4 questions you should always ask your doctor | Christer Mjåset

譯者: Lilian Chiu 審譯者: SF Huang

I am a neurosurgeon,

我是神經外科醫生，

and I'm here to tell you today that people like me need your help.

今天我是來告訴大家， 像我這樣的人需要你們的協助。

And in a few moments, I will tell you how.

等一下我就會告訴大家怎麼做。

But first, let me start off by telling you about a patient of mine.

但，首先讓我先談談我的一位病人。

This was a woman in her 50s,

她是一位五十多歲的女子，

she was in generally good shape,

身體狀況大致不錯，

but she had been in and out of hospital a few times

但她因為治療乳癌

due to curative breast cancer treatment.

已經進出過醫院好幾次了。

Now she had gotten a prolapse from a cervical disc,

現在她因頸椎的椎間盤突出，

giving her radiating pain of a tense kind,

而讓她的右手臂有很劇烈的

out into the right arm.

放射性疼痛。

Looking at her MRI before the consultation,

在諮詢之前我先看了她的磁振造影，

I decided to suggest an operation.

我決定要建議她動手術。

Now, neck operations like these are standardized, and they're quick.

像這樣的頸部手術是 標準化且很快速的。

But they carry a certain risk.

但仍然有一些風險。

You make an incision right here,

從這裡切開，

and you dissect carefully past the trachea,

小心地切過去，繞過氣管，

the esophagus,

繞過食道，

and you try not to cut into the internal carotid artery.

試著不要切到頸內動脈。

(Laughter)

（笑聲）

Then you bring in the microscope,

接著顯微鏡登場，

and you carefully remove the disc and the prolapse

然後小心地移除椎間盤 壓迫神經根管的地方，

in the nerve root canal,

without damaging the cord and the nerve root

不能損害到就在底下幾毫米的 脊髓神經及神經根。

lying only millimeters underneath.

The worst case scenario is the damage to the cord,

最糟糕的狀況就是傷到脊髓神經，

which can result in paralysis from the neck down.

可能會造成脖子以下癱瘓。

Explaining this to the patient, she fell silent.

我向病人解釋這些之後，她沉默了。

And after a few moments,

一會兒之後，

she uttered a few very decisive words for me and for her.

她說出了對我及對她來說 都非常果敢的話。

"Doctor, is this really necessary?"

「醫生，這真的有必要嗎？」

(Laughter)

（笑聲）

And you know what I realized, right there and then?

各位知道我在那當下領悟了什麼嗎？

It was not.

沒有必要。

In fact, when I get patients like this woman,

事實上，當我看到 像這名女子的病人時，

I tend to advise not to operate.

我會傾向建議不要動手術。

So what made me do it this time?

那麼，這次我為什麼會這麼做？

Well, you see,

嗯，要知道，

this prolapse was so delicate,

這個突出是如此的微妙，

I could practically see myself pulling it out of the nerve root canal

在她進入諮詢室之前，

我就可以看見自己 把它從神經根管中拔出來。

before she entered the consultation room.

I have to admit it, I wanted to operate on her.

我得承認，我想要幫她動手術。

I'd love to operate on her.

我很想幫她動手術。

Operating, after all, is the most fun part of my job.

畢竟，手術是我工作中 最有趣的部分。

(Laughter)

（笑聲）

I think you can relate to this feeling.

我想你們可以體會這種感覺。

My architect neighbor says he loves to just sit and draw

我那個當建築師的鄰居說，

他喜歡的就只是 坐下來繪製和設計房子。

and design houses.

He'd rather do that all day

他寧可整天做這件事，

than talk to the client paying for the house

也不想跟付錢買房子的客戶交談，

that might even give him restrictions on what to do.

這個客戶可能還會框限他的想法。

But like every architect,

但就像建築師一樣， 每一位外科醫生

every surgeon needs to look their patient in the eye

都得坦誠地與病人交流且和病人一起

and together with the patient,

they need to decide on what is best for the person having the operation.

決定動手術是否是最好的選擇。

And that might sound easy.

聽起來可能很簡單。

But let's look at some statistics.

