How do we heal medicine? | Atul Gawande

譯者: Serena Chang 審譯者: Dennis Guo

I got my start

當我開始從事

in writing and research

寫作和研究時

as a surgical trainee,

我還是一個

as someone who was a long ways away

對任何事都一竅不通的

from becoming any kind of an expert at anything.

外科實習醫生。

So the natural question you ask then at that point

所以在這個情形時, 你自然而然會問

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

我要如何在我想做的事物上精益求精？

And it became a question of,

然後問題就變成

how do we all get good

“我們”該如何

at what we're trying to do?

把“我們”想做的事情做好？

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

學習各種技巧，吸收大量的知識，

try to learn all the material you have to absorb

並且應用在你負責的工作上

at any task you're taking on.

是一件困難的事。

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

外科醫生必須考慮縫合和切割傷口，

but then also how I pick the right person

我同時也要挑選適合的團隊

to come to an operating room.

進入手術房

And then in the midst of all this

面對這所有的過程

came this new context

我一直思考

for thinking about what it meant to be good.

到底甚麼樣才稱做把事情做好。

In the last few years

最近這幾年

we realized we were in the deepest crisis

我們的醫療體系

of medicine's existence

面臨嚴重的危機

due to something you don't normally think about

因為身為一個醫生

when you're a doctor

你所關心的是

concerned with how you do good for people,

如何盡全力去醫治病人

which is the cost

而不是去在意

of health care.

醫療成本。

There's not a country in the world

但現在世界上每個國家

that now is not asking

都想知道

whether we can afford what doctors do.

是否自己能夠支付醫療行為的代價。

The political fight that we've developed

這也形成政治上的爭論

has become one around

問題總圍繞在

whether it's the government that's the problem

政府是否該為此負責?

or is it insurance companies that are the problem.

還是保險公司才是罪魁禍首？

And the answer is yes and no;

你可以說是，也可以說不是；

it's deeper than all of that.

但這個問題的答案不是這麼表面的。

The cause of our troubles

造成現今困境的原因

is actually the complexity that science has given us.

可以說是科學發展日趨複雜的結果。

And in order to understand this,

為了瞭解這個觀點

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

讓我們回到幾個世代之前。

I want to take you back

我們回到

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

醫生兼作家Lewis Thomas

Lewis Thomas was a physician-writer,

寫"最稚齡的科學."這本書的時候。

one of my favorite writers.

他是我最喜歡的作家之一。

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

他的書中描述了

what it was like to be a medical intern

當時在波士頓醫院

at the Boston City Hospital

身為實習醫生時的情況。

in the pre-penicillin year

那是在西元1937年

of 1937.

盤尼西林發明前的年代。

It was a time when medicine was cheap

那個時候，醫藥費很便宜

and very ineffective.

但也沒什麼效果。

If you were in a hospital, he said,

他說，當時的醫院

it was going to do you good

對病人的幫助

only because it offered you

僅僅在於提供病人

some warmth, some food, shelter,

一些溫暖，食物和庇護

and maybe the caring attention

也許還有來自護士的

of a nurse.

悉心照料。

Doctors and medicine

醫生和藥物

made no difference at all.

對病情沒有多大影響。

That didn't seem to prevent the doctors

但即使如此，

from being frantically busy in their days,

當時的醫師

as he explained.

仍然非常忙碌。

What they were trying to do

他們試圖

was figure out whether you might have one of the diagnoses

想要從病人的診斷書中

for which they could do something.

看看有什麼是他們能做的。

And there were a few.

當然，很少。

You might have a lobar pneumonia, for example,

舉例來說，如果你是一個肺炎病人

and they could give you an antiserum,

醫生會給你抗血清的藥，

an injection of rabid antibodies

注射藥性強的抗體

to the bacterium streptococcus,

對抗鏈球菌。

if the intern sub-typed it correctly.

