How do we heal medicine? | Atul Gawande

翻译人员: Kang Rong SUN 校对人员: Karen SONG

I got my start

我的职业生涯

in writing and research

从写作、研究开始

as a surgical trainee,

当时还是个外科实习医生

as someone who was a long ways away

像很多人一样，需要经历漫漫长路

from becoming any kind of an expert at anything.

才能成为某个领域的专家

So the natural question you ask then at that point

因而，在当时那个阶段你自然要问

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

我该如何做好自己所尝试做的这一领域？

And it became a question of,

这个问题会演变成

how do we all get good

我们怎样才能做好

at what we're trying to do?

我们正在努力做的这件事？

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

要掌握技术着实不易

try to learn all the material you have to absorb

需要对所学内容都吸收消化

at any task you're taking on.

无论做什么

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

就拿我来说，我必须学会如何缝合、如何开刀

but then also how I pick the right person

还得知道如何选择对的人

to come to an operating room.

进入手术室

And then in the midst of all this

在以上思考过程中

came this new context

还隐藏这一个问题

for thinking about what it meant to be good.

那就是：究竟什么才是造福于人？

In the last few years

在过去几年中

we realized we were in the deepest crisis

我们意识到自己深陷

of medicine's existence

医学危机

due to something you don't normally think about

原因在于有些事情

when you're a doctor

作为医生很难考虑到

concerned with how you do good for people,

关于如何造福于人

which is the cost

例如，医疗卫生的

of health care.

成本问题

There's not a country in the world

世界上没有一个国家

that now is not asking

不在问

whether we can afford what doctors do.

自己是否能支付医疗行为的代价

The political fight that we've developed

这也引发了政治上的争论

has become one around

争论焦点围绕着

whether it's the government that's the problem

究竟是政府

or is it insurance companies that are the problem.

还是保险公司才是罪魁祸首

And the answer is yes and no;

答案既“是”，也“否”

it's deeper than all of that.

还有更深层次的回答

The cause of our troubles

造成麻烦的根源

is actually the complexity that science has given us.

其实是科学带来的复杂性

And in order to understand this,

为了让大家更好地理解这个观点

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

让我带大家回顾几代人之前的情况

I want to take you back

我想带大家回到

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

刘易斯-托马斯写下《最年轻的科学》的那个时代

Lewis Thomas was a physician-writer,

刘易斯-托马斯是一位医生兼作家

one of my favorite writers.

也是我最喜爱的作家之一

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

他在书中描述了

what it was like to be a medical intern

作一名实习医生的生活

at the Boston City Hospital

在当时的波士顿市立医院

in the pre-penicillin year

在盘尼西林尚未发现的年代

of 1937.

那是1937年

It was a time when medicine was cheap

当时药物很便宜

and very ineffective.

但疗效也不好

If you were in a hospital, he said,

他写道：如果你去看病

it was going to do you good

医院对你的唯一帮助

only because it offered you

就是提供了

some warmth, some food, shelter,

给你提供了温暖、食物、住所，

and maybe the caring attention

或许还有来自护士的

of a nurse.

关怀

Doctors and medicine

医生和药物的作用

made no difference at all.

无关紧要

That didn't seem to prevent the doctors

即使这样

from being frantically busy in their days,

当时的医生们还是忙得不可开交

as he explained.

对此，他解释道

What they were trying to do

他们努力想做的

was figure out whether you might have one of the diagnoses

就是弄清楚患者是否适用于某种诊断

for which they could do something.

是他们可以治疗的

And there were a few.

这样的病症不多

You might have a lobar pneumonia, for example,

比如说，你患有大叶性肺炎

and they could give you an antiserum,

医生可以对你进行抗血清治疗

an injection of rabid antibodies

为你注射狂犬病抗体

to the bacterium streptococcus,

以此对抗链球菌

if the intern sub-typed it correctly.

