Ivan Oransky: Are we over-medicalized?

譯者: Marssi Draw 審譯者: Yuguo Zhang

Those of you who have seen the film "Moneyball,"

在場看過電影「魔球」

or have read the book by Michael Lewis,

或者看過麥可．路易斯書的人

will be familiar with the story of Billy Beane.

對比利．比恩的故事並不陌生吧

Billy was supposed to be a tremendous ballplayer; all the scouts told him so.

所有的球探都告訴比利他原本會是個傑出的球員

They told his parents that

他們告訴他的父母

they predicted that he was going to be a star.

他們預測比利將成為明日之星

But what actually happened when he signed the contract -- and by the way, he didn't

但當他簽了合約後的事實是－

want to sign that contract, he wanted to go to college --

順帶一提，他並不想要簽那個合約，他想上大學

which is what my mother, who actually does love me,

這就是為什麼愛我的媽媽

said that I should do too, and I did --

說我也應該去上大學，然後我去了－

well, he didn't do very well. He struggled mightily.

嗯…他沒有做得很好，而且做得非常辛苦。

He got traded a couple of times, he ended up in the Minors for most of his career,

他被交易了幾次，他的職業生涯大多在小聯盟裡

and he actually ended up in management. He ended up as a General Manager of the

最終他成為了球隊經理

Oakland A's.

Now for many of you in this room, ending up in management, which is also what I've done,

他擔任了奧克蘭運動家隊的的經理

回到在座的各位來說，和我一樣以管理階層的身份離開

is seen as a success.

被認為是成功的

I can assure you that for a kid trying to make it in the Bigs,

我能向你保證對於那些想打進大聯盟的孩子們來說

going into management ain't no success story. It's a failure.

進入到管理階層並不是成功的故事，那是失敗。

And what I want to talk to you about today, and share with you, is that our

而我今天想跟你們分享的是

healthcare system, our medical system, is just as bad at predicting

我們的保健、醫藥系統

what happens to people in it -- patients, others --

對於預測人們或是病人發生了什麼事

as those scouts were at predicting what would happen to Billy Beane.

就和球探們預測比利．比恩的未來一樣不準

And yet, every day

然後，每一天

thousands of people in this country

這個國家裡有成千上萬的人

are diagnosed with preconditions.

被診斷出生病的前兆

We hear about pre-hypertension, we hear about pre-dementia,

我們到到有高血壓的前兆、痴呆的前兆

we hear about pre-anxiety, and I'm pretty sure that I diagnosed myself with

焦慮症的前兆 我非常確定在那個綠色的房間裡

that in the green room.

我認為我患了焦慮症

We also refer to subclinical conditions.

我們也被暗示有症狀不顯著的病症

There's subclinical atherosclerosis, subclinical hardening of the arteries,

可能是症狀不顯著的動脈粥樣硬化、動脈硬化

obviously linked to heart attacks, potentially.

明顯地被聯結為潛在的心臟病

One of my favorites is called subclinical acne.

我最愛的一種稱為症狀不顯著的粉刺

If you look up subclinical acne, you may find a website, which I did,

如果你查詢這個症狀，你會和我一樣發現一個網站

which says that this is the easiest type of acne to treat.

裡頭提到了這是最容易治療的粉刺種類

You don't have the pustules or the redness and inflammation.

你沒有膿皰、紅腫或發炎

Maybe that's because you don't actually have acne.

或許這是因為你其實根本就沒有粉刺

I have a name for all of these conditions, it's another precondition:

我為這些病症取了一個名字，這又是另一個前兆了：

I call them preposterous.

我稱它為荒唐病

In baseball, the game follows the pre-game.

在棒球裡，正式比賽在熱身賽之後

Season follows the pre-season.

球季在賽前季之後

But with a lot of these conditions, that actually isn't the case, or at least it isn't the

但是在許多情況中根本不會有病

case all the time. It's as if there's a rain delay, every single time in many cases.

至少是大部份的時候都不會有病 那就好像隨時隨地都有遇雨停賽的可能

We have pre-cancerous lesions,

我們有癌症的徵兆

which often don't turn into cancer.

