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.
當了十幾年的醫師, 我照護過無家可歸的退伍軍人, 也照護過勞動階級的家庭。 我照護的人都住在或工作在 即使不惡劣也很糟的環境下。 這樣的工作讓我相信 我們需要以完全不同的方式 來看醫療的問題。 我們需要的醫療系統 不能只是單診療 病人來診所時的症狀, 而是要實際 從源頭查看及改善健康狀況。 健康不是從 診療室的四面牆開始, 而是從我們居住及工作、 吃、喝、睡覺、 學習及享樂的地方開始, 從我們花大把時間的地方開始。
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."
所以這個不同的醫療方法 是什麼樣子? 這個能從源頭改善健康的方法? 為了解釋清楚, 我跟大家說說小維的故事。 小維是我第 17 號病人, 我每天要看 26 名病人, 診所位於洛杉磯南區。 她來我的診所看慢性頭痛。 這個頭痛已經持續好多年, 而這段經歷讓她非常非常困擾。 其實在她來看我們的三個星期前, 她才去過洛杉磯的某急診室。 這個急診室的醫師說, 「小維,我們做了幾項檢查, 結果都很正常, 所以我現在給你開一些止痛藥, 妳要回去看妳的家庭醫師, 但是如果還繼續痛,或是更痛, 妳再回來找我們。」
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.
小維謹遵這些制式的醫囑, 最後還是回去急診室了。 她回去不只一次,她去了三次。 在小維來找我們前的那三個星期, 她回去急診室三次。 她來來回回, 進進出出各個醫院及診所, 就像之前一年一樣, 想要找解方卻徒勞無功。 小維來我們的診所, 無論她看了多少醫療專家, 小維還是病著。
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.
她到我們的診所時, 我們試了一種不同的療法。 我們的療法從我們的醫務助理開始, 這位助理有同等學歷的訓練, 也很瞭解這個社區。 我們的醫務助理問了幾個例行問題。 她問,「妳主訴的症狀是什麼?」 「頭痛。」 「那我們量一下生命徵象」, 量一下妳的血壓心跳。 但我們還要多問幾個問題, 對小維及許多類似的 洛杉磯南區病人, 就跟生命徵象一樣重要的問題。 「小維,可不可以告訴我 妳住的地方的情況? 特別是妳住處的狀況? 有發霉嗎?有漏水嗎? 家裡有蟑螂嗎?」 結果是,小維家三「有」: 蟑螂、漏水、發霉。 我拿到那張病歷,看了一下, 然後我轉轉門把 進入診間。
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."
你得了解,小維 就像我有幸照護的 大部分病人一樣, 是個有尊嚴、不可輕忽, 有著鮮明個性的人, 但在這裡,她坐在 我的診療檯上痛苦地蜷縮著。 她的頭很明顯搏痛著, 擱在她的手上。 她抬起頭, 我看著她的臉,說了妳好, 然後我立刻注意到 在她的鼻樑上, 皮膚有一道皺摺。 在醫學上,我們稱這道皺摺為 「過敏性敬禮徵」。 這通常發生在 有慢性過敏的兒童上。 起因是長期上下磨擦鼻子, 想要擺脫那些過敏症狀。 但是,在這的小維, 已經是成年婦女, 卻還是有過敏的示警徵兆。 幾分鐘後,我一邊問小維問題, 一邊檢查及聽她說, 我說:「小維, 我想我知道妳得了什麼。 我認為妳是慢性過敏, 而且我認為妳還有偏頭痛及鼻塞, 我想這些都跟妳住的地方有關。」 她看起來有點鬆了口氣, 因為這是她第一次得到真的診斷, 但我說:「小維, 現在我們來談一下治療方法。 我們會針對妳的症狀開幾款藥, 但我也想把妳轉診給一位專科, 如果妳同意。」
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."
不過,專科 在洛杉磯南區有點難找, 所以她看了我一眼,好像在說, 「真的?」 我說,「小維,其實我說的這位專科 是我所謂的社區保健員, 如果妳同意,這個人 會到妳家試著了解情況, 看看為什麼漏水及發霉, 試著幫妳解決房子的狀況, 我認為是這些造成妳的症狀, 如果有必要,這位專科還會幫妳轉診 去另一位專科,我們叫他公益律師, 因為妳的房東很可能 沒有按照法律規定替妳修房子。」
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.