但，讓我們來看些統計數字。

The tonsils are the two lumps in the back of your throat.

扁桃腺是喉嚨後面的兩塊隆起。

They can be removed surgically,

可以用手術將它們切除，

and that's called a tonsillectomy.

那稱為扁桃腺切除術。

This chart shows the operation rate of tonsillectomies in Norway

這張圖上顯示的是在挪威不同區域的

扁桃腺切除術施行率。

in different regions.

What might strike you is that there is twice the chance

各位可能會感到驚訝的是，

that your kid -- because this is for children --

你的孩子—— 這是針對孩子的統計——

will get a tonsillectomy in Finnmark than in Trondheim.

在芬馬克要動扁桃腺切除術的機率 是在特隆赫姆的兩倍。

The indications in both regions are the same.

這兩個區域的適應症都是一樣的。

There should be no difference, but there is.

動手術的機率理應沒差別，其實不然。

Here's another chart.

這是另一張圖。

The meniscus helps stabilize the knee

半月板的功能是穩定膝蓋，

and can be torn or fragmented acutely,

有可能局部或全部被撕裂或破裂，

topically during sports like soccer.

比如會因為踢足球等運動造成。

What you see here is the operation rate for this condition.

各位在這裡看到的是 針對這種狀況的開刀率。

And you see that the operation rate in Møre og Romsdal

可以發現，在默勒－魯姆斯達爾郡的

is five times the operation rate in Stavanger.

開刀率是斯塔萬格的五倍。

Five times.

五倍之多。

How can this be?

怎麼會這樣？

Did the soccer players in Møre og Romsdal

默勒－魯姆斯達爾郡的足球員踢球時 比全國其他的球員更會耍小動作嗎？

play more dirty than elsewhere in the country?

(Laughter)

（笑聲）

Probably not.

可能不是。

I added some information now.

現在我再增加一些資訊。

What you see now is the procedures performed

各位現在可以看到，淺藍色的 是在公立醫院中所進行的手術，

in public hospitals, in light blue,

the ones in private clinics are light green.

私人診所則用淺綠色表示。

There is a lot of activity in the private clinics

在默勒－魯姆斯達爾郡的私人診所

in Møre og Romsdal, isn't there?

有很多活動，對吧？

What does this indicate?

那是什麼意思？

A possible economic motivation to treat the patients.

有可能他們是基於 經濟上的動機去治療病人。

And there's more.

還不只如此。

Recent research has shown that the difference of treatment effect

近期研究顯示，針對膝蓋所做的 一般物理治療和手術，

between regular physical therapy and operations for the knee --

在治療效果上的差別——

there is no difference.

是沒有差別。

Meaning that most of the procedures performed

意思就是，在剛剛那張圖上

on the chart I've just shown

大部分所執行的手術

could have been avoided, even in Stavanger.

其實是可以避免的， 在斯塔萬格也一樣。

So what am I trying to tell you here?

所以，我想要告訴各位什麼？

Even though most indications for treatments in the world

即使全世界大部分的治療適應症

are standardized,

都已標準化，

there is a lot of unnecessary variation of treatment decisions,

在治療的決策上仍然有不必要的差異，

especially in the Western world.

特別是在西方世界。

Some people are not getting the treatment that they need,

有些人沒有得到他們需要的治療，

but an even greater portion of you

但，更高比例的人

are being overtreated.

是被過度治療的。

"Doctor, is this really necessary?"

「醫生，這真的有必要嗎？」

I've only heard that question once in my career.

我在職涯中只聽過一次這個問題。

My colleagues say they never heard these words from a patient.

我同事說他們從來沒有 聽過病人這麼問過。

And to turn it the other way around,

換個方向來看，

你認為如果提出這個問題，

how often do you think you'll get a "no" from a doctor

if you ask such a question?

會多常從醫生口中聽到「沒必要」？

Researchers have investigated this,

研究者調查了這件事，

and they come up with about the same "no" rate

他們所得到的「沒必要」率

wherever they go.

在各地都差不多。是三成。

And that is 30 percent.

