I am a palliative care physician and I would like to talk to you today about health care. I'd like to talk to you about the health and care of the most vulnerable population in our country -- those people dealing with the most complex serious health issues. I'd like to talk to you about economics as well. And the intersection of these two should scare the hell out of you -- it scares the hell out of me.
我是一名安宁护理医师, 今天我想和你们聊聊医疗保健。 我和你们谈谈健康和理疗 关于我们国家中最脆弱的人群—— 解决最复杂最严重的健康问题的人们。 我也想和你们聊聊经济学, 而这两者的交集应该会 让你们感到很恐惧, 它已经吓坏我了。
I'd also like to talk to you about palliative medicine: a paradigm of care for this population, grounded in what they value. Patient-centric care based on their values that helps this population live better and longer. It's a care model that tells the truth and engages one-on-one and meets people where they're at.
我也想和你们谈谈安宁护理: 一个基于一类人群价值观念的治疗方法, 基于他们的价值观,以病人为中心, 帮助了这类人群活得更好,更久。 是一个告诉我们事实, 并与病人一对一, 并于他们实地接触的治疗方式。
I'd like to start by telling the story of my very first patient. It was my first day as a physician, with the long white coat ... I stumbled into the hospital and right away there's a gentleman, Harold, 68 years old, came to the emergency department. He had had headaches for about six weeks that got worse and worse and worse and worse. Evaluation revealed he had cancer that had spread to his brain. The attending physician directed me to go share with Harold and his family the diagnosis, the prognosis and options of care.
我将从讲述我第一个病人的故事开始, 那是我成为医生的第一天, 穿着白大褂, 我走进了医院 马上就有一名68岁叫哈罗德的男士, 来到了急诊科。 他已经头疼了大约六周, 而且变得越来越严重。 诊断显示他得了癌症, 已经扩散到大脑。 他的主治医师建议我 告诉哈罗德和他的家人 诊断、预后和护理选项。
Five hours into my new career, I did the only thing I knew how. I walked in, sat down, took Harold's hand, took his wife's hand and just breathed.
在我新事业开始的5小时, 我做了我唯一知道该怎么做的事。 我走进病房, 坐了下来, 握住哈罗德的手, 拿起他妻子的手, 接着就只是呼吸,
He said, "It's not good news is it, sonny?"
他问 “孩子,不是什么好消息对吧?”
I said, "No."
我说 “是的”
And so we talked and we listened and we shared. And after a while I said, "Harold, what is it that has meaning to you? What is it that you hold sacred?"
于是我们与对方沟通、倾听和分享。 过了一会儿,我问道 “哈罗德,对你来说什么是 有意义的事情? 什么事情你觉得是神圣的?”
And he said, "My family."
他说, “我的家人。”
I said, "What do you want to do?"
“你接下来想做什么?”
He slapped me on the knee and said, "I want to go fishing."
他拍拍我的膝盖说: “我想去钓鱼。”
I said, "That, I know how to do."
我说 “这个我知道怎么做。”
Harold went fishing the next day. He died a week later.
第二天哈罗德去钓鱼了。 一周后他去世。
As I've gone through my training in my career, I think back to Harold. And I think that this is a conversation that happens far too infrequently. And it's a conversation that had led us to crisis, to the biggest threat to the American way of life today, which is health care expenditures.
在我在职业生涯中的培训后, 我总回想起哈罗德。 我认为这种对话 发生得过于频繁。 是这种对话导致我们走向了危机, 那就是对美国现代生活最大的威胁, 即医疗保健支出。
So what do we know? We know that this population, the most ill, takes up 15 percent of the gross domestic product -- nearly 2.3 trillion dollars. So the sickest 15 percent take up 15 percent of the GDP. If we extrapolate this out over the next two decades with the growth of baby boomers, at this rate it is 60 percent of the GDP. Sixty percent of the gross domestic product of the United States of America -- it has very little to do with health care at that point. It has to do with a gallon of milk, with college tuition. It has to do with every thing that we value and every thing that we know presently. It has at stake the free-market economy and capitalism of the United States of America.