小維幾個月後跑回來。 她同意所有上述的治療計畫。 她告訴我們她的症狀 改善了 90%, 她可以花更多時間在工作 及跟家人相處上,不用常常 在洛杉磯的急診室來回奔波。 小維有很明顯的進步。 她的幾個兒子,其中一個有氣喘, 不再像以前一樣病著。 她好多了,而且一點也不意外, 小維的房屋狀況也改善了。
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.
我們採用的這種迥異的方法 為什麼能提供更好的照護? 讓病人少跑急診室,更健康? 很簡單,就從那個問題開始: 「小維,妳住在哪?」 但更重要的是,我們推出 一種系統,讓我們能問小維 及數百計像小維那樣的人 幾個簡單問題, 對她的社區很重要的環境問題, 健康的源頭問題, 因為不幸的是,有時候疾病的確 從像南洛杉磯一樣的地方開始。 在那個社區,不合格的房屋 及食物供給不穩定是最主要的問題, 是我們身為診所必須注意到的事, 但在其他的社區問題可能是 交通運輸的天然障礙、肥胖、 家附近有沒有公園、槍枝暴力。
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,我們推出的這種系統 有成效, 而這種方法我稱為上游管理。 在座很多人都很熟悉的名詞。 這來自一個很常聽到的 公共衛生界寓言。 這是三個朋友的寓言。 想像一下你是這三個朋友之一, 你們走到一條河。 風景很美, 但有個小孩的哭聲劃破了寧靜, 而且其實有好幾個孩子 在水裡需要救援。 所以你會去做 但願每個人都會做的事。 你與你的朋友趕快跳進去。 第一個朋友說, 我要去救那些快沉下去的, 那些快要掉到瀑布下面的幾個。 第二個朋友說,我來造個木筏。 我要確保 流到瀑布邊的人能少幾個。 透過造木筏, 讓我們多領幾個人到安全區, 把幾根樹枝綁在一起。 一段時間後,他們成功了, 但也不盡然, 因為成效不如預期。 更多人成為漏網之魚, 所以他們終於往上游看, 發現他們第三個朋友 不在視線範圍內。 最後他們終於看到她。 她在水裡。她愈游愈遠, 朝上游去,邊游邊救兒童, 他們對著她喊:「妳要去哪裡? 這裡還有兒童要救。」 她回答說: 「我要去找 是誰或是什麼東西 丟這些兒童進水裡。」 在醫療界,我們有第一個朋友: 我們有專科醫師, 我們有外傷外科醫師、 加護病房護士、 急診室醫師。 我們有搶救生命的人, 你在急難中最需要的人。 我們也知道我們有第二個朋友: 我們有造筏的人。 那就是第一線的臨床醫師。 那些人在醫療團隊裡 照護你的慢性疾病、 你的糖尿病、你的高血壓、 幫你做年度健檢、 盯著你按時打疫苗。 同時也確保你有木筏可乘, 把你帶到安全的地方。 雖然這些都很重要也很必要, 但我們最缺的卻是第三個朋友。 我們沒有足夠向上游的人。 向上游的人是醫療照護專家, 但瞭解健康起始於 我們居住工作及玩樂的地方, 但除了那樣的體認, 還能動員各種資源以創建系統, 使他們的診所及醫院 能真正開始著手處理這個問題, 能將眾人與他們 在診所的四面牆外 所需的資源連結在一起。
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.
現在你可能會問個很明顯的問題, 有很多醫界同僚都這麼問: 「醫師與護士還要去考慮 交通及住房的問題? 我們不是只要提供藥丸及醫療處置, 並確定我們會專心 做手上的工作就好?」 的確,將人從水邊救起 已經是夠重要的工作。 誰有那麼多時間? 我卻認為,假如我們以科學為指引, 就知道找到上游管理方法 是絕對必要的。 科學家現在知道 生活及工作條件, 我們都是其中的部分, 對我們健康的影響 比遺傳還超過兩倍之多, 而且生活及工作條件, 我們環境的結構, 我們的社交圈交織在一起的方式, 及其對我們行為的影響, 通通加在一起, 對我們的健康影響 比醫師及醫院開出的 藥丸及醫療處置總合 超過五倍之多。 生活及工作條件加在一起, 佔了可預防性死亡的 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."
