I got my start in writing and research as a surgical trainee, as someone who was a long ways away from becoming any kind of an expert at anything. So the natural question you ask then at that point is, how do I get good at what I'm trying to do? And it became a question of, how do we all get good at what we're trying to do?
當我開始從事 寫作和研究時 我還是一個 對任何事都一竅不通的 外科實習醫生。 所以在這個情形時, 你自然而然會問 我要如何在我想做的事物上精益求精? 然後問題就變成 “我們”該如何 把“我們”想做的事情做好?
It's hard enough to learn to get the skills, try to learn all the material you have to absorb at any task you're taking on. I had to think about how I sew and how I cut, but then also how I pick the right person to come to an operating room. And then in the midst of all this came this new context for thinking about what it meant to be good.
學習各種技巧,吸收大量的知識, 並且應用在你負責的工作上 是一件困難的事。 外科醫生必須考慮縫合和切割傷口, 我同時也要挑選適合的團隊 進入手術房 面對這所有的過程 我一直思考 到底甚麼樣才稱做把事情做好。
In the last few years we realized we were in the deepest crisis of medicine's existence due to something you don't normally think about when you're a doctor concerned with how you do good for people, which is the cost of health care. There's not a country in the world that now is not asking whether we can afford what doctors do. The political fight that we've developed has become one around whether it's the government that's the problem or is it insurance companies that are the problem. And the answer is yes and no; it's deeper than all of that.
最近這幾年 我們的醫療體系 面臨嚴重的危機 因為身為一個醫生 你所關心的是 如何盡全力去醫治病人 而不是去在意 醫療成本。 但現在世界上每個國家 都想知道 是否自己能夠支付醫療行為的代價。 這也形成政治上的爭論 問題總圍繞在 政府是否該為此負責? 還是保險公司才是罪魁禍首? 你可以說是,也可以說不是; 但這個問題的答案不是這麼表面的。
The cause of our troubles is actually the complexity that science has given us. And in order to understand this, I'm going to take you back a couple of generations. I want to take you back to a time when Lewis Thomas was writing in his book, "The Youngest Science." Lewis Thomas was a physician-writer, one of my favorite writers. And he wrote this book to explain, among other things, what it was like to be a medical intern at the Boston City Hospital in the pre-penicillin year of 1937. It was a time when medicine was cheap and very ineffective. If you were in a hospital, he said, it was going to do you good only because it offered you some warmth, some food, shelter, and maybe the caring attention of a nurse. Doctors and medicine made no difference at all. That didn't seem to prevent the doctors from being frantically busy in their days, as he explained.
造成現今困境的原因 可以說是科學發展日趨複雜的結果。 為了瞭解這個觀點 讓我們回到幾個世代之前。 我們回到 醫生兼作家Lewis Thomas 寫"最稚齡的科學."這本書的時候。 他是我最喜歡的作家之一。 他的書中描述了 當時在波士頓醫院 身為實習醫生時的情況。 那是在西元1937年 盤尼西林發明前的年代。 那個時候,醫藥費很便宜 但也沒什麼效果。 他說,當時的醫院 對病人的幫助 僅僅在於提供病人 一些溫暖,食物和庇護 也許還有來自護士的 悉心照料。 醫生和藥物 對病情沒有多大影響。 但即使如此, 當時的醫師 仍然非常忙碌。
What they were trying to do was figure out whether you might have one of the diagnoses for which they could do something. And there were a few. You might have a lobar pneumonia, for example, and they could give you an antiserum, an injection of rabid antibodies to the bacterium streptococcus, if the intern sub-typed it correctly. If you had an acute congestive heart failure, they could bleed a pint of blood from you by opening up an arm vein, giving you a crude leaf preparation of digitalis and then giving you oxygen by tent. If you had early signs of paralysis and you were really good at asking personal questions, you might figure out that this paralysis someone has is from syphilis, in which case you could give this nice concoction of mercury and arsenic -- as long as you didn't overdose them and kill them. Beyond these sorts of things, a medical doctor didn't have a lot that they could do.