那么我们知道些什么? 我们清楚这群病入膏肓的人 耗费了15%的国内生产总值—— 大约2.3万亿美元。 病得最重的15%的人 占用了15%的GDP。 如果我们以此来推断二十年后, 随着婴儿潮一代人的变老, 这个比率是60%的GDP。 整个美国 60%的国内生产总值 在那个时候已经和医疗保健关系不大了。 它和一加仑牛奶, 大学学费有关, 它与每一件我们重视的事情, 和每一件我们现在已知的事情有关。 这和美国岌岌可危的 自由市场经济和资本主义有关。
Let's forget all the statistics for a minute, forget the numbers. Let's talk about the value we get for all these dollars we spend. Well, the Dartmouth Atlas, about six years ago, looked at every dollar spent by Medicare -- generally this population. We found that those patients who have the highest per capita expenditures had the highest suffering, pain, depression. And, more often than not, they die sooner.
让我们忘记那些统计数据一分钟, 让我们来谈谈从所有 花出去的钱中得到的价值。 大概六年前, 达特茅斯阿特拉斯项目, 查看了医疗保险支出的每一分钱, 通常就是这群人。 我们发现那些人均支出最高的病人, 承受着最严重的病痛和绝望, 但是他们往往更早离世。
How can this be? We live in the United States, it has the greatest health care system on the planet. We spend 10 times more on these patients than the second-leading country in the world. That doesn't make sense. But what we know is, out of the top 50 countries on the planet with organized health care systems, we rank 37th. Former Eastern Bloc countries and sub-Saharan African countries rank higher than us as far as quality and value.
为什么会这样? 我们生活在美国, 拥有全球最好的医疗保健系统。 我们花费在这些病人上的, 比世界第二大国多10倍。 这不合理。 但是我们知道的是, 在全球前五十拥有 有组织的医疗保健系统的国家中, 我们排第三十七位。 原东欧集团国家和 撒哈拉以南非洲国家, 在质量和价值上都比我们排名更高。
Something I experience every day in my practice, and I'm sure, something many of you on your own journeys have experienced: more is not more. Those individuals who had more tests, more bells, more whistles, more chemotherapy, more surgery, more whatever -- the more that we do to someone, it decreases the quality of their life. And it shortens it, most often.
有件事我每天都能在实践中感受到, 我也确信这是你们中的 很多人在生命旅程中感受过: 更多不等于更好。 那些做了更多的测试的人, 更多钟声与哨声, 做了更多的化疗、更多的手术等等, 我们对某人做得越多, 他们的生活质量就减少得越多。 也常常缩短了他们的生命。
So what are we going to do about this? What are we doing about this? And why is this so? The grim reality, ladies and gentlemen, is that we, the health care industry -- long white-coat physicians -- are stealing from you. Stealing from you the opportunity to choose how you want to live your lives in the context of whatever disease it is. We focus on disease and pathology and surgery and pharmacology. We miss the human being. How can we treat this without understanding this? We do things to this; we need to do things for this.
那么我们该做些什么呢? 我们该怎么做? 为什么事情是这样的? 严峻的现实是,女士们先生们, 我们,整个医疗保健业, 长白大褂的医生们, 正在偷取你们的东西。 窃取了你们机会, 自己选择自己的生活, 不论你们得了什么病。 我们关注病症、病理、手术 以及药理学。 我们却忘了人本身。 我们没有了解这个 又怎么能治疗呢? 我们对人的疾病做了很多, 但我们需要对人本身做些事情。
The triple aim of healthcare: one, improve patient experience. Two, improve the population health. Three, decrease per capita expenditure across a continuum. Our group, palliative care, in 2012, working with the sickest of the sick -- cancer, heart disease, lung disease, renal disease, dementia -- how did we improve patient experience?
医疗保健的三个目标是: 一,改善病人体验。 二,改善人民健康。 三,减少周期性的人均消费。 我们的安宁护理团队 在2012年研究最严重的病症—— 癌症, 心脏病、肺部疾病, 肾脏疾病, 痴呆。 我们如何改善病人体验的呢?
"I want to be at home, Doc."
