【TED演讲201】拿什么拯救我们的医疗？演说者：Atul Gawande

我们的医疗系统破败不堪。医生们开出昂贵无比的诊断书和处方，但他们却忽视了核心问题：真真切切地治疗患者。医生、作家阿图尔-葛王德建议我们退一步思考，换一个角度看待医疗行业——摈弃个人主义，建立团队合作。

演说者：Atul Gawande

演说题目：拿什么拯救我们的医疗？

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 中英文对照翻译

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?

我的职业生涯从写作、研究开始。当时还是个外科实习医生，像很多人一样，需要经历漫漫长路，才能成为某个领域的专家。因而，在当时那个阶段你自然要问，我该如何做好自己所尝试做的这一领域？这个问题会演变成，我们怎样才能做好我们正在努力做的这件事？

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.

要掌握技术着实不易，需要对所学内容都吸收消化。无论做什么，就拿我来说，我必须学会如何缝合、如何开刀。还得知道如何选择对的人进入手术室，在以上思考过程中，还隐藏这一个问题那就是：究竟什么才是造福于人？

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. 

在过去几年中，我们意识到自己深陷，医学危机。原因在于有些事情，作为医生很难考虑到，关于如何造福于人。例如，医疗卫生的成本问题。

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.

世界上没有一个国家不在问自己是否能支付医疗行为的代价。这也引发了政治上的争论。争论焦点围绕着究竟是政府还是保险公司才是罪魁祸首答案既“是”，也“否”还有更深层次的回答。

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. 

造成麻烦的根源其实是科学带来的复杂性。为了让大家更好地理解这个观点，让我带大家回顾几代人之前的情况。我想带大家回到刘易斯-托马斯写下《最年轻的科学》的那个时代。刘易斯-托马斯是一位医生兼作家，也是我最喜爱的作家之一。

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.

他在书中描述了作一名实习医生的生活。在当时的波士顿市立医院，在盘尼西林尚未发现的年代。那是1937年，当时药物很便宜但疗效也不好，他写道：如果你去看病，医院对你的唯一帮助，就是提供了给你提供了温暖、食物、住所， 或许还有来自护士的关怀、医生和药物的作用，无关紧要，即使这样，当时的医生们还是忙得不可开交。对此，他解释道。

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. 

他们努力想做的，就是弄清楚患者是否适用于某种诊断是他们可以治疗的。这样的病症不多，比如说，你患有大叶性肺炎，医生可以对你进行抗血清治疗，为你注射狂犬病抗体以此对抗链球菌，前提是实习医生分类正确。

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.

如果你不幸突发急性充血性心脏衰竭，医生可以给你放一品脱的血，从割开的手臂静脉里他们会为你准备一剂粗糙的洋地黄叶制剂，然后让你在氧幕里吸氧。如果你出现瘫痪的前期症状、如果你很善于问个人问题，你或许会发现，这个病人的瘫痪很有可能是梅毒引发的。因此你可以开出汞和砷的混合药剂，只要不过量使用，不会置他们于死地，除此之外，医师能做的事并不多。

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. 

也就在那个时代，医疗的核心 形成了。那就是如何做好我们所做的事，以及如何建立医疗体系。当时，医生能知道当时所有的医疗技术，一个人就可以记住所有的医疗知识，也能实施所有的医疗行为。

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.

如果你有处方权、如果你有一名护士、如果你有一所医院或许可以给你一个栖身之所，得到一些基本的工具。你凭一己之力可以完成所有的事，你可以处理骨折、可以抽血可以验血可以用显微镜观察；你可以组织切片，可以注射抗血清 这是工匠一般的生活。

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. 

最终，我们成功建立起了医疗文化和价值体系。医生最应擅长的事，就是行事大胆、充满勇气并且要独立工作，自给自足自主是至高无上的价值观。往后推几代人来看今天，世界好像完全变了个样。

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.

我们现在的治疗手段，几乎能处理上万种，人类可能患上的疑难杂症。尽管不能治愈所有疾病，我们不能保证每个人都长命百岁、无病无患，但是我们可以让多数人，过上健康长寿的生活。

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，实现这一结果的代价是什么呢？如今我们已经发现了4000种药物介入和外科手术。我们研制了6000种药物，这还仅仅是我现在处方权允许的范围，我们正在尝试把这些治疗手段和药物，推广到更多地方，挨家挨户地深入大众，覆盖我们国家的每一寸土地，乃至全球各个角落。我们已经到了这样的地步，作为医生，我们认识到自己不能知晓一切，也不能一一做到仅凭一己之力是不行的。

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. 

