A few years ago, I broke into my own house. I had just driven home, it was around midnight in the dead of Montreal winter, I had been visiting my friend, Jeff, across town, and the thermometer on the front porch read minus 40 degrees -- and don't bother asking if that's Celsius or Fahrenheit, minus 40 is where the two scales meet -- it was very cold. And as I stood on the front porch fumbling in my pockets, I found I didn't have my keys. In fact, I could see them through the window, lying on the dining room table where I had left them. So I quickly ran around and tried all the other doors and windows, and they were locked tight. I thought about calling a locksmith -- at least I had my cellphone, but at midnight, it could take a while for a locksmith to show up, and it was cold. I couldn't go back to my friend Jeff's house for the night because I had an early flight to Europe the next morning, and I needed to get my passport and my suitcase.
幾年前,我闖進自己家裡。 當時我剛開車回到家, 就在蒙特婁寒冬中的午夜時分, 我剛拜訪完住在 鎮上另一邊的朋友傑夫。 門廊前的溫度計顯示零下40度 - 就別問我是攝氏還是華氏了, 零下40度剛好是 攝氏等於華氏的溫度 - 非常地寒冷。 當我站在門廊前翻著口袋時, 發現鑰匙不在自己身上。 事實上,我還能從窗外看到那串鑰匙, 它就被我擱在餐桌上靜靜地躺著。 所以我快速繞了一圈, 試了試所有的門和窗戶, 發現每一扇都鎖得緊緊的。 我想著要不要找鎖匠來 - 至少手機還在身上, 但在這種午夜時分, 要找鎖匠來可有得等了, 天氣又這麼冷。 我也不能再回去傑夫那借住一晚, 因為隔天一早我就得飛到歐洲, 我得拿到我的護照和行李。
So, desperate and freezing cold, I found a large rock and I broke through the basement window, cleared out the shards of glass, I crawled through, I found a piece of cardboard and taped it up over the opening, figuring that in the morning, on the way to the airport, I could call my contractor and ask him to fix it. This was going to be expensive, but probably no more expensive than a middle-of-the-night locksmith, so I figured, under the circumstances, I was coming out even.
所以,在這個令人絕望 又冷得要命的時刻, 我找到一塊大石後, 砸破地下室的玻璃, 清了清玻璃碎片後 就爬了進去, 然後找了一片厚紙板 貼在窗戶破掉的地方, 心裡估算著明天早上往機場的路上 可以打電話給我的承包商, 請他幫我修好玻璃。 維修費一定很貴, 但應該不會比午夜時分 請鎖匠來開鎖還貴, 所以我想,在當時的情況下, 這個決定也沒讓我虧到。
Now, I'm a neuroscientist by training and I know a little bit about how the brain performs under stress. It releases cortisol that raises your heart rate, it modulates adrenaline levels and it clouds your thinking. So the next morning, when I woke up on too little sleep, worrying about the hole in the window, and a mental note that I had to call my contractor, and the freezing temperatures, and the meetings I had upcoming in Europe, and, you know, with all the cortisol in my brain, my thinking was cloudy, but I didn't know it was cloudy because my thinking was cloudy.
因為我是個受過訓練的神經學家, 對於大腦在壓力之下的運作略有了解, 我知道它會釋出皮質醇, 增加你的心跳、 調解腎上腺素、 並讓你思緒渾沌不清。 所以第二天早上, 當我從嚴重不足的睡眠中醒來後, 就開始擔心玻璃上的那個破洞, 心裡一直惦記著要打電話給承包商, 天氣又冷得要命, 還有即將要在歐洲開的那些會議, 而你知道的,因為有許多皮質醇在大腦裡, 我的思緒一片渾沌, 而正因它一片渾沌, 我根本沒發現它一片渾沌
(Laughter)
(笑聲)
And it wasn't until I got to the airport check-in counter, that I realized I didn't have my passport.
而當我到達機場的報到櫃台時, 我才發現自己竟然沒帶護照。
(Laughter)
(笑聲)
So I raced home in the snow and ice, 40 minutes, got my passport, raced back to the airport, I made it just in time, but they had given away my seat to someone else, so I got stuck in the back of the plane, next to the bathrooms, in a seat that wouldn't recline, on an eight-hour flight. Well, I had a lot of time to think during those eight hours and no sleep.