他們試圖 想要從病人的診斷書中 看看有什麼是他們能做的。 當然,很少。 舉例來說,如果你是一個肺炎病人 醫生會給你抗血清的藥, 注射藥性強的抗體 對抗鏈球菌。 前提是實習醫生的血型分類正確。 如果你有充血性心臟衰竭, 醫生可能會從你的手臂靜脈 抽出一品脫的血, 給你天然植物調配的強心劑, 再提供你氧氣帳。 如果病人有癱瘓的早期徵兆, 當醫生緊密的追蹤病人的私生活時 可能會發現 癱瘓的原因來自梅毒感染 這時病人會被注射適量的 汞和砷的混合劑– 如果注射過量,可能連病人一起殺死了。 除了這些治療之外 醫生能做的很有限。
This was when the core structure of medicine was created -- what it meant to be good at what we did and how we wanted to build medicine to be. It was at a time when what was known you could know, you could hold it all in your head, and you could do it all. If you had a prescription pad, if you had a nurse, if you had a hospital that would give you a place to convalesce, maybe some basic tools, you really could do it all. You set the fracture, you drew the blood, you spun the blood, looked at it under the microscope, you plated the culture, you injected the antiserum. This was a life as a craftsman.
在那樣的年代, 醫生們盡力做好份內工作 建立期望中的醫療行為 醫藥體系的核心架構於是開始形成。 在當時, 醫生可以記住所有的醫學知識 也能夠獨立從事所有已知的醫療行為 所以如果一個醫生有配製處方的藥室 有一個護士 有一個可以讓病人休息的場所或醫院 或許再加上一些基本的工具 就可以完成所有的治療。 你可以處理骨折、抽血、 分析病人血液, 並且用顯微鏡觀察, 你可以作組織培養、可以注射抗血清。 這是像工匠或技師一樣的工作。
As a result, we built it around a culture and set of values that said what you were good at was being daring, at being courageous, at being independent and self-sufficient. Autonomy was our highest value. Go a couple generations forward to where we are, though, and it looks like a completely different world. We have now found treatments for nearly all of the tens of thousands of conditions that a human being can have. We can't cure it all. We can't guarantee that everybody will live a long and healthy life. But we can make it possible for most.
當時的醫師們勇於冒險 充滿勇氣 獨立工作 且自給自足, 最終,我們建立了 醫療體系獨有的文化和價值標準。 獨立自主是我們高度推崇的價值。 回到現在, 我們處在一個 完全不同的環境。 我們幾乎能夠治療 人類會發生的 數以千計的病症。 當然,我們沒辦法克服所有疾病 我們也沒有辦法保證每個人活得更久更健康。 但我們盡可能 做到最好。
But what does it take? Well, we've now discovered 4,000 medical and surgical procedures. We've discovered 6,000 drugs that I'm now licensed to prescribe. And we're trying to deploy this capability, town by town, to every person alive -- in our own country, let alone around the world. And we've reached the point where we've realized, as doctors, we can't know it all. We can't do it all by ourselves.
但是這要付出的代價是甚麼? 我們現在已經擁有 4000種內外科療法 我可以開立的處方藥 有6000種。 我們還試著將醫療 挨家挨戶的 深入我們我們國家 甚至於全世界 去治療所有的人。 但是現在,我們已經知道 身為醫生 我們沒辦法靠自己 知道所有的醫學知識 完成所有醫療行為。
There was a study where they looked at how many clinicians it took to take care of you if you came into a hospital, as it changed over time. And in the year 1970, it took just over two full-time equivalents of clinicians. That is to say, it took basically the nursing time and then just a little bit of time for a doctor who more or less checked in on you once a day. By the end of the 20th century, it had become more than 15 clinicians for the same typical hospital patient -- specialists, physical therapists, the nurses.
