Stefan Larsson: What doctors can learn from each other

翻译人员: Shengwei Cai 校对人员: Peipei Xiang

Five years ago, I was on a sabbatical,

五年前趁休假的时候，

and I returned to the medical university

我回到我曾就读的

where I studied.

医学院。

I saw real patients and I wore the white coat

我穿上白大褂，见了真正的病人，

for the first time in 17 years,

这是自我17年前

in fact since I became a management consultant.

成为管理顾问以来的头一次。

There were two things that surprised me

我在那里的一个月，

during the month I spent.

有两件事情让我吃惊。

The first one was that the common theme

第一，医学院里

of the discussions we had were hospital budgets

常常讨论的话题是医院的预算

and cost-cutting,

和削减开支。

and the second thing, which really bothered me,

第二，也是真正让我忧心的

actually, was that several of the colleagues I met,

是我遇到的几位同事。

former friends from medical school,

他们是我在医学院的昔日好友，

who I knew to be some of the smartest,

他们是我所认识的最聪明，

most motivated, engaged and passionate people

最有积极性的，热衷参与

I'd ever met,

并富有激情的人。

many of them had turned cynical, disengaged,

但是，他们中的很多人，现在变得漠然且愤世嫉俗，

or had distanced themselves from hospital management.

或与医院管理保持距离。

So with this focus on cost-cutting,

当我们专注于削减开支的时候，

I asked myself, are we forgetting the patient?

我问我自己，我们是否忘记了病人的存在？

Many countries that you represent

很多国家，包括你们的，

and where I come from

也包括我的，

struggle with the cost of healthcare.

都在为医疗保健支出而烦恼。

It's a big part of the national budgets.

这项支出占据了国家预算的很大一部分。

And many different reforms aim at holding back this growth.

而许多医疗体制改革的目标 就是控制这项支出的增加。

In some countries, we have long waiting times

在一些国家，看病等待期很长，

for patients for surgery.

特别是需要手术的病人。

In other countries, new drugs are not being reimbursed,

还有一些国家，新药没有补助，

and therefore don't reach patients.

于是病人也不能用上新药。

In several countries, doctors and nurses

在很多的国家，医生和护士

are the targets, to some extent, for the governments.

在一定程度上成为政府削减开支的针对目标。

After all, the costly decisions in health care

毕竟，那些花费昂贵的医疗措施

are taken by doctors and nurses.

都是由医生和护士来决定的。

You choose an expensive lab test,

是这些人在选择高成本的实验，

you choose to operate on an old and frail patient.

也是这些人在选择给孱弱的老人做手术。

So, by limiting the degrees of freedom of physicians,

所以，（政府想）通过限制医生的自由，

this is a way to hold costs down.

来达到降低开支的目的。

And ultimately, some physicians will say today

最后导致的结果是医生发现

that they don't have the full liberty

他们没有充分的自由来

to make the choices they think are right for their patients.

为他们的病人选择最适合他们的治疗方案，

So no wonder that some of my old colleagues

怪不得我过去的同事们

are frustrated.

那么沮丧。

At BCG, we looked at this,

在BCG（波士顿咨询公司），我们分析了这个问题，

and we asked ourselves,

我们问自己，

this can't be the right way of managing healthcare.

这样管理医疗保健的方法肯定是不正确的。

And so we took a step back and we said,

所以我们退一步想

"What is it that we are trying to achieve?"

“我们到底想要取得什么成效？”

Ultimately, in the healthcare system,

归根结底，在医疗保健系统里，

we're aiming at improving health for the patients,

我们的目标是要改善病人的身体状况，

and we need to do so at a limited,

而且是要在一定限度内

or affordable, cost.

或者说能负担得起的情况下。

We call this value-based healthcare.

我们称之为“以价值为基础的医疗保健”。

On the screen behind me, you see what we mean

在我身后的屏幕上你们可以看到

by value:

我所谓“价值”就是：

outcomes that matter to patients

对病人有用的结果

relative to the money we spend.

除以看病的费用。

This was described beautifully in a book in 2006

这在一本2006年出版的由Michael Porter

by Michael Porter and Elizabeth Teisberg.

和Elizabeth Teisberg合著的书里解释得非常清楚。

On this picture, you have my father-in-law

在这张照片里，你们可以看到我的岳父

surrounded by his three beautiful daughters.

和他的三个漂亮的女儿。

When we started doing our research at BCG,

我们开始在BCG做研究的时候，

we decided not to look so much at the costs,

我们决定先不看费用是多少，

but to look at the quality instead,

而是看质量。

and in the research, one of the things

在研究中，（医院之间）

that fascinated us was the variation we saw.

