Stefan Larsson: What doctors can learn from each other

Translator: 杏儀 歐陽 Reviewer: Bighead Ge

Five years ago, I was on a sabbatical,

五年前，我放咗一年假

and I returned to the medical university

之後我返去我以前讀過嘅醫學院

where I studied.

I saw real patients and I wore the white coat

十七年嚟，自從我做咗顧問之後

我第一次見到病人同著住白袍

for the first time in 17 years,

in fact since I became a management consultant.

嗰個月裡面，有兩樣令到我好驚訝

There were two things that surprised me

during the month I spent.

The first one was that the common theme

第一樣，嚟嚟去去都只係講同一樣嘢

of the discussions we had were hospital budgets

唔係醫院預算，就係開源節流

and cost-cutting,

and the second thing, which really bothered me,

第二樣，真係令我非常煩

actually, was that several of the colleagues I met,

就喺之前識得嘅幾個同事

former friends from medical school,

以前讀醫學院嘅同學

who I knew to be some of the smartest,

佢哋都好醒目

most motivated, engaged and passionate people

好有鬥志、有承擔、滿腔熱血

I'd ever met,

many of them had turned cynical, disengaged,

但係，佢哋好多都睇穿人性嘅羞惡

已經無曬擔戴

or had distanced themselves from hospital management.

又或者已經對醫院管理置之不理

So with this focus on cost-cutting,

所以呢，當醫院講緊節流

I asked myself, are we forgetting the patient?

我就問自己

我哋係唔係忘記咗病人呢？

Many countries that you represent

在座各位你哋嘅國家，同我嘅國家

and where I come from

struggle with the cost of healthcare.

都要處理醫療嘅開支問題

It's a big part of the national budgets.

呢樣係佔咗國家預算嘅一大筆

And many different reforms aim at holding back this growth.

好多唔同嘅改革 都想限制醫療嘅開支增長

In some countries, we have long waiting times

有啲國家，病人做手術要排好耐

for patients for surgery.

In other countries, new drugs are not being reimbursed,

有啲國家，新藥唔可以報銷

and therefore don't reach patients.

所以新藥病人用唔到

In several countries, doctors and nurses

有啲國家，醫生同護士某程度上

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

係政府落手嘅對象

After all, the costly decisions in health care

畢竟，醫療開支係由醫生同護士做決定

are taken by doctors and nurses.

You choose an expensive lab test,

你揀好貴嘅實驗測試

you choose to operate on an old and frail patient.

你選擇幫又老又殘嘅病人做手術

So, by limiting the degrees of freedom of physicians,

就係咁，政府想限制醫生

this is a way to hold costs down.

從而削減開支

And ultimately, some physicians will say today

到最後，有啲醫生就話

that they don't have the full liberty

佢哋就算覺得有啲決定對病人有益

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

佢哋都落實唔到

So no wonder that some of my old colleagues

所以，都好難怪我有啲舊同事咁沮喪

are frustrated.

At BCG, we looked at this,

喺 BCG，我哋討論到呢個問題

and we asked ourselves,

我哋問自己

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

咁樣做醫療管理係行唔通？

And so we took a step back and we said,

所以我哋退後一步諗︰

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

我哋想達到咩目標？

Ultimately, in the healthcare system,

我哋希望喺醫療系統裡面

we're aiming at improving health for the patients,

用有限或負擔得起嘅預算

and we need to do so at a limited,

最終可以改善病人健康

or affordable, cost.

We call this value-based healthcare.

我哋叫呢個做 以成本效益為本嘅醫療

On the screen behind me, you see what we mean

我身後嘅屏幕，大家可以見到何謂價值

by value:

outcomes that matter to patients

既可以幫到病人

relative to the money we spend.

我哋開支又可以控制喺合埋水平

This was described beautifully in a book in 2006

2006 年一本書描述得好好

by Michael Porter and Elizabeth Teisberg.

書嘅作者係 Michael Porter 同 Elizabeth Teisberg

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

呢張相，你見我岳父同佢身邊三個女

surrounded by his three beautiful daughters.

When we started doing our research at BCG,

當時我哋喺 BCG 開始做研究

we decided not to look so much at the costs,

我哋決定唔好太介意使費幾多

but to look at the quality instead,

反而要注重研究質量

and in the research, one of the things

研究裏面，有一樣嘢令我哋讚嘆嘅

that fascinated us was the variation we saw.