Meaning, three out of 10 times,

也就是說，十次中有三次，

your doctor prescribes or suggests something

你的醫生開的處方或建議的治療

that is completely unnecessary.

是完全沒必要的。

And you know what they claim the reason for this is?

各位知道他們為此 所宣稱的理由是什麼嗎？

Patient pressure.

病人壓力。

In other words, you.

換言之，是你們。

You want something to be done.

你們希望醫生做點什麼。

A friend of mine came to me for medical advice.

我有一位朋友來找我詢求醫療建議。

This is a sporty guy,

他愛運動，

he does a lot of cross-country skiing in the winter time,

冬天時他很常越野滑雪，

he runs in the summer time.

夏天時則是跑步。

And this time, he'd gotten a bad back ache whenever he went jogging.

這次，他只要慢跑就有嚴重的背痛。

So much that he had to stop doing it.

痛到他只得停止跑步。

I did an examination, I questioned him thoroughly,

我幫他做了檢查，詳細的問診，

and what I found out is that he probably had a degenerated disc

我發現，他可能是脊椎下段

in the lower part of his spine.

發生了椎間盤退化。

Whenever it got strained, it hurt.

只要它受到壓力就會痛。

He'd already taken up swimming instead of jogging,

他已經用游泳取代慢跑， 已經沒其他的可做了。

there was really nothing to do,

所以，我告訴他：「在訓練方面， 你得要仔細做選擇。

so I told him, "You need to be more selective

when it comes to training.

Some activities are good for you,

有些活動對你是好的， 有些則不是。」

some are not."

His reply was,

他的回應是：

"I want an MRI of my back."

「我想要做背部磁振造影。」

"Why do you want an MRI?"

「你為何想做磁振造影？」

"I can get it for free through my insurance at work."

「我的工作有投保，不用負擔費用。」

"Come on," I said -- he was also, after all, my friend.

「拜託，」我說—— 畢竟，他也是我的朋友。

"That's not the real reason."

「那不是真正的原因。」

"Well, I think it's going to be good to see how bad it looks back there."

「嗯，我認為能看看 背後有多糟也不錯。」

"When did you start interpreting MRI scans?" I said.

我說：「你何時開始解讀 磁振造影掃瞄結果了？」

(Laughter)

（笑聲）

"Trust me on this.

「這件事就相信我吧，

You're not going to need the scan."

你不需要掃瞄。」

"Well," he said,

他說：「嗯，」

and after a while, he continued, "It could be cancer."

一會兒，他繼續說： 「有可能是癌症。」

(Laughter)

（笑聲）

He got the scan, obviously.

很顯然，他還是做了掃瞄。

And through his insurance at work,

透過他工作的保險， 他去找了我的一位同事，

he got to see one of my colleagues at work,

telling him about the degenerated disc,

同事告訴他椎間盤退化的事，

that there was nothing to do,

沒有其他可以做的，

and that he should keep on swimming and quit the jogging.

所以他應該要繼續游泳，放棄慢跑。

一陣子後，我和他再次見面，他說：

After a while, I met him again and he said,

「至少現在我知道它是什麼了。」

"At least now I know what this is."

But let me ask you a question.

但，讓我請問各位。

What if all of you in this room with the same symptoms had an MRI?

如果這間房間中每個有這種 症狀的人都去做磁振造影會如何？

And what if all the people in Norway

如果每個在挪威偶爾有背痛的人

had an MRI due to occasional back pain?

都去做磁振造影呢？

The waiting list for an MRI would quadruple, maybe even more.

磁振造影的等候名單可能會 變成四倍或更長。

And you would all take the spot on that list

你們會把在等候名單上

from someone who really had cancer.

真正癌症患者的名額給佔去了。

So a good doctor sometimes says no,

所以，好的醫生有時會說不，

but the sensible patient also turns down, sometimes,

但，理性的病人有時也會拒絕

an opportunity to get diagnosed or treated.

被診斷或治療的機會。

"Doctor, is this really necessary?"

「醫生，這真的有必要嗎？」

I know this can be a difficult question to ask.

我知道要問這個問題很難。

In fact, if you go back 50 years,

事實上，五十年前，

this was even considered rude.