但是最終通常都不會變成癌症

And yet,

還有

if you take, for example, subclinical osteoporosis, a bone thinning disease,

以症狀不顯著的骨質疏鬆症為例

the precondition,

這是一種骨質薄化的病症

otherwise known as osteopenia,

如果你將它視為骨質減少

you would have to treat 270 women for three years

你必須在三年內治療270位女性

in order to prevent one broken bone.

以免其中一位跌斷了骨頭

That's an awful lot of women

當你計算有多少女性

when you multiply by the number of women who were diagnosed

被診斷為骨質減少時 所得到的數字

with this osteopenia.

將會非常驚人

And so is it any wonder,

是否有人懷疑過

given all of the costs and the side effects

花費這些錢

of the drugs that we're using to treat these preconditions, that every year

還有為了治療這些徵兆而服用的藥物所帶來的副作用

we're spending more than two trillion dollars on healthcare and yet

我們已在健康管理上花費超過兩萬億美元

100,000 people a year -- and that's a conservative estimate -- are dying

而且保守估計每年還有十萬人面臨死亡

not because of the conditions they have,

他們不是因為有了什麼疾病

but because of the treatments that we're giving them and the complications of those treatments?

而是因為我們給他的治療所產生的併發症 讓他面臨死亡

We've medicalized everything

在這個國家

in this country.

我們一直用醫藥的方式來處理每件事

Women in the audience, I have some

在場的女性朋友

pretty bad news that you already know,

有幾個壞消息是您已經知道的

and that's that every aspect of your life

那就是您生命中的每一個面向

has been medicalized.

都已被醫藥化了

Strike one is when you hit puberty.

第一個階段是在你年輕的時候

You now have something that happens to you once a month that has been medicalized.

有一個東西是每個月出現一次 那也已經被醫藥化了

It's a condition;

這是一種已經被治療的症狀

it has to be treated. Strike two

第二個階段是

is if you get pregnant.

如果你懷孕了

That's been medicalized as well.

這件事也被醫藥化了

You have to have a high-tech experience

你必須要經歷高科技的懷孕過程

of pregnancy, otherwise something might go wrong.

否則可能會有問題

Strike three is menopause.

第三個階段是更年期

We all know what happened when millions of women were given hormone replacement therapy

我們都知道幾十年來上百萬位婦女

for menopausal symptoms

被以荷爾蒙替代療法來治療更年期的症狀

for decades until all of a sudden we realized, because a study came out, a big one,

直到某一刻國家衛生研究所發表了一篇研究

NIH-funded.

我們才突然驚醒

It said,

這份研究報告指出

actually, a lot of that hormone replacement therapy may be doing more harm than good

事實上，對許多婦女來說

for many of those women.

荷爾蒙替代療法可能造成更多的傷害

Just in case,

遠多於它所帶來的幫助

I don't want to leave the men out --

比方說

I am one, after all --

我不想讓男人離開

I have really bad news for all of you in this room,

畢竟我也是個男人

and for everyone

我有一個壞消息要告訴在座的男性

listening and watching elsewhere:

以及在任何地方的觀眾朋友

You all have

你們都有

a universally fatal condition.

致命的病症

So, just take a moment.

因此，請深呼吸片刻

It's called pre-death.

這叫作死亡前兆

Every single one of you has it, because you have the risk factor for it,

每一個人都有這個病症 因為你們都有一個可能致死的危險因子

which is being alive.

那就是活著

But I have some good news for you, because

但是我有一個好消息要告訴你

I'm a journalist, I like to end things in a happy way or a forward-thinking way.

因為我是個新聞工作者 我喜歡讓事情以快樂或是正向思考的方式來作結

And that good news is that if you can survive to the end of my talk, which

這個好消息是如果你能夠在我的演講後倖存

we'll see if that happens for everyone,

稍後見分曉

you will be a pre-vivor.

你就會是一位有「倖存前兆」的人

I made up pre-death.

我虛構了死亡前兆這個詞

If I used someone else's pre-death, I apologize,

如果我用了某個人創造的這個詞

I think I made it up.

