Want to get great at something? Get a coach | Atul Gawande

譯者: Marssi Draw 審譯者: Adrienne Lin

I don't come to you today as an expert.

我今天不是以專家的身分來，

I come to you as someone who has been really interested

我來是因為我一直很想知道

in how I get better at what I do

要怎麼讓自己做得更好，

and how we all do.

我們要怎麼做得更好。

I think it's not just how good you are now,

這件事不只關於你現在多好，

I think it's how good you're going to be that really matters.

你會變得多好才是重點。

I was visiting this birth center in the north of India.

我之前在北印度一間婦產中心

I was watching the birth attendants,

觀察接生人員，

and I realized I was witnessing in them an extreme form of this very struggle,

我意識到自己目睹他們 用一種很極端的方式使勁掙扎，

which is how people improve in the face of complexity --

就是人在面對複雜情況的時候 進步的那個樣子，

or don't.

或沒進步的樣子。

The women here are delivering in a region

女性在這區一般產房生產

where the typical birth center has a one-in-20 death rate for the babies,

要面對二十分之一的嬰兒死亡率，

and the moms are dying at a rate ten times higher than they do elsewhere.

母親的死亡率比其他地方高出十倍。

Now, we've known the critical practices

現在我們已經知道

數十年來讓嬰兒活產的關鍵措施。

that stop the big killers in birth for decades,

and the thing about it is that even in this place --

但問題是即使在這裡，

in this place especially,

尤其是這裡，

the simplest things are not simple.

最簡單的事情都辦不到。

We know for example you should wash hands and put on clean gloves,

例如我們應該要洗手、戴乾淨手套，

but here,

但是這裡，

the tap is in another room,

水龍頭在別的房間，

and they don't have clean gloves.

而且他們沒有乾淨的手套。

To reuse their gloves,

為了重覆使用手套，

they wash them in this basin of dilute bleach,

他們用這盆稀釋的漂白水洗，

but you can see there's still blood on the gloves from the last delivery.

但是大家可以看到， 手套上還有之前接生的血漬。

Ten percent of babies are born with difficulty breathing everywhere.

10% 的嬰兒出生時會呼吸困難， 不管在哪都一樣。

We know what to do.

我們知道怎麼應對。

You dry the baby with a clean cloth to stimulate them to breathe.

用一塊乾淨的布擦乾嬰兒， 刺激他們呼吸，

If they don't start to breathe,

如果他們還沒開始呼吸，

you suction out their airways.

就抽吸他們的呼吸道。

And if that doesn't work, you give them breaths with the baby mask.

如果還不行， 就給他們戴嬰兒氧氣罩。

But these are skills that they've learned mostly from textbooks,

這些方法他們幾乎都在課本上學過，

and that baby mask is broken.

但是嬰兒氧氣罩壞了。

In this one disturbing image for me

這個畫面讓我很難受，

is a picture that brings home just how dire the situation is.

完全顯示出情況有多慘。

This is a baby 10 minutes after birth,

這個小孩剛出生十分鐘，

and he's alive,

他還活著，

but only just.

但只剩一絲殘息。

No clean cloth,

沒有乾淨的布，

has not been dried,

沒有被擦乾，

not warming skin to skin,

身體還沒完全變暖，

an unsterile clamp across the cord.

未殺菌的鉗子剪斷臍帶。

He's an infection waiting to happen,

他可能快被感染，

and he's losing his temperature by the minute.

每分鐘都在失溫。

Successful child delivery requires a successful team of people.

成功接生需要一組成功團隊。

A whole team has to be skilled and coordinated;

每個人都應該技巧熟練、合作無間，

the nurses who do the deliveries in a place like this,

要有能在這種地方接生的護理師，

the doctor who backs them up,

要有能夠支援的醫生，

the supply clerk who's responsible for 22 critical drugs and supplies

要有負責打點 22 種重要藥物 和醫療用品的補給員，

being in stock and at the bedside,

確保有現貨放在床邊，

the medical officer in charge,

要有醫務官負責

responsible for the quality of the whole facility.

所有設備的品質。

The thing is they are all experienced professionals.

重點是他們全都是 有經驗的專業人員。

I didn't meet anybody who hadn't been part of thousands of deliveries.

我碰過的每一個都接生過好幾千次。

But against the complexities that they face,

但是面對這複雜的情況，

they seem to be at their limits.

他們就像已經做到極限，

They were not getting better anymore.

沒辦法做得更好。

It's how good you're going to be that really matters.