問這個問題可能還會被視為無禮。

(Laughter)

（笑聲）

If the doctor had decided what to do with you,

如果醫生決定了 要如何處理你的狀況，

that's what you did.

你就要照做。

A colleague of mine, now a general practitioner,

我的一個同事，現在是家醫科醫師，

was sent away to a tuberculosis sanatorium as a little girl,

她小時候被送到結核病療養院，

for six months.

待了六個月。

It was a terrible trauma for her.

這對她來說是很大的創傷。

She later found out, as a grown-up,

長大後，她發現，

that her tests on tuberculosis had been negative all along.

她的結核病檢測結果 一直都是陰性的。

The doctor had sent her away on nothing but wrong suspicion.

醫生只因錯誤的臆測 就把她送進療養院。

No one had dared or even considered confronting him about it.

沒有人敢，甚至沒有人 想過要和醫生對質。

Not even her parents.

連她的父母也沒有。

Today, the Norwegian health minister

現今，挪威健康部長

talks about the patient health care service.

談到病人健康照護服務。

The patient is supposed to get advice from the doctor about what to do.

病人應該要向醫生取得 如何治療的建議。

This is great progress.

這是很大的進展。

But it also puts more responsibility on you.

但這也會讓你們承擔更多的責任。

You need to get in the front seat with your doctor

你們得要和醫生一起坐到前座上，

and start sharing decisions on where to go.

開始一起決定要往哪個方向走。

So, the next time you're in a doctor's office,

所以，下次進入醫生辦公室時，

I want you to ask,

我希望各位能夠問：

"Doctor, is this really necessary?"

「醫生，這真的有必要嗎？」

And in my female patient's case,

在我那位女病人的案例中，

the answer would be no,

答案是不必要，

but an operation could also be justified.

但如要動手術也是合理正當的。

"So doctors, what are the risks attached to this operation?"

「那麼醫生，這項 手術的風險是什麼？」

Well, five to ten percent of patients will have worsening of pain symptoms.

5% 到 10% 的病人

會有更糟的疼痛症狀。

One to two percent of patients

1% 到 2% 的病人

will have an infection in the wound or even a rehemorrhage

傷口會感染或甚至發生大出血，

that might end up in a re-operation.

最後可能要重新開刀。

0.5 percent of patients also experience permanent hoarseness

0.5 % 的病人會有永久性的沙啞，

and a few, but still a few,

雖然是少數，但仍然有人

will experience reduced function in the arms or even legs.

會發現手臂甚至腿部的功能下降。

"Doctor, are there other options?"

「醫生，有其他選擇嗎？」

Yes, rest and physical therapy over some time

是的，休息和物理治療一段時間

might get you perfectly well.

可能會讓你康復得很好。

"And what happens if I don't do anything?"

「如果我什麼都不做，會如何？」

It's not recommended,

不建議這樣，

but even then, there's a slight chance that you will get well.

但，如果真的如此， 也有微小的機會可能會好起來。

Four questions.

四個問題。

Simple questions.

很簡單的問題。

Consider them your new toolbox to help us.

把它們視為你們用來 協助我們的新工具盒。

Is this really necessary?

這真的有必要嗎？

What are the risks?

風險是什麼？

Are there other options?

有其他選擇嗎？

And what happens if I don't do anything?

如果我什麼都不做，會如何？

Ask them when your doctor wants to send you to an MRI,

對你的醫生提出上述問題， 當他要把你送去做磁振造影時、

when he prescribes antibiotics

當他要開抗生素給你時，

or suggests an operation.

或他建議你要動手術時。

What we know from research

我們從研究得知，

is that one out of five of you, 20 percent,

五個人中就有一個，即兩成，

will change your opinion on what to do.

會改變心意而做出不同的選擇。

And by doing that, you will not only have made your life

藉由這麼做，你不僅讓你的人生

a whole lot easier, and probably even better,

輕鬆許多，可能還會變得更好，

but the whole health care sector

此外，整個健康照護部門

will have benefited from your decision.

也會因為你的選擇而受益。

Thank you.

謝謝。

(Applause)

（掌聲）