For over a decade as a doctor, I've cared for homeless veterans, for working-class families. I've cared for people who live and work in conditions that can be hard, if not harsh, and that work has led me to believe that we need a fundamentally different way of looking at healthcare. We simply need a healthcare system that moves beyond just looking at the symptoms that bring people into clinics, but instead actually is able to look and improve health where it begins. And where health begins is not in the four walls of a doctor's office, but where we live and where we work, where we eat, sleep, learn and play, where we spend the majority of our lives.
做医生的十年以来, 我治疗过流浪的老兵, 也治疗过工薪阶层的家庭。 我治疗过那些生活或工作在 艰苦条件中的人们, 这些工作经历让我坚信, 我们需要一种新的视角 来看待医疗。 我们真正需要的医疗卫生系统, 是一个不只把患者接到诊所里, 诊断他们的症状, 而是能够从源头上, 关注和改善人们的健康。 健康问题不是 从医生的办公室里开始的, 而是源自我们生活和 工作的地方, 源自于跟我们的衣食住行 息息相关的地方, 那些我们花费大半生所生活的地方。
So what does this different approach to healthcare look like, an approach that can improve health where it begins? To illustrate this, I'll tell you about Veronica. Veronica was the 17th patient out of my 26-patient day at that clinic in South Central Los Angeles. She came into our clinic with a chronic headache. This headache had been going on for a number of years, and this particular episode was very, very troubling. In fact, three weeks before she came to visit us for the first time, she went to an emergency room in Los Angeles. The emergency room doctors said, "We've run some tests, Veronica. The results are normal, so here's some pain medication, and follow up with a primary care doctor, but if the pain persists or if it worsens, then come on back."
那么,这个全新的医疗卫生系统 是怎样的呢? 什么样的方式可以从源头上 改善我们的健康? 为了阐明这个问题,让我来和你们 说说Veronica的故事。 Veronica是我某天在 洛杉矶南中心诊所接待的 26位患者中的第17位。 她来我们诊所是因为患有慢性头痛。 这头痛已持续好几年了, 她这个特殊的病例 非常棘手。 事实上,在她第一次来 拜访我们的三周前, 她去过了洛杉矶的一处急诊室。 急诊室的医生说, “我们对你做了些测试,Veronica. 结果很正常, 你可以先吃些头疼药, 服用后跟基础护理医师进行反馈, 但如果疼痛持续或变严重, 那就再回来找我们。”
Veronica followed those standard instructions and she went back. She went back not just once, but twice more. In the three weeks before Veronica met us, she went to the emergency room three times. She went back and forth, in and out of hospitals and clinics, just like she had done in years past, trying to seek relief but still coming up short. Veronica came to our clinic, and despite all these encounters with healthcare professionals, Veronica was still sick.
Veronica遵循了这些常规的医疗指示, 之后她又回急诊室来了。 她回来不止一次,而是两次。 在Veronica与我们见面前的三周里, 她已经去过三次急诊室。 她来来回回地跑, 反复进出医院和诊所, 就像她在过去几年间所做的一样, 她试着寻找解决头疼的方法, 但仍以失败告终。 最后,Veronica来到我们的诊所, 尽管之前尝试了各种专业医疗手段, 她的病却扔没有好转。
When she came to our clinic, though, we tried a different approach. Our approach started with our medical assistant, someone who had a GED-level training but knew the community. Our medical assistant asked some routine questions. She asked, "What's your chief complaint?" "Headache." "Let's get your vital signs" — measure your blood pressure and your heart rate, but let's also ask something equally as vital to Veronica and a lot of patients like her in South Los Angeles. "Veronica, can you tell me about where you live? Specifically, about your housing conditions? Do you have mold? Do you have water leaks? Do you have roaches in your home?" Turns out, Veronica said yes to three of those things: roaches, water leaks, mold. I received that chart in hand, reviewed it, and I turned the handle on the door and I entered the room.