前提是实习医生分类正确

If you had an acute congestive heart failure,

如果你不幸突发急性充血性心脏衰竭

they could bleed a pint of blood from you

医生可以给你放一品脱的血

by opening up an arm vein,

从割开的手臂静脉里

giving you a crude leaf preparation of digitalis

他们会为你准备一剂粗糙的洋地黄叶制剂

and then giving you oxygen by tent.

然后让你在氧幕里吸氧

If you had early signs of paralysis

如果你出现瘫痪的前期症状

and you were really good at asking personal questions,

如果你很善于问个人问题

you might figure out

你或许会发现

that this paralysis someone has is from syphilis,

这个病人的瘫痪很有可能是梅毒引发的

in which case you could give this nice concoction

因此你可以开出

of mercury and arsenic --

汞和砷的混合药剂

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

只要不过量使用，不会置他们于死地

Beyond these sorts of things,

除此之外

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

医师能做的事并不多

This was when the core structure of medicine

也就在那个时代，医疗的核心

was created --

形成了

what it meant to be good at what we did

那就是如何做好我们所做的事

and how we wanted to build medicine to be.

以及如何建立医疗体系

It was at a time

当时

when what was known you could know,

医生能知道当时所有的医疗技术

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

一个人就可以记住所有的医疗知识，也能实施所有的医疗行为

If you had a prescription pad,

如果你有处方权

if you had a nurse,

如果你有一名护士

if you had a hospital

如果你有一所医院

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

或许可以给你一个栖身之所，得到一些基本的工具

you really could do it all.

你凭一己之力可以完成所有的事

You set the fracture, you drew the blood,

你可以处理骨折，可以抽血

you spun the blood,

可以验血

looked at it under the microscope,

可以用显微镜观察

you plated the culture, you injected the antiserum.

你可以组织切片，可以注射抗血清

This was a life as a craftsman.

这是工匠一般的生活

As a result, we built it around

最终，我们成功

a culture and set of values

建立起了医疗文化和价值体系

that said what you were good at

医生最应擅长的事

was being daring,

就是行事大胆

at being courageous,

充满勇气

at being independent and self-sufficient.

并且要独立工作，自给自足

Autonomy was our highest value.

自主是至高无上的价值观

Go a couple generations forward

往后推几代人

to where we are, though,

来看今天

and it looks like a completely different world.

世界好像完全变了个样

We have now found treatments

我们现在的治疗手段

for nearly all of the tens of thousands of conditions

几乎能处理上万种

that a human being can have.

人类可能患上的疑难杂症

We can't cure it all.

尽管不能治愈所有疾病

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

我们不能保证每个人都长命百岁、无病无患

But we can make it possible

但是我们可以让多数人

for most.

过上健康长寿的生活

But what does it take?

但是，实现这一结果的代价是什么呢？

Well, we've now discovered

如今我们已经发现了

4,000 medical and surgical procedures.

4000种药物介入和外科手术

We've discovered 6,000 drugs

我们研制了6000种药物

that I'm now licensed to prescribe.

这还仅仅是我现在处方权允许的范围

And we're trying to deploy this capability,

我们正在尝试把这些治疗手段和药物，推广到更多地方

town by town,

挨家挨户地

to every person alive --

深入大众

in our own country,

覆盖我们国家的每一寸土地

let alone around the world.

乃至全球各个角落

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

我们已经到了这样的地步

as doctors,

作为医生

we can't know it all.

我们认识到自己不能知晓一切

We can't do it all

也不能一一做到

by ourselves.

仅凭一己之力是不行的

There was a study where they looked

曾经有一项研究

at how many clinicians it took to take care of you

调查了不同时代下，照顾一名患者

if you came into a hospital,

在医院里

as it changed over time.

需要多少医务人员

And in the year 1970,

在1970年

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

一般需要两名全职临床医务人员

That is to say,

也就是说

it took basically the nursing time

基本上是护士照料时间

and then just a little bit of time for a doctor

加上医生的一点点时间

who more or less checked in on you

医生的时间只用来做查房

once a day.