曾经有一项研究调查了不同时代下，照顾一名患者在医院里需要多少医务人员。在1970年，一般需要两名全职临床医务人员。

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.

也就是说，基本上是护士照料时间加上医生的一点点时间，医生的时间只用来做查房，一般一天一次。到了20世纪末年这一数字上升到15名临床医务人员照顾同样一名典型的住院患者，包括专科医生、普科医生以及护士。

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.

如今我们都是专科医生，即便是基本卫生医疗单位的医生。每个人也只提供自己专业范围内的一点点关怀。但是为了坚持我们建立的医疗价值体系针对“勇敢”、“独立”、“自给自足”对所有这些人而言，就会变成一场灾难。我们培训、雇佣、奖励医生把他们变成牛仔那样，但是我们真正需要的是赛车维修队针对病人的维修队。

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. 

我们身边就有这样的实例证明，我们社区中40%的冠状动脉患者接受的治疗是不全面或不妥当的。60%哮喘、中风病人接受的治疗是不全面或不妥当的。

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.

200万人在医院的时候，受到感染这些感染是他们原本所没有的，因为有人忽略了最基本的卫生问题。我们的经验表明，当人们生病时需要得到别人的帮助，应该是医生们的帮助，可以让我们找到那些令人放心的医生勤奋努力、受过良好培训、并且聪明过人，还可以得益于尖端技术，这些都会给我们莫大的希望。但极少能见到，所有这些持续地共同作用于你 ，贯穿整个医疗过程，并且确保成功。

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." 

另外一个征兆，我们需要维修队的原因是现有医疗体系高昂到无法控制的成本问题。我想，在我们的医疗行业百思不得其解的就是这个成本问题。我们想说：“这就是现实……这就是医药行业必需的“ 

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.

当你从用阿司匹林治疗关节炎的地方，那往往是没有效果的。到现在，对于严重病患，我们可以做手术更换人工髋关节或膝盖，那将帮助病人恢复原本可能丧失的功能安好地度过几十年，这是一个多戏剧化的改变啊。因此，如果说花4万美元进行个髋关节移植手术，而不是花10美分买阿司匹林来缓解，哪个更昂贵呢？这就是现实。

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. 

但我认为，我们忽略了一些事实，这些事实告诉我们，我们能做的其实有很多。我们看到一些数据，关于医疗行为的结果，尽管环境日益复杂。我们发现最昂贵的医疗，不见得是最好的，反之亦然。

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.

最好的医疗通常花不了几个钱而且更简单。人们在那种情况下效率更高。这一发现的含义在于我们还有希望。因为，假如我们想要获得最好的结果，要用到最贵的医疗，在一国范围内、或者在世界范围内最贵，那么我们真的要去讨论的就是配额制度，决定哪些人不能享受医疗保险，那将会成为唯一的选择。

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. 

但如果我们看看积极的反面事例，确实存在以最低的成本，获得最佳效果的例子 。我们发现最像“系统”的是最成功的。也就是说，我们发现了平衡所有不同部分，不同因素的方法让各个部分变成一个整体。

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.

仅有好的组成部分是远远不够的。然而我们正是对医药的组成部分太过痴迷了，我们想要最好的药物、最好的技术、最好的专科医生，但我们却不曾想过，这些如何组合在一起这其实是个很糟糕的战略设计。

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.

有一个很著名的思考实验验证了这个想法，实验是这样的，假如你用最好的汽车零件，能造出怎样一辆车？你可以用保时捷的刹车、法拉利的引擎、沃尔沃的车身，宝马的底盘，你把这些都组装在一起会得到一辆怎样的车呢？答案是：一堆很贵的垃圾，一辆完全不能开的车，有时候医药行业也是这样，它并非一个系统。

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.

然而，为了组建一个体系，当所有部分都组合到一起，你需要有特定的技巧，来让它运作起来，让它看起来像回事儿。首当其冲的是辨识成功的能力以及辨识失败的能力。假如你是一名专科医生，如果你无法很好地设想最终结果，你必须认真分析数据，这听上去非常无趣。

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. 

我的一个外科医生同事，在爱荷华州锡达拉皮兹工作，他对一个问题产生了兴趣，那就是：他们在锡达拉皮兹做了多少个CT扫描？他对此很感兴趣，因为政府报告、新闻报道、期刊论文都在说现在做的CT扫描过量了。

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.

但他没在自己的病人中看到这个问题。因此他提出这一疑问：”我们究竟做了多少CT扫描呢？“ 他想得到这一数据，于是他花了3个月时间，此前，在他的社区，没人有过这个疑问。后来，他发现社区的300,000人中，过去一年间，他们曾做了52,000次CT扫描，于是他们发现了一个问题。

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.