但当她来我们诊所的时候, 我们尝试了一种不同的方法。 我们首先得到了医疗助理的帮助, 她受过GED专业训练 (持有普通教育发展证书), 而且熟悉我们所在的社区。 我们的医疗助理问了一些常规问题。 她问:“你的主要症状是什么?” ——“头疼。” “让我们来测一些重要指标”—— 也就是量一量血压,测一测心律, 但也让我们问些同样重要的问题吧, 许多像Veronica一样, 居住在洛杉矶南部的病人 都会面临的问题。 “Veronica,你能告诉我们你住在哪吗? 特别说明下你的居住条件,好吗? 家里有发霉吗,有漏水吗? 有蟑螂吗?” 结果,Veronica对其中三个问题的回答 是肯定的: 有蟑螂,房屋漏水,已经发霉。 我拿到了那份记录, 从头至尾又看了一遍, 我推开了门, 然后进了房间。
You should understand that Veronica, like a lot of patients that I have the privilege of caring for, is a dignified person, a formidable presence, a personality that's larger than life, but here she was doubled over in pain sitting on my exam table. Her head, clearly throbbing, was resting in her hands. She lifted her head up, and I saw her face, said hello, and then I immediately noticed something across the bridge of her nose, a crease in her skin. In medicine, we call that crease the allergic salute. It's usually seen among children who have chronic allergies. It comes from chronically rubbing one's nose up and down, trying to get rid of those allergy symptoms, and yet, here was Veronica, a grown woman, with the same telltale sign of allergies. A few minutes later, in asking Veronica some questions, and examining her and listening to her, I said, "Veronica, I think I know what you have. I think you have chronic allergies, and I think you have migraine headaches and some sinus congestion, and I think all of those are related to where you live." She looked a little bit relieved, because for the first time, she had a diagnosis, but I said, "Veronica, now let's talk about your treatment. We're going to order some medications for your symptoms, but I also want to refer you to a specialist, if that's okay."
你们要知道,Veronica, 像我有幸接诊过的大多数病人一样, 是一位端庄的女性,一个强大的存在, 她的人格比生命更宏大。 但此时此刻她在我的 体检台上, 却经历着超出常人的痛苦。 她抱着头,正忍受着阵阵抽痛。 然后,她抬起了头。 我看到了她的脸,说了声你好, 接着我马上意识到 她的鼻梁有些不对劲, 那里的皮肤有褶皱。 在医学上,我们称之为“变应性鼻炎”。 它通常见于有慢性过敏的孩子身上。 孩子为了摆脱过敏症状, 长期地上下摩擦鼻子从而致病。 但现在,这发生在Veronica—— 一位成年女性身上, 她的身上出现了同样的过敏现象。 在之后的几分钟里, 我问了Veronica一些问题, 为她做体检,听她讲述病情, 我说:“Veronica, 我想我知道是怎么回事了。 我觉得是慢性过敏, 我猜你还伴有偏头痛和鼻窦充血, 而这些,在我看来 都和你住的地方有关。” 她看上去稍稍宽慰了些, 因为这是她第一次得到了确诊, 但我说:“好,Veronica, 现在让我们来谈谈你的治疗方案。 我们将会为你的症状开些药, 但如果可以的话, 我想为你介绍一位专家。”
Now, specialists are a little hard to find in South Central Los Angeles, so she gave me this look, like, "Really?" And I said, "Veronica, actually, the specialist I'm talking about is someone I call a community health worker, someone who, if it's okay with you, can come to your home and try to understand what's going on with those water leaks and that mold, trying to help you manage those conditions in your housing that I think are causing your symptoms, and if required, that specialist might refer you to another specialist that we call a public interest lawyer, because it might be that your landlord isn't making the fixes he's required to make."
时至今日,在洛杉矶中南部 已经很难找到专家了, 于是,她看着我, 就像在说:“真的吗?” 而我回答道:“事实上,Veronica, 我说的专家 是一位社区卫生工作者, 如果方便的话, 他可以到你家里来, 试着找出房子漏水、发霉的原因, 试着帮你解决这些房屋问题, 我觉得正是这些导致了你的症状, 如果你觉得有必要,那位专家也许 会为你引荐另一位专家, 我们称之为公益律师, 因为,也许你的健康问题要归咎于 你的房东不愿意掏钱修缮房屋。”
Veronica came back in a few months later. She agreed to all of those treatment plans. She told us that her symptoms had improved by 90 percent. She was spending more time at work and with her family and less time shuttling back and forth between the emergency rooms of Los Angeles. Veronica had improved remarkably. Her sons, one of whom had asthma, were no longer as sick as they used to be. She had gotten better, and not coincidentally, Veronica's home was better too.