有一個研究統計 究竟需要多少醫護人員 去照顧一個進到醫院的病人, 結果隨著年代不同而有很大差異。 1970年代, 只需要兩個全職醫護人員。 也就是說, 除了基礎護理的時間外, 只要一個醫生 一天一次 確認一下病人情況。 到了20世紀末, 一個同樣的病人 需要專科醫生、物理治療師 護士等 超過15個醫護人員處理。
We're all specialists now, even the primary care physicians. Everyone just has a piece of the care. But holding onto that structure we built around the daring, independence, self-sufficiency of each of those people has become a disaster. We have trained, hired and rewarded people to be cowboys. But it's pit crews that we need, pit crews for patients.
現在所有的醫生的都是專科醫生, 甚至基礎治療的醫生也不例外。 每個醫護 提供一小部分照顧。 每個醫師都 充滿勇氣、獨立工作、 且自信滿滿。 這些都醫師養成教育所重視的價值 但反而讓醫療體系變成一場災難。 我們訓練、雇用並獎勵醫護人員 希望他們像牛仔一樣勇敢能幹。 但其實我們需要的是賽車維修隊, 一個針對病人的維修團隊。
There's evidence all around us: 40 percent of our coronary artery disease patients in our communities receive incomplete or inappropriate care. 60 percent of our asthma, stroke patients receive incomplete or inappropriate care. Two million people come into hospitals and pick up an infection they didn't have because someone failed to follow the basic practices of hygiene. Our experience as people who get sick, need help from other people, is that we have amazing clinicians that we can turn to -- hardworking, incredibly well-trained and very smart -- that we have access to incredible technologies that give us great hope, but little sense that it consistently all comes together for you from start to finish in a successful way.
我們身邊就有例子可以證明: 在我們社會上 40%的冠狀動脈病人 沒有得到適當的治療。 60%的 氣喘或中風病人 沒有接受完整或適當的照護。 高達兩百萬的人進出醫院後 被感染了 原先沒有的病菌。 只因為醫護疏忽了 基礎衛生工作。 我們的經驗是 當有人生病 需要別人的幫助時 我們有優秀的醫生 我們可以化身為 認真工作, 受過非常良好訓練, 而且很聰明的醫生 我們可以接觸到先進的醫學科技 讓我們擁抱更好的希望 但請注意 所有的一切都為你而準備好的 從開始到結束 由一個成功的方式到來
There's another sign that we need pit crews, and that's the unmanageable cost of our care. Now we in medicine, I think, are baffled by this question of cost. We want to say, "This is just the way it is. This is just what medicine requires." When you go from a world where you treated arthritis with aspirin, that mostly didn't do the job, to one where, if it gets bad enough, we can do a hip replacement, a knee replacement that gives you years, maybe decades, without disability, a dramatic change, well is it any surprise that that $40,000 hip replacement replacing the 10-cent aspirin is more expensive? It's just the way it is.
也有另外一個現象是 我們需要維修人員 而對我們的服務而言 這是個無法控制好的預算 現今的醫藥界, 我想 我們正為了預算的問題而苦惱 我們想說:“這就是這樣。 這就是醫藥界需要的呀“ 當你的想法是 用阿斯匹靈來治關節炎 雖然並沒有什麼用 轉換到另一種想法是, 當關節炎變非常非常糟了 我們可以做髖關節替換手術, 膝蓋替換手術 然後可以讓你好幾年, 也許好幾十年 都不會不良於行 一個戲劇化的轉變 四萬美金的髖關節替換手術 取代了10美分的阿斯匹靈 這不是很讓人驚訝嗎? 是不是更貴呢? 事情就是這樣的
But I think we're ignoring certain facts that tell us something about what we can do. As we've looked at the data about the results that have come as the complexity has increased, we found that the most expensive care is not necessarily the best care. And vice versa, the best care often turns out to be the least expensive -- has fewer complications, the people get more efficient at what they do. And what that means is there's hope. Because [if] to have the best results, you really needed the most expensive care in the country, or in the world, well then we really would be talking about rationing who we're going to cut off from Medicare. That would be really our only choice.