係我哋見到分別

You compare hospitals in a country,

你比較一個國家嘅醫院

you'll find some that are extremely good,

你會發現有啲醫院做得好好

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

但其他好多醫院就水皮

The differences were dramatic.

分別非常之大

Erik, my father-in-law,

Erik 我嘅岳父

he suffers from prostate cancer,

佢有前列腺癌

and he probably needs surgery.

佢需要做手術

佢宜家住喺歐洲，佢可以選擇去德國

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

that has a well-reputed healthcare system.

德國有出名嘅醫療系統

If he goes there and goes to the average hospital,

如果佢選擇去嗰度

住一間中等水平嘅醫院

he will have the risk of becoming incontinent

佢手術後大小失禁嘅機會係 50%

by about 50 percent,

so he would have to start wearing diapers again.

如果真係咁嘅話，佢就又要再著過尿片

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

你掟個銀仔，50% 風險都幾多

If he instead would go to Hamburg,

但係，如果佢決定去漢堡

and to a clinic called the Martini-Klinik,

一間叫 Martini-Klinik 嘅診所

the risk would be only one in 20.

風險就會降到 5%

Either you a flip a coin,

一係你就 50% 風險

or you have a one in 20 risk.

一係就 5% 風險

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

差別好大，兩者相差十倍

When we look at many hospitals

只有當我哋去睇好多醫院 睇唔同嘅病

for many different diseases,

we see these huge differences.

我哋至知道有咁大嘅分別

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

但事前你同我都唔知道。我哋冇數據

And often, the data actually doesn't exist.

好多時，數據根本唔存在

Nobody knows.

從來冇人知兩間醫院有分別

So going the hospital is a lottery.

所以去醫院就好似買六合彩咁

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

宜家，已經唔使再估估下

我哋有希望

In the late '70s, there were a group

七十年代尾，有一班瑞典整形外科醫生

of Swedish orthopedic surgeons

who met at their annual meeting,

佢哋每年都開會

and they were discussing the different procedures

討論佢哋臀部手術過程中

they used to operate hip surgery.

用嘅唔同方法步驟

To the left of this slide, you see a variety

投影片左邊，你可以見到

of metal pieces, artificial hips that you would use

唔同嘅金屬件、人造臀部 應用喺病人身上

for somebody who needs a new hip.

They all realized they had their individual way of operating.

佢哋都知道，佢哋各自有一套手術方法

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

個個都話佢嘅技術係最優秀

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

但冇一個知道佢哋自己嗰個係最好

So they said, "We probably need to measure quality

所以佢哋就話︰「我哋要評估質素，

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

咁樣先知邊個最好，學最好嗰個。」

So they in fact spent two years debating,

跟住，佢哋用咗兩年時間拗，譬如

"So what is quality in hip surgery?"

臀部手術嘅質量點樣定義？

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

「我哋評估呢個。」

「唔係，我哋評估嗰個。」

And they finally agreed.

最後佢哋至達成共識

And once they had agreed, they started measuring,

有咗共識之後

佢哋就開始評估，開始交換數據

and started sharing the data.

Very quickly, they found that if you put cement

好快，佢哋就發現

如果先將膠接劑放入病人舊骨度

in the bone of the patient

before you put the metal shaft in,

再將金屬桿放入去

it actually lasted a lot longer,

咁樣會更加持久耐用

and most patients would never have to be

而且大部分病人有生之年 都唔需要再做手術

re-operated on in their lifetime.

They published the data,

呢班人登咗呢啲數據

and it actually transformed clinical practice in the country.

將佢哋國家嘅臨床診治模式 嚟個大革新

Everybody saw this makes a lot of sense.

人人都覺得咁樣做更加合理

Since then, they publish every year.

嗰次之後，佢哋就年年刊登一次

Once a year, they publish the league table:

佢哋每年都會刊登一個表：

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

話畀人知邊個係最好同最差嘅醫生

And they visit each other to try to learn,

而且佢哋會逐個拜訪、學習

so a continuous cycle of improvement.

所以至會不斷有改善

For many years, Swedish hip surgeons

多年嚟，就算只有

少數瑞典臀部手術嘅醫生有評估結果

had the best results in the world,

但佢哋做出嚟嘅手術結果 係全世界最好嘅

at least for those who actually were measuring,

and many were not.

Now I found this principle really exciting.