前提是實習醫生的血型分類正確。

If you had an acute congestive heart failure,

如果你有充血性心臟衰竭，

they could bleed a pint of blood from you

醫生可能會從你的手臂靜脈

by opening up an arm vein,

抽出一品脫的血，

giving you a crude leaf preparation of digitalis

給你天然植物調配的強心劑，

and then giving you oxygen by tent.

再提供你氧氣帳。

If you had early signs of paralysis

如果病人有癱瘓的早期徵兆，

and you were really good at asking personal questions,

當醫生緊密的追蹤病人的私生活時

you might figure out

可能會發現

that this paralysis someone has is from syphilis,

癱瘓的原因來自梅毒感染

in which case you could give this nice concoction

這時病人會被注射適量的

of mercury and arsenic --

汞和砷的混合劑–

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

如果注射過量，可能連病人一起殺死了。

Beyond these sorts of things,

除了這些治療之外

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

醫生能做的很有限。

This was when the core structure of medicine

在那樣的年代，

was created --

醫生們盡力做好份內工作

what it meant to be good at what we did

建立期望中的醫療行為

and how we wanted to build medicine to be.

醫藥體系的核心架構於是開始形成。

It was at a time

在當時，

when what was known you could know,

醫生可以記住所有的醫學知識

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

也能夠獨立從事所有已知的醫療行為

If you had a prescription pad,

所以如果一個醫生有配製處方的藥室

if you had a nurse,

有一個護士

if you had a hospital

有一個可以讓病人休息的場所或醫院

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

或許再加上一些基本的工具

you really could do it all.

就可以完成所有的治療。

You set the fracture, you drew the blood,

你可以處理骨折、抽血、

you spun the blood,

分析病人血液，

looked at it under the microscope,

並且用顯微鏡觀察，

you plated the culture, you injected the antiserum.

你可以作組織培養、可以注射抗血清。

This was a life as a craftsman.

這是像工匠或技師一樣的工作。

As a result, we built it around

當時的醫師們勇於冒險

a culture and set of values

充滿勇氣

that said what you were good at

獨立工作

was being daring,

且自給自足，

at being courageous,

最終，我們建立了

at being independent and self-sufficient.

醫療體系獨有的文化和價值標準。

Autonomy was our highest value.

獨立自主是我們高度推崇的價值。

Go a couple generations forward

回到現在，

to where we are, though,

我們處在一個

and it looks like a completely different world.

完全不同的環境。

We have now found treatments

我們幾乎能夠治療

for nearly all of the tens of thousands of conditions

人類會發生的

that a human being can have.

數以千計的病症。

We can't cure it all.

當然，我們沒辦法克服所有疾病

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

我們也沒有辦法保證每個人活得更久更健康。

But we can make it possible

但我們盡可能

for most.

做到最好。

But what does it take?

但是這要付出的代價是甚麼？

Well, we've now discovered

我們現在已經擁有

4,000 medical and surgical procedures.

4000種內外科療法

We've discovered 6,000 drugs

我可以開立的處方藥

that I'm now licensed to prescribe.

有6000種。

And we're trying to deploy this capability,

我們還試著將醫療

town by town,

挨家挨戶的

to every person alive --

深入我們我們國家

in our own country,

甚至於全世界

let alone around the world.

去治療所有的人。

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

但是現在，我們已經知道

as doctors,

身為醫生

we can't know it all.

我們沒辦法靠自己

We can't do it all

知道所有的醫學知識

by ourselves.

完成所有醫療行為。

There was a study where they looked

有一個研究統計

at how many clinicians it took to take care of you

究竟需要多少醫護人員

if you came into a hospital,

去照顧一個進到醫院的病人，

as it changed over time.

結果隨著年代不同而有很大差異。

And in the year 1970,

1970年代，

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

只需要兩個全職醫護人員。

That is to say,

也就是說，

it took basically the nursing time

除了基礎護理的時間外，

and then just a little bit of time for a doctor

只要一個醫生

who more or less checked in on you

一天一次

once a day.

