TEDGlobal 2011
Abraham Verghese: A doctor's touch
Abraham Verghese: Liječnikov dodir
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Suvremena medicina je u opasnosti da izgubi moćno, staromodno oruđe: ljudski dodir. Liječnik i pisac Abraham Verghese opisuje naš čudan novi svijet u kojem su pacijenti samo obični podaci, i poziva na povratak tradicionalnog fizikalnog pregleda „jedan na jedan".
Abraham Verghese - Physician and author
In our era of the patient-as-data-point, Abraham Verghese believes in the old-fashioned physical exam, the bedside chat, the power of informed observation. Full bio
In our era of the patient-as-data-point, Abraham Verghese believes in the old-fashioned physical exam, the bedside chat, the power of informed observation. Full bio
Double-click the English transcript below to play the video.
00:15
A few months ago,
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Prije nekoliko mjeseci,
00:17
a 40 year-old woman came to an emergency room
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40-godišnja žena je došla na hitni prijem
00:20
in a hospital close to where I live,
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bolnice, blizu koje živim.
00:22
and she was brought in confused.
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Dovezena je zbunjena.
00:24
Her blood pressure was an alarming
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Njezin krvni tlak je bio zabrinjavajućih
00:26
230 over 170.
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230 sa 170.
00:29
Within a few minutes, she went into cardiac collapse.
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Za nekoliko minuta je doživjela srčani zastoj.
00:32
She was resuscitated, stabilized,
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Oživljavana je i stabilizirana,
00:35
whisked over to a CAT scan suite
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odvedena na CT
00:37
right next to the emergency room,
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odmah uz hitni prijem,
00:39
because they were concerned about blood clots in the lung.
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jer su bili zabrinuti zbog ugrušaka u plućima.
00:42
And the CAT scan revealed
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I CT nije pokazao
00:44
no blood clots in the lung,
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krvne ugruške u plućima,
00:46
but it showed bilateral, visible, palpable breast masses,
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već obostrane, vidljive, palpabilne tvorbe u dojkama,
00:51
breast tumors,
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tumore dojke,
00:53
that had metastasized widely
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koji su opsežno metastazirali
00:55
all over the body.
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po cijelom tijelu.
00:57
And the real tragedy was, if you look through her records,
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A prava tragedija je bila to što, kada biste pogledali njezinu dokumentaciju,
01:00
she had been seen
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je bila pregledana
01:02
in four or five other health care institutions
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u četiri ili pet drugih zdravstvenih ustanova
01:04
in the preceding two years.
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u prethodne dvije godine.
01:06
Four or five opportunities
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Četiri ili pet prilika
01:08
to see the breast masses, touch the breast mass,
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da se uoče tvorbe u dojkama, da se opipaju te tvorbe,
01:10
intervene at a much earlier stage
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da se intervenira u puno ranijem stadiju
01:13
than when we saw her.
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od onoga u kojem smo je mi vidjeli.
01:15
Ladies and gentlemen,
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Dame i gospodo,
01:17
that is not an unusual story.
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ovo nije neuobičajena priča.
01:19
Unfortunately, it happens all the time.
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Nažalost, stalno se događa.
01:22
I joke, but I only half joke,
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Obično se šalim, ali samo djelomice,
01:24
that if you come to one of our hospitals missing a limb,
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da ako dođete u jednu od naših bolnica bez noge ili ruke,
01:27
no one will believe you till they get a CAT scan, MRI
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nitko vam neće vjerovati dok se ne napravi CT, MRI
01:30
or orthopedic consult.
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ili konzilijarni pregled ortopeda.
01:32
I am not a Luddite.
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Nisam Ludit.
01:34
I teach at Stanford.
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Predajem na Stanfordu.
01:36
I'm a physician practicing with cutting-edge technology.
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Liječnik sam koji koristi naprednu tehnologiju.
01:38
But I'd like to make the case to you
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Ali želim obraniti tezu
01:40
in the next 17 minutes
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u sljedećih 17 minuta
01:42
that when we shortcut the physical exam,
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da kada skratimo fizikalni pregled,
01:46
when we lean towards ordering tests
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kada težište stavljamo na laboratorijske pretrage
01:48
instead of talking to and examining the patient,
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umjesto na razgovor s pacijentom i na pregled,
01:51
we not only overlook simple diagnoses
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ne samo da previdimo jednostavne dijagnoze
01:54
that can be diagnosed at a treatable, early stage,
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koje mogu biti dijagnosticirane u izlječivom, ranom stadiju,
01:57
but we're losing much more than that.
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nego gubimo mnogo više.
01:59
We're losing a ritual.