Veronica在几个月后回来了。 她对整个治疗计划感到满意。 她告诉我们, 她的症状已经改善了90%。 她可以花更多的时间 在工作和家庭上了, 也省下了在洛杉矶的 急诊室来回奔波的时间。 Veronica的生活得到了显著改善。 她还有一个患哮喘的儿子, 他们病情都得到了缓解。 她的病好多了,同时,理所当然的, 她的居住环境也变好了。
What was it about this different approach we tried that led to better care, fewer visits to the E.R., better health? Well, quite simply, it started with that question: "Veronica, where do you live?" But more importantly, it was that we put in place a system that allowed us to routinely ask questions to Veronica and hundreds more like her about the conditions that mattered in her community, about where health, and unfortunately sometimes illness, do begin in places like South L.A. In that community, substandard housing and food insecurity are the major conditions that we as a clinic had to be aware of, but in other communities it could be transportation barriers, obesity, access to parks, gun violence.
我们所尝试的这种 改善医疗的方式, 更少去急诊室,却可以更健康, 这说明了什么呢? 其实很简单,这始于最初那个问题: “Veronica,你住在哪儿?” 但更重要的是,我们建立了一个机制, 通过一些例行的提问, 对Veronica,和几百名像她一样 生活在那个社区的人的 居住环境加以关注, 而那里才是南洛杉矶这样的 地区健康问题 甚至是疾病的根源所在。 在这样的社区,劣质的房屋, 食品安全问题可能是我们诊所 应该关注的主要问题。 但在其他社区,问题可能是 交通拥堵、肥胖、 没有公园、枪支暴力。
The important thing is, we put in place a system that worked, and it's an approach that I call an upstream approach. It's a term many of you are familiar with. It comes from a parable that's very common in the public health community. This is a parable of three friends. Imagine that you're one of these three friends who come to a river. It's a beautiful scene, but it's shattered by the cries of a child, and actually several children, in need of rescue in the water. So you do hopefully what everybody would do. You jump right in along with your friends. The first friend says, I'm going to rescue those who are about to drown, those at most risk of falling over the waterfall. The second friends says, I'm going to build a raft. I'm going to make sure that fewer people need to end up at the waterfall's edge. Let's usher more people to safety by building this raft, coordinating those branches together. Over time, they're successful, but not really, as much as they want to be. More people slip through, and they finally look up and they see that their third friend is nowhere to be seen. They finally spot her. She's in the water. She's swimming away from them upstream, rescuing children as she goes, and they shout to her, "Where are you going? There are children here to save." And she says back, "I'm going to find out who or what is throwing these children in the water." In healthcare, we have that first friend — we have the specialist, we have the trauma surgeon, the ICU nurse, the E.R. doctors. We have those people that are vital rescuers, people you want to be there when you're in dire straits. We also know that we have the second friend — we have that raft-builder. That's the primary care clinician, people on the care team who are there to manage your chronic conditions, your diabetes, your hypertension, there to give you your annual checkups, there to make sure your vaccines are up to date, but also there to make sure that you have a raft to sit on and usher yourself to safety. But while that's also vital and very necessary, what we're missing is that third friend. We don't have enough of that upstreamist. The upstreamists are the health care professionals who know that health does begin where we live and work and play, but beyond that awareness, is able to mobilize the resources to create the system in their clinics and in their hospitals that really does start to approach that, to connect people to the resources they need outside the four walls of the clinic.
