Stefan Larsson: What doctors can learn from each other

譯者: Ron Chao 審譯者: Ada Wang

Five years ago, I was on a sabbatical,

五年前我放了一段給薪假

and I returned to the medical university

回到醫學院

where I studied.

我的母校

I saw real patients and I wore the white coat

實際看到病人，而且我還穿著白袍

for the first time in 17 years,

已經17年沒有這種經驗

in fact since I became a management consultant.

我成為管理顧問以後就停止了

There were two things that surprised me

在醫學院的那個月

during the month I spent.

有兩件事令我訝異

The first one was that the common theme

第一件是我們討論的主題

of the discussions we had were hospital budgets

常常圍繞著醫院預算

and cost-cutting,

和削減成本

and the second thing, which really bothered me,

第二件事真的令我不安

actually, was that several of the colleagues I met,

有關我遇到的幾位同儕

former friends from medical school,

我讀醫學院時交的朋友

who I knew to be some of the smartest,

我知道他們是我所認識的人中最聰明

most motivated, engaged and passionate people

最積極、最投入

I'd ever met,

也最有熱誠的人

many of them had turned cynical, disengaged,

但其中許多人變得悲觀、消極

or had distanced themselves from hospital management.

或者不願與醫院管理沾上邊

So with this focus on cost-cutting,

所以強調削減成本

I asked myself, are we forgetting the patient?

我捫心自問：我們是否忽略了病人

Many countries that you represent

很多你們所代表的國家

and where I come from

以及我的國家

struggle with the cost of healthcare.

都忙於應付保健的成本

It's a big part of the national budgets.

該成本佔了國家大量的預算

And many different reforms aim at holding back this growth.

許多改革專注於控制成本增長

In some countries, we have long waiting times

在許多國家，得等上很長一段時間

for patients for surgery.

病人才能動手術

In other countries, new drugs are not being reimbursed,

其他國家，病人須自費買新藥

and therefore don't reach patients.

因此無法使用新藥

In several countries, doctors and nurses

有些國家的醫生和護士

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

或多或少成了政府的標靶

After all, the costly decisions in health care

畢竟保健的重大花費

are taken by doctors and nurses.

掌握在醫生和護士的手中

You choose an expensive lab test,

他們選擇昂貴的檢測

you choose to operate on an old and frail patient.

他們選擇為體弱的老人動手術

So, by limiting the degrees of freedom of physicians,

因此，限制醫生選擇的自由

this is a way to hold costs down.

是壓低成本的一種方式

And ultimately, some physicians will say today

終於有些醫生如今表示

that they don't have the full liberty

他們不能完全自由地

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

替病人的福利把關

So no wonder that some of my old colleagues

難怪我的一些舊同僚會感到挫敗

are frustrated.

難怪我的一些舊同僚會感到挫敗

At BCG, we looked at this,

我們在BCG（波士頓顧問公司）探討了該現象

and we asked ourselves,

我們捫心自問

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

這種保健管理是行不通的

And so we took a step back and we said,

所以我們退一步思考

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

那我們的目標是什麼

Ultimately, in the healthcare system,

保健體系終究是

we're aiming at improving health for the patients,

為了改善病人的健康

and we need to do so at a limited,

並且在此目標下還須節制成本

or affordable, cost.

至少要能夠負擔得起

We call this value-based healthcare.

我們稱之為「價值為主的保健」

On the screen behind me, you see what we mean

螢幕上是我們所定義的價值

by value:

螢幕上是我們所定義的價值

outcomes that matter to patients

病人關心的成效

relative to the money we spend.

相對於花費

This was described beautifully in a book in 2006

2006年一本書對此有極佳的描述

by Michael Porter and Elizabeth Teisberg.

作者是波特與泰斯伯格 （Michael Porter and Elizabeth Teisberg）

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

這張照片是我的岳父

surrounded by his three beautiful daughters.

和圍繞他的三個女兒

When we started doing our research at BCG,

我們在BCG開始研究時

we decided not to look so much at the costs,

決定不要著重於成本

but to look at the quality instead,

而是要重視品質

and in the research, one of the things

研究當中有一件事讓我們相當感興趣

that fascinated us was the variation we saw.