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Gubimo ritual.
02:01
We're losing a ritual that I believe is transformative, transcendent,
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Gubimo ritual za kojeg smatram da je preobražavajuć, transcendentalan,
02:04
and is at the heart
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i čini suštinu
02:06
of the patient-physician relationship.
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odnosa između pacijenta i liječnika.
02:08
This may actually be heresy to say this at TED,
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Možda je hereza što ću ovo reći na TED-u,
02:11
but I'd like to introduce you
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ali htio bih vas upoznati
02:13
to the most important innovation,
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s najvažnijom inovacijom,
02:15
I think, in medicine
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po mom mišljenju, u medicini
02:17
to come in the next 10 years,
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koja će doći u sljedećih 10 godina.
02:19
and that is the power of the human hand --
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To je moć ljudske ruke --
02:21
to touch, to comfort, to diagnose
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da dodirne, utješi, dijagnosticira
02:24
and to bring about treatment.
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i započne liječenje.
02:26
I'd like to introduce you first to this person
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Prvo bih vas želio upoznati s ovom osobom,
02:29
whose image you may or may not recognize.
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čiju sliku možda prepoznajete.
02:31
This is Sir Arthur Conan Doyle.
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Ovo je Sir Arthur Conan Doyle.
02:33
Since we're in Edinburgh, I'm a big fan of Conan Doyle.
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S obzirom da smo u Edinburgu, veliki sam obožavatelj Conana Doylea.
02:36
You might not know that Conan Doyle went to medical school
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Mozda ne znate da je Conan Doyle išao na medicinski fakultet
02:38
here in Edinburgh,
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ovdje u Edinburgu,
02:40
and his character, Sherlock Holmes,
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i njegov lik, Sherlock Holmes,
02:42
was inspired by Sir Joseph Bell.
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je bio nadahnut Sirom Josephom Bellom.
02:45
Joseph Bell was an extraordinary teacher by all accounts.
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Joseph Bell je bio izuzetan učitelj u svakom pogledu.
02:48
And Conan Doyle, writing about Bell,
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I Conan Doyle, pišući o Bellu,
02:51
described the following exchange
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je opisao sljedeći razgovor
02:53
between Bell and his students.
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između Bella i njegovih studenata.
02:55
So picture Bell sitting in the outpatient department,
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Zamislite Bella kako sjedi u ambulanti,
02:58
students all around him,
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studenti oko njega,
03:00
patients signing up in the emergency room
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pacijenti se upisuju na hitni prijem
03:02
and being registered and being brought in.
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registriraju se i uvode unutra.
03:05
And a woman comes in with a child,
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I ulazi jedna žena s djetetom,
03:07
and Conan Doyle describes the following exchange.
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i Conan Doyle opisuje sljedeći razgovor.
03:10
The woman says, "Good Morning."
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Žena kaže, „Dobro jutro.”
03:14
Bell says, "What sort of crossing did you have
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Bell kaže, “Kakav vam je bio prijelaz
03:17
on the ferry from Burntisland?"
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trajektom od Burntislanda?”
03:20
She says, "It was good."
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Ona odogovori, “Bio je dobar.”
03:22
And he says, "What did you do with the other child?"
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Potom on kaže, „Što ste napravili s drugim djetetom?”
03:25
She says, "I left him with my sister at Leith."
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Ona kaže, „Ostavila sam ga kod svoje sestre u Leithu.”
03:28
And he says,
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I on kaže,
03:30
"And did you take the shortcut down Inverleith Row
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„Jeste li išli prečacem kroz Inverleith Row
03:32
to get here to the infirmary?"
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da dođete ovdje u ambulantu?”
03:34
She says, "I did."
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Ona kaže, „Jesmo.”
03:36
And he says, "Would you still be working at the linoleum factory?"
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I on kaže, „Da li možda još radite u tvornici linoleuma?”
03:40
And she says, "I am."
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Ona kaže, „Radim.”
03:42
And Bell then goes on to explain to the students.
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Bell je potom objasnio studentima.
03:44
He says, "You see, when she said, 'Good morning,'
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Kaže, „Vidite, kada je rekla ‘Dobro jutro.’
03:47
I picked up her Fife accent.
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primjetio sam njezin naglasak iz Fifa.
03:49
And the nearest ferry crossing from Fife is from Burntisland.
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A najbliži trajekt koji dolazi iz Fifea kreće iz Burntislanda.
03:52
And so she must have taken the ferry over.
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Tako da je morala doći trajektom.