所以我在冰雪中疾馳回家, 花了40分鐘, 拿到護照後再火速回到機場, 在最後關頭總算趕上, 但他們已經把我的座位 先讓給別人了, 於是我只能被擠到 飛機的最後方、廁所旁的位子, 座椅還無法向後倾斜, 而且得撐8小時。 好吧,至少在這8小時中 我有很多時間思考,反正也別想睡了。
(Laughter)
(笑聲)
And I started wondering, are there things that I can do, systems that I can put into place, that will prevent bad things from happening? Or at least if bad things happen, will minimize the likelihood of it being a total catastrophe. So I started thinking about that, but my thoughts didn't crystallize until about a month later. I was having dinner with my colleague, Danny Kahneman, the Nobel Prize winner, and I somewhat embarrassedly told him about having broken my window, and, you know, forgotten my passport, and Danny shared with me that he'd been practicing something called prospective hindsight.
然後我開始想,我能不能先做些什麼, 或是設置好什麼機制, 來幫助我避免壞事發生? 或至少發生了壞事之後, 能把造成重大損害的可能性降到最低, 所以我開始思考這些事, 但我的思緒直到一個月後才漸漸清晰。 那時我正和我的同事,諾貝爾經濟學獎 得主丹尼爾‧卡尼曼一起吃晚餐, 我有點不好意思地 提到破窗進入自己家裡、 還有忘記帶護照等等的事, 於是丹尼爾和我分享 他正在實行一種叫做 「前瞻性後見之明」的東西。
(Laughter)
(笑聲)
It's something that he had gotten from the psychologist Gary Klein, who had written about it a few years before, also called the pre-mortem. Now, you all know what the postmortem is. Whenever there's a disaster, a team of experts come in and they try to figure out what went wrong, right? Well, in the pre-mortem, Danny explained, you look ahead and you try to figure out all the things that could go wrong, and then you try to figure out what you can do to prevent those things from happening, or to minimize the damage.
這東西是他從心理學家 蓋瑞.克萊恩那裡得來的, 幾年前他曾寫過相關著作, 又將其稱為「事前剖析」。 各位一定都知道事後剖析是什麼。 每當有災難降臨, 一組專家就會來到事發現場, 設法釐清出了什麼問題,對吧? 那麼,事前剖析,根據丹尼爾的解釋, 就是你先往前看, 設法找出所有可能出錯的事, 接著再嘗試找出對應的解決方式 來防止這些事發生或將傷害降到最低。
So what I want to talk to you about today are some of the things we can do in the form of a pre-mortem. Some of them are obvious, some of them are not so obvious. I'll start with the obvious ones.
所以今天要和各位聊的, 是我們能用「事前剖析」來做些什麼。 有些顯而易見,有些不那麼明顯。 我先從顯而易見的開始。
Around the home, designate a place for things that are easily lost. Now, this sounds like common sense, and it is, but there's a lot of science to back this up, based on the way our spatial memory works. There's a structure in the brain called the hippocampus, that evolved over tens of thousands of years, to keep track of the locations of important things -- where the well is, where fish can be found, that stand of fruit trees, where the friendly and enemy tribes live. The hippocampus is the part of the brain that in London taxicab drivers becomes enlarged. It's the part of the brain that allows squirrels to find their nuts. And if you're wondering, somebody actually did the experiment where they cut off the olfactory sense of the squirrels, and they could still find their nuts. They weren't using smell, they were using the hippocampus, this exquisitely evolved mechanism in the brain for finding things. But it's really good for things that don't move around much, not so good for things that move around. So this is why we lose car keys and reading glasses and passports. So in the home, designate a spot for your keys -- a hook by the door, maybe a decorative bowl. For your passport, a particular drawer. For your reading glasses, a particular table. If you designate a spot and you're scrupulous about it, your things will always be there when you look for them.