一般一天一次

By the end of the 20th century,

到了20世纪末年

it had become more than 15 clinicians

这一数字上升到15名临床医务人员

for the same typical hospital patient --

照顾同样一名典型的住院患者

specialists, physical therapists,

包括专科医生、普科医生

the nurses.

以及护士

We're all specialists now,

如今我们都是专科医生

even the primary care physicians.

即便是基本卫生医疗单位的医生

Everyone just has

每个人也只

a piece of the care.

提供自己专业范围内的一点点关怀

But holding onto that structure we built

但是为了坚持我们建立的医疗价值体系

around the daring, independence,

针对“勇敢”、“独立”

self-sufficiency

“自给自足”

of each of those people

对所有这些人而言

has become a disaster.

就会变成一场灾难

We have trained, hired and rewarded people

我们培训、雇佣、奖励医生

to be cowboys.

把他们变成牛仔那样

But it's pit crews that we need,

但是我们真正需要的是赛车维修队

pit crews for patients.

针对病人的维修队

There's evidence all around us:

我们身边就有这样的实例证明

40 percent of our coronary artery disease patients

我们社区中40%的

in our communities

冠状动脉患者

receive incomplete or inappropriate care.

接受的治疗是不全面或不妥当的

60 percent

60%

of our asthma, stroke patients

哮喘、中风病人

receive incomplete or inappropriate care.

接受的治疗是不全面或不妥当的

Two million people come into hospitals

200万人在医院的时候

and pick up an infection

受到感染

they didn't have

这些感染是他们原本所没有的

because someone failed to follow

因为有人忽略了

the basic practices of hygiene.

最基本的卫生问题

Our experience

我们的经验表明

as people who get sick,

当人们生病时

need help from other people,

需要得到别人的帮助

is that we have amazing clinicians

应该是医生们的帮助

that we can turn to --

可以让我们找到那些令人放心的医生

hardworking, incredibly well-trained and very smart --

勤奋努力、受过良好培训、并且聪明过人

that we have access to incredible technologies

还可以得益于尖端技术

that give us great hope,

这些都会给我们莫大的希望

but little sense

但极少能见到

that it consistently all comes together for you

所有这些持续地共同作用于你

from start to finish

贯穿整个医疗过程

in a successful way.

并且确保成功

There's another sign

另外一个征兆

that we need pit crews,

我们需要维修队的原因

and that's the unmanageable cost

是现有医疗体系高昂到无法控制的

of our care.

成本问题

Now we in medicine, I think,

我想，在我们的医疗行业

are baffled by this question of cost.

百思不得其解的就是这个成本问题

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

我们想说：“这就是现实……

This is just what medicine requires."

这就是医药行业必需的“

When you go from a world

当你从

where you treated arthritis with aspirin,

用阿司匹林治疗关节炎的地方

that mostly didn't do the job,

那往往是没有效果的

to one where, if it gets bad enough,

到现在，对于严重病患

we can do a hip replacement, a knee replacement

我们可以做手术更换人工髋关节或膝盖

that gives you years, maybe decades,

那将帮助病人恢复原本可能丧失的功能

without disability,

安好地度过几十年

a dramatic change,

这是一个多戏剧化的改变啊

well is it any surprise

因此，如果说

that that $40,000 hip replacement

花4万美元进行个髋关节移植手术

replacing the 10-cent aspirin

而不是花10美分买阿司匹林来缓解

is more expensive?

哪个更昂贵呢？

It's just the way it is.

这就是现实

But I think we're ignoring certain facts

但我认为，我们忽略了一些事实

that tell us something about what we can do.

这些事实告诉我们，我们能做的其实有很多

As we've looked at the data

我们看到一些数据

about the results that have come

关于医疗行为的结果

as the complexity has increased,

尽管环境日益复杂

we found

我们发现

that the most expensive care

最昂贵的医疗

is not necessarily the best care.