重要的是,我们建立的机制 奏效了, ——我把它称为“逆流机制“ (upstream approach)。 你们中许多人可能都熟悉。 它来自一个在公共卫生领域里 非常著名的寓言故事。 这是一则有关”三个朋友“的寓言。 假设有3个朋友来到河边, 你是其中之一。 河边景色优美, 但却被一个孩子的哭声打破了, 实际是上好几个孩子 都掉进了河里,亟待营救。 所以你们本能的做了此刻该做的事。 你和朋友们径直跳入河中。 第一个朋友说,我去救那些 快要淹死的孩子、 那些濒临落下瀑布的孩子。 第二个朋友说, 那我去造只筏子。 来确保更少的孩子 会漂到瀑布边缘。 我们用它来把更多的孩子 送到安全地带, 把树枝绑起来(造只筏子)就好。 时间一分一秒过去, 他们成功救起一些人, 但还没达到预期的数量。 激流把更多人冲走了, 当他们终于抬起头时, 却发现第三个朋友 不见了踪影。 他们最终发现了她。 她在水里,她游得越来越远, 逆流而上,沿途救起孩子们, 然后他们朝她喊:“你要去哪? 这儿有这么多孩子等待救援。” 她回答道: “我要去找出 是谁或什么原因, 让这些孩子掉进了水里。” 在医疗卫生中心, 我们有第一个朋友—— 我们有专家, 有创伤外科医师, 有负责重症监护的护士, 还有急诊医生。 我们有这些必要的救援者, 他们是你处于水深火热中时, 最需要的人。 我们也知道,我们有第二个朋友—— 我们有木筏建造者。 基础护理临床医生, 医疗团队中治疗你的 慢性疾病症状的人, 监护你的糖尿病、高血压, 他们每年为你进行体检, 确保你接种了最新的疫苗, 他们同时也确保你有一只木筏, 可以随时送你去安全地带的人。 但与此同时, 很重要也十分必要的是, 被我们忽视了的,那第三个朋友。 我们并没有足够的那种”逆流而上者“。 逆流而上者是健康护理专家, 他们知道健康来自于我们 工作、生活、娱乐的地方。 但他们不仅要能意识到这一点, 还得有能力调集资源, 在他们的诊所里、医院里 建立起一套系统, 这样才能真正地接近源头, 把病人和他们需要的资源联系起来 ——那些资源可能并不在诊所里。
Now you might ask, and it's a very obvious question that a lot of colleagues in medicine ask: "Doctors and nurses thinking about transportation and housing? Shouldn't we just provide pills and procedures and just make sure we focus on the task at hand?" Certainly, rescuing people at the water's edge is important enough work. Who has the time? I would argue, though, that if we were to use science as our guide, that we would find an upstream approach is absolutely necessary. Scientists now know that the living and working conditions that we all are part of have more than twice the impact on our health than does our genetic code, and living and working conditions, the structures of our environments, the ways in which our social fabric is woven together, and the impact those have on our behaviors, all together, those have more than five times the impact on our health than do all the pills and procedures administered by doctors and hospitals combined. All together, living and working conditions account for 60 percent of preventable death.
现在你也许会问, 也是许多从医的同事显然会问的问题: “医生和护士还要考虑 交通和住房的问题? 难道我们不应该只是提供药片和处方 并且确保自己专注于手头的工作吗?” 诚然,拯救处于瀑布边缘的人 是足够重要的工作了。 谁还有时间干别的? 但我会说,即使这样, 如果我们有科学的方法做指导, 就会发现逆流而上寻找根源 是绝对必要的。 科学家现在已经了解, 我们每个人都置身其中的 这个工作和 生活环境, 对我们健康的影响,是我们自身 基因编码的两倍还要多, 而我们的工作生活处境, 环境结构组成, 我们的社会网络联结的方式, 以及它们对我们行为的影响, 这些全部加起来,比医院 和医生开出的 所有处方和药物 对我们健康的影响的五倍还多。 这些所有的,生活和工作条件, 在可预防的死亡中占了60%。
Let me give you an example of what this feels like. Let's say there was a company, a tech startup that came to you and said, "We have a great product. It's going to lower your risk of death from heart disease." Now, you might be likely to invest if that product was a drug or a device, but what if that product was a park? A study in the U.K., a landmark study that reviewed the records of over 40 million residents in the U.K., looked at several variables, controlled for a lot of factors, and found that when trying to adjust the risk of heart disease, one's exposure to green space was a powerful influence. The closer you were to green space, to parks and trees, the lower your chance of heart disease, and that stayed true for rich and for poor. That study illustrates what my friends in public health often say these days: that one's zip code matters more than your genetic code. We're also learning that zip code is actually shaping our genetic code. The science of epigenetics looks at those molecular mechanisms, those intricate ways in which our DNA is literally shaped, genes turned on and off based on the exposures to the environment, to where we live and to where we work. So it's clear that these factors, these upstream issues, do matter. They matter to our health, and therefore our healthcare professionals should do something about it. And yet, Veronica asked me perhaps the most compelling question I've been asked in a long time. In that follow-up visit, she said, "Why did none of my doctors ask about my home before? In those visits to the emergency room, I had two CAT scans, I had a needle placed in the lower part of my back to collect spinal fluid, I had nearly a dozen blood tests. I went back and forth, I saw all sorts of people in healthcare, and no one asked about my home."