悬殊的治疗质量相当引人注目。

You compare hospitals in a country,

比较同一个国家里的不同医院

you'll find some that are extremely good,

你会找到一些做的非常好的医院，

but you'll find a large number that are vastly much worse.

但是也有大量医院做的极为糟糕。

The differences were dramatic.

这之间的差异非常显著。

Erik, my father-in-law,

我的岳父，Erik，

he suffers from prostate cancer,

患有前列腺癌，

and he probably needs surgery.

很可能需要手术。

Now living in Europe, he can choose to go to Germany

他住在欧洲，他可以选择去德国治疗，

that has a well-reputed healthcare system.

那里有声望不错的医疗保健系统。

If he goes there and goes to the average hospital,

如果他去了德国的一家普通医院，

he will have the risk of becoming incontinent

他将面临大小便失禁的风险，

by about 50 percent,

差不多有五十百分的几率，

so he would have to start wearing diapers again.

那他将有可能要重新开始穿尿布。

You flip a coin. Fifty percent risk. That's quite a lot.

这和掷硬币的几率一样。 50％的风险，不是一般的高。

If he instead would go to Hamburg,

如果他换而选择去汉堡，

and to a clinic called the Martini-Klinik,

去一个叫“Martini”的医院，

the risk would be only one in 20.

风险几率则减少到5%。

Either you a flip a coin,

一边是像掷硬币一样的50%的风险，

or you have a one in 20 risk.

另一边是仅有的5%。

That's a huge difference, a seven-fold difference.

这是个巨大的差别，有7倍之多。

When we look at many hospitals

我们调查过很多医院，

for many different diseases,

和很多不同的疾病，

we see these huge differences.

我们都发现了这样巨大的差别。

But you and I don't know. We don't have the data.

但是你我不一定都知道，因为我们没有数据。

And often, the data actually doesn't exist.

而通常，这些数据根本不存在。

Nobody knows.

没人知道。

So going the hospital is a lottery.

于是，去医院看病变成了买乐透。

Now, it doesn't have to be that way. There is hope.

但是，其实不一定得这样。我们还是有希望的。

In the late '70s, there were a group

在70年代后期，有这么一群

of Swedish orthopedic surgeons

瑞士外科整形医生，

who met at their annual meeting,

在年会上，

and they were discussing the different procedures

他们讨论到目前众多的

they used to operate hip surgery.

用于髋关节手术的方法。

To the left of this slide, you see a variety

在幻灯片的左边，是各种各样的

of metal pieces, artificial hips that you would use

金属配件和髋关节假体，用于治疗

for somebody who needs a new hip.

需要髋关节置换手术的病人。

They all realized they had their individual way of operating.

他们意识到他们每个人的方法都不同。

They all argued that, "My technique is the best,"

而且他们都认为“我的方法最好”。

but none of them actually knew, and they admitted that.

但其实，没人知道哪个办法最好， 他们也承认这一点。

So they said, "We probably need to measure quality

所以他们说，“我们可能需要做质量评估

so we know and can learn from what's best."

来得知哪个是最好的方法，并学习它。”

So they in fact spent two years debating,

事实上，他们花了两年时间来辩论

"So what is quality in hip surgery?"

该如何评价髋关节手术的质量。

"Oh, we should measure this." "No, we should measure that."

有的说应该评价这个指标，有的说那个。

And they finally agreed.

最终他们达成了共识。

And once they had agreed, they started measuring,

之后，他们便开始（给手术结果）做评估，

and started sharing the data.

也开始共享数据。

Very quickly, they found that if you put cement

很快，他们发现如果

in the bone of the patient

在把金属轴插入大腿骨之前

before you put the metal shaft in,

先打入粘合剂，

it actually lasted a lot longer,

这能使手术结果保持更长时间，

and most patients would never have to be

而且绝大多数病人

re-operated on in their lifetime.

终身不用再做手术。

They published the data,

他们发布了这些数据，

and it actually transformed clinical practice in the country.

而这一举动改变了整个国家的临床实践。

Everybody saw this makes a lot of sense.

大家都发现这样做很有意义。

Since then, they publish every year.

从此以后，他们每年都做数据发布。

Once a year, they publish the league table:

每年发布一次积分榜。

who's best, who's at the bottom?

谁拔头筹，谁垫底，（一目了然）。

And they visit each other to try to learn,

他们还通过访问来相互学习，

so a continuous cycle of improvement.

进入了一个不断进步的循环。

For many years, Swedish hip surgeons

多年来， 瑞士的髋关节置换手术的

had the best results in the world,

治疗效果问鼎全球，

at least for those who actually were measuring,

至少对那些有真正参与评估的医生来说，

and many were not.

不过也有人没有这么做。

Now I found this principle really exciting.