如有雷同，純屬巧合

I didn't make up pre-vivor.

我並沒有虛構倖存前兆者

Pre-vivor is what a particular cancer advocacy group would like everyone who

倖存前兆者是一個多麼特殊的癌症提倡團體

just has a risk factor,

希望每個人都有危險因子

but hasn't actually had that cancer,

但是事實上

to call themselves.

他們連這個癌症的名字都沒有

You are a pre-vivor.

你是一個倖存前兆者

We've had HBO here this morning. I'm wondering if Mark Burnett is anywhere in the

我們今早在這裡看了HBO電影台

audience, I'd like to suggest

我很好奇如果馬克伯內特在場

a reality TV show called "Pre-vivor."

我會建議他拍一場叫「倖存前兆者」的實鏡電視秀

If you develop a disease, you're off the island.

如果你生了病，你就得離開這座島

But the problem is, we have a system

但是問題是

that is completely --

我們有一種非常徹底且基本的宣傳機制

basically promoted this.

我們是被選出來的

We've selected, at every point in this system,

在這個機制的每一分一毫都被安排好了

to do what we do, and to give everyone a precondition and then eventually

我們要做的事、給每個人一個前兆

a condition, in some cases.

接著其中一部份則成了病症

Start with the doctor-patient relationship. Doctors, most of them,

以醫病關係來作說明

are in a fee-for-service system. They are basically incentivized to do more --

大部份的醫生都在收費服務的機制裡

procedures, tests,

基本上他們樂於做更多手續、測驗

prescribe medications.

開立處方箋

Patients come to them,

病人前來就醫

they want to do something. We're Americans, we can't just stand

他們想要某種東西 我們是美國人，我們不會只是站在那裡

there, we have to do something. And so they want a drug.

我們需要做點什麼 因此他們得到了藥物與治療

They want a treatment. They want to be told, this is what you have and this is how

他們想要聽到這是你目前可以用的藥 以及你如何治療病症

you treat it. If the doctor doesn't give you that,

如果醫生沒有給你這些東西

you go somewhere else.

你就會另外找一家醫院

That's not very good for doctors' business.

這對醫生的生意來說不太好

Or even worse,

更糟的可能是

if you are diagnosed with something eventually, and the doctor didn't order that test,

如果最後你被診斷出某種疾病

you get sued.

而之前的醫生沒有做那些檢驗，你就會告他

We have pharmaceutical companies that are constantly trying to expand

我們有不斷嘗試開發出適用各種病症藥品的製藥廠

the indications, expand the number of people who are eligible for a given treatment,

擴展能夠得到合適處方藥物的病人

because that obviously helps their bottom line. We have advocacy groups,

因為那很顯然的滿足了最基本的需求

like the one that's come up with pre-vivor,

我們有像「倖存前兆者」的提倡團體

who want to make more and more people feel they are at risk, or might have a condition,

試著想要讓更多人覺得他們身處危機、患有病症

so that they can raise more funds

因此他們可以得到更多的贊助

and raise visibility, et cetera.

提升能見度等等

But this isn't actually,

然而這並非屬實

despite what journalists typically do, this isn't actually about blaming

不管新聞工作者怎麼做

particular players.

都不是在責備特別的球員

We are all responsible.

我們都很盡責

I'm responsible.

我也很盡責

I actually root for the Yankees, I mean talk about

其實我支持洋基隊

rooting for the worst possible

我的意思是當你可以做任何事情的時候

offender when it comes to doing everything you can do.

支持最有可能的罪犯

Thank you.

謝謝

But everyone is responsible.

但是每個人都是負責任的

I went to medical school,

我曾去過醫學院

and I didn't have a course called How to Think Skeptically,

卻沒有一堂叫做「如何保持懷疑態度的思考」

or How Not to Order Tests.

或是「如何避免做檢驗」

We have this system

我們的體制如此

where that's what you do.