我给你们举个例子吧。 我们假设有一个公司,科技创业公司, 对你说:“我们有了个伟大的产品, 可以降低你因心脏病死亡的风险。” 那么,你可能会愿意为他们公司投资, 开发这么一种新药物或者医疗设备。 但如果他们的产品是一座公园呢? 在英国有一项研究, ——一项里程碑式的研究, 调查了4000万英国居民, 通过控制诸多因素, 关注了若干变量,最后得出结论: 当我们试图控制、调节心脏病的风险时, 患者在绿色空间中生活 对其有极大的影响。 你越靠近绿色空间 ——像公园和树木, 你犯心脏病的概率就越小。 而这一点,对穷人和富人都一样适用。 这一研究,证实了我在 公共健康领域的朋友 近来常说的话: 一个人的邮政编码, 比他的基因编码更重要。 我们也知道,邮政编码(地理位置) 实际上也在塑造我们的基因编码。 表观遗传学家观察了分子机制, ——我们的DNA逐一组合起来的 复杂的方式, 基因的激活和休眠, 是基于所暴露的环境, 基于我们生活和工作的地方。 所以显而易见的是,这些因素 这些逆流而上的问题,确实重要。 它们关乎我们的健康, 因此我们的医疗卫生人员 应该在这方面有所作为。 然而,Veronica也问了我一个 也许是最值得注意的问题, 这问题被问过很多次了。 在那次随访中,她说: “为什么之前那些医生 从未问过我的住房情况? 我去急诊室的时候, 做过2次CAT扫描, 他们还在我背部下方插了根针 收集脊髓液, 还做了一大堆血液测试。 我来来回回地跑, 找过医疗卫生中心所有类别的医师, 却没有任何人询问过我的住宅情况。“
The honest answer is that in healthcare, we often treat symptoms without addressing the conditions that make you sick in the first place. And there are many reasons for that, but the big three are first, we don't pay for that. In healthcare, we often pay for volume and not value. We pay doctors and hospitals usually for the number of services they provide, but not necessarily on how healthy they make you. That leads to a second phenomenon that I call the "don't ask, don't tell" approach to upstream issues in healthcare. We don't ask about where you live and where you work, because if there's a problem there, we don't know what to tell you. It's not that doctors don't know these are important issues. In a recent survey done in the U.S. among physicians, over 1,000 physicians, 80 percent of them actually said that they know that their patients' upstream problems are as important as their health issues, as their medical problems, and yet despite that widespread awareness of the importance of upstream issues, only one in five doctors said they had any sense of confidence to address those issues, to improve health where it begins. There's this gap between knowing that patients' lives, the context of where they live and work, matters, and the ability to do something about it in the systems in which we work.