那就是各家醫院素質的參差不齊

You compare hospitals in a country,

比較同一國家的醫院

you'll find some that are extremely good,

會發現有部分表現極佳

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

但還是有很大一部份的醫院素質差許多

The differences were dramatic.

優劣之間的差距驚人

Erik, my father-in-law,

我的岳父艾瑞克

he suffers from prostate cancer,

罹患了攝護腺癌

and he probably needs surgery.

可能需要動手術

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

他現居歐洲，可以選擇去德國就醫

that has a well-reputed healthcare system.

德國的保健體系聲譽卓著

If he goes there and goes to the average hospital,

他如果去德國一家普通的醫院

he will have the risk of becoming incontinent

手術後尿失禁的風險

by about 50 percent,

大約是百分之五十的可能性

so he would have to start wearing diapers again.

不幸的話，他就必須再度穿尿褲

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

一半的風險，等於擲硬幣，機率相當大

If he instead would go to Hamburg,

如果他去德國漢堡就醫

and to a clinic called the Martini-Klinik,

去當地的馬丁尼診所（Martini-Klinik）

the risk would be only one in 20.

風險只有二十分之一

Either you a flip a coin,

看你是要擲硬幣

or you have a one in 20 risk.

還是要冒那二十分之一的風險

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

二者差距之大，是十倍之差

When we look at many hospitals

我們檢視了許多醫院

for many different diseases,

觀察許多不同疾病

we see these huge differences.

我們看到這種極大的差異

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

但是一般人不會知道 因為我們沒有這些資料

And often, the data actually doesn't exist.

而且通常這種資料並不存在

Nobody knows.

沒人知道差別

So going the hospital is a lottery.

所以去醫院等於是抽籤

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

我們不見得命該如此 還是有希望的

In the late '70s, there were a group

在1970年代晚期 有一群瑞典骨科醫生

of Swedish orthopedic surgeons

在1970年代晚期 有一群瑞典骨科醫生

who met at their annual meeting,

在醫學年會上相遇

and they were discussing the different procedures

會中他們探討應用在 髖關節手術的種種不同程序

they used to operate hip surgery.

會中他們探討應用在 髖關節手術的種種不同程序

To the left of this slide, you see a variety

圖左有多種

of metal pieces, artificial hips that you would use

金屬物件，那是人工髖關節

for somebody who needs a new hip.

用於需要置換髖關節的人

They all realized they had their individual way of operating.

醫生們都知道各自的程序不同

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

他們都聲稱「我的技術最好」

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

但他們也承認沒人能確定

So they said, "We probably need to measure quality

所以他們表示，我們可能需要衡量品質

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

這樣才能向最佳醫生學習

So they in fact spent two years debating,

於是他們花了兩年時間辯論

"So what is quality in hip surgery?"

髖關節手術品質的評估標準是什麼

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

噢，該測量這個 不，該測量那個

And they finally agreed.

他們最後達成協議

And once they had agreed, they started measuring,

一旦大家同意，他們開始測量

and started sharing the data.

並且開始分享數據

Very quickly, they found that if you put cement

他們很快發現，如果先把膠結材料

in the bone of the patient

填入病人的骨頭

before you put the metal shaft in,

然後再置入金屬關節

it actually lasted a lot longer,

其實會大大提高耐用度

and most patients would never have to be

大多數病人不再需要

re-operated on in their lifetime.

日後重做手術

They published the data,

他們發表了結果

and it actually transformed clinical practice in the country.

並且改變了全國的手術程序

Everybody saw this makes a lot of sense.

大家都認為這很明智

Since then, they publish every year.

從此以後，他們每年發表

Once a year, they publish the league table:

每年公佈一次成績單

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

誰領先，誰殿後

And they visit each other to try to learn,

他們互相參訪學習

so a continuous cycle of improvement.

不斷地循環改進

For many years, Swedish hip surgeons

有很多年，瑞典的髖關節醫生

had the best results in the world,

手術的結果全世界最佳

at least for those who actually were measuring,

至少參與測量的醫生如此

and many were not.

很多醫生並未參與

Now I found this principle really exciting.

我認為這個原則真的令人興奮

So the physicians get together,

醫生聚集起來

they agree on what quality is,

訂出一個品質的標準

they start measuring, they share the data,

開始測量，並分享數據

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

找出最佳醫生，然後向其學習

Continuous improvement.