在房子四處,給每個容易 遺失的東西一個專屬位置。 這聽起來像是常識,也確實是, 但它有許多理論基礎可為其佐證, 像是我們空間記憶的運作方式。 大腦裡有個結構叫做海馬體, 它經過成千上萬年的演化而來, 負責追蹤每個重要物品的位置 - 例如井的位置、哪裡可以捕到魚、 果樹的位置、 或是同盟及敵對的部落在哪裡等等。 海馬體是大腦裡的一部分, 倫敦的計程車司機 這個部分比常人還大。 松鼠可以順利找到松果 也是靠大腦的這個部分。 如果你有興趣, 有人的確做過這個實驗, 在他們切斷松鼠的嗅覺之後, 發現牠們仍能找到松果。 牠們用的不是嗅覺,而是海馬體, 大腦裡一個為了找到東西 而高度演化而成的機制。 但它對靜止不動的物體比較有用, 對會移動的東西就沒那麼有效。 這就是為什麼我們很容易 遺失鑰匙、老花眼鏡和護照。 所以在家時,幫你的鑰匙 找個固定位置 - 例如掛在門上、或放在裝飾性的碗裡。 至於護照,擺在某個特定的抽屜裡。 老花眼鏡則可以固定放在某個桌子上。 如果東西都放到定位而且你夠留意, 當需要時,永遠能在定位找到東西。
What about travel? Take a cell phone picture of your credit cards, your driver's license, your passport, mail it to yourself so it's in the cloud. If these things are lost or stolen, you can facilitate replacement.
那旅行時該怎麼辦? 用手機幫你的信用卡拍幾張照, 還有駕照、護照也拍幾張, 然後寄給自己,照片就會在雲端留存。 如果這些東西掉了或被偷, 至少有東西先擋著用。
Now these are some rather obvious things. Remember, when you're under stress, the brain releases cortisol. Cortisol is toxic, and it causes cloudy thinking. So part of the practice of the pre-mortem is to recognize that under stress you're not going to be at your best, and you should put systems in place.
這些都是相對明顯的事。 記住,當你處在壓力中, 你的大腦會釋放皮質醇。 皮質醇是有害的,他會阻礙你的思考。 所以「事前剖析」部分的實踐方式, 是要意識到壓力會讓你 無法處在最佳狀態, 所以你得將事情安排得井然有序。
And there's perhaps no more stressful a situation than when you're confronted with a medical decision to make. And at some point, all of us are going to be in that position, where we have to make a very important decision about the future of our medical care or that of a loved one, to help them with a decision.
而可能沒有任何狀況 比當你面臨醫療決策時 更令人感到壓力了。 在人生的某個時刻, 我們都面臨這樣的狀況, 迫使我們必須做出重大決策, 而這個決策可能事關 我們所愛的人未來的醫療照護, 必須幫他們做個選擇。
And so I want to talk about that. And I'm going to talk about a very particular medical condition. But this stands as a proxy for all kinds of medical decision-making, and indeed for financial decision-making, and social decision-making -- any kind of decision you have to make that would benefit from a rational assessment of the facts.
所以我想談談這個情境。 我特別想談論的是 這個特殊的醫療情境。 但這個情境可以代表所有的醫療決策, 事實上,還可以代表財務決策、社交決策 - 任何一種你必須 針對事實進行理性評估的決策。
So suppose you go to your doctor and the doctor says, "I just got your lab work back, your cholesterol's a little high." Now, you all know that high cholesterol is associated with an increased risk of cardiovascular disease, heart attack, stroke. And so you're thinking having high cholesterol isn't the best thing, and so the doctor says, "You know, I'd like to give you a drug that will help you lower your cholesterol, a statin." And you've probably heard of statins, you know that they're among the most widely prescribed drugs in the world today, you probably even know people who take them. And so you're thinking, "Yeah! Give me the statin."
所以假如你去看醫生,醫生告訴你: 「我剛拿到你的檢驗報告, 你的膽固醇偏高。」 在座各位都知道高膽固醇 可能會增加心血管疾病、 心臟病及中風的風險。 所以你開始想 高膽固醇可不是什麼好事, 然後醫生接著說:「我想幫你開一種藥 來幫助你降低膽固醇, 叫斯達汀(statin)。」 你可能聽過斯達汀類藥物, 知道它們是當今世上 最廣泛地被開立的藥物, 你甚至可能認識正在服用的人。 所以你想著: 「好啊!給我來點斯達汀。」 但這時候,你應該要問一個問題,
But there's a question you should ask at this point, a statistic you should ask for that most doctors don't like talking about, and pharmaceutical companies like talking about even less. It's for the number needed to treat. Now, what is this, the NNT? It's the number of people that need to take a drug or undergo a surgery or any medical procedure before one person is helped. And you're thinking, what kind of crazy statistic is that? The number should be one. My doctor wouldn't prescribe something to me if it's not going to help. But actually, medical practice doesn't work that way. And it's not the doctor's fault, if it's anybody's fault, it's the fault of scientists like me. We haven't figured out the underlying mechanisms well enough. But GlaxoSmithKline estimates that 90 percent of the drugs work in only 30 to 50 percent of the people. So the number needed to treat for the most widely prescribed statin, what do you suppose it is? How many people have to take it before one person is helped? 300. This is according to research by research practitioners Jerome Groopman and Pamela Hartzband, independently confirmed by Bloomberg.com. I ran through the numbers myself. 300 people have to take the drug for a year before one heart attack, stroke or other adverse event is prevented.