03:55
You notice that the coat she's carrying
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Primjetite da je kaput kojeg drži
03:57
is too small for the child who is with her,
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premalen za dijete koje je s njom,
04:00
and therefore, she started out the journey with two children,
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stoga je počela put s dvoje djece,
04:03
but dropped one off along the way.
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ali je ostavila jedno putem.
04:06
You notice the clay on the soles of her feet.
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Primjetite glinu na njenim tabanima.
04:08
Such red clay is not found within a hundred miles of Edinburgh,
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Tako crvenu glinu ne možete naći stotinama kilometara od Edinburga,
04:12
except in the botanical gardens.
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osim u botaničkim vrtovima.
04:14
And therefore, she took a short cut down Inverleith Row
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Stoga je išla prečacem kroz Inverleith Row
04:17
to arrive here.
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da bi stigla ovdje.
04:19
And finally, she has a dermatitis
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I naposljetku, ima dermatitis
04:21
on the fingers of her right hand,
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na prstima desne ruke,
04:23
a dermatitis that is unique
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dermatitis koji je jedinstven
04:25
to the linoleum factory workers in Burntisland."
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radnicima tvornice linoleuma u Burntislandu.”
04:28
And when Bell actually strips the patient,
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A kada Bell još i skine pacijenticu,
04:30
begins to examine the patient,
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počne pregledavati pacijenticu,
04:32
you can only imagine how much more he would discern.
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možete i sami zamisliti koliko bi još zaključaka mogao donijeti.
04:35
And as a teacher of medicine, as a student myself,
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A kao učitelj medicine, i kao student,
04:38
I was so inspired by that story.
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bio sam jako nadahnut ovom pričom.
04:40
But you might not realize
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Ali možda ne shvaćate
04:42
that our ability to look into the body
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da je naša sposobnost da pogledamo u tijelo
04:44
in this simple way, using our senses,
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na ovaj jednostavan način, koristeći naša osjetila,
04:46
is quite recent.
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počela tek nedavno.
04:48
The picture I'm showing you is of Leopold Auenbrugger
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Slika koju vam pokazujem, prikazuje Leopolda Auenbruggera,
04:51
who, in the late 1700s,
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koji je krajem 18. stoljeća
04:53
discovered percussion.
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otkrio perkusiju.
04:55
And the story is that Leopold Auenbrugger
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A priča kaže da je Leopold Auenbrugger
04:58
was the son of an innkeeper.
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bio sin gostioničara.
05:01
And his father used to go down into the basement
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Njegov otac bi išao u podrum
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to tap on the sides of casks of wine
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i kuckao bi po stijenkama vinskih bačvi
05:06
to determine how much wine was left
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da odredi koliko je vina ostalo
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and whether to reorder.
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i da li treba još naručiti.
05:10
And so when Auenbrugger became a physician,
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Kada je Auenbrugger postao liječnik
05:12
he began to do the same thing.
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počeo je raditi istu stvar.
05:14
He began to tap on the chests of his patients,
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Počeo je lupkati po prsima pacijenata
05:17
on their abdomens.
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i po njihovim trbusima.
05:19
And basically everything we know about percussion,
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I praktički sve što znamo o perkusiji,
05:21
which you can think of as an ultrasound of its day --
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koju možete zamisliti kao ultrazvuk svog doba,
05:25
organ enlargement, fluid around the heart, fluid in the lungs,
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povećanje organa, tekućina oko srca, tekućina u plućima,
05:28
abdominal changes --
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promjene u trbuhu,
05:30
all of this he described in this wonderful manuscript
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sve je to opisao u ovom predivnom rukopisu
05:32
"Inventum Novum," "New Invention,"
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„Inventum Novum”, „Novi izum”,
05:35
which would have disappeared into obscurity,
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koji bi otišao u zaborav
05:37
except for the fact that this physician, Corvisart,
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da ga ovaj liječnik, Corvisart,
05:40
a famous French physician --
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poznati francuski liječnik,
05:42
famous only because he was physician to this gentleman --
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poznat jedino zato što je bio liječnik ovog gospodina,
05:45
Corvisart repopularized and reintroduced the work.
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Corvisart je ponovno popularizirao i predstavio ovaj rad.
05:49
And it was followed a year or two later
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Godinu-dvije nakon toga je popraćen
05:51
by Laennec discovering the stethoscope.
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Laennecovim otkrićem stetoskopa.
05:54
Laennec, it is said, was walking in the streets of Paris
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Priča se da je Laennec hodao ulicama Pariza
05:57
and saw two children playing with a stick.
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i vidio dvoje djece kako se igraju sa štapom.
05:59
One was scratching at the end of the stick,
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Jedan je strugao jedan kraj štapa,
06:02
another child listened at the other end.