坦率地说,这是因为在医疗卫生中心, 在治疗病症时,我们通常不将 导致你生病的环境因素放在首位考虑。 有很多因素导致了这一现象, 说三个主要的, 排在第一的是,这么做不赚钱。 在医疗卫生中心,我们通常 根据”数量“而非”质量“来支付报酬。 我们根据医院和医生 提供服务的次数来付钱, 而不是取决于他们使你变得多健康。 这导致了第二个现象,我叫它 在医疗卫生系统里,关于逆流问题的 ”别问,别说“倾向。 我们不问你住在哪儿,在哪儿工作, 因为如果那儿有问题, 我们都不知道该如何解释。 医生不是不知道这些问题有多重要。 在最近一次对美国医生进行的调查中, 超过1000位受访医生中 80%的人确实表示, 他们知道患者的”上游问题“ 和他们的健康问题一样重要, 和医疗问题一样重要。 然而,尽管对上游问题的 重要性有着普遍共识, 只有五分之一的医生说 他们有自信能解决这些问题, 从源头上改善患者健康。 在了解患者的生活, 他们居住、工作的环境, 遇到的问题, 以及我们现有的医疗系统 做提供的帮助, 这二者之间的供求严重不匹配。
This is a huge problem right now, because it leads them to this next question, which is, whose responsibility is it? And that brings me to that third point, that third answer to Veronica's compelling question. Part of the reason that we have this conundrum is because there are not nearly enough upstreamists in the healthcare system. There are not nearly enough of that third friend, that person who is going to find out who or what is throwing those kids in the water. Now, there are many upstreamists, and I've had the privilege of meeting many of them, in Los Angeles and in other parts of the country and around the world, and it's important to note that upstreamists sometimes are doctors, but they need not be. They can be nurses, other clinicians, care managers, social workers. It's not so important what specific degree upstreamists have at the end of their name. What's more important is that they all seem to share the same ability to implement a process that transforms their assistance, transforms the way they practice medicine. That process is a quite simple process. It's one, two and three. First, they sit down and they say, let's identify the clinical problem among a certain set of patients. Let's say, for instance, let's try to help children who are bouncing in and out of the hospital with asthma. After identifying the problem, they then move on to that second step, and they say, let's identify the root cause. Now, a root cause analysis, in healthcare, usually says, well, let's look at your genes, let's look at how you're behaving. Maybe you're not eating healthy enough. Eat healthier. It's a pretty simplistic approach to root cause analyses. It turns out, it doesn't really work when we just limit ourselves that worldview. The root cause analysis that an upstreamist brings to the table is to say, let's look at the living and the working conditions in your life. Perhaps, for children with asthma, it's what's happening in their home, or perhaps they live close to a freeway with major air pollution that triggers their asthma. And perhaps that's what we should mobilize our resources to address, because that third element, that third part of the process, is that next critical part of what upstreamists do. They mobilize the resources to create a solution, both within the clinical system, and then by bringing in people from public health, from other sectors, lawyers, whoever is willing to play ball, let's bring in to create a solution that makes sense, to take those patients who actually have clinical problems and address their root causes together by linking them to the resources you need. It's clear to me that there are so many stories of upstreamists who are doing remarkable things. The problem is that there's just not nearly enough of them out there. By some estimates, we need one upstreamist for every 20 to 30 clinicians in the healthcare system. In the U.S., for instance, that would mean that we need 25,000 upstreamists by the year 2020. But we only have a few thousand upstreamists out there right now, by all accounts, and that's why, a few years ago, my colleagues and I said, you know what, we need to train and make more upstreamists.