但我想我們忽略了某些 告訴我們可以做的事的事實 我們看著那些 越來越複雜的 成果數據時 我們發現 最貴的醫療照護 並不見得是最好的照護 而反者亦然 最好的照料 通常都是那些不貴的 沒有什麼糾紛的 人們可以經由他們的行為中變得更有效率 這也意味著 希望是存在的 因為(如果)要有最好的結局 你絕對需要最貴的醫療照護 在這個國家, 或在這個世界 那 我們真的需要討論到配給的問題 哪些人我們需要停止提供醫療照護 而這是我們的唯一選擇
But when we look at the positive deviants -- the ones who are getting the best results at the lowest costs -- we find the ones that look the most like systems are the most successful. That is to say, they found ways to get all of the different pieces, all of the different components, to come together into a whole. Having great components is not enough, and yet we've been obsessed in medicine with components. We want the best drugs, the best technologies, the best specialists, but we don't think too much about how it all comes together. It's a terrible design strategy actually.
但當我們看著那些有正面反應的異變者 -- 那些用著最低廉的價格 得到最好的照護的人們 -- 我們會發現最成功的案例 是最系統性的 那也意味著, 他們找到 把所有不一樣的事物 所有不同的要件 全部統整在一起的方法 有最好的要件還不夠 雖然過去我們為了一些醫藥界的要件而著迷 我們想要最好的藥品, 最好的醫學科技, 最好的專科醫生 但我們沒有好好想過 如何把這些要件組合在一起 這實際上是個不好的設計方式
There's a famous thought experiment that touches exactly on this that said, what if you built a car from the very best car parts? Well it would lead you to put in Porsche brakes, a Ferrari engine, a Volvo body, a BMW chassis. And you put it all together and what do you get? A very expensive pile of junk that does not go anywhere. And that is what medicine can feel like sometimes. It's not a system.
有個有名的思想實驗 剛好跟我們討論的東西有關連 實驗是, 如果你組一台車 用最好的零組件 你用了保時捷的煞車 法拉利的引擎 富豪的車身, BMW的 底盤 然後你組裝完後你得到的是? 一堆昂貴的卻根本也不能用的垃圾 而有時醫藥界正是如此 這不是系統性的
Now a system, however, when things start to come together, you realize it has certain skills for acting and looking that way. Skill number one is the ability to recognize success and the ability to recognize failure. When you are a specialist, you can't see the end result very well. You have to become really interested in data, unsexy as that sounds.
系統性的治療,是 當事情能組合在一起時 你會發現它 有些特定的功能 第一個功能是 發現成功的能力 和發現弱點的能力 當你是個專科醫生 你沒辦法準確的看到最後的結果 你必須變得對於數據很有興趣 但這聽起來很無聊
One of my colleagues is a surgeon in Cedar Rapids, Iowa, and he got interested in the question of, well how many CT scans did they do for their community in Cedar Rapids? He got interested in this because there had been government reports, newspaper reports, journal articles saying that there had been too many CT scans done. He didn't see it in his own patients. And so he asked the question, "How many did we do?" and he wanted to get the data. It took him three months. No one had asked this question in his community before. And what he found was that, for the 300,000 people in their community, in the previous year they had done 52,000 CT scans. They had found a problem.
我有個同事是在愛荷華州的Cedar Rapids 那邊當外科醫生 而他對於以下這個問題很有興趣 他們為了Cedar Rapids 這個社區 做了多少電腦斷層掃描? 他對這個很有興趣 因為曾經有政府的報告 報紙報導, 雜誌報導 指出電腦斷層掃描過多的情形。 他沒在自己的病人裡發現這個情形 所以他想問:“我們到底做了多少電腦斷層掃描?“ 他想得到這些數據 他花了三個月的時間 在他的社區裡從來沒有人想過這個問題 然後他找到的結果是 他們社區裡的三十萬人 在過去的一年裡 他們做了五萬兩千份電腦斷層掃描 他們發現了個問題
Which brings us to skill number two a system has. Skill one, find where your failures are. Skill two is devise solutions. I got interested in this when the World Health Organization came to my team asking if we could help with a project to reduce deaths in surgery. The volume of surgery had spread around the world, but the safety of surgery had not. Now our usual tactics for tackling problems like these are to do more training, give people more specialization or bring in more technology.