你能做得多好，才是重點。

It presses on a fundamental question.

這又涉及一個基本的問題。

How do professionals get better at what they do?

專業人員要怎麼做得更好？

How do they get great?

要怎麼做到最好？

And there are two views about this.

關於這個有兩種觀點。

One is the traditional pedagogical view.

第一種是傳統教學的觀點。

That is that you go to school,

就是你上學、

you study, you practice, you learn, you graduate,

研讀、練習、學習、畢業，

and then you go out into the world

然後出校園進入世界，

and you make your way on your own.

用自己的方式走自己的路。

A professional is someone who is capable of managing their own improvement.

專業人員有能力讓自己進步。

That is the approach that virtually all professionals have learned by.

各行各業都學過怎麼做。

That's how doctors learn,

醫生就是這麼學的，

that's how lawyers do,

還有律師也是，

scientists ...

科學家……

musicians.

音樂家。

And the thing is, it works.

重點是，這些方法有用。

Consider for example legendary Juilliard violin instructor Dorothy DeLay.

例如茱莉亞學院的小提琴 傳奇教師桃樂絲．狄蕾。

She trained an amazing roster of violin virtuosos:

她訓練過的小提琴大師 名單熠熠生輝：

Midori, Sarah Chang, Itzhak Perlman.

五嶋綠、張永宙、伊扎克．帕爾曼。

Each of them came to her as young talents,

每個好手在年輕時就拜師學藝，

and they worked with her over years.

跟著她很多年。

What she worked on most, she said,

她說，自己做最多的是

was inculcating in them habits of thinking and of learning

灌輸他們思考和學習的習慣，

so that they could make their way in the world without her

如此一來他們學成後， 無需她隨侍在側，

when they were done.

就可以自己闖蕩世界。

Now, the contrasting view comes out of sports.

體育界持相反觀點。

And they say "You are never done,

他們說：「永遠學不完，

everybody needs a coach."

每個人都要教練。」

Everyone.

無一例外。

The greatest in the world needs a coach.

世界上最厲害的運動員也需要教練。

So I tried to think about this as a surgeon.

我把這件事套在外科上思考。

Pay someone to come into my operating room,

付錢請人到我的開刀房，

observe me and critique me.

觀察我、評論我，

That seems absurd.

好像有點奇怪。

Expertise means not needing to be coached.

專家意謂著不需再受教。

So then which view is right?

哪個觀點正確？

I learned that coaching came into sports as a very American idea.

我發現運動界開始提倡找教練 是很美式的做法。

In 1875,

1875 年的時候，

Harvard and Yale played one of the very first American-rules football games.

哈佛和耶魯對打 當時少見的橄欖球賽。

Yale hired a head coach;

耶魯聘了一位總教練；

Harvard did not.

哈佛沒有。

The results?

結果呢？

Over the next three decades,

之後三十年

Harvard won just four times.

哈佛只贏了四次。

Harvard hired a coach.

哈佛之後也請了教練。

(Laughter)

（笑聲）

And it became the way that sports works.

這件事就變成體育界常態。

But is it necessary then?

但是真的有必要嗎？

Does it transfer into other fields?

其它領域也適用嗎？

I decided to ask, of all people,

我決定去問

Itzhak Perlman.

伊扎克．帕爾曼。

He had trained the Dorothy DeLay way

他在桃樂絲．狄蕾門下受訓，

and became arguably the greatest violinist of his generation.

成為他那一代 可說是最成功的小提琴家。

One of the beautiful things about getting to write for "The New Yorker"

幫《紐約客》寫文章 最棒的一件事情是

我打給電話找人，他們會回電。

is I call people up, and they return my phone calls.

(Laughter)

（笑聲）

And Perlman returned my phone call.

帕爾曼先生回了我電話。

So we ended up having an almost two-hour conversation

結果我們談了將近兩小時，

about how he got to where he got in his career.

他告訴我他怎麼達到現在的境界。

And I asked him, I said, "Why don't violinists have coaches?"

我問他： 「為什麼小提琴家不請教練？」

And he said, "I don't know,

他說：「我也不知道，

but I always had a coach."

但我以前都有教練。」

"You always had a coach?"

「你以前都有教練？」

"Oh yeah, my wife, Toby."

「對啊，是我老婆，桃比。」

They had graduated together from Juilliard,

他們一起從茱莉亞學院畢業，

and she had given up her job as a concert violinist

她放棄當小提琴演奏家，

to be his coach,

改當他的教練，

sitting in the audience,

坐在觀眾席，

observing him and giving him feedback.