不见得是最好的

And vice versa,

反之亦然

the best care

最好的医疗

often turns out to be the least expensive --

通常花不了几个钱

has fewer complications,

而且更简单

the people get more efficient at what they do.

人们在那种情况下效率更高

And what that means

这一发现的含义在于

is there's hope.

我们还有希望

Because [if] to have the best results,

因为，假如我们想要获得最好的结果

you really needed the most expensive care

要用到最贵的医疗

in the country, or in the world,

在一国范围内、或者在世界范围内最贵

well then we really would be talking about rationing

那么我们真的要去讨论的就是配额制度

who we're going to cut off from Medicare.

决定哪些人不能享受医疗保险

That would be really our only choice.

那将会成为唯一的选择

But when we look at the positive deviants --

但如果我们看看积极的反面事例

the ones who are getting the best results

确实存在以最低的成本

at the lowest costs --

获得最佳效果的例子

we find the ones that look the most like systems

我们发现最像“系统”的

are the most successful.

是最成功的

That is to say, they found ways

也就是说，我们发现了

to get all of the different pieces,

平衡所有不同部分

all of the different components,

不同因素的方法

to come together into a whole.

让各个部分变成一个整体

Having great components is not enough,

仅有好的组成部分是远远不够的

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

然而我们正是对医药的组成部分太过痴迷了

We want the best drugs, the best technologies,

我们想要最好的药物、最好的技术

the best specialists,

最好的专科医生

but we don't think too much

但我们却不曾想过

about how it all comes together.

这些如何组合在一起

It's a terrible design strategy actually.

这其实是个很糟糕的战略设计

There's a famous thought experiment

有一个很著名的思考实验

that touches exactly on this

验证了这个想法

that said, what if you built a car

实验是这样的，假如你用最好的汽车零件

from the very best car parts?

能造出怎样一辆车？

Well it would lead you to put in Porsche brakes,

你可以用保时捷的刹车

a Ferrari engine,

法拉利的引擎

a Volvo body, a BMW chassis.

沃尔沃的车身，宝马的底盘

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

你把这些都组装在一起会得到一辆怎样的车呢？

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

答案是：一堆很贵的垃圾，一辆完全不能开的车

And that is what medicine can feel like sometimes.

有时候医药行业也是这样

It's not a system.

它并非一个系统

Now a system, however,

然而，为了组建一个体系

when things start to come together,

当所有部分都组合到一起

you realize it has certain skills

你需要有特定的技巧

for acting and looking that way.

来让它运作起来，让它看起来像回事儿

Skill number one

首当其冲的是

is the ability to recognize success

辨识成功的能力

and the ability to recognize failure.

以及辨识失败的能力

When you are a specialist,

假如你是一名专科医生

you can't see the end result very well.

如果你无法很好地设想最终结果

You have to become really interested in data,

你必须认真分析数据

unsexy as that sounds.

这听上去非常无趣

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

我的一个外科医生同事，在爱荷华州锡达拉皮兹工作

and he got interested in the question of,

他对一个问题产生了兴趣

well how many CT scans did they do

那就是：他们在锡达拉皮兹

for their community in Cedar Rapids?

做了多少个CT扫描？

He got interested in this

他对此很感兴趣

because there had been government reports,

因为政府报告

newspaper reports, journal articles

新闻报道、期刊论文

saying that there had been too many CT scans done.

都在说现在做的CT扫描过量了

He didn't see it in his own patients.

但他没在自己的病人中看到这个问题

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

因此他提出这一疑问：”我们究竟做了多少CT扫描呢？“

and he wanted to get the data.

他想得到这一数据

It took him three months.

于是他花了3个月时间

No one had asked this question in his community before.

此前，在他的社区，没人有过这个疑问

And what he found was that,

后来，他发现

for the 300,000 people in their community,

在社区的300,000人中

in the previous year

过去一年间

they had done 52,000 CT scans.