確認一下病人情況。

By the end of the 20th century,

到了20世紀末，

it had become more than 15 clinicians

一個同樣的病人

for the same typical hospital patient --

需要專科醫生、物理治療師

specialists, physical therapists,

護士等

the nurses.

超過15個醫護人員處理。

We're all specialists now,

現在所有的醫生的都是專科醫生，

even the primary care physicians.

甚至基礎治療的醫生也不例外。

Everyone just has

每個醫護

a piece of the care.

提供一小部分照顧。

But holding onto that structure we built

每個醫師都

around the daring, independence,

充滿勇氣、獨立工作、

self-sufficiency

且自信滿滿。

of each of those people

這些都醫師養成教育所重視的價值

has become a disaster.

但反而讓醫療體系變成一場災難。

We have trained, hired and rewarded people

我們訓練、雇用並獎勵醫護人員

to be cowboys.

希望他們像牛仔一樣勇敢能幹。

But it's pit crews that we need,

但其實我們需要的是賽車維修隊，

pit crews for patients.

一個針對病人的維修團隊。

There's evidence all around us:

我們身邊就有例子可以證明：

40 percent of our coronary artery disease patients

在我們社會上

in our communities

40%的冠狀動脈病人

receive incomplete or inappropriate care.

沒有得到適當的治療。

60 percent

60%的

of our asthma, stroke patients

氣喘或中風病人

receive incomplete or inappropriate care.

沒有接受完整或適當的照護。

Two million people come into hospitals

高達兩百萬的人進出醫院後

and pick up an infection

被感染了

they didn't have

原先沒有的病菌。

because someone failed to follow

只因為醫護疏忽了

the basic practices of hygiene.

基礎衛生工作。

Our experience

我們的經驗是

as people who get sick,

當有人生病

need help from other people,

需要別人的幫助時

is that we have amazing clinicians

我們有優秀的醫生

that we can turn to --

我們可以化身為

hardworking, incredibly well-trained and very smart --

認真工作, 受過非常良好訓練, 而且很聰明的醫生

that we have access to incredible technologies

我們可以接觸到先進的醫學科技

that give us great hope,

讓我們擁抱更好的希望

but little sense

但請注意

that it consistently all comes together for you

所有的一切都為你而準備好的

from start to finish

從開始到結束

in a successful way.

由一個成功的方式到來

There's another sign

也有另外一個現象是

that we need pit crews,

我們需要維修人員

and that's the unmanageable cost

而對我們的服務而言

of our care.

這是個無法控制好的預算

Now we in medicine, I think,

現今的醫藥界, 我想

are baffled by this question of cost.

我們正為了預算的問題而苦惱

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

我們想說：“這就是這樣。

This is just what medicine requires."

這就是醫藥界需要的呀“

When you go from a world

當你的想法是

where you treated arthritis with aspirin,

用阿斯匹靈來治關節炎

that mostly didn't do the job,

雖然並沒有什麼用

to one where, if it gets bad enough,

轉換到另一種想法是, 當關節炎變非常非常糟了

we can do a hip replacement, a knee replacement

我們可以做髖關節替換手術, 膝蓋替換手術

that gives you years, maybe decades,

然後可以讓你好幾年, 也許好幾十年

without disability,

都不會不良於行

a dramatic change,

一個戲劇化的轉變

well is it any surprise

四萬美金的髖關節替換手術

that that $40,000 hip replacement

取代了10美分的阿斯匹靈

replacing the 10-cent aspirin

這不是很讓人驚訝嗎？

is more expensive?

是不是更貴呢？

It's just the way it is.

事情就是這樣的

But I think we're ignoring certain facts

但我想我們忽略了某些

that tell us something about what we can do.

告訴我們可以做的事的事實

As we've looked at the data

我們看著那些

about the results that have come

越來越複雜的

as the complexity has increased,

成果數據時

we found

我們發現

that the most expensive care

最貴的醫療照護

is not necessarily the best care.