我發現呢個措施真係好好

So the physicians get together,

醫生可以走埋一齊，傾好質素嘅定義

they agree on what quality is,

they start measuring, they share the data,

佢哋量度同交換數據

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

跟最好嘅學習，不斷咁改善

Continuous improvement.

Now, that's not the only exciting part.

呢個唔止令人開心

That's exciting in itself.

佢本身就係一樣好嘢

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

你諗返起計算開支嘅方程式

and look at that,

就會發現之前嗰啲關注質素嘅人

it turns out, those who have focused on quality,

they actually also have the lowest costs,

雖然冇將開支擺喺首位

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

但佢哋嘅使費都係最低

So if you look at the hip surgery story again,

所以，你睇返幾年前 一個臀部手術嘅研究

there was a study done a couple years ago

where they compared the U.S. and Sweden.

比較美國同瑞典

They looked at how many patients have needed

研究人員統計

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

幾多個病人需要喺第一次手術之後

七年內要再做手術

In the United States, the number was three times

美國嘅數字比瑞典高出三倍

higher than in Sweden.

So many unnecessary surgeries,

咁樣講

好多病人做咗好多不必要嘅手術

and so much unnecessary suffering

經歷過好多不必要嘅痛苦

for all the patients who were operated on

in that seven year period.

Now, you can imagine how much savings

你又可以想像社會可以慳返幾多錢

there would be for society.

We did a study where we looked at OECD data.

我哋做過一個研究

觀察經濟合作與發展組織 OECD 嘅數據

OECD does, every so often,

OECD 定期調查成員國嘅生活質素

look at quality of care

where they can find the data across the member countries.

佢哋集合成員國嘅數據

The United States has, for many diseases,

美國好多病嘅治療水平都係 低於 OECD 嘅平均

actually a quality which is below the average

in OECD.

Now, if the American healthcare system

咁樣講

would focus a lot more on measuring quality,

如果美國醫療系統 專注多啲喺質素上面

and raise quality just to the level of average OECD,

將水平提高到 OECD 嘅平均水平

it would save the American people

就可以幫到美國人 每年慳返五千億美元

500 billion U.S. dollars a year.

That's 20 percent of the budget,

亦即係慳返國家醫療預算嘅兩成

of the healthcare budget of the country.

Now you may say that these numbers

你可能話

呢啲數據好好，非常合邏輯

are fantastic, and it's all logical,

but is it possible?

但係，有冇可能做到？

This would be a paradigm shift in healthcare,

呢個會係醫療嘅改革示例

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

我堅信，不單止可以做到

but it has to be done.

而且必須要做

The agents of change are the doctors and nurses

而改革者係醫療系統嘅醫生同護士

in the healthcare system.

In my practice as a consultant,

我做諮詢咁耐

I meet probably a hundred or more than a hundred

年年都會見過百個 甚至更多嘅醫生、護士

doctors and nurses and other hospital

or healthcare staff every year.

同其他醫護員工

The one thing they have in common is

佢哋有一個共同點：

they really care about what they achieve

佢哋真係好緊張 為病人服務嘅質素

in terms of quality for their patients.

Physicians are, like most of you in the audience,

醫生，正如在座咁多位一樣

very competitive.

非常拼搏

They were always best in class.

佢哋一直都係班內最優秀

We were always best in class.

我哋一直都係班內最優秀

And if somebody can show them that the result

如果有人可以話畀佢哋知

佢哋醫人嘅結果比其他人差

they perform for their patients

is no better than what others do,

they will do whatever it takes to improve.

佢哋會用盡一切方法改善

But most of them don't know.

但係，佢哋大部分 都唔知道比其他人差

But physicians have another characteristic.

但係醫生有另一個特點：

They actually thrive from peer recognition.

佢哋渴望得到行內認同

If a cardiologist calls another cardiologist

如果一個心臓科醫生

打電話畀對手醫院嘅一個心臓科醫生

in a competing hospital

and discusses why that other hospital

問佢點解佢間醫院有更好結果時

has so much better results, they will share.

嗰個醫生會分享俾佢聽

They will share the information on how to improve.

佢哋會分享改善方法

So it is, by measuring and creating transparency,

所以，因為有透明度，你可以不斷改善

you get a cycle of continuous improvement,

which is what this slide shows.

正如投影片所講一樣

Now, you may say this is a nice idea,

咁你可能會話，諗法唔錯

but this isn't only an idea.

但係呢個唔止係諗法

This is happening in reality.