他们曾做了52,000次CT扫描

They had found a problem.

于是他们发现了一个问题

Which brings us to skill number two a system has.

也就引出了我要说的运作系统的第二项技巧

Skill one, find where your failures are.

技巧1是：发现我们错在哪里

Skill two is devise solutions.

技巧2是：设计解决方案

I got interested in this

我对此也颇感兴趣

when the World Health Organization came to my team

世界卫生组织曾来找我的团队

asking if we could help with a project

问我们是否能帮他们做一个项目

to reduce deaths in surgery.

来降低外科手术的死亡率

The volume of surgery had spread

如今外科手术在世界范围内

around the world,

数量日益增长

but the safety of surgery

但是手术的安全性

had not.

却令人担忧

Now our usual tactics for tackling problems like these

现在我们普遍的做法是

are to do more training,

开展更多培训

give people more specialization

让医生更加专业

or bring in more technology.

或者提高技术

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

所以，在手术中，我们的医生都是非常专业的

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

受过非常好的教育和培训

And yet we see unconscionable levels

然而我们还是看到高得不正常的

of death, disability

死亡率和致残率

that could be avoided.

这些原本都是可以避免的

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

因此我们参考了其他高风险行业的做法

We looked at skyscraper construction,

我们观察了摩天大楼的建设

we looked at the aviation world,

我们研究了飞机制造业

and we found

然后发现

that they have technology, they have training,

他们有技术、他们有培训

and then they have one other thing:

而且他们还有一样东西

They have checklists.

那就是检查表

I did not expect

我没有想到自己

to be spending a significant part

作为一名哈佛外科医生

of my time as a Harvard surgeon

会把大部分时间

worrying about checklists.

用来烦恼检查表这个东西

And yet, what we found

然而，我们发现

were that these were tools

正是这个工具

to help make experts better.

帮助专家达到最佳效果

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

我们得到了波音公司首席安全工程师的帮助

Could we design a checklist for surgery?

我们请教他如何设计一张用于外科手术的清单？

Not for the lowest people on the totem pole,

并非为了社会底层人士

but for the folks

而是针对

who were all the way around the chain,

在这条产业链的每个环节上的人

the entire team including the surgeons.

包括外科医生在内的整个团队

And what they taught us

他们教我们的是

was that designing a checklist

要设计好检查表

to help people handle complexity

来帮助人们处理复杂问题

actually involves more difficulty than I had understood.

其实比想象的要难

You have to think about things

你必须考虑很多问题

like pause points.

比如“暂停时点”

You need to identify the moments in a process

你需要认识到整个流程中的一些时刻

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

能够在危险来临前及时发现问题

and do something about it.

作出处理以免酿成大祸

You have to identify

你必须把它当做

that this is a before-takeoff checklist.

是一张飞机起飞前的检查表

And then you need to focus on the killer items.

你一定要关注一些至关重要的项目

An aviation checklist,

在一份飞机制造检查表上

like this one for a single-engine plane,

就像这张针对单引擎飞机的检查清单

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

它可不是驾驶飞机的窍门

it's a reminder of the key things

而是对关键问题的提醒

that get forgotten or missed

如果他们不去检查

if they're not checked.

很可能会遗漏这些问题

So we did this.

因此我们也效仿了他们的做法

We created a 19-item two-minute checklist

我们设计了一张检查表，19个项目，用时2分钟

for surgical teams.

针对手术团队

We had the pause points

其中包含“暂停时点”

immediately before anesthesia is given,

例如，实施麻醉前

immediately before the knife hits the skin,

手术刀接触病人皮肤之前

immediately before the patient leaves the room.