也帶出了一個系統中的第二個功能 第一種能力是, 發現你的弱點 第二種能力是設計解決方法 我對於這個有興趣 當世界衛生組織來到我的團隊 詢問我們是否能參加 減少手術致死機率的項目時 手術的數量在 世界上不斷的增加 但手術的安全性 並沒有增加 現在我們對於這些問題的解決方法是 做更多的訓練 讓人們變得更專業 或者提供更多的醫療科技
Well in surgery, you couldn't have people who are more specialized and you couldn't have people who are better trained. And yet we see unconscionable levels of death, disability that could be avoided. And so we looked at what other high-risk industries do. We looked at skyscraper construction, we looked at the aviation world, and we found that they have technology, they have training, and then they have one other thing: They have checklists. I did not expect to be spending a significant part of my time as a Harvard surgeon worrying about checklists. And yet, what we found were that these were tools to help make experts better. We got the lead safety engineer for Boeing to help us.
在手術領域裡, 你沒有辦法擁有那些再更加專科的人 你也沒有辦法擁有那些訓練得更好的人 現在我們看到不合理的 死亡和殘障比例 都是可以被避免的 所以我們調查了另一個更高風險的行業 我們調查摩天大樓的建造工程 我們看到航空世界 然後我們發現 他們擁有先進的科技, 他們也有良好的訓練 而他們也有另外一件事 他們有清單 我並不期望 身為一個哈佛來的外科醫生 要花特定的時間 擔心清單這件事情 現今, 我們發現的是 有工具可以幫助我們 讓專業人員變得更好 我們需要引進波音的工程師來幫助我們
Could we design a checklist for surgery? Not for the lowest people on the totem pole, but for the folks who were all the way around the chain, the entire team including the surgeons. And what they taught us was that designing a checklist to help people handle complexity actually involves more difficulty than I had understood. You have to think about things like pause points. You need to identify the moments in a process when you can actually catch a problem before it's a danger and do something about it. You have to identify that this is a before-takeoff checklist. And then you need to focus on the killer items. An aviation checklist, like this one for a single-engine plane, isn't a recipe for how to fly a plane, it's a reminder of the key things that get forgotten or missed if they're not checked.
我們能設計給外科醫生的清單嗎? 不是為了在低層的人員們而設計 而是為了那些 在工作鍊旁 整個隊伍的人員, 而其中也包含了外科醫生 而他們教我們的是 設計清單可以 幫助人們更好的處理 比我能理解還要難上好幾倍的困難事物 你必須考慮這些事情 像是個暫停的時刻 你必須在危險前發現問題的存在時 學會如此的暫停 然後試圖解決問題 你必須指認出 這是個起飛或開始前的確認清單 然後你需要專注於最重要以及最難的項目 一個航空界的清單 像是這個單引擎的飛機的清單 不是教你如何開飛機 是提醒常會被忘記或忽略的 重要事物清單 如果他們沒被確認
So we did this. We created a 19-item two-minute checklist for surgical teams. We had the pause points immediately before anesthesia is given, immediately before the knife hits the skin, immediately before the patient leaves the room. And we had a mix of dumb stuff on there -- making sure an antibiotic is given in the right time frame because that cuts the infection rate by half -- and then interesting stuff, because you can't make a recipe for something as complicated as surgery. Instead, you can make a recipe for how to have a team that's prepared for the unexpected. And we had items like making sure everyone in the room had introduced themselves by name at the start of the day, because you get half a dozen people or more who are sometimes coming together as a team for the very first time that day that you're coming in.