並不見得是最好的照護

And vice versa,

而反者亦然

the best care

最好的照料

often turns out to be the least expensive --

通常都是那些不貴的

has fewer complications,

沒有什麼糾紛的

the people get more efficient at what they do.

人們可以經由他們的行為中變得更有效率

And what that means

這也意味著

is there's hope.

希望是存在的

Because [if] to have the best results,

因為（如果）要有最好的結局

you really needed the most expensive care

你絕對需要最貴的醫療照護

in the country, or in the world,

在這個國家, 或在這個世界

well then we really would be talking about rationing

那 我們真的需要討論到配給的問題

who we're going to cut off from Medicare.

哪些人我們需要停止提供醫療照護

That would be really our only choice.

而這是我們的唯一選擇

But when we look at the positive deviants --

但當我們看著那些有正面反應的異變者 --

the ones who are getting the best results

那些用著最低廉的價格

at the lowest costs --

得到最好的照護的人們 --

we find the ones that look the most like systems

我們會發現最成功的案例

are the most successful.

是最系統性的

That is to say, they found ways

那也意味著, 他們找到

to get all of the different pieces,

把所有不一樣的事物

all of the different components,

所有不同的要件

to come together into a whole.

全部統整在一起的方法

Having great components is not enough,

有最好的要件還不夠

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

雖然過去我們為了一些醫藥界的要件而著迷

We want the best drugs, the best technologies,

我們想要最好的藥品, 最好的醫學科技,

the best specialists,

最好的專科醫生

but we don't think too much

但我們沒有好好想過

about how it all comes together.

如何把這些要件組合在一起

It's a terrible design strategy actually.

這實際上是個不好的設計方式

There's a famous thought experiment

有個有名的思想實驗

that touches exactly on this

剛好跟我們討論的東西有關連

that said, what if you built a car

實驗是, 如果你組一台車

from the very best car parts?

用最好的零組件

Well it would lead you to put in Porsche brakes,

你用了保時捷的煞車

a Ferrari engine,

法拉利的引擎

a Volvo body, a BMW chassis.

富豪的車身, BMW的 底盤

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

然後你組裝完後你得到的是？

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

一堆昂貴的卻根本也不能用的垃圾

And that is what medicine can feel like sometimes.

而有時醫藥界正是如此

It's not a system.

這不是系統性的

Now a system, however,

系統性的治療，是

when things start to come together,

當事情能組合在一起時

you realize it has certain skills

你會發現它

for acting and looking that way.

有些特定的功能

Skill number one

第一個功能是

is the ability to recognize success

發現成功的能力

and the ability to recognize failure.

和發現弱點的能力

When you are a specialist,

當你是個專科醫生

you can't see the end result very well.

你沒辦法準確的看到最後的結果

You have to become really interested in data,

你必須變得對於數據很有興趣

unsexy as that sounds.

但這聽起來很無聊

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

我有個同事是在愛荷華州的Cedar Rapids 那邊當外科醫生

and he got interested in the question of,

而他對於以下這個問題很有興趣

well how many CT scans did they do

他們為了Cedar Rapids 這個社區

for their community in Cedar Rapids?

做了多少電腦斷層掃描？

He got interested in this

他對這個很有興趣

because there had been government reports,

因為曾經有政府的報告

newspaper reports, journal articles

報紙報導, 雜誌報導

saying that there had been too many CT scans done.

指出電腦斷層掃描過多的情形。

He didn't see it in his own patients.

他沒在自己的病人裡發現這個情形

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

所以他想問：“我們到底做了多少電腦斷層掃描？“

and he wanted to get the data.

他想得到這些數據

It took him three months.

他花了三個月的時間

No one had asked this question in his community before.

在他的社區裡從來沒有人想過這個問題

And what he found was that,

然後他找到的結果是

for the 300,000 people in their community,

他們社區裡的三十萬人

in the previous year

在過去的一年裡

they had done 52,000 CT scans.

他們做了五萬兩千份電腦斷層掃描

They had found a problem.

他們發現了個問題

Which brings us to skill number two a system has.