病人离开手术室之前

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

检查表上不乏很多看上去很简单的事情

making sure an antibiotic is given in the right time frame

例如，确保在正确的时间使用抗生素

because that cuts the infection rate by half --

光这一点就让感染率下降了一半

and then interesting stuff,

还有些有意思的事

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

你无法为手术这样复杂的事情事先开出处方

Instead, you can make a recipe

然而，你却可以开处方

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

给这个团队，使他们能更好地去面对突发状况

And we had items like making sure everyone in the room

我们列出的项目中就包括：确保每个在房间的人

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

都在手术开始前互相做了自我介绍

because you get half a dozen people or more

因为很多时候，起码有六个人

who are sometimes coming together as a team

在这个新组建的团队中

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

都是初次见面

We implemented this checklist

后来，我们在世界上8所医院

in eight hospitals around the world,

执行、推广了这份检查表

deliberately in places from rural Tanzania

其中包括坦桑尼亚的乡村

to the University of Washington in Seattle.

也包括在西雅图的华盛顿大学

We found that after they adopted it

我们发现，当他们使用了这份检查表之后

the complication rates fell

复杂程度大大降低

35 percent.

降低了35%

It fell in every hospital it went into.

每所医院都是如此

The death rates fell

死亡率也降低了

47 percent.

降低了47%

This was bigger than a drug.

这比任何一种药物都管用

(Applause)

（掌声）

And that brings us

这将引出

to skill number three,

第三项技巧

the ability to implement this,

执行能力

to get colleagues across the entire chain

让所有产业链上的同事

to actually do these things.

都能切实地这样做事

And it's been slow to spread.

推广这些很花时间

This is not yet our norm in surgery --

这还不是我们做手术的规范

let alone making checklists

更别说

to go onto childbirth and other areas.

应用于例如分娩等其他紧迫的领域

There's a deep resistance

在执行中往往会遇到强大的阻力

because using these tools

因为使用这些工具

forces us to confront

会迫使我们去面对

that we're not a system,

我们还未成为“系统”这一事实

forces us to behave with a different set of values.

会迫使我们不得不用另一套价值观去操作

Just using a checklist

使用一份检查表

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

需要你用与以往不同的价值操守

like humility,

例如谦虚

discipline,

纪律

teamwork.

团队合作

This is the opposite of what we were built on:

这与我们所建立的价值观刚好背道而驰：

independence, self-sufficiency,

独立、自给自足

autonomy.

自治

I met an actual cowboy, by the way.

说到这儿，我想起来曾经遇到过一个真正的牛仔

I asked him, what was it like

我问他：牛仔到底是如何

to actually herd a thousand cattle

将上千头牛

across hundreds of miles?

放牧几百英里

How did you do that?

你们是怎么做的？

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

他回答说：“我们有牛仔驻扎在牧区的几个地点”

They communicate electronically constantly,

他们通过电子设备不断交流

and they have protocols and checklists

他们有规章制度和各种检查表

for how they handle everything --

去处理发生的各种情况

(Laughter)

（笑声）

-- from bad weather

比如，恶劣天气

to emergencies or inoculations for the cattle.

比如，突发事件，或者为牛群接种

Even the cowboys are pit crews now.

如今，就连牛仔们也组成了维修队

And it seemed like time

似乎是时候

that we become that way ourselves.

我们也变成那样了

Making systems work

靠“系统”来工作

is the great task of my generation

这正是我们这代人

of physicians and scientists.

作为医生和科学家的的首要任务

But I would go further and say

进一步说

that making systems work,

要让“系统”运转起来

whether in health care, education,

无论是医疗、教育

climate change,

还是气候变化

making a pathway out of poverty,

还是消除贫困

is the great task of our generation as a whole.

都是我们这代人，作为一个整体需要完成的重要任务

In every field, knowledge has exploded,

在各个领域都有知识爆炸

but it has brought complexity,

情况更加复杂

it has brought specialization.

专业性更强

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

我们别无选择

but to recognize,

只能去认识到

as individualistic as we want to be,

尽管我们都崇尚个人主义

complexity requires

但复杂性要求我们

group success.

取得集体成功

We all need to be pit crews now.

我们全都需要成为维修队

Thank you.

谢谢大家

(Applause)

（掌声）