我发现这一实践非常振奋人心。

So the physicians get together,

即医生们聚到一起，

they agree on what quality is,

共同决定什么是高质量，

they start measuring, they share the data,

他们开始量收集并共享数据，

they find who's best, and they learn from it.

他们发现哪个方法最好，然后加以学习。

Continuous improvement.

不断改进。

Now, that's not the only exciting part.

这还不是仅有的振奋人心的地方。

That's exciting in itself.

当然这本身已经令人振奋。

But if you bring back the cost side of the equation,

但是，如果把”成本“放回到我们的公式里，

and look at that,

然后观察它，

it turns out, those who have focused on quality,

你会发现那些重视质量的（医院）

they actually also have the lowest costs,

恰恰在花销上是最少的。

although that's not been the purpose in the first place.

虽然这并不是当初刻意设计的。

So if you look at the hip surgery story again,

如果回头再看髋关节手术的故事，

there was a study done a couple years ago

几年以前，他们做了一个研究

where they compared the U.S. and Sweden.

拿美国和瑞士做了比较。

They looked at how many patients have needed

他们调查了在第一次手术后

to be re-operated on seven years after the first surgery.

7年内需要再手术的病人的数量。

In the United States, the number was three times

在美国，这个数字比瑞士

higher than in Sweden.

高出三倍。

So many unnecessary surgeries,

太多不必要的手术，

and so much unnecessary suffering

给这些七年内

for all the patients who were operated on

再次接受手术的病人

in that seven year period.

带来了太多不必要的痛苦。

Now, you can imagine how much savings

现在你可以想象换种方法

there would be for society.

能给社会节省多少开支。

We did a study where we looked at OECD data.

我们根据OECD数据做了一个研究。

OECD does, every so often,

偶尔，OECD（经济合作与发展组织）会根据

look at quality of care

他们可以找到的会员国家

where they can find the data across the member countries.

的数据来调查医疗护理的质量。

The United States has, for many diseases,

事实上，美国在很多疾病上

actually a quality which is below the average

的保健质量是低于

in OECD.

OECD平均水平的。

Now, if the American healthcare system

那么，如果美国医疗系统

would focus a lot more on measuring quality,

致力于做更多的质量评价，

and raise quality just to the level of average OECD,

并且把质量提高到OECD的平均水平，

it would save the American people

可为美国人民缩减

500 billion U.S. dollars a year.

每年五千亿美元的开支。

That's 20 percent of the budget,

这占到了美国整个国家

of the healthcare budget of the country.

医疗保健预算的20%。

Now you may say that these numbers

你可能会说，这些数字

are fantastic, and it's all logical,

看上去很美，也符合逻辑，

but is it possible?

可这现实吗？

This would be a paradigm shift in healthcare,

这将是医疗保健的模式改变，

and I would argue that not only can it be done,

我认为，这不仅可以做到，

but it has to be done.

而且必须做到。

The agents of change are the doctors and nurses

而医生和护士将是

in the healthcare system.

医疗系统变革的主力。

In my practice as a consultant,

在我做顾问期间，

I meet probably a hundred or more than a hundred

我每年要接触上百名

doctors and nurses and other hospital

医生，护士，

or healthcare staff every year.

以及医院职工。

The one thing they have in common is

他们有着一个共同点，

they really care about what they achieve

就是他们真正最关心的是

in terms of quality for their patients.

如何保障病人的医疗质量。

Physicians are, like most of you in the audience,

医生和在做的各位一样，

very competitive.

是非常有竞争意识的。

They were always best in class.

他们一直是班上最优秀的，

We were always best in class.

我们总是班上最优秀的。

And if somebody can show them that the result

如果有人能告诉他们，

they perform for their patients

他们的医疗效果

is no better than what others do,

并不比其他医生强，

they will do whatever it takes to improve.

他们将不惜一切来改善现状。

But most of them don't know.

但是他们很多人不知道。

But physicians have another characteristic.

医生还有一个特点，

They actually thrive from peer recognition.

他们喜欢得到同行的褒奖。

If a cardiologist calls another cardiologist

如果一个心脏科医生向

in a competing hospital

另一家竞争医院的心脏科医生

and discusses why that other hospital

咨询为什么他们的

has so much better results, they will share.

治疗效果更好，他们会分享经验。

They will share the information on how to improve.

他们会交流如何改善治疗效果的经验。

So it is, by measuring and creating transparency,

正是通过医疗效果量化和透明化，

you get a cycle of continuous improvement,

我们进入了一个不断改善的正循环，

which is what this slide shows.

正如这张幻灯片所示。

Now, you may say this is a nice idea,

现在，你可能觉得这是个不错的主意，

but this isn't only an idea.

不过这已经不仅仅是个“主意”了，

This is happening in reality.