也帶出了一個系統中的第二個功能

Skill one, find where your failures are.

第一種能力是, 發現你的弱點

Skill two is devise solutions.

第二種能力是設計解決方法

I got interested in this

我對於這個有興趣

when the World Health Organization came to my team

當世界衛生組織來到我的團隊

asking if we could help with a project

詢問我們是否能參加

to reduce deaths in surgery.

減少手術致死機率的項目時

The volume of surgery had spread

手術的數量在

around the world,

世界上不斷的增加

but the safety of surgery

但手術的安全性

had not.

並沒有增加

Now our usual tactics for tackling problems like these

現在我們對於這些問題的解決方法是

are to do more training,

做更多的訓練

give people more specialization

讓人們變得更專業

or bring in more technology.

或者提供更多的醫療科技

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

在手術領域裡, 你沒有辦法擁有那些再更加專科的人

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

你也沒有辦法擁有那些訓練得更好的人

And yet we see unconscionable levels

現在我們看到不合理的

of death, disability

死亡和殘障比例

that could be avoided.

都是可以被避免的

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

所以我們調查了另一個更高風險的行業

We looked at skyscraper construction,

我們調查摩天大樓的建造工程

we looked at the aviation world,

我們看到航空世界

and we found

然後我們發現

that they have technology, they have training,

他們擁有先進的科技, 他們也有良好的訓練

and then they have one other thing:

而他們也有另外一件事

They have checklists.

他們有清單

I did not expect

我並不期望

to be spending a significant part

身為一個哈佛來的外科醫生

of my time as a Harvard surgeon

要花特定的時間

worrying about checklists.

擔心清單這件事情

And yet, what we found

現今, 我們發現的是

were that these were tools

有工具可以幫助我們

to help make experts better.

讓專業人員變得更好

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

我們需要引進波音的工程師來幫助我們

Could we design a checklist for surgery?

我們能設計給外科醫生的清單嗎？

Not for the lowest people on the totem pole,

不是為了在低層的人員們而設計

but for the folks

而是為了那些

who were all the way around the chain,

在工作鍊旁

the entire team including the surgeons.

整個隊伍的人員, 而其中也包含了外科醫生

And what they taught us

而他們教我們的是

was that designing a checklist

設計清單可以

to help people handle complexity

幫助人們更好的處理

actually involves more difficulty than I had understood.

比我能理解還要難上好幾倍的困難事物

You have to think about things

你必須考慮這些事情

like pause points.

像是個暫停的時刻

You need to identify the moments in a process

你必須在危險前發現問題的存在時

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

學會如此的暫停

and do something about it.

然後試圖解決問題

You have to identify

你必須指認出

that this is a before-takeoff checklist.

這是個起飛或開始前的確認清單

And then you need to focus on the killer items.

然後你需要專注於最重要以及最難的項目

An aviation checklist,

一個航空界的清單

like this one for a single-engine plane,

像是這個單引擎的飛機的清單

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

不是教你如何開飛機

it's a reminder of the key things

是提醒常會被忘記或忽略的

that get forgotten or missed

重要事物清單

if they're not checked.

如果他們沒被確認

So we did this.

那我們就會這樣

We created a 19-item two-minute checklist

我們給手術團隊創造了19個項目

for surgical teams.

兩分鐘的確認清單

We had the pause points

我們有暫停的時刻

immediately before anesthesia is given,

就在麻醉開始前

immediately before the knife hits the skin,

就在手術刀碰觸到皮膚前

immediately before the patient leaves the room.