那我們就會這樣 我們給手術團隊創造了19個項目 兩分鐘的確認清單 我們有暫停的時刻 就在麻醉開始前 就在手術刀碰觸到皮膚前 就在病患離開手術室前 而我們有許多蠢事列在上面 只為了確定抗生素是在正確的時間點提供的 因為他們能讓感染機率減半 而有趣的是 因為你沒有辦法為了手術這樣複雜的事情列張清單 取而代之的是, 你可以列張 如何讓整個團隊為了無法預期的事情作準備的清單 而我們有像是確認每個在手術室裡的人 都有在手術開始前自我介紹的選項, 因為你有六個或更多的人 是在這個手術團隊被組成前 從來也不認識彼此的
We implemented this checklist in eight hospitals around the world, deliberately in places from rural Tanzania to the University of Washington in Seattle. We found that after they adopted it the complication rates fell 35 percent. It fell in every hospital it went into. The death rates fell 47 percent. This was bigger than a drug.
我們在世界上八個醫院裡 實行這個清單計畫 特意從塔桑尼亞的郊區 到西雅圖的華盛頓大學 我們發現在他們接受這項激化後 糾紛發生的機率下降 百分之三十五 每間醫院都是如此 手術死亡的機率降低 百分之四十七 在藥物方面降低更多
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And that brings us to skill number three, the ability to implement this, to get colleagues across the entire chain to actually do these things. And it's been slow to spread. This is not yet our norm in surgery -- let alone making checklists to go onto childbirth and other areas. There's a deep resistance because using these tools forces us to confront that we're not a system, forces us to behave with a different set of values. Just using a checklist requires you to embrace different values from the ones we've had, like humility, discipline, teamwork. This is the opposite of what we were built on: independence, self-sufficiency, autonomy.
而這也讓我們討論到 第三種能力 能執行這項計畫的能力 讓每個工作鍊上的人員 能實際上執行這些事 而這散播的很慢 這還不是我們手術界的傳統 讓清單設計 執行到生產和其他領域 實際上有一定的人抗拒這項計畫 因為使用這些工具 強迫我們去面對 我們不是一個整體的系統的現實 強迫我們去表現出不一樣的價值觀 用這個清單 需要我們擁有和以往不一樣的價值觀念 像是人性 紀律 團隊合作 和我們現今擁有的 獨立, 自我滿足 自治相差甚遠
I met an actual cowboy, by the way. I asked him, what was it like to actually herd a thousand cattle across hundreds of miles? How did you do that? And he said, "We have the cowboys stationed at distinct places all around." They communicate electronically constantly, and they have protocols and checklists for how they handle everything -- (Laughter) -- from bad weather to emergencies or inoculations for the cattle. Even the cowboys are pit crews now. And it seemed like time that we become that way ourselves.
順道一提, 我遇到一個真正的牛仔 我問他, 在數百英里上畜牧一千隻的牛 是怎樣的感覺? 你怎麼辦到的呀? 他說:“我們在各地都有駐紮的牛仔“ “他們定時用電子通訊設備溝通“ 而他們有協議好也有清單確認 他們遇到事情要如何處理 -- (笑聲) -- 從惡劣的天氣 到緊急狀況或為牲畜接種 連牛仔都是維修人員啦 看起來我們現在該是 變成和他們一樣的時候了
Making systems work is the great task of my generation of physicians and scientists. But I would go further and say that making systems work, whether in health care, education, climate change, making a pathway out of poverty, is the great task of our generation as a whole. In every field, knowledge has exploded, but it has brought complexity, it has brought specialization. And we've come to a place where we have no choice but to recognize, as individualistic as we want to be, complexity requires group success. We all need to be pit crews now.
讓整個體制一體的運作 將是我們這個醫生和科學家世代 最艱鉅的任務 但我想更深入的說 讓這個體制運作 不管是醫學照護, 教育 天氣轉變 改變貧窮 都是我們整個世代需要完成的艱鉅任務 在每個領域, 知識都爆炸性的增加了 但這也將一切複雜化 也帶來了持續的專業化。 而現在我們已經沒有其他的選擇 我們必須清楚知道 我們想要個人主義 但解決困難的問題需要 團隊的合作才能成功 我們現在都需要維修人員
Thank you.
謝謝大家
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