它正在发生。

We're creating a global community,

我们正在打造一个全球共同体，

and a large global community,

一个很大的全球共同体，

where we'll be able to measure and compare

来量化和对比

what we achieve.

我们的成效。

Together with two academic institutions,

BCG与两个学术院校，

Michael Porter at Harvard Business School,

哈佛商学院的Michael Porter，

and the Karolinska Institute in Sweden,

以及瑞典的Karolinka学院，

BCG has formed something we call ICHOM.

合作成立了ICHOM（发音“阿嚏”）

You may think that's a sneeze,

你们可能会觉得这听起来

but it's not a sneeze, it's an acronym.

像打喷嚏，其实这是个缩写。

It stands for the International Consortium

它的意思是“健康结果测评

for Health Outcome Measurement.

的国际联盟”。

We're bringing together leading physicians

我们把顶尖的医生和病人

and patients to discuss, disease by disease,

集合起来，针对每一种疾病

what is really quality,

讨论是什么决定了医疗质量，

what should we measure,

我们应该如何衡量，

and to make those standards global.

最后形成全球统一标准。

They've worked -- four working groups have worked

在过去一年里，我们有四个小组在工作，

during the past year:

他们的项目是：

cataracts, back pain,

白内障，背部疼痛，

coronary artery disease, which is, for instance, heart attack,

冠状动脉疾病，比如心脏病，

and prostate cancer.

和前列腺癌。

The four groups will publish their data

这四个小组会在今年十一月

in November of this year.

发表研究数据。

That's the first time we'll be comparing

这将是我们第一次

apples to apples, not only within a country,

在国家之间对比（疾病医疗的效果），

but between countries.

而不是仅限于单一国家内。

Next year, we're planning to do eight diseases,

明年我们计划研究8种疾病，

the year after, 16.

后年，增加到16种。

In three years' time, we plan to have covered

我们计划用三年时间

40 percent of the disease burden.

完成对40％的疾病的分析。

Compare apples to apples. Who's better?

比较治疗方案之间哪个更好，

Why is that?

为什么更好？

Five months ago,

五个月前，

I led a workshop at the largest university hospital

我在北欧最大的医学院

in Northern Europe.

组织了一次专题讨论会。

They have a new CEO, and she has a vision:

他们换了新的CEO，而她的愿景是：

I want to manage my big institution much more

“我希望把管理重点放在

on quality, outcomes that matter to patients.

保证病人的治疗质量和效果上。”

This particular day, we sat in a workshop

在这天的研讨会上，我们跟医护人员

together with physicians, nurses and other staff,

和后勤人员一起

discussing leukemia in children.

谈到患白血病的孩子。

The group discussed,

我们讨论到

how do we measure quality today?

我们该如何评价治疗结果？

Can we measure it better than we do?

我们在评估上能如何改进？

We discussed, how do we treat these kids,

我们还讨论到，该如治疗这些孩子？

what are important improvements?

哪些对他们来说是重要的改善？

And we discussed what are the costs for these patients,

我们还提到费用问题。

can we do treatment more efficiently?

我们有更有效的治疗方案吗？

There was an enormous energy in the room.

整个讨论气氛非常热烈。

There were so many ideas, so much enthusiasm.

每个人都热情洋溢，提出了很多想法。

At the end of the meeting,

会议结束的时候，

the chairman of the department, he stood up.

部门主席站了起来，

He looked over the group and he said --

他注视着大家，然后说，

first he raised his hand, I forgot that --

差点忘了，他先举手了，

he raised his hand, clenched his fist,

他举起手来，攥成拳头，

and then he said to the group, "Thank you.

然后，他对大家说：“谢谢。

Thank you. Today, we're finally discussing

谢谢。今天我们终于讨论到了

what this hospital does the right way."

我们这家医院做的一件正确的事情。”

By measuring value in healthcare,

（我们所说的）医疗保健的价值，

that is not only costs

不只是要考虑费用，

but outcomes that matter to patients,

还要为我们的病人带来有效的治疗。

we will make staff in hospitals

我们要让医院和医保系统的员工

and elsewhere in the healthcare system

不再是（医疗成本的）负担，

not a problem but an important part of the solution.

而成为（化解成本的）重要组成部分。

I believe measuring value in healthcare

我相信，通过衡量

will bring about a revolution,

医疗保健的价值会带来一次革命，

and I'm convinced that the founder

我也相信现代医学的奠基人

of modern medicine, the Greek Hippocrates,

一位以病人至上的

who always put the patient at the center,

古希腊的希波克拉底（希腊的名医，称医药之父）

he would smile in his grave.

看到这些，会含笑九泉的。

Thank you.

谢谢。

(Applause)

（掌声）