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dok je drugo dijete slušalo na drugom kraju.
06:04
And Laennec thought this would be a wonderful way
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I Laennec je pomislio kako bi ovo bio divan način
06:06
to listen to the chest or listen to the abdomen
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slušanja prsa ili trbuha
06:08
using what he called "the cylinder."
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koristeći „cilindar”, kako ga je nazvao.
06:10
Later he renamed it the stethoscope.
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Kasnije ga je preimenovao u stetoskop.
06:12
And that is how stethoscope and auscultation was born.
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I tako su se rodili stetoskop i auskultacija.
06:16
So within a few years,
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Tako da je unutar nekoliko godina,
06:18
in the late 1800s, early 1900s,
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krajem 19. i početkom 20. stoljeća,
06:20
all of a sudden,
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iznenada
06:22
the barber surgeon had given way
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brijač-kirurg bio zamijenjen
06:25
to the physician who was trying to make a diagnosis.
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liječnikom, koji je pokušavao postaviti dijagnozu.
06:28
If you'll recall, prior to that time,
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Ako se sjećate, prije toga
06:30
no matter what ailed you, you went to see the barber surgeon
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bez obzira na vaše tegobe, išli ste brijaču-kirurgu,
06:33
who wound up cupping you,
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koji vam je na kraju puštao krv pomoću roga,
06:35
bleeding you, purging you.
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pustio vam krv, pročistio vas.
06:37
And, oh yes, if you wanted,
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I da, ako ste htjeli,
06:39
he would give you a haircut -- short on the sides, long in the back --
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podšišao vas je, kratko sa strane, dugo odostraga,
06:42
and pull your tooth while he was at it.
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i izvadio vam zub, kad ste već tamo.
06:44
He made no attempt at diagnosis.
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Nije ni pokušavao postaviti dijagnozu.
06:46
In fact, some of you might well know
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Štoviše, neki od vas možda i znaju
06:48
that the barber pole, the red and white stripes,
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da brijački stup, sa crvenim i bijelim prugama,
06:51
represents the blood bandages of the barber surgeon,
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predstavlja krvave zavoje brijača-kirurga,
06:54
and the receptacles on either end
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a posude na oba kraja
06:56
represent the pots in which the blood was collected.
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predstavljaju vrčeve u kojima se skupljala krv.
06:59
But the arrival of auscultation and percussion
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Ali dolazak perkusije i auskultacije
07:02
represented a sea change,
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je predstavljao postupnu promjenu,
07:04
a moment when physicians were beginning to look inside the body.
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trenutak kada su liječnici počeli gledati u tijelo.
07:07
And this particular painting, I think,
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A posebice ova slika, po mom mišljenju,
07:10
represents the pinnacle, the peak, of that clinical era.
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predstavlja vrh, vrhunac tog kritičnog razdoblja.
07:13
This is a very famous painting:
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Ovo je vrlo poznata slika:
07:15
"The Doctor" by Luke Fildes.
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„Liječnik” Luka Fildesa.
07:18
Luke Fildes was commissioned to paint this by Tate,
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Tate je naručio sliku od Luka Fildesa,
07:21
who then established the Tate Gallery.
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i potom je osnovao Tate galeriju.
07:23
And Tate asked Fildes to paint a painting
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Tate je zamolio Fildesa da naslika sliku
07:25
of social importance.
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od društvenog značaja.
07:27
And it's interesting that Fildes picked this topic.
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Zanimljivo je da je Fildes izabrao ovu temu.
07:30
Fildes' oldest son, Philip,
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Fildesov najstariji sin Philip
07:33
died at the age of nine on Christmas Eve
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je umro u dobi od devet godina na Badnjak
07:36
after a brief illness.
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nakon kratke bolesti.
07:38
And Fildes was so taken by the physician
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Fildes je bio toliko zadivljen liječnikom
07:41
who held vigil at the bedside for two, three nights,
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koji je probdio dvije-tri noći uz krevet djeteta,
07:45
that he decided that he would try and depict
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da je odlučio pokušati prikazati
07:47
the physician in our time --
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liječnika našeg vremena,
07:49
almost a tribute to this physician.
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skoro poput odavanja počasti tom liječniku.
07:51
And hence the painting "The Doctor," a very famous painting.
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I tako je nastala slika „Liječnik”, vrlo poznata slika.
07:54
It's been on calendars, postage stamps in many different countries.
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Bila je na kalendarima, poštanskim markama mnogih zemalja.
07:57
I've often wondered, what would Fildes have done
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Često sam se zapitao, što bi Fildes napravio
08:00
had he been asked to paint this painting
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da su ga zatražili da naslika ovu sliku
08:02
in the modern era,
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u modernom dobu,
08:04
in the year 2011?