现在,这已经成为一个大问题了, 因为这将人们引向了 下一个问题,那就是: ”谁应该对此负责?“ 而这就将我带到了第三点, Veronica那个引人注目的问题的 第三个答案。 导致我们困境的一部分原因, 是因为在医疗系统中没有足够的 逆流而上者。 我们没有足够多的那种”第三位朋友“, 那位要去找出 是谁或什么原因, 让这些孩子掉进了水里的人。 现在,出现了许多逆流而上者, 我有幸可以在洛杉矶 或国内其他地区, 以及世界各地见到他们, 值得指出的是,逆流而上者, 可能是医生,但并不一定是。 他们也可以是护士、 别的卫生工作者、 护理管理者、社会工作者。 逆流而上者不需要 有什么特定的头衔。 更重要的是他们都具备 相同的能力,可以去推动 医疗系统改革的过程, 改变他们医学实践的方式。 这一过程十分简单, 它就是:一,二,三。 第一步,他们坐下来,说 “让我们从一群特定患者中找出 共同存在的临床问题。” 比如说, “让我们试着去帮助那些 反复进出医院的 哮喘儿童。 一旦抓住了问题的实质, 他们就进入“第二步”, 然后他们说, “让我们找到问题的根源。” 好,问题根源分析,在医疗卫生领域, 他们经常会说, “好吧,让我们看看你的基因, 再让我们看看你的生活方式如何。 也许你吃得不够健康。 赶紧改善饮食吧!” 这是一种过于简化的 分析根源的方法。 事实上,如果我们只把自己的视野 限制于此, 这种治疗就起不到什么作用。 逆流而上者做的 问题根源分析是这样的: “让我们看看你生活和 工作的环境怎么样。” 也许,对患有哮喘的孩子们来说, 可能是他们家里有什么问题, 或他们住的离高速公路比较近, 那里空气污染严重, 会引发他们的哮喘。 也许这正是我们应该 调集资源去解决的, 因为那第三个元素, 这个过程中的“第三步”, 也就是逆流而上者将要采取的 关键步骤。 他们调集资源来设计一个解决方案, 不仅仅是在临床医学系统, 还要从公共卫生系统, 从其他领域,找律师等等, 任何一个愿意出一份力的人, 把他们都集中到一起, 设计一个有效的解决方案, 去找出病人的问题根源, 将他们与需要的资源连接起来, 从而合力解决医疗中的根源问题。 对我来说,很显然, 逆流而上者做出的 引人注目的成就数不胜数。 问题是, 这样的逆流而上者还是不够多。 经过估算,我们认为医疗卫生系统中 每20到30位患者就需要一位逆流而上者。 例如,在美国,这意味着 到2020年时我们将需要25000个 逆流而上者。 但我们现在只有几千个逆流而上者, 数来数去只有这么多, 这就是为何, 几年前我和我的同事会说: 你们知道吗,我们需要训练和培养 更多的逆流而上者。
So we decided to start an organization called Health Begins, and Health Begins simply does that: We train upstreamists. And there are a lot of measures that we use for our success, but the main thing that we're interested in is making sure that we're changing the sense of confidence, that "don't ask, don't tell" metric among clinicians. We're trying to make sure that clinicians, and therefore their systems that they work in have the ability, the confidence to address the problems in the living and working conditions in our lives. We're seeing nearly a tripling of that confidence in our work.
所以我们决定发起一个叫 ”健康起航”(Health Begins)的组织, 任务很简单: 我们训练逆流而上者。 我们有很多种衡量自己成就的方式, 但我们最关注的是 确保我们在改变 医疗领域的信心, 也就是改变临床医师中的 “别问,别说”现象。 我们正在试着让医师 及他们所在的医疗卫生系统, 有能力和自信, 去找出那些来自我们的 生活、工作环境里的问题。 我们正在我们的工作中, 见证着三倍于那样的自信。
It's remarkable, but I'll tell you the most compelling part of what it means to be working with upstreamists to gather them together. What is most compelling is that every day, every week, I hear stories just like Veronica's. There are stories out there of Veronica and many more like her, people who are coming to the healthcare system and getting a glimpse of what it feels like to be part of something that works, a health care system that stops bouncing you back and forth but actually improves your health, listens to you who you are, addresses the context of your life, whether you're rich or poor or middle class.