觀察他、給他意見。

"Itzhak, in that middle section,

「伊扎克，中間那段，

you know you sounded a little bit mechanical.

聽起來有點生硬。

What can you differently next time?"

下次你可以怎麼改？」

It was crucial to everything he became, he said.

他說這件事對他的成就功不可沒。

Turns out there are numerous problems in making it on your own.

事實證明，自己追求進步 會有很多問題。

You don't recognize the issues that are standing in your way

你不會意識到卡住你的問題，

or if you do,

即使你知道問題，

you don't necessarily know how to fix them.

也不見得知道該怎麼改善。

And the result is that somewhere along the way,

結果就是成長路上的某一刻

you stop improving.

你不再進步。

And I thought about that,

我思考了這一點，

and I realized that was exactly what had happened to me as a surgeon.

了解到那就是我身為外科醫師 所碰到的問題。

I'd entered practice in 2003,

我 2003 年開始行醫，

and for the first several years,

頭幾年

it was just this steady, upward improvement in my learning curve.

我在學習中一直穩定成長。

I watched my complication rates drop from one year to the next.

我看著我病人的併發率年年下降，

And after about five years,

大概五年後

they leveled out.

就停在那邊。

And a few more years after that,

之後又過了幾年，

I realized I wasn't getting any better anymore.

我知道自己沒有再進步了。

And I thought: "Is this as good as I'm going to get?"

我心想：「這就是我的能耐了嗎？」

So I thought a little more and I said ...

我再想了一下之後決定：

"OK,

「好，

I'll try a coach."

我要找教練。」

So I asked a former professor of mine who had retired,

所以我問了我之前的教授， 他退休了，

his name is Bob Osteen,

叫做鮑伯．歐斯汀，

and he agreed to come to my operating room

他答應我到我的手術房

and observe me.

觀察我。

The case --

第一個病例，

I remember that first case.

我記得很清楚，

It went beautifully.

那個手術開得很漂亮。

I didn't think there would be anything much he'd have to say

結束後，我覺得他不會有什麼好說的。

when we were done.

Instead, he had a whole page dense with notes.

但是他寫了一整張密密麻麻的筆記。

(Laughter)

（笑聲）

"Just small things," he said.

「一些小事而已，」他說。

(Laughter)

（笑聲）

But it's the small things that matter.

但魔鬼藏在細節裡。

"Did you notice that the light had swung out of the wound

「你有發現開刀的時候，

during the case?

燈沒有對著傷口照嗎？

You spent about half an hour

你有半小時

just operating off the light from reflected surfaces."

用反射光動手術。」

"Another thing I noticed," he said,

「我還注意到一件事，」他說，

"Your elbow goes up in the air every once in a while.

「你的手肘三不五時會往上提。

That means you're not in full control.

表示你沒有完全控制自己。

A surgeon's elbows should be down at their sides resting comfortably.

外科醫生的手肘應該要自然下垂。

So that means if you feel your elbow going in the air,

如果你覺得手肘往上提，

就應該要換器具， 或是移動一下腳步。」

you should get a different instrument, or just move your feet."

It was a whole other level of awareness.

這是完全不同程度的體認。

And I had to think,

我當時想，

you know, there was something fundamentally profound about this.

這件事從根本來看意義深遠。

He was describing what great coaches do,

他說的話就是好教練做的事，

and what they do is they are your external eyes and ears,

他們當你身外的眼睛和耳朵，

providing a more accurate picture of your reality.

提供你更精確的現實。

They're recognizing the fundamentals.

他們看出根本原因。

They're breaking your actions down

他們分解你的動作，

and then helping you build them back up again.

再幫你重新組合起來。

After two months of coaching,

兩個月的訓練後，

I felt myself getting better again.

我發現自己又進步了。

And after a year,

一年之後，

I saw my complications drop down even further.

我病人的併發症案例降更低了。

It was painful.

過程很痛苦。

I didn't like being observed,

我不喜歡被觀察，

and at times I didn't want to have to work on things.

有時候我不想被逼著改掉習慣。

I also felt there were periods where I would get worse before I got better.

我也覺得在我進步之前， 有段時間在退步。

But it made me realize

但這件事讓我了解

that the coaches were onto something profoundly important.

這些指導影響深遠，意義重大。

In my other work,

我的另一份工作是

I lead a health systems innovation center called Ariadne Labs,

主持阿里亞尼醫藥創新中心，

where we work on problems in the delivery of health care,

我們處理產房裡碰到的問題，

including global childbirth.