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u 2011. godini.
08:07
Would he have substituted a computer screen
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Bi li računalni zaslon stavio
08:11
for where he had the patient?
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umjesto pacijenta?
08:13
I've gotten into some trouble in Silicon Valley
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Malo sam upao u nevolje u Silikonskoj dolini
08:15
for saying that the patient in the bed
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zato što sam rekao da je pacijent u krevetu
08:17
has almost become an icon
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praktički postao ikona
08:20
for the real patient who's in the computer.
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pravog pacijenta, koji je u računalu.
08:23
I've actually coined a term for that entity in the computer.
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Čak sam osmislio i naziv za to stvorenje u računalu.
08:26
I call it the iPatient.
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Zovem ga iPacijent.
08:28
The iPatient is getting wonderful care all across America.
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iPacijent dobiva predivnu skrb diljem Amerike.
08:31
The real patient often wonders,
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Pravi pacijent se često pita
08:33
where is everyone?
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gdje su svi.
08:35
When are they going to come by and explain things to me?
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Kada će netko doći i objasniti mi stvari?
08:38
Who's in charge?
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Tko je glavni?
08:40
There's a real disjunction between the patient's perception
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Postoji pravi nesrazmjer između pacijentove predodžbe
08:43
and our own perceptions as physicians of the best medical care.
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i naše vlastite, kao liječnika, u tome što znači najbolja medicinska skrb.
08:46
I want to show you a picture
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Želim vam pokazati sliku
08:48
of what rounds looked like
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kako su vizite izgledale
08:50
when I was in training.
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dok sam se ja školovao.
08:52
The focus was around the patient.
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Težište je bilo oko pacijenta.
08:54
We went from bed to bed. The attending physician was in charge.
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Išli smo od kreveta do kreveta. Vodeći liječnik je bio glavni.
08:57
Too often these days,
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Danas prečesto
08:59
rounds look very much like this,
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vizite izgledaju ovako,
09:01
where the discussion is taking place
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raspravlja se
09:03
in a room far away from the patient.
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u sobi daleko od pacijenta.
09:06
The discussion is all about images on the computer, data.
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Rasprava se svede na slike na računalu, na podatke.
09:09
And the one critical piece missing
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I nedostaje jedan ključan dio,
09:11
is that of the patient.
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a to je pacijent.
09:13
Now I've been influenced in this thinking
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Na ovo moje razmišljanje su utjecale
09:16
by two anecdotes that I want to share with you.
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dvije anegdote, koje želim podijeliti s vama.
09:19
One had to do with a friend of mine who had a breast cancer,
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Jedna je o mojoj prijateljici, koja je imala tumor dojke,
09:22
had a small breast cancer detected --
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otkrili su joj mali tumor dojke.
09:25
had her lumpectomy in the town in which I lived.
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Obavljena je lumpektomija u gradu u kojem sam živio.
09:27
This is when I was in Texas.
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To je bilo dok sam živio u Teksasu.
09:29
And she then spent a lot of time researching
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Nakon toga je provela puno vremena u traženju
09:32
to find the best cancer center in the world
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najboljeg centra za tumore u svijetu
09:35
to get her subsequent care.
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za nastavak njege.
09:37
And she found the place and decided to go there, went there.
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Našla je mjesto i odlučila je otići tamo. Otišla je tamo.
09:40
Which is why I was surprised a few months later
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I zato sam bio iznenađen nekoliko mjeseci nakon toga
09:43
to see her back in our own town,
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kada sam je vidio u našem gradu,
09:46
getting her subsequent care with her private oncologist.
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kako prima daljnju njegu kod svog privatnog onkologa.
09:49
And I pressed her, and I asked her,
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I inzistirao sam, i pitao sam je.
09:51
"Why did you come back and get your care here?"
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„Zašto si se vratila i dobivaš medicinsku njegu ovdje?“
09:54
And she was reluctant to tell me.
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Nećkala se.
09:56
She said, "The cancer center was wonderful.
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Rekla je, „Znaš, centar za tumore je bio predivan.
09:59
It had a beautiful facility,
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Imali su predivne prostore,
10:01
giant atrium, valet parking,
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golemo predvorje, privatno parkiranje,
10:03
a piano that played itself,
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klavir koji je sam svirao,
10:05
a concierge that took you around from here to there.
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djelatnik centra koji vas je vodio uokolo.
10:08
But," she said,
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Ali, “ rekla je,
10:10
"but they did not touch my breasts."
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„ali, nitko nije dodirnuo moje grudi.”