這個問題是大部分醫生 都不願談論到的統計數據, 製藥公司甚至提到更少。 這個數據就是NNT-- 「需要治療的人數」。 那麼,這個「NNT」是什麼呢? ( 用來衡量藥物治療有效性的一種指標 ) 它是指--某藥物或手術或療程 平均每多少人裡, 才有一人從中獲得助益。 你可能會想,這是哪門子統計數字? 這個數據應該就是" 1 " 啊。 我的醫生理當不會開立 對我沒有幫助的藥物。 但事實上,醫療的實務 不是這樣運作的。 而這不是醫生的錯, 如果一定要說是誰的錯, 那就是像我這樣的科學家。 我們還不夠了解這些藥品 基礎的運作機制。 然而葛蘭素史克公司 (全球第三大製藥商)預測, 高達90%的藥品 都只對30%至50%的人有效。 那麼對最廣泛應用的 斯達汀來說,所需治療人數 你猜猜看是多少? 每多少人裡才有一人從中獲得助益? 300.... 這個數據來自一個研究, 由醫療研究者傑若‧古柏曼 和潘蜜拉‧哈茨班德進行, 同時被Bloomberg.com網站 獨立證實的研究。 我自己想了一下這個數字。 300個人必須服用這種藥物一年, 才能阻止一次心臟病、 中風或其他病變。
Now you're probably thinking, "Well, OK, one in 300 chance of lowering my cholesterol. Why not, doc? Give me the prescription anyway." But you should ask at this point for another statistic, and that is, "Tell me about the side effects." Right? So for this particular drug, the side effects occur in five percent of the patients. And they include terrible things -- debilitating muscle and joint pain, gastrointestinal distress -- but now you're thinking, "Five percent, not very likely it's going to happen to me, I'll still take the drug." But wait a minute. Remember under stress you're not thinking clearly. So think about how you're going to work through this ahead of time, so you don't have to manufacture the chain of reasoning on the spot. 300 people take the drug, right? One person's helped, five percent of those 300 have side effects, that's 15 people. You're 15 times more likely to be harmed by the drug than you are to be helped by the drug.
現在你可能在想,「好吧,至少 有 1/300的機率能降低我的膽固醇。 為何不要呢,醫生?還是開給我吧。」 但這時你得問到另一個統計數據, 也就是,「副作用是什麼?」對吧? 以這種藥而言, 它會對5%的病患產生副作用。 它們包含很可怕的症狀 - 例如四肢無力、關節疼痛、 腸胃不適 - 但現在你可能又想,「就5%嘛, 不會這麼剛好發生在我身上, 我還是吃這個藥吧。」 但等一等。 記得在壓力下你並沒有思考得很透徹。 所以事先想想你該怎麼處理這個狀況, 你就不用事到臨頭再 進行一連串的推理了。 每300個人,對吧?才有一個有用, 這300人裡有5%會產生副作用, 也就是15人。 這個藥對你造成傷害的可能性, 高達對你有所幫助的15倍之多。
Now, I'm not saying whether you should take the statin or not. I'm just saying you should have this conversation with your doctor. Medical ethics requires it, it's part of the principle of informed consent. You have the right to have access to this kind of information to begin the conversation about whether you want to take the risks or not.
現在我要說的, 不是你應該服用斯達汀與否。 而是你得和你的醫生談談。 在醫學道德上這是需要的, 這是知情同意原則的一部份。 你有權得知這樣的資訊, 來和醫生討論 你是否願意承擔這些風險。
Now you might be thinking I've pulled this number out of the air for shock value, but in fact it's rather typical, this number needed to treat. For the most widely performed surgery on men over the age of 50, removal of the prostate for cancer, the number needed to treat is 49. That's right, 49 surgeries are done for every one person who's helped. And the side effects in that case occur in 50 percent of the patients. They include impotence, erectile dysfunction, urinary incontinence, rectal tearing, fecal incontinence. And if you're lucky, and you're one of the 50 percent who has these, they'll only last for a year or two.
