

kan du ikke se slutresultatet sårligt godt.

You have to become really interested in data,

Du skal blive virkeligt interesseret i data,

unsexy as that sounds.

lige så usexet som det lyder.

One of my colleagues is a surgeon in Cedar Rapids, Iowa,

En af mine kollegaer er kirurg i Cedar Rapids, Iowa,

and he got interested in the question of,

og han blev interesseret i spørgsmålet om

well how many CT scans did they do

hvor mange CT- skanninger de lavede

for their community in Cedar Rapids?

for deres distrikt i Cedar Rapids.

He got interested in this

Han blev interesseret i dette

because there had been government reports,

fordi der havde været regeringsrapporter,

newspaper reports, journal articles

avisartikler og tidsskriftartikler

saying that there had been too many CT scans done.

som sagde at der havde været alt for mange CT-skanninger.

He didn't see it in his own patients.

Han så det ikke med sine egne patienter.

And so he asked the question, "How many did we do?"

Så han stillede spørgsmålet: "Hvor mange udfører vi?"

and he wanted to get the data.

Og han ønskede at få fat i data.

It took him three months.

Det tog ham tre måneder.

No one had asked this question in his community before.

Ingen havde spurgt om dette i hans distrikt før.

And what he found was that,

Og hvad han fandt var at

for the 300,000 people in their community,

for de 300.000 mennesker i deres distrikt,

in the previous year

var der i det forrige år

they had done 52,000 CT scans.

udført 52.000 CT-skanninger.

They had found a problem.

De havde fundet et problem.

Which brings us to skill number two a system has.

Hvilket bringer os til færdighed nummer to som et system har.

Skill one, find where your failures are.

Færdighed et, find ud af hvor dine fiaskoer er.

Skill two is devise solutions.

Færdighed nummer to er at finde løsninger.

I got interested in this

Jeg blev interesseret i dette

when the World Health Organization came to my team

da WHO kom til mit team

asking if we could help with a project

og spurgte om vi kunne hjælpe med et projekt

to reduce deaths in surgery.

for at reducere dødsfald i kirurgi.

The volume of surgery had spread

Mængden af kirurgi har spredt

around the world,

sig rundt i verdenen,

but the safety of surgery

men sikkerheden i kirurgi

had not.

har ikke.

Now our usual tactics for tackling problems like these

Nu er vores sædvanlige taktik med at takle problemer som disse

are to do more training,

at lave mere træning,

give people more specialization

give vores folk mere specialisering

or bring in more technology.

eller bruge mere teknologi.

Well in surgery, you couldn't have people who are more specialized

Med kirurgi kan du bare ikke finde folk som er mere specialiserede

and you couldn't have people who are better trained.

og du kan ikke finde folk som er bedre trænnet.

And yet we see unconscionable levels

Og stadigvæk ser vi disse uforståelige niveauer

of death, disability

af dødsfald, bivirkninger

that could be avoided.

som kunne være undgået.

And so we looked at what other high-risk industries do.

Så vi kiggede på hvad andre høj-risiko industrier gør.

We looked at skyscraper construction,

Vi kiggede på skyskraber konstruktion,

we looked at the aviation world,

vi kiggede på luftfartsindustrien,

and we found

og vi fandt

that they have technology, they have training,

at de havde teknologi, de havde træning

and then they have one other thing:

og de havde endnu en ting:

They have checklists.

De havde checklister.

I did not expect

Jeg forventede ikke

to be spending a significant part

at jeg skulle bruge en væsentlig del

of my time as a Harvard surgeon

af min tid som en Harvard kirurg

worrying about checklists.

med at bekymre mig om checklister.

And yet, what we found

Men dog fandt vi

were that these were tools

at disse var redskabet

to help make experts better.

til at gøre eksperter bedre.

We got the lead safety engineer for Boeing to help us.

Vi fik en sikkerhedsingeniør fra Boing til at hjælpe os.

Could we design a checklist for surgery?

Kunne vi designe en checkliste for kirurger?

Not for the lowest people on the totem pole,

Ikke for de nederste folk på totempælen,

but for the folks

men for folkene

who were all the way around the chain,

fra top til bund,

the entire team including the surgeons.

hele holdet inklusiv kirurgerne.

And what they taught us

Og hvad de lærte os

was that designing a checklist

var at, det at designe en checkliste

to help people handle complexity

som skal hjælp folk at håndtere kompleksitet

actually involves more difficulty than I had understood.

faktisk indeholder flere vanskeligheder end jeg havde forestillet mig.

You have to think about things

Du må forestille dig disse ting

like pause points.

som pauser.

You need to identify the moments in a process

Du har behov for at identificerer øjeblikke i processen

when you can actually catch a problem before it's a danger

hvor du kan fange et problem før det udvikler sig til en fare

and do something about it.

og gøre noget ved det.

You have to identify

Du må identificere

that this is a before-takeoff checklist.

at dette er en før-start-checkliste.

And then you need to focus on the killer items.

Og du skal fokusere på det vigtige.

An aviation checklist,

En fly checkliste,

like this one for a single-engine plane,

som denne for et enmotorsfly,

isn't a recipe for how to fly a plane,

er ikke en opskrift på hvordan man flyver et fly,

it's a reminder of the key things

det er en huskeliste over de nøgle punkter,

that get forgotten or missed

som kan glemmes eller tabes

if they're not checked.

hvis de ikke er checkede.

So we did this.

Så vi gjorde dette.

We created a 19-item two-minute checklist

Vi lavede en 19 punkts tominutters checkliste

for surgical teams.

for kirurgiske teams.