10:14
Now you and I could argue
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Vi i ja bismo mogli braniti stajalište
10:16
that they probably did not need to touch her breasts.
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da vjerojatno nisu ni trebali dodirnuti njene grudi.
10:18
They had her scanned inside out.
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Pregledali su je iznutra i izvana.
10:20
They understood her breast cancer at the molecular level;
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Shvaćali su njezin tumor na molekularnoj razini.
10:23
they had no need to touch her breasts.
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Nije bilo potrebe dirati njezine grudi.
10:25
But to her, it mattered deeply.
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Ali njoj je to bilo od izrazite važnosti.
10:28
It was enough for her to make the decision
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To joj je bilo dovoljno da donese odluku
10:32
to get her subsequent care with her private oncologist
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da daljnju njegu prima kod svog privatnog onkologa,
10:35
who, every time she went,
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koji je svaki put kada je došla
10:37
examined both breasts including the axillary tail,
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pregledao obje dojke, uključujući i aksilarni rep,
10:40
examined her axilla carefully,
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pažljivo pregledao obje aksile,
10:42
examined her cervical region, her inguinal region,
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pregledao vrat, preponsku regiju,
10:44
did a thorough exam.
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napravio je opsežni pregled.
10:46
And to her, that spoke of a kind of attentiveness that she needed.
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Njoj je to govorilo u prilog pažnji, koju je trebala.
10:50
I was very influenced by that anecdote.
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Ova anegdota je imala veliki utjecaj na mene.
10:52
I was also influenced by another experience that I had,
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Na mene je utjecalo i jedno iskustvo koje sam imao,
10:55
again, when I was in Texas, before I moved to Stanford.
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opet, kada sam bio u Teksasu, prije no što sam se preselio na Stanford.
10:58
I had a reputation
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Pratio me glas
11:00
as being interested in patients
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da me zanimaju pacijenti
11:02
with chronic fatigue.
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koji boluju od kroničnog umora.
11:05
This is not a reputation you would wish on your worst enemy.
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To ne biste poželjeli svojem najgorem neprijatelju.
11:09
I say that because these are difficult patients.
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To kažem zato što su to zahtjevni pacijenti.
11:12
They have often been rejected by their families,
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Često su ih se njihove obitelji odrekle,
11:15
have had bad experiences with medical care
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imali su loša iskustva s medicinskom njegom
11:17
and they come to you fully prepared
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i dolaze vam potpuno spremni
11:20
for you to join the long list of people
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da ćete se i vi pridružiti dugom popisu ljudi
11:22
who's about to disappoint them.
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koji će ih razočarati.
11:24
And I learned very early on with my first patient
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Vrlo sam rano naučio sa svojim prvim pacijentom
11:27
that I could not do justice
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da ne mogu dati dovoljno pažnje
11:29
to this very complicated patient
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ovom kompliciranom pacijentu
11:31
with all the records they were bringing
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sa svom dokumentacijom koju donosi
11:33
in a new patient visit of 45 minutes.
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i s trajanjem posjeta od 45 minuta.
11:35
There was just no way.
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Jednostavno nije bilo šanse.
11:37
And if I tried, I'd disappoint them.
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A da sam pokušao, razočarao bi ih.
11:40
And so I hit on this method
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I tako sam počeo s metodom
11:42
where I invited the patient
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kojom bih zatražio od pacijenta
11:44
to tell me the story for their entire first visit,
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da mi priča tijekom cijelog prvog posjeta,
11:47
and I tried not to interrupt them.
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i pokušao sam ih ne prekidati.
11:50
We know the average American physician
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Znamo da prosječni američki liječnik
11:52
interrupts their patient in 14 seconds.
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prekine svojeg pacijenta za 14 sekundi.
11:55
And if I ever get to heaven,
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I ako ikad odem u raj
11:57
it will be because I held my piece for 45 minutes
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to će biti zato što sam 45 minuta mirno slušao
12:00
and did not interrupt my patient.
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svojeg pacijenta bez prekidanja.
12:02
I then scheduled the physical exam for two weeks hence,
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Potom sam naručio pacijenta za fizikalni pregled za dva tjedna,
12:05
and when the patient came for the physical,
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i kada je pacijent došao na pregled
12:07
I was able to do a thorough physical,
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mogao sam napraviti detaljni fizikalni pregled,
12:09
because I had nothing else to do.
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zato što nisam imao ništa drugo za raditi.
12:11
I like to think that I do a thorough physical exam,
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Smatram da radim detaljan fizikalni pregled,
12:14
but because the whole visit was now about the physical,
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ali zbog toga što je cijeli dolazak sada bio zbog pregleda,
12:17
I could do an extraordinarily thorough exam.