不斷改進

Now, that's not the only exciting part.

這不是唯一值得興奮的部分

That's exciting in itself.

雖然已經很令人興奮了

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

但是如果再把成本

and look at that,

加入考量

it turns out, those who have focused on quality,

我們發現注重品質的醫生

they actually also have the lowest costs,

其醫療成本也最低

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

雖然成本一開始不是考量

So if you look at the hip surgery story again,

我們再以髖關節手術為例

there was a study done a couple years ago

幾年前有研究

where they compared the U.S. and Sweden.

比較美國和瑞典

They looked at how many patients have needed

檢視有多少病人需要

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

在首次手術七年後再動手術

In the United States, the number was three times

美國的數目

higher than in Sweden.

是瑞典的三倍

So many unnecessary surgeries,

太多可以避免的手術

and so much unnecessary suffering

太多可以避免的痛苦

for all the patients who were operated on

必需再動手術的病人

in that seven year period.

在七年間可避免的痛苦

Now, you can imagine how much savings

想想看，避免重做手術

there would be for society.

將替社會省下多少錢

We did a study where we looked at OECD data.

我們研究OECD的資料 （OECD為經濟合作開發組織之簡稱 ）

OECD does, every so often,

OECD經常檢視保健的品質

look at quality of care

OECD經常檢視保健的品質

where they can find the data across the member countries.

只要他們能獲取成員國的資料

The United States has, for many diseases,

在美國，許多疾病

actually a quality which is below the average

其實醫療品質

in OECD.

低於OECD的平均值

Now, if the American healthcare system

如果美國的保健體系

would focus a lot more on measuring quality,

能夠更加著重於衡量品質

and raise quality just to the level of average OECD,

並把品質提高至OECD的平均水準

it would save the American people

將替美國人

500 billion U.S. dollars a year.

每年省5000億美元

That's 20 percent of the budget,

那是預算的兩成

of the healthcare budget of the country.

全國保健的預算

Now you may say that these numbers

你可能會說，這些數字

are fantastic, and it's all logical,

太棒了，而且言之成理

but is it possible?

但實際可行嗎

This would be a paradigm shift in healthcare,

保健需要典範轉移

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

我主張不但做得到

but it has to be done.

而且必須做到

The agents of change are the doctors and nurses

改革的推手是醫生和護士

in the healthcare system.

他們身處保健體系

In my practice as a consultant,

我以顧問的身份

I meet probably a hundred or more than a hundred

每年大概會遇到上百位

doctors and nurses and other hospital

醫生和護士，以及其他

or healthcare staff every year.

醫院職員或保健工作人員

The one thing they have in common is

這些人的共同點是

they really care about what they achieve

他們非常在意自己的成就

in terms of quality for their patients.

治病品質方面的成就

Physicians are, like most of you in the audience,

醫生，就像大多數在場者

very competitive.

非常好勝

They were always best in class.

他們總是名列前茅

We were always best in class.

我們總是名列前茅

And if somebody can show them that the result

如果有人能證實

they perform for their patients

他們治病的成效

is no better than what others do,

沒比別人好

they will do whatever it takes to improve.

他們會竭盡所能去改進

But most of them don't know.

但多數不知道互相的成績

But physicians have another characteristic.

但是醫生還有一個特性

They actually thrive from peer recognition.

同儕的認可會讓他們進步

If a cardiologist calls another cardiologist

如果心臟病科醫生打電話給

in a competing hospital

另一家競爭醫院的同行

and discusses why that other hospital

討論對方的醫院為什麼

has so much better results, they will share.

成效好那麼多，他們會分享

They will share the information on how to improve.

他們會分享如何改善的資訊

So it is, by measuring and creating transparency,

所以藉由衡量品質與公開資訊

you get a cycle of continuous improvement,

就能夠促使改進不斷地循環發生

which is what this slide shows.

就是這個圖顯示的

Now, you may say this is a nice idea,

或許你會說這是好主意

but this isn't only an idea.

但這不只一個主意

This is happening in reality.