讓我舉個例子來看看這是什麼感覺。 就說有家公司,一家科技新創公司 來你這裡說:「我們有個很棒的產品。 會降低你死於心臟病的風險。」 那麼,你很可能會願意投資, 如果那個產品是種藥或儀器的話, 但是如果那個產品是座公園? 在英國有項研究, 一項具里程碑意義的研究,檢閱了 英國超過四千萬居民的紀錄, 他們看了幾項變數, 即幾項管制因子,發現 當試著校正心臟病的風險, 一個人能否接觸綠地 有很大的影響。 你越接近綠地、 公園及樹木, 你得心臟病的機會就愈低, 無論貧富皆準。 那項研究闡明了我在公衛界的朋友 這些日子常常說的: 就是一個人的郵遞區號 比你的遺傳密碼還重要。 我們也了解到郵遞區號 其實會改變我們的遺傳密碼。 表觀遺傳學就是要看這些分子機制, 那些真的會改變 我們 DNA 的複雜機制, 基因開、關, 基於其所暴露的環境, 及我們在哪裡生活在哪裡工作。 所以很清楚這些因素, 這些上游的問題,的確至關重要。 它們對我們的健康至關重要, 因此我們的醫療專家 應該為此出力。 但是,小維問了我 一個可說是長久以來 我一直難以回答的問題, 在回診那天,她問: 「為什麼我的醫師 以前都不問我住家的狀況? 去急診室的那幾次, 我做了兩次斷層掃瞄, 有針穿刺進我的下背部 抽取脊髓液, 我大概抽了將近一打的血。 我進進出出, 我看過各種醫療照護人員, 從來沒有人問過我的家。」
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.
最誠實的答案是在醫療界, 我們常常只是頭痛醫頭、腳痛醫腳, 有很多因素造成這樣,但三大點 是第一,我們拿不到錢。 在醫療界,我們計量不計質。 我們通常付醫師及醫院的錢 是以診療過多少人來算, 不見得是看他們有沒有醫好你。 這就導致第二個現象我叫它 「你不說我不問」, 普遍存在醫療界的上游問題。 我們不問你住哪、在哪工作, 因為如果那裡有問題, 我們也不知道要給你什麼建議。 醫師不是不了解 這些是很重要的問題。 最近有項針對美國醫師的調查, 問了超過一千名醫師, 其中有 80% 真的說 他們知道他們病人的上游問題 與他們的健康問題一樣重要, 也與醫療問題一樣重要。 但儘管對上游問題的重要性 有如此廣泛的意識, 只有五分之一的醫師說他們有 相當程度的信心應付這個問題, 找出改善健康的源頭。 瞭解病人的生活, 即他們生活及工作的背景 很重要是一回事, 但有能力在我們工作的系統中 為之出力又是另一回事。
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.
這是現在很大的問題, 因為這導引出下一個問題,就是 這是誰的責任? 這也帶出我的第三點, 小維難題的第三個答案。 造成我們這個難題的部分原因 在於在醫療系統內, 根本就沒有足夠的上游管理人。 根本就沒有足夠的第三個朋友, 就是那個要去找出 誰或什麼東西把孩子進水裡的人。 現在,的確有很多上游管理人, 我有幸遇過許多位, 在洛杉磯及這個國家的其它地方 及全世界都遇到過, 值得注意的是很多上游管理人 有時候的確是醫師, 但不一定得是醫師。 他們也可以是護士、其他臨床師、 照護策劃管理人、社工。 上游管理人在名字後面 掛什麼學位頭銜並不重要。 重要的是他們幾乎 都有能力落實執行某種步驟 以改造他們援助的手法, 改造他們行醫的方法。 那種步驟是還滿簡單的步驟。 就是一二三。 第一,他們坐下來說, 我們來鑑別一下到底 為什麼某些病人會有這種臨床問題。 舉個例, 讓我們試試幫助 因為氣喘而在醫院 進進出出的兒童。 診斷出問題後, 他們就進到下一步, 他們說,讓我們來找根源。 現在,根本原因分析, 在醫療界通常這麼說, 讓我們看一下你的基因, 看一下你的行為。 可能你吃得不夠健康。 那就吃健康點。 這是過度簡單化的 根本原因分析方法。 結果是,這個方法根本沒有用 因為我們限制了自己的視界。 上游管理人提出的根本原因分析 會這麼說,讓我們看一下 你的生活及工作條件。 也許,對有氣喘的孩童, 家裡的狀況是原因, 或是因為他們住在 空氣很糟的高速公路旁, 引發了他們的氣喘。 這大概是我們應該動員 所有資源來對付的事, 因為第三個因素, 步驟的第三部分, 是上游管理人會做的 下一步關鍵部分。 他們會動員所有的資源 以找出解決的方法, 無論在臨床系統內, 或是之後在公衛界找人、 其他部門、律師 任何願意參與的人皆可, 讓我們把這些人引進, 找出合理的解決方法, 把這些有實際臨床問題的病人 幫助他們治本, 把他們與你所需的資源連在一起。 對我而言這很清楚,有很多故事在說 上游管理人所做卓越非凡的事。 問題是這樣的人不夠多。 粗估我們在醫療系統內 每 20 至 30 位臨床醫師 就需要一位上游管理人。 在美國,舉個例,這意味著 我們在 2020 年前, 需要二萬五千名上游管理人。 但是現在據說我們只有少少的 幾千名上游管理人, 而這就是為什麼在幾年前, 我與幾位同僚說, 你知道嗎,我們需要訓練出 更多上游管理人。
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.