We had the pause points

Vi havde pauser

immediately before anesthesia is given,

lige inden bedøvelsen blev givet,

immediately before the knife hits the skin,

lige inden skalpelen rammer huden,

immediately before the patient leaves the room.

lige inden patienten forlader operationsstuen.

And we had a mix of dumb stuff on there --

Og vi havde en blanding af banale ting her --

making sure an antibiotic is given in the right time frame

At være sikker på at antibiotika bliver givet indenfor de rigtige tidsramme,

because that cuts the infection rate by half --

fordi det halvere antallet af infektioner --

and then interesting stuff,

og så det interessante,

because you can't make a recipe for something as complicated as surgery.

fordi du ikke kan lave en opskrift på noget så kompliceret som kirurgi.

Instead, you can make a recipe

I stedet for kan du lave en opskrift

for how to have a team that's prepared for the unexpected.

på hvordan holdet skal være forberedt på det uforudsete.

And we had items like making sure everyone in the room

Og vi havde ting som at være sikker på at alle i rummet

had introduced themselves by name at the start of the day,

havde introduceret dem selv med navn ved dagen start,

because you get half a dozen people or more

fordi du har et halvt dusin folk eller mere

who are sometimes coming together as a team

hvor nogen sommetider er sammen som et hold

for the very first time that day that you're coming in.

for den første gang den dag hvor du kommer ind.

We implemented this checklist

Vi indførte denne checkliste

in eight hospitals around the world,

på otte hospitaler rund om i verden,

deliberately in places from rural Tanzania

spændende fra landlige områder i Tanzania

to the University of Washington in Seattle.

til University of Washington i Seattle.

We found that after they adopted it

Vi fandt at efter de indførte den

the complication rates fell

faldt raten af komplikationer

35 percent.

med 35 procent.

It fell in every hospital it went into.

Den faldt på samtlige hospitaler hvor den blev indført.

The death rates fell

Dødsraten faldt

47 percent.

med 47 procent.

This was bigger than a drug.

Dette var meget mere end med et medikament.

(Applause)

(Bifald)

And that brings us

Og det bringer os

to skill number three,

til færdighed nummer tre,

the ability to implement this,

evnen til at indføre dette,

to get colleagues across the entire chain

at få kollegaer fra top til bund

to actually do these things.

til rent faktisk at gøre disse ting.

And it's been slow to spread.

Og det har været langsomt til at spredes.

This is not yet our norm in surgery --

Det er ikke vores norm i kirurgi --

let alone making checklists

at lave checklister

to go onto childbirth and other areas.

fora t gå i gang med fødsler eller andre områder

There's a deep resistance

Det er en stor modstand

because using these tools

fordi at bruge disse redskaber

forces us to confront

tvinger os til at indse

that we're not a system,

at vi er ikke et system,

forces us to behave with a different set of values.

tvinger os til at agere ud fra et andet sæt af værdier.

Just using a checklist

Bare det at bruge en checkliste

requires you to embrace different values from the ones we've had,

kræver at du omfavner nogle andre værdier end dem vi havde,

like humility,

som ydmyghed,

discipline,

disciplin,

teamwork.

holdarbejde.

This is the opposite of what we were built on:

Det er det modsatte af hvad vi er opflasket med:

independence, self-sufficiency,

Uafhængighed, selvtilstrækkelighed,

autonomy.

autonomi.

I met an actual cowboy, by the way.

Jeg mødte forresten en rigtig cowboy.

I asked him, what was it like

Jeg spurgte ham hvordan det var

to actually herd a thousand cattle

at drive tusinde stykker kvæg

across hundreds of miles?

gennem hundrede af miles?

How did you do that?

Hvordan gør du?

And he said, "We have the cowboys stationed at distinct places all around."

Og han sagde:"Vi har cowboys placeret på bestemte steder hele vejen rundt."

They communicate electronically constantly,

De kommunikere konstant elektronisk,

and they have protocols and checklists

de har protokoller og checklister

for how they handle everything --

for hvordan de håndtere alt --

(Laughter)

(Latter)

-- from bad weather

-- fra dårligt vejr

to emergencies or inoculations for the cattle.

til nødsituationer eller vaccineringer af kvæget.

Even the cowboys are pit crews now.

Selv cowboys er mekanikere ne.

And it seemed like time

og det ser ud til at være på tide

that we become that way ourselves.

at vi også selv bliver det.

Making systems work

At få systemer til at virke

is the great task of my generation

er den store opgave for min generation

of physicians and scientists.

af læger og videnskabsfolk.

But I would go further and say

Men jeg vil gå længere og sige

that making systems work,

at få systemer til at virke

whether in health care, education,

hvad enten der er indenfor sundhed, uddannelse,

climate change,

klimaforandringer,

making a pathway out of poverty,

finde vej ud af fattigdom,

is the great task of our generation as a whole.

er den store udfordring for vores generation som helhed.

In every field, knowledge has exploded,

Indenfor hvert eneste område er viden eksploderet

but it has brought complexity,

men det har medført kompleksitet,

it has brought specialization.

det har medført specialisering.

And we've come to a place where we have no choice

Og vi er kommet dertil hvor vi ikke har noget valg

but to recognize,

end at erkende,

as individualistic as we want to be,

som de individualister vi gerne vil være,

complexity requires

kompleksitet kræver

group success.

gruppesucces.

We all need to be pit crews now.

Vi bliver nødt til at at være mekanikere nu.

Thank you.

Mange tak.

(Applause)

(Bifald)