呢樣嘢真係發生咗

We're creating a global community,

我哋嘗試令到全世界 都可以評估同比較醫療結果

and a large global community,

where we'll be able to measure and compare

what we achieve.

Together with two academic institutions,

BCG 聯同兩間學術機構

Michael Porter at Harvard Business School,

哈佛商學院嘅 Michael Porter

and the Karolinska Institute in Sweden,

同瑞士嘅卡羅林斯卡醫學院

BCG has formed something we call ICHOM.

已經成立咗一個叫 ICHOM 嘅機構

You may think that's a sneeze,

你可能以為我打乞嗤

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

呢個唔係乞嗤，而係一個縮寫

It stands for the International Consortium

全名係︰健康成果測量國際聯盟

for Health Outcome Measurement.

We're bringing together leading physicians

我哋令頂尖醫生同病人 一齊討論每一種疾病

and patients to discuss, disease by disease,

what is really quality,

咩為之質素

what should we measure,

我哋應該量度啲乜嘢

and to make those standards global.

務求令標準國際化

They've worked -- four working groups have worked

佢哋都做緊

during the past year:

舊年有四個工作小組做梗 白內障、背痛

cataracts, back pain,

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

冠心病，例如心臓病

and prostate cancer.

同前列腺癌

The four groups will publish their data

四個小組會喺今年十一月 刊登佢哋嘅數據

in November of this year.

That's the first time we'll be comparing

呢次會係第一次 我哋真正比較到同類嘅嘢

apples to apples, not only within a country,

唔止係比較國內

but between countries.

而係比較唔同國家

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

下一年，我哋計劃研究八種疾病

the year after, 16.

再下一年，研究十六種

In three years' time, we plan to have covered

三年內，我哋計劃覆蓋 疾病總數嘅四成

40 percent of the disease burden.

Compare apples to apples. Who's better?

比較同類型邊個好啲？

Why is that?

同埋點解？

Five months ago,

五個月前，我喺北歐最大嘅大學醫院

I led a workshop at the largest university hospital

in Northern Europe.

主持一個工作坊

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

怇哋請咗新 CEO，佢有一個願景：

I want to manage my big institution much more

令醫院注重多啲病人嘅 醫療質素同醫療成果

on quality, outcomes that matter to patients.

This particular day, we sat in a workshop

嗰日，我哋喺工作坊

同一啲醫生、護士同其他員工一齊坐

together with physicians, nurses and other staff,

discussing leukemia in children.

討論兒童白血病

The group discussed,

我哋討論咗：

how do we measure quality today?

我哋應該點樣評估質素？

Can we measure it better than we do?

現有評估方法可唔可以改善？

We discussed, how do we treat these kids,

我哋討論：點樣醫好呢啲兒童

what are important improvements?

有咩重大嘅進步？

And we discussed what are the costs for these patients,

我哋又討論：啲病人要使幾多錢

can we do treatment more efficiently?

我哋可唔可以更有效咁治療？

There was an enormous energy in the room.

當時房裏邊啲人好積極

There were so many ideas, so much enthusiasm.

有好多想法、好熱情

At the end of the meeting,

會議結束時，系主任企起身

the chairman of the department, he stood up.

He looked over the group and he said --

佢望下小組

佢舉手，緊握拳頭

first he raised his hand, I forgot that --

he raised his hand, clenched his fist,

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

然後對小組嘅人講：

「多謝你哋，今日我哋終於可以討論

Thank you. Today, we're finally discussing

what this hospital does the right way."

呢間醫院應該點樣做。」

By measuring value in healthcare,

通過評估醫療成效

that is not only costs

其中不單止費用，仲包括治療嘅成果

but outcomes that matter to patients,

we will make staff in hospitals

我哋會令到醫院嘅員工

and elsewhere in the healthcare system

以至醫療系統其他崗位

not a problem but an important part of the solution.

唔再係煩惱

而係解決方案嘅重要一部分

I believe measuring value in healthcare

我相信，評估醫療成效會帶嚟革命

will bring about a revolution,

and I'm convinced that the founder

我相信現代醫學嘅始祖

of modern medicine, the Greek Hippocrates,

希臘嘅希波克拉底

who always put the patient at the center,

一位永遠將病人放喺第一位嘅人

he would smile in his grave.

會喺上天覺得欣慰

Thank you.

多謝

（掌聲）

(Applause)