這個主意正在實現

We're creating a global community,

我們正在創立一個全球社群

and a large global community,

大型的全球社群

where we'll be able to measure and compare

我們在其中可以衡量比較

what we achieve.

大家的成績

Together with two academic institutions,

兩家學術機構

Michael Porter at Harvard Business School,

哈佛商學院的波特教授

and the Karolinska Institute in Sweden,

以及瑞典的卡洛林斯卡（Karolinska）學院

BCG has formed something we call ICHOM.

和BCG共同成立了ICHOM

You may think that's a sneeze,

你或許以為那是打噴嚏

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

但那是一個縮寫

It stands for the International Consortium

全名是「國際衡量健康成效聯盟」

for Health Outcome Measurement.

全名是「國際衡量健康成效聯盟」

We're bringing together leading physicians

我們聚集了頂尖的醫師

and patients to discuss, disease by disease,

還有病人，逐一討論各種疾病

what is really quality,

品質到底是什麼

what should we measure,

該如何衡量

and to make those standards global.

並且制定全球的標準

They've worked -- four working groups have worked

目前四個工作小組

during the past year:

在過去一年已有成果

cataracts, back pain,

白內障，背痛

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

冠狀動脈疾病 就是心臟病這類的疾病

and prostate cancer.

攝護腺癌

The four groups will publish their data

這四個小組的研究數據

in November of this year.

將在今年11月發表

That's the first time we'll be comparing

這將是我們首次

apples to apples, not only within a country,

用同一標準比較，不只是國內互比

but between countries.

也是國際之間互比

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

明年我們計劃比較八種疾病

the year after, 16.

後年16種疾病

In three years' time, we plan to have covered

三年之內，我們計劃涵蓋

40 percent of the disease burden.

四成病人所患的疾病

Compare apples to apples. Who's better?

拿蘋果和蘋果比，看看誰較佳

Why is that?

為什麼較佳

Five months ago,

五個月前

I led a workshop at the largest university hospital

我在北歐最大的教學醫院 主持了一個研討會

in Northern Europe.

我在北歐最大的教學醫院 主持了一個研討會

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

新院長表示她的願景是

I want to manage my big institution much more

對於這個大型機構的管理 我要更加注重病人關心的品質和成效

on quality, outcomes that matter to patients.

對於這個大型機構的管理 我要更加注重病人關心的品質和成效

This particular day, we sat in a workshop

那天我們在研討會上

together with physicians, nurses and other staff,

和醫生、護士，及其他工作人員

discussing leukemia in children.

討論兒童白血病

The group discussed,

我們討論到

how do we measure quality today?

現在是如何衡量品質

Can we measure it better than we do?

衡量方法能改進嗎

We discussed, how do we treat these kids,

我們討論治療兒童的方法

what are important improvements?

有什麼要項仍待改進

And we discussed what are the costs for these patients,

我們討論到這些病人的花費

can we do treatment more efficiently?

治療是否能夠更有效率

There was an enormous energy in the room.

全場活力十足

There were so many ideas, so much enthusiasm.

充滿了主意，充滿了熱情

At the end of the meeting,

會議結束時

the chairman of the department, he stood up.

該部門的主任起立

He looked over the group and he said --

看著與會成員，說道

first he raised his hand, I forgot that --

我忘了，他是先舉手

he raised his hand, clenched his fist,

他舉手，握著拳頭

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

然後跟大家說：謝謝

Thank you. Today, we're finally discussing

謝謝，我們今天討論醫院的方式

what this hospital does the right way."

終於走對路了

By measuring value in healthcare,

藉由衡量保健的價值

that is not only costs

不僅考量費用

but outcomes that matter to patients,

也包括病人關心的成效

we will make staff in hospitals

會使得醫院的職員

and elsewhere in the healthcare system

和保健體系其他工作人員

not a problem but an important part of the solution.

不再是問題，反而是解決方案的重點

I believe measuring value in healthcare

我相信衡量保健的價值

will bring about a revolution,

會引發變革

and I'm convinced that the founder

我相信現代醫學之父

of modern medicine, the Greek Hippocrates,

古希臘的希波克拉底

who always put the patient at the center,

他總是以病人為中心

he would smile in his grave.

將會含笑九泉

Thank you.

謝謝

(Applause)

（掌聲）