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mogao sam obaviti iznimno detaljan fizikalan pregled.
12:20
And I remember my very first patient in that series
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I sjećam se da mi je prvi pacijent iz te grupe
12:24
continued to tell me more history
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nastavio pričati svoju anamnezu
12:26
during what was meant to be the physical exam visit.
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tijekom posjete koja je trebala biti samo fizikalni pregled.
12:29
And I began my ritual.
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I počeo sam svoj ritual.
12:31
I always begin with the pulse,
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Uvijek počinjem s pulsom,
12:33
then I examine the hands, then I look at the nail beds,
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potom pregledam ruke, pogledam ležište nokta,
12:36
then I slide my hand up to the epitrochlear node,
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onda prođem rukom do epitrohlearnog limfnog čvora,
12:38
and I was into my ritual.
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i bio sam u svom ritualu.
12:40
And when my ritual began,
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A kada je moj ritual počeo,
12:42
this very voluble patient
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ovaj vrlo govorljiv pacijent
12:44
began to quiet down.
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je postajao sve tiši.
12:46
And I remember having a very eerie sense
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I sjećam se da sam imao jezovit osjećaj
12:49
that the patient and I
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da smo pacijent i ja
12:52
had slipped back into a primitive ritual
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ušli u primitivni ritual
12:54
in which I had a role
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u kojem sam ja imao ulogu
12:56
and the patient had a role.
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i pacijent je imao ulogu.
12:58
And when I was done,
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I kada sam bio gotov,
13:00
the patient said to me with some awe,
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pacijent mi je rekao s blagim strahopoštovanjem,
13:02
"I have never been examined like this before."
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„Nikad me nitko nije ovako pregledao.“
13:05
Now if that were true,
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Ako je to istina,
13:07
it's a true condemnation of our health care system,
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to bi bila prava osuda našeg zdravstvenog sustava,
13:09
because they had been seen in other places.
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zato što su bili pregledani na drugim mjestima.
13:12
I then proceeded to tell the patient,
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Onda sam nastavio govoriti pacijentu,
13:14
once the patient was dressed,
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kada je bio obučen,
13:16
the standard things that the person must have heard in other institutions,
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standardne stvari koje je sigurno čuo u ostalim institucijama,
13:19
which is, "This is not in your head.
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a to su, „Ovo nije u vašoj glavi.
13:21
This is real.
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Ovo je stvarno.
13:23
The good news, it's not cancer, it's not tuberculosis,
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Dobra je vijest da se ne radi o tumoru ili o tuberkulozi,
13:26
it's not coccidioidomycosis or some obscure fungal infection.
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niti o kokcidioidomikozi ili nekoj drugoj bizarnoj gljivičnoj infekciji.
13:29
The bad news is we don't know exactly what's causing this,
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Loša vijest je da ne znamo točno uzrok vašim tegobama,
13:32
but here's what you should do, here's what we should do."
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ali trebali biste napraviti sljedeće, trebali bismo napraviti sljedeće.“
13:35
And I would lay out all the standard treatment options
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I iznio bih sve standardne mogučnosti liječenja,
13:38
that the patient had heard elsewhere.
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koje je pacijent čuo i prije.
13:41
And I always felt
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I uvijek sam mislio
13:43
that if my patient gave up the quest
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da ako moj pacijent odustane od potrage za
13:45
for the magic doctor, the magic treatment
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čarobnim liječnikom, čarobnim liječenjem,
13:48
and began with me on a course towards wellness,
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i krene sa mnom na put prema dobrostanju,
13:51
it was because I had earned the right
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to znači da sam zavrijedio pravo
13:53
to tell them these things
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da im kažem takve stvari
13:55
by virtue of the examination.
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na temelju pregleda.
13:57
Something of importance had transpired in the exchange.
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Nešto važno se odvilo tijekom te razmjene.
14:01
I took this to my colleagues
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Iznio sam to svojim kolegama
14:03
at Stanford in anthropology
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na Stanfordu na antropologiji
14:05
and told them the same story.
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i ispričao sam im istu priču.
14:07
And they immediately said to me,
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I odmah su mi rekli,
14:09
"Well you are describing a classic ritual."
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„Opisuješ klasični ritual.“
14:11
And they helped me understand
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Pomogli su mi da shvatim
14:13
that rituals are all about transformation.
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da je bit rituala u preobrazbi.
14:16
We marry, for example,
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Primjerice, vjenčamo se
14:18
with great pomp and ceremony and expense
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u velikoj raskoši, ceremoniji i o velikom trošku
14:21
to signal our departure
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da označimo naš odlazak
14:23
from a life of solitude and misery and loneliness
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iz života samoće, jada i usamljenosti
14:25
to one of eternal bliss.
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u život vječnog blagostanja.
14:28
I'm not sure why you're laughing.
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Ne znam zašto se smijete.
14:30
That was the original intent, was it not?
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To je bila izvorna zamisao, zar ne?
14:32
We signal transitions of power
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Označavamo prijelaze moći
14:34
with rituals.
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ritualima.
14:36
We signal the passage of a life with rituals.
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Označavamo prolaznost života ritualima.
14:38
Rituals are terribly important.
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Rituali su iznimno važni.
14:40
They're all about transformation.
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Njihova bit je u preobrazbi.
14:42
Well I would submit to you
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Pa, predložio bih vam
14:44
that the ritual
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da je ritual
14:46
of one individual coming to another
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dolaska jednog pojedinca drugome
14:48
and telling them things
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i pričanje o stvarima,
14:50
that they would not tell their preacher or rabbi,
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koje ne bi rekli svojem svećeniku ili rabinu,
14:53
and then, incredibly on top of that,
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i onda, začuđujuće, povrh toga
14:55
disrobing and allowing touch --
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skidanje odjeće i dopuštanje dodira.
14:58
I would submit to you that that is a ritual of exceeding importance.
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Predložio bih da je taj ritual od iznimne važnosti.
15:02
And if you shortchange that ritual
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I ako loše obavite ovaj ritual
15:04
by not undressing the patient,
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tako da ne skinete pacijenta,
15:06
by listening with your stethoscope on top of the nightgown,
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ili slušate stetoskopom preko ogrtača,
15:09
by not doing a complete exam,
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ili ne obavite cjeloviti pregled,
15:11
you have bypassed on the opportunity
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propustili ste priliku
15:13
to seal the patient-physician relationship.
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učvrstiti odnos između pacijenta i liječnika.
15:17
I am a writer,
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Ja sam spisatelj,
15:19
and I want to close by reading you a short passage that I wrote
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i želio bih završiti izlaganje s čitanjem kratkog odlomka kojeg sam napisao,
15:23
that has to do very much with this scene.
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koji ima veze s ovom situacijom.
15:25
I'm an infectious disease physician,
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Ja sam infektolog,
15:27
and in the early days of HIV, before we had our medications,
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i u počecima HIV-a, prije nego smo imali naše lijekove,
15:30
I presided over so many scenes like this.
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prisustvovao sam mnogim situacijama poput ove.
15:34
I remember, every time I went to a patient's deathbed,
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Sjećam se da svaki put kada bih išao do pacijenta na smrtnoj postelji,
15:37
whether in the hospital or at home,
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bilo u bolnici ili kod kuće,
15:39
I remember my sense of failure --
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sjećam se svog osjećaja poraza,
15:43
the feeling of I don't know what I have to say;
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osjećaja da ne znam što moram reći;
15:45
I don't know what I can say;
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ne znam što mogu reći,
15:47
I don't know what I'm supposed to do.
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ne znam što bih trebao napraviti.
15:49
And out of that sense of failure,
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I iz tog osjećaja neuspjeha,
15:51
I remember, I would always examine the patient.
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sjećam se, uvijek bih pregledao pacijenta.
15:54
I would pull down the eyelids.
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Pogledao bih njihove kapke.
15:56
I would look at the tongue.
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Pogledao bih im jezik.
15:58
I would percuss the chest. I would listen to the heart.
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Perkutirao bih prsa. Poslušao bih srce.
16:01
I would feel the abdomen.
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Opipao bih trbuh.
16:03
I remember so many patients,
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Sjećam se mnogih pacijenata,
16:06
their names still vivid on my tongue,
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njihova imena još uvijek prisutna na mojim usnama,
16:08
their faces still so clear.
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njihova lica još uvijek jasna.
16:10
I remember so many huge, hollowed out, haunted eyes
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Sjećam se toliko velikih, upalih, ukletih očiju
16:14
staring up at me as I performed this ritual.
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kako me gledaju, dok obavljam ovaj ritual.
16:17
And then the next day,
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I onda bih došao sljedeći dan
16:19
I would come, and I would do it again.
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i ponovio ga.
16:21
And I wanted to read you this one closing passage
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Htio sam vam pročitati i ovaj završni odlomak
16:24
about one patient.
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o jednom pacijentu.
16:26
"I recall one patient
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„Sjećam se jednog pacijenta
16:28
who was at that point
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koji u tom stadiju
16:30
no more than a skeleton