包含全球嬰兒出生率。

As part of it,

其中，

we had worked with the World Health Organization

我們和世界衛生組織合作

to devise a safe childbirth checklist.

設計出一套安全生產清單。

It lays out the fundamentals.

清單上列出所有基本要件，

It breaks down the fundamentals --

瓦解基本要件──

the critical actions a team needs to go through

一連串團隊必須做的動作──

when a woman comes in in labor,

從產婦進產房來分娩、

when she's ready to push,

她準備好用力推，

when the baby is out,

到嬰兒出生，

and then when the mom and baby are ready to go home.

最後母子準備回家。

And we knew

我們知道，

that just handing out a checklist wasn't going to change very much,

一張清單不會改變太多，

and even just teaching it in the classroom wasn't necessarily going to be enough

即使是在教室裡教都不見得能

to get people to make the changes that you needed to bring it alive.

讓人做出可以讓嬰兒活下來的改變。

And I thought on my experience and said,

我考量了我的經驗後說：

"What if we tried coaching?

「要不要試看看找教練？

What if we tried coaching at a massive scale?"

要不要試看看大規模找教練來做？」

We found some incredible partners,

我們找到一些很棒的夥伴，

including the government of India,

包含印度政府，

and we ran a trial there in 120 birth centers.

我們在當地 120 間產婦中心測試。

In Uttar Pradesh, in India's largest state.

在印度最大的行政區北方邦，

Half of the centers basically we just observed,

有一半的診所，我們單純觀察，

but the other half got visits from coaches.

另一半會有教練過去。

We trained an army of doctors and nurses like this one

我們訓練一批醫師和護理師，像她，

who learned to observe the care and also the managers

他們學習觀察產房的護理 和管理階層，

and then help them build on their strengths

然後幫他們加強能力，

and address their weaknesses.

指出他們的弱點。

One of the skills for example they had to work on with people --

舉例來說，他們和人工作 必須有的一項技巧，

turned out to be fundamentally important --

事後證明這很重要，

就是溝通。

was communication.

Getting the nurses to practice speaking up when the baby mask is broken

讓護理師練習勇於發言， 比如說，嬰兒氧氣罩壞掉、

or the gloves are not in stock

手套庫存量不夠、

or someone's not washing their hands.

有人沒洗手。

And then getting others, including the managers,

然後讓其他人，包含管理階層，

to practice listening.

練習傾聽。

This small army of coaches ended up coaching 400 nurses

這一小批教練最後 訓練了四百位護理師、

and other birth attendants,

接生員、

and 100 physicians and managers.

一百名外科醫生和管理人員。

We tracked the results across 160,000 births.

我們追蹤 16 萬名新生兒，

The results ...

結果……

in the control group you had --

在控制組的是

and these are the ones who did not get coaching --

沒有受訓的人，

they delivered on only one-third of 18 basic practices

我們測量的 18 個基本要件當中，

他們只做到三分之一。

that we were measuring.

And most important was over the course of the years of study,

最重要的是經過多年研究，

we saw no improvement over time.

我們在過程中沒看到進步。

The other folks got four months of coaching

其他接受四個月訓練的人，

and then it tapered off over eight months,

接下來的八個月訓練逐漸變少，

and we saw them increase

我們看見他們進步到

to greater than two-thirds of the practices being delivered.

做到超過三分之二的基本要件。

It works.

結果奏效。

We could see the improvement in quality,

我們可以看到品質進步，

and you could see it happen across a whole range of centers

你可以看到許多診所都有成效，

that suggested that coaching could be a whole line of way

這表示訓練可能是一條路，

that we bring value to what we do.

彰顯我們專業的價值。

You can imagine the whole job category that could reach out in the world

你可以想見這能延續到世界上各行各業

and that millions of people could fulfill.

能滿足上百萬人。

We were clearly at the beginning of it, though,

不過我們顯然才剛起步，

because there was still a distance to go.

還有一段路要走。

You have to put all of the checklist together

要把所有確認事項放在一起，

to achieve the substantial reductions in mortality.

才能真的減少死亡率。

But we began seeing the first places that were getting there,

但我們開始看到第一批產房進步，

and this center was one of them

這是其中一間，

because coaching helped them learn to execute on the fundamentals.

因為訓練幫他們學習從根本做起。

And you could see it here.