現在你可能在想, 我只是為了嚇嚇大家才丟出這個數字, 但實際上,這個治療所需人數 是相對具有代表性的。 對於50歲以上男性最常進行的手術, 做的最多的手術是為治療 前列腺癌而切除前列腺, 治療所需人數是49。 沒錯,每49個手術 才有一人真正受益。 而所有的病患中, 有50%可能產生副作用, 包含陽痿、勃起功能障礙, 尿失禁、直腸撕裂、 和排糞失禁。 如果你夠幸運, 而你是這50%之一的話, 這些副作用只會維持一到兩年。
So the idea of the pre-mortem is to think ahead of time to the questions that you might be able to ask that will push the conversation forward. You don't want to have to manufacture all of this on the spot. And you also want to think about things like quality of life. Because you have a choice oftentimes, do you I want a shorter life that's pain-free, or a longer life that might have a great deal of pain towards the end? These are things to talk about and think about now, with your family and your loved ones. You might change your mind in the heat of the moment, but at least you're practiced with this kind of thinking.
所以「事前剖析」這個方法是事先想好 所有你能問的問題, 讓討論能進行得更順利。 你不會希望事到臨頭才處理這些問題。 你也會希望能想想生活品質之類的事。 因為很多時候你其實有選擇機會, 「我想要短暫一點、 但沒有痛苦的人生, 還是長一點,但可能得 一路忍受痛苦的人生?」 這些都是值得思考的事,所以趕快 和家人及你所愛的人好好想想。 你還是可能一時激動改變心意, 但至少你已練習過這樣的思考。
Remember, our brain under stress releases cortisol, and one of the things that happens at that moment is a whole bunch on systems shut down. There's an evolutionary reason for this. Face-to-face with a predator, you don't need your digestive system, or your libido, or your immune system, because if you're body is expending metabolism on those things and you don't react quickly, you might become the lion's lunch, and then none of those things matter. Unfortunately, one of the things that goes out the window during those times of stress is rational, logical thinking, as Danny Kahneman and his colleagues have shown. So we need to train ourselves to think ahead to these kinds of situations.
請記住,我們的大腦 會在壓力下釋放皮質醇, 在此情況下會發生的事 就是整個系統一起停工。 在生物演化上這是有道理的。 當獵食者就在你面前時, 你不需要你的消化系統、 也不需要性慾、或是免疫系統, 因為如果你的身體將代謝反應 擴展到這些事情上, 你無法快速反應, 可能讓你變成獅子的午餐, 然後這些事情就再也不重要了。 很不幸地, 能讓我們在這種高壓時刻 脫離險境的東西之一, 就是理性、邏輯思考, 正如丹尼爾.卡尼曼 和他的同事證明的。 所以我們得訓練自己 在遇到這種狀況前預先思考。
I think the important point here is recognizing that all of us are flawed. We all are going to fail now and then. The idea is to think ahead to what those failures might be, to put systems in place that will help minimize the damage, or to prevent the bad things from happening in the first place.
我想此處的重點是 要認清我們自己並不是完美的。 我們無論如何都會出錯。 但我們可以預先思考可能會出什麼錯, 然後事先把事情安排妥當, 將傷害降到最低, 或是在一開始就避免壞事發生。
Getting back to that snowy night in Montreal, when I got back from my trip, I had my contractor install a combination lock next to the door, with a key to the front door in it, an easy to remember combination. And I have to admit, I still have piles of mail that haven't been sorted, and piles of emails that I haven't gone through. So I'm not completely organized, but I see organization as a gradual process, and I'm getting there.
回到蒙特婁那個大雪紛飛的夜晚, 當我從歐洲回來後, 我請承包商在門的旁邊 裝了一個密碼鎖, 裡面裝著前門的鑰匙, 並設定了一個好記的密碼。 而我必須承認, 我還有許多郵件沒有整理, 也有許多電子郵件還沒看完。 所以我並不是個井然有序的人, 但我將井然有序視為一個漸進的過程, 而我會越來越井然有序。
Thank you very much.
非常感謝各位。
(Applause)
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