也就引出了我要说的运作系统的第二项技巧。技巧1是：发现我们错在哪里；技巧2是：设计解决方案。我对此也颇感兴趣，世界卫生组织曾来找我的团队，问我们是否能帮他们做一个项目，来降低外科手术的死亡率。如今外科手术在世界范围内，数量日益增长，但是手术的安全性，却令人担忧，现在我们普遍的做法是，开展更多培训让医生更加专业或者提高技术。

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. 

所以，在手术中，我们的医生都是非常专业的，受过非常好的教育和培训。然而我们还是看到高得不正常的死亡率和致残率。这些原本都是可以避免的。因此我们参考了其他高风险行业的做法。

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.

我们观察了摩天大楼的建设，我们研究了飞机制造业。然后发现，他们有技术、他们有培训，而且他们还有一样东西，那就是检查表。我没有想到自己作为一名哈佛外科医生，会把大部分时间用来烦恼检查表这个东西，然而，我们发现正是这个工具帮助专家达到最佳效果，我们得到了波音公司首席安全工程师的帮助。

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. 

我们请教他如何设计一张用于外科手术的清单？并非为了社会底层人士。而是针对在这条产业链的每个环节上的人。包括外科医生在内的整个团队。他们教我们的是，要设计好检查表来帮助人们处理复杂问题，其实比想象的要难，你必须考虑很多问题。

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.

比如“暂停时点”，你需要认识到整个流程中的一些时刻，能够在危险来临前及时发现问题，作出处理以免酿成大祸。你必须把它当做，是一张飞机起飞前的检查表，你一定要关注一些至关重要的项目。在一份飞机制造检查表上就像这张针对单引擎飞机的检查清单，它可不是驾驶飞机的窍门，而是对关键问题的提醒，如果他们不去检查，很可能会遗漏这些问题。

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 -- 

因此我们也效仿了他们的做法。我们设计了一张检查表，19个项目，用时2分钟针对手术团队其中包含“暂停时点” 。例如，实施麻醉前、手术刀接触病人皮肤之前、病人离开手术室之前，检查表上不乏很多看上去很简单的事情。例如，确保在正确的时间使用抗生素，光这一点就让感染率下降了一半。

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.

还有些有意思的事，你无法为手术这样复杂的事情事先开出处方。然而，你却可以开处方给这个团队，使他们能更好地去面对突发状况，我们列出的项目中就包括：确保每个在房间的人都在手术开始前互相做了自我介绍。因为很多时候，起码有六个人，在这个新组建的团队中，都是初次见面。

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.

后来，我们在世界上8所医院执行、推广了这份检查表。其中包括坦桑尼亚的乡村，也包括在西雅图的华盛顿大学。我们发现，当他们使用了这份检查表之后，复杂程度大大降低，降低了35%。每所医院都是如此，死亡率也降低了，降低了47% 。这比任何一种药物都管用。

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. 

这将引出第三项技巧，执行能力。让所有产业链上的同事都能切实地这样做事。推广这些很花时间，这还不是我们做手术的规范，更别说应用于例如分娩等其他紧迫的领域。

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.

在执行中往往会遇到强大的阻力，因为使用这些工具，会迫使我们去面对我们还未成为“系统”这一事实。会迫使我们不得不用另一套价值观去操作，使用一份检查表，需要你用与以往不同的价值操守例如谦虚、纪律、团队合作。这与我们所建立的价值观刚好背道而驰：独立、自给自足、自治、

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." 

说到这儿，我想起来曾经遇到过一个真正的牛仔。我问他：牛仔到底是如何将上千头牛，放牧几百英里，你们是怎么做的？他回答说：“我们有牛仔驻扎在牧区的几个地点。”

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.

他们通过电子设备不断交流，他们有规章制度和各种检查表去处理发生的各种情况 （笑声）比如恶劣天气，比如突发事件，或者为牛群接种。如今，就连牛仔们也组成了维修队，似乎是时候我们也变成那样了。

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. 

靠“系统”来工作这正是我们这代人作为医生和科学家的的首要任务。进一步说，要让“系统”运转起来，无论是医疗、教育还是气候变化，还是消除贫困，都是我们这代人，作为一个整体需要完成的重要任务。

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.Thank you.

在各个领域都有知识爆炸，情况更加复杂专业性更强，我们别无选择。只能去认识到，尽管我们都崇尚个人主义，但复杂性要求我们，取得集体成功，我们全都需要成为维修队。谢谢.

Remark：一切权益归TED所有，更多TED相关信息可至官网www.ted.com查询！