“我想待在家里,医生。”
"OK, we'll bring the care to you."
“可以,我们会把治疗带给你。”
Quality of life, enhanced. Think about the human being.
生活提高了。 想想人类本身。
Two: population health. How did we look at this population differently, and engage with them at a different level, a deeper level, and connect to a broader sense of the human condition than my own? How do we manage this group, so that of our outpatient population, 94 percent, in 2012, never had to go to the hospital? Not because they couldn't. But they didn't have to. We brought the care to them. We maintained their value, their quality.
二,人群健康。 我们怎样不同地看待这类人群, 怎样和他们在不同且更深层面打交道, 怎样了解比原有更多的病况? 我们怎样管理这类人群, 而使我们的病人, 94%在2012年不需要去医院? 并不是因为他们不能, 而是因为他们没有必要。 我们把治疗带去给他们。 我们维持着他们的 价值、他们的生活质量。
Number three: per capita expenditures. For this population, that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP, we reduced health care expenditures by nearly 70 percent. They got more of what they wanted based on their values, lived better and are living longer, for two-thirds less money.
三,人均支出。 对这类人群而言, 现在是2.3万亿美元, 20年后是60%的GDP。 我们降低了近70%的医疗保健支出。 基于他们的价值观,他们收获了更多, 活得更好,也活得更久, 只用了三分之一的钱。
While Harold's time was limited, palliative care's is not. Palliative care is a paradigm from diagnosis through the end of life. The hours, weeks, months, years, across a continuum -- with treatment, without treatment.
虽然哈罗德的时间是有限的, 但安宁护理的不是。 安宁护理是从诊断到死亡的治疗方式。 日复一日, 周复一周,月复一月,年复一年。 跨过一个周期, 接受或没接受治疗的。
Meet Christine. Stage III cervical cancer, so, metastatic cancer that started in her cervix, spread throughout her body. She's in her 50s and she is living. This is not about end of life, this is about life. This is not just about the elderly, this is about people.
来认识一下克里斯汀。 宫颈癌三期, 转移性肿瘤开始从她的子宫 蔓延至她的全身 她已经50多岁了而且她还活着。 这不是关于生命的终结, 这关乎生命。 这也不是只关乎于老年人, 而是关乎全人类。
This is Richard. End-stage lung disease.
这是理查德, 肺病终末期。
"Richard, what is it that you hold sacred?"
“理查德,你觉得 什么东西是神圣的?”
"My kids, my wife and my Harley."
“我的孩子们、 我的妻子和我的哈雷。”
(Laughter)
(笑声)
"Alright! I can't drive you around on it because I can barely pedal a bicycle, but let's see what we can do."
“好吧! 我无法骑哈雷载着你, 因为我几乎不会骑自行车。 但是我们看看能做什么。”
Richard came to me, and he was in rough shape. He had this little voice telling him that maybe his time was weeks to months. And then we just talked. And I listened and tried to hear -- big difference. Use these in proportion to this.
理查德找到我, 他的身体很疲倦。 有个微小的声音告诉他 也许他只有几个星期 到几个月的时间了。 于是我们就聊天, 我倾听,并试图去理解, 这是很大的不同, 听和说要成比例。
I said, "Alright, let's take it one day at a time," like we do in every other chapter of our life. And we have met Richard where Richard's at day-to-day. And it's a phone call or two a week, but he's thriving in the context of end-stage lung disease.
我说, “好的,一天一天地过。” 像我们在生命其他篇章中做的一样。 我们见到了理查德平常的样子, 一周一到两次的通话, 他却在肺病终末期的情况下精神焕发。
Now, palliative medicine is not just for the elderly, it is not just for the middle-aged. It is for everyone.
现在安宁护理已经不仅限于老人, 也不仅限于中年人。 这适合所有人。
Meet my friend Jonathan. We have the honor and pleasure of Jonathan and his father joining us here today. Jonathan is in his 20s, and I met him several years ago. He was dealing with metastatic testicular cancer, spread to his brain. He had a stroke, he had brain surgery, radiation, chemotherapy. Upon meeting him and his family, he was a couple of weeks away from a bone marrow transplant, and in listening and engaging, they said, "Help us understand -- what is cancer?"