这是个非凡的成就, 但我要说,与逆流而上者共事, 将他们的力量聚集起来 所蕴含的意义是最鼓舞人心的部分。 最令人兴奋的是,每天、每周, 我都会听到像Veronica一样的故事。 有很多和Veronica相似的故事, 甚至越来越多, 那些前来医疗卫生中心的人们 正实际地体验着 我们的工作成果, 这个医疗卫生系统 不再来来回回地折腾你, 而是能够实际改善你的健康, 倾听你的故事, 了解你的生活经历, 无论你是富人,还是穷人,或者中产阶级。
These stories are compelling because not only do they tell us that we're this close to getting the healthcare system that we want, but that there's something that we can all do to get there. Doctors and nurses can get better at asking about the context of patients' lives, not simply because it's better bedside manner, but frankly, because it's a better standard of care. Healthcare systems and payers can start to bring in public health agencies and departments and say, let's look at our data together. Let's see if we can discover some patterns in our data about our patients' lives and see if we can identify an upstream cause, and then, as importantly, can we align the resources to be able to address them? Medical schools, nursing schools, all sorts of health professional education programs can help by training the next generation of upstreamists. We can also make sure that these schools certify a backbone of the upstream approach, and that's the community health worker. We need many more of them in the healthcare system if we're truly going to have it be effective, to move from a sickcare system to a healthcare system. But finally, and perhaps most importantly, what do we do? What do we do as patients? We can start by simply going to our doctors and our nurses, to our clinics, and asking, "Is there something in where I live and where I work that I should be aware of?" Are there barriers to health that I'm just not aware of, and more importantly, if there are barriers that I'm surfacing, if I'm coming to you and I'm saying I think have a problem with my apartment or at my workplace or I don't have access to transportation, or there's a park that's way too far, so sorry doctor, I can't take your advice to go and jog, if those problems exist, then doctor, are you willing to listen? And what can we do together to improve my health where it begins?
这些故事令人印象深刻,是因为 它们不仅让我们知道了我们的工作 已经如此接近理想的医疗系统, 还让我们知道了要如何实现这个目标。 医护人员通过询问患者的生活情况, 可以更好地为他们服务, 不仅仅因为更好的问诊态度, 坦率地说, 还因为这代表着更高水准的医疗方式。 医疗卫生系统和纳税人可以共同 建立相关的公共卫生机构和部门, 然后说: 让我们共享数据。 看看能否从患者的生活数据上 找出一些端倪, 从而诊断出上游的诱因, 然后,同样重要的,能否调整社会资源 来解决这些问题? 医学院校,护理学校, 所有医疗卫生专业教育项目 都能够通过训练新一代的 逆流而上者来帮助我们。 我们也很确定,这些学校 将成为“逆流机制”的中坚力量, 那将是一个先进卫生工作者的群体。 我们的医疗卫生系统里 需要很多这样的人, ——如果我们确实想让它变得更高效, 让它从一个“只关心病痛”的系统, 转变成一个“关注健康”的系统。 但最终,也许是最重要的是: 我们能做些什么? 作为患者该应该怎么做? 很简单,当我们到诊所时, 面对我们的医生、护士, 我们可以问:“我居住和工作的地方 有没有什么值得注意的?” 是否存在一些被我忽视的 影响我健康的细节? 而更重要的是, 如果真的存在一些问题, 我已经察觉到了,然后找到医生说: 我觉得我的公寓或者办公环境 可能有些问题, 或者我家附近交通不便, 或是,那个公园离我家太远, 抱歉,医生, 我无法听从你的建议, 每天去公园慢跑。 如果这些问题真的存在, 那么,医生,你愿意去倾听吗? 我们能彼此配合 从根源上改善我的健康吗?
If we're all able to do this work, doctors and healthcare systems, payers, and all of us together, we'll realize something about health. Health is not just a personal responsibility or phenomenon. Health is a common good. It comes from our personal investment in knowing that our lives matter, the context of where we live and where we work, eat, and sleep, matter, and that what we do for ourselves, we also should do for those whose living and working conditions again, can be hard, if not harsh. We can all invest in making sure that we improve the allocation of resources upstream, but at the same time work together and show that we can move healthcare upstream. We can improve health where it begins.
如果我们都能做到这些, 从医生,到医疗系统, 到纳税人,我们所有人一起, 就能实现一种不同以往的健康状况。 健康不仅是患者个人的责任或现象。 健康是共同利益。 它来自我们的个人生活投资, 要认识到:生活是不能将就的, 我们居住与工作的环境、 饮食、睡眠…它们都很重要, 而这些我们为自己做的事, 同样也应该为那些 生活和工作环境 相对比较艰苦的人去做。 当然,我们都可以寄希望于 能提升”上游“资源的分配。 但同时,我们可以协同合作, 来证明,我们能让医疗卫生系统 ”逆流而上“地 解决问题。 我们可以从根源上改善健康。
Thank you.
谢谢。
(Applause)
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