所以我們決定創辦一個組織, 稱為「健康源」, 「健康源」只作這件事: 我們訓練上游管理人。 我們使用許多方法 評量我們是否成功, 但我們最主要的目標 是確定我們要改變信心, 改變在臨床醫師間 「你不問我不說」的制式心態。 我們試著要確定臨床醫師, 及他們工作的系統 因而有能力、有信心 能解決我們生活 及工作條件的問題。 我們看見在我們的努力下 信心增加了二倍。
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.
成效顯著, 但我要告訴你們最有趣的部分 就是與上游管理人合作 把他們集合在一起是什麼意思。 最有趣的是每一天, 每一週我都聽到像小維的故事。 多的是像小維 一般的故事, 人們進入一個醫療系統 窺視能參與 有成效系統的感覺, 一種醫療系統不再把你當足球踢, 卻能實際改善你的健康, 傾聽你的人生, 處理你的生活背景, 無論你是貧富還是中產階級。
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?
這些故事引人注意,因為 它們不但告訴我們,我們有多接近 我們想要的醫療保健系統, 也告訴我們, 我們能合作達成這件事。 醫師及護士能做得更好, 只要他們問問病人的生活背景, 因為這不僅是更好的醫療服務態度, 但坦白說,這也是更好的照護標準。 醫療系統及醫療給付單位 可以開始把公衛局 及衛生署帶進來並說, 讓我們一起來看看數據。 看一看我們能否在數據中 發現病人的生活型態, 看看我們能否找出發病的源頭。 然後,同樣重要的是, 我們能不能運用資源 去解決這個問題? 醫學院、護理學院、 各種專業醫療教育課程 都可以訓練下一代的 上游管理人來達成目標。 我們也要確定這些學校 要認證上游管理的基礎, 即社區保健員。 在醫療系統內我們需要更多這種人, 如果我們真的想要有成效的話, 要從「疾病」照護系統 變成「健康」照護系統。 但最後一點, 或許也是最重要的一點, 我們要怎麼做? 身為病人我們要怎麼做? 我們可以這樣開始:去看醫生、 看護理師、去診所時, 問他們,「在我居住 及工作的地方, 有什麼是我該注意的嗎?」 有什麼讓我不健康的事物 是我從沒注意到的嗎? 更重要的是,如果真有這種障礙 我意識到了,如果我來你這裡, 而且告訴你,我認為在我的公寓 或我的工作場所的確有問題, 或是我無法搭公共交通工具, 或公園離我太遠, 所以真抱歉醫師, 我無法採納你的建議 去慢跑, 如果這些問題的確存在, 那醫師,你願意聽嗎? 我們能一同做什麼 從源頭改善我的健康?
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.
如果我們能一同做這件事, 醫師及醫療系統, 醫療給付單位,及所有的人都一起, 我們就能瞭解健康的真義。 健康不僅是個人的責任或現象。 健康是共有財。 它始於我們個人付出心力瞭解 我們的生活非常重要, 我們生活及工作的地方的背景、 我們吃、睡也非常重要, 我們不但要為自己做, 我們同時也應該要為那些 生活及工作條件, 再說一次, 即使不惡劣也很糟的人做這件事。 我們要付出心力確保我們改善 上游資源的分配, 但同時也要一同合作 證明我們能將醫療系統 帶往上游。 我們能從源頭改善健康。
Thank you.
謝謝。
(Applause)
(掌聲)