在這邊可以看到成果。

This is a 23-year-old woman

這位婦女 23 歲，

who had come in by ambulance,

她被救護車送來，

in labor with her third child.

準備生她的第三胎。

She broke her water in the triage area,

她在檢傷分類區的時候羊水破了，

so they brought her directly to the labor and delivery room,

所以直接被送到產房，

and then they ran through their checks.

然後醫護人員逐項確認清單。

I put the time stamp on here

我在照片上標了時間，

so you could see how quickly all of this happens

你們就能看到這些事發生有多快，

and how much more complicated that makes things.

還有事情變得多複雜。

Within four minutes,

不過幾分鐘，

they had taken the blood pressure, measured her pulse

他們已經幫她量血壓、測脈博

and also measured the heart rate of the baby.

和小孩的心跳。

That meant that the blood pressure cuff and the fetal Doppler monitor,

這表示血壓計和胎心儀都在這邊，

they were all there, and the nurse knew how to use them.

而且護理師知道要怎麼操作。

The team was skilled and coordinated.

這組團隊訓練有素、合作無間。

The mom was doing great,

媽媽的狀況很好，

the baby's heart rate was 143, which is normal.

嬰兒心跳 143 下，很正常。

Eight minutes later, the intensity of the contractions picked up,

八分鐘後，宮縮變強，

so the nurse washed her hands,

所以護理師洗手、

put on clean gloves,

戴上乾淨的手套，

examined her and found that her cervix was fully dilated.

檢查產婦，發現她子宮頸完全張開，

The baby was ready to come.

嬰兒準備好要出生了。

She then went straight over to do her next set of checks.

所以她直接確認下一套清單。

All of the equipment, she worked her way through

她一一確認所有儀器

and made sure she had everything she needed at the bedside.

和所需物品都在床邊。

The baby mask was there, the sterile towel,

嬰兒氧氣罩、無菌布，

the sterile equipment that you needed.

所有你需要的無菌用品都在。

And then three minutes later, one push and that baby was out.

三分鐘後，推一下寶寶就出來了。

(Applause)

（掌聲）

I was watching this delivery,

我看這個生產過程的時候，

and suddenly I realized that the mood in that room had changed.

突然意識到房裡的氣氛變了。

The nurse was looking at the community health worker

護理師看著社區保健員

who had come in with the woman

和產婦一起進來，

because that baby did not seem to be alive.

因為寶寶好像沒有活下來。

She was blue and floppy and not breathing.

她膚色鐵青、全身鬆軟、沒有呼吸。

She would be one of that one-in-20.

她可能會是那 20 個之中的一個。

But the nurse kept going with her checkpoints.

但是護理師繼續確認清單，

She dried that baby with a clean towel.

用乾淨的布擦乾嬰兒。

And after a minute, when that didn't stimulate that baby,

一分鐘後， 嬰兒沒有受刺激開始呼吸，

she ran to get the baby mask

她跑去拿嬰兒氧氣罩，

and the other one went to get the suction.

另一位去拿抽吸器。

She didn't have a mechanical suction because you could count on electricity,

因為電力的問題， 她沒有電動抽吸器，

她用口部抽吸器，

so she used a mouth suction,

and within 20 seconds,

20 秒內，

she was clearing out that little girl's airways.

她開始清小女嬰的呼吸道，

And she got back a green, thick liquid,

清出綠色濃稠的液體，

and within a minute of being able to do that

可以開始不斷抽吸後一分鐘內

and suctioning out over and over,

that baby started to breathe.

寶寶開始呼吸了。

(Applause)

（掌聲）

Another minute and that baby was crying.

下一刻寶寶就哭了。

And five minutes after that,

五分鐘後，

she was pink and warming on her mother's chest,

粉嫩溫暖的她就在母親的懷裡，

and that mother reached out to grab that nurse's hand,

這位媽媽伸手握住護理師的手，

and they could all breathe.

她們都能呼吸了。

I saw a team transformed because of coaching.

我看到因為訓練，讓一組團隊改變。

And I saw at least one life saved because of it.

我看到至少因此救了一條人命。

We followed up with that mother a few months later.

幾個月後我們追蹤這位母親。

Mom and baby were doing great.

她和寶寶都很好。

The baby's name is Anshika.

寶寶叫安希卡，

It means "beautiful."

是「美麗」的意思。

And she is what's possible

她的存在證實了，

when we really understand

當我們知道如何精益求精時。

how people get better at what they do.

美麗成果就有可能實現。

Thank you.

謝謝。

(Applause)

（掌聲）