见见我的朋友乔纳森。 我们很荣幸和快乐, 乔纳森和他的父亲今天也在场。 乔纳森20多岁, 我在几年前就遇见他了。 他得了转移性睾丸癌, 扩散到了他的脑部。 他中风了, 他做了脑部手术, 放疗、化疗。 在见到他和他的家人时, 他的骨髓移植还有几个星期, 他认真地听着, 他们说, “帮帮我们理解,什么是癌症?”
How did we get this far without understanding what we're dealing with? How did we get this far without empowering somebody to know what it is they're dealing with, and then taking the next step and engaging in who they are as human beings to know if that is what we should do? Lord knows we can do any kind of thing to you. But should we?
我们是怎么走到这步 却并不了解我们在和什么打交道的? 我们是怎么走到这步却不授予 人们对病情的知情权, 然后采取下一个步骤, 让他们知道作为人类他们是谁 并知道他们该做什么? 上帝知道我们能对你做任何事情。 但是我们应该吗?
And don't take my word for it. All the evidence that is related to palliative care these days demonstrates with absolute certainty people live better and live longer. There was a seminal article out of the New England Journal of Medicine in 2010. A study done at Harvard by friends of mine, colleagues. End-stage lung cancer: one group with palliative care, a similar group without. The group with palliative care reported less pain, less depression. They needed fewer hospitalizations. And, ladies and gentlemen, they lived three to six months longer. If palliative care were a cancer drug, every cancer doctor on the planet would write a prescription for it. Why don't they? Again, because we goofy, long white-coat physicians are trained and of the mantra of dealing with this, not with this.
不要相信我的话。 最近所有和安宁护理相关的证据 论证了人们绝对活得更好和更久。 一篇在“新英格兰医学杂志”上的 开创性的文章, 在2012年。 一项我的朋友同事在哈佛大学的实验, 肺病终末期, 一组做安宁护理, 一个对照组不做。 做了安宁护理的那组 报告了更少的痛苦, 更少的抑郁。 他们需要较少的住院治疗, 女士们先生们, 他们多活了三到六个月。 如果安宁护理是一种癌症药物, 地球上的每一位 癌症医生都会开这个处方。 他们为什么不呢? 因为我们这些愚蠢的白大褂医生们 是被训练来治病的, 而不是救人。
This is a space that we will all come to at some point. But this conversation today is not about dying, it is about living. Living based on our values, what we find sacred and how we want to write the chapters of our lives, whether it's the last or the last five. What we know, what we have proven, is that this conversation needs to happen today -- not next week, not next year. What is at stake is our lives today and the lives of us as we get older and the lives of our children and our grandchildren. Not just in that hospital room or on the couch at home, but everywhere we go and everything we see. Palliative medicine is the answer to engage with human beings, to change the journey that we will all face, and change it for the better.
这是一个我们都会碰到的时刻。 但今天这个对话不是关于死亡, 而是关于活着。 活着为了价值观和我们珍惜的东西, 和我们想如何去书写人生篇章, 无论这是最后一篇, 或者最后五篇。 我们知道的是, 我们已经证明的是, 这种对话今天就需要发生, 不是下个星期,不是明年 面临危机的的是我们现在的生活, 我们老了以后的生活, 和我们孙子和曾孙的生活。 不只是在病房里, 或者家里的沙发上, 而是我们遇见的所有地方和事情。 安宁护理是与人类接触, 改变我们都会面临的旅程, 并把它变得更美好的答案,
To my colleagues, to my patients, to my government, to all human beings, I ask that we stand and we shout and we demand the best care possible, so that we can live better today and ensure a better life tomorrow. We need to shift today so that we can live tomorrow.
向我的同事们, 我的病人们, 我的政府, 所有的人类, 我请求你们去主张、呼吁、要求 尽可能的最好的治疗, 所以我们可以在今天活得更好 并确保明天更好的生活。 我们需要改变今天, 所以我们才可以生活在明天。
Thank you very much.
非常感谢。
(Applause)
(掌声)