就在病患離開手術室前

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

而我們有許多蠢事列在上面

making sure an antibiotic is given in the right time frame

只為了確定抗生素是在正確的時間點提供的

because that cuts the infection rate by half --

因為他們能讓感染機率減半

and then interesting stuff,

而有趣的是

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

因為你沒有辦法為了手術這樣複雜的事情列張清單

Instead, you can make a recipe

取而代之的是, 你可以列張

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

如何讓整個團隊為了無法預期的事情作準備的清單

And we had items like making sure everyone in the room

而我們有像是確認每個在手術室裡的人

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

都有在手術開始前自我介紹的選項，

because you get half a dozen people or more

因為你有六個或更多的人

who are sometimes coming together as a team

是在這個手術團隊被組成前

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

從來也不認識彼此的

We implemented this checklist

我們在世界上八個醫院裡

in eight hospitals around the world,

實行這個清單計畫

deliberately in places from rural Tanzania

特意從塔桑尼亞的郊區

to the University of Washington in Seattle.

到西雅圖的華盛頓大學

We found that after they adopted it

我們發現在他們接受這項激化後

the complication rates fell

糾紛發生的機率下降

35 percent.

百分之三十五

It fell in every hospital it went into.

每間醫院都是如此

The death rates fell

手術死亡的機率降低

47 percent.

百分之四十七

This was bigger than a drug.

在藥物方面降低更多

(Applause)

（全場鼓掌）

And that brings us

而這也讓我們討論到

to skill number three,

第三種能力

the ability to implement this,

能執行這項計畫的能力

to get colleagues across the entire chain

讓每個工作鍊上的人員

to actually do these things.

能實際上執行這些事

And it's been slow to spread.

而這散播的很慢

This is not yet our norm in surgery --

這還不是我們手術界的傳統

let alone making checklists

讓清單設計

to go onto childbirth and other areas.

執行到生產和其他領域

There's a deep resistance

實際上有一定的人抗拒這項計畫

because using these tools

因為使用這些工具

forces us to confront

強迫我們去面對

that we're not a system,

我們不是一個整體的系統的現實

forces us to behave with a different set of values.

強迫我們去表現出不一樣的價值觀

Just using a checklist

用這個清單

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

需要我們擁有和以往不一樣的價值觀念

like humility,

像是人性

discipline,

紀律

teamwork.

團隊合作

This is the opposite of what we were built on:

和我們現今擁有的

independence, self-sufficiency,

獨立, 自我滿足

autonomy.

自治相差甚遠

I met an actual cowboy, by the way.

順道一提, 我遇到一個真正的牛仔

I asked him, what was it like

我問他,

to actually herd a thousand cattle

在數百英里上畜牧一千隻的牛

across hundreds of miles?

是怎樣的感覺？

How did you do that?

你怎麼辦到的呀？

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

他說：“我們在各地都有駐紮的牛仔“

They communicate electronically constantly,

“他們定時用電子通訊設備溝通“

and they have protocols and checklists

而他們有協議好也有清單確認

for how they handle everything --

他們遇到事情要如何處理 --

(Laughter)

（笑聲）

-- from bad weather

-- 從惡劣的天氣

to emergencies or inoculations for the cattle.

到緊急狀況或為牲畜接種

Even the cowboys are pit crews now.

連牛仔都是維修人員啦

And it seemed like time

看起來我們現在該是

that we become that way ourselves.

變成和他們一樣的時候了

Making systems work

讓整個體制一體的運作

is the great task of my generation

將是我們這個醫生和科學家世代

of physicians and scientists.

最艱鉅的任務

But I would go further and say

但我想更深入的說

that making systems work,

讓這個體制運作

whether in health care, education,

不管是醫學照護, 教育

climate change,

天氣轉變

making a pathway out of poverty,

改變貧窮

is the great task of our generation as a whole.

都是我們整個世代需要完成的艱鉅任務

In every field, knowledge has exploded,

在每個領域, 知識都爆炸性的增加了

but it has brought complexity,

但這也將一切複雜化

it has brought specialization.

也帶來了持續的專業化。

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

而現在我們已經沒有其他的選擇

but to recognize,

我們必須清楚知道

as individualistic as we want to be,

我們想要個人主義

complexity requires

但解決困難的問題需要

group success.

團隊的合作才能成功

We all need to be pit crews now.

我們現在都需要維修人員

Thank you.

謝謝大家

(Applause)

（全場鼓掌）