而你只能在其中做該做的事

And it actually took being a journalist

這其實讓身為記者的我了解所有這些動機

to understand all these incentives. You know, economists like to say,

你知道經濟學者可能會說

there are no bad people,

世界上沒有不好的人

there are just bad incentives.

只有不好的動機

And that's actually true.

確實如此

Because what we've created is a sort of Field of Dreams, when it comes to medical technology.

因為我們創造了一種醫學界的《夢幻成真》

So when you put another MRI in every corner, you put a robot

當你在每一個角落擺一台核磁共振儀器

in every hospital saying that everyone has to have robotic surgery.

就等於你在每一間醫院放了一個機器人 他會告訴每個人都需要機器手術

Well, we've created a system where if you build it, they will come.

我們已經建立了一個機制 一旦建立了，事情就會順其而行

But you can actually perversely

但是你也可以倔將地告訴人們

tell people to come, convince them

說服他們

that they have to come.

一定要這麼做

It was when I became a journalist that I really realized how I was part of this problem,

一直到我當了記者後 我才理解到原來我也是問題的一部份

and how we all are part of this problem.

而且我們大家都是這個問題的一部份

I was medicalizing every risk factor, I was writing stories, commissioning stories,

過去我醫藥化每一個風險因子

every day, that were trying to,

我每天都寫了很多故事且授權故事

not necessarily make people worried, although that was what often happened.

目的是不讓人們感到如此焦慮 雖然這種事很常發生

But, you know, there are ways out.

但是你知道 事情總有解決的辦法

I saw my own internist last week,

上個星期我去見了我的內科醫生

and he said to me,

他告訴我

"You know," and he told me something that

「你知道的，你該減肥了。」

everyone in this audience could have told me for free,

每一個在場的觀眾都可以免費告訴我這件事

but I paid him for the privilege, which is that

但是我卻得花錢請他跟我說

I need to lose some weight.

那就是我該減肥了

Well, he's right. I've had honest-to-goodness high blood pressure

好吧，他是對的

for a dozen years now, same

我確實是好幾十年的高血壓患者

age my father got it,

我父親在我這個年紀的時候也一樣

and it's a real disease. It's not pre-hypertension, it's actual

而且這是一個真的疾病，這不是前兆而已

hypertension, high blood pressure.

這是真的高血壓

Well, he's right,

好吧，他是對的

but he didn't say to me,

但是他沒有告訴我

well, you have pre-obesity or

嘿，你有肥胖的前兆

you have pre-diabetes, or anything like that. He didn't say,

或是你糖尿病的前兆，或是那之類的病症 他一點也沒有說

better start taking this Statin, you need to lower your cholesterol.

他用了一個比較好的方式告訴我 你該減少你的膽固醇攝取量

No, he said, "Go out and lose some weight. Come back and see me in a bit,

喔，不對， 他是說：「出門去減個肥吧！之後再來和我見面

or just give me a call and let me know how you're doing."

還是打個電話通知我，讓我知道你已經開始減肥了

So that's, to me,

對我來說

a way forward.

這是一條可行的路

Billy Beane, by the way, learned the same thing.

順帶一提

He learned,

比利．比恩也學到了同樣的道理

from watching this kid who he eventually hired, who was really successful for him,

他終於僱用了這個孩子，而這個孩子也真的成功了

that it wasn't swinging for the fences, it wasn't swinging at every pitch

他在這之中學到了並不只是要打出全壘打

like the sluggers do, which is what all the expensive teams like the Yankees like to --

不是每一球都要像打擊率高的選手一樣每球必中 這就和洋基隊那種熱門球隊的作法一樣

they like to pick up those guys.

他們喜歡挑選那樣的人

This kid told him, you know, you gotta watch the guys, and you gotta go out and find

這個孩子告訴他，你要好好觀察這些人

the guys who like to walk,

然後找出一個喜歡走路的人

because getting on base by a walk

因為步行上壘是件好事

is just as good, and in our healthcare system

而在我們的醫藥體系中

we need to figure out,

我們需要認出

is that really a good pitch

這是真的好球嗎？

or should we let it go by and not swing at everything?

還是就此遺忘，別理這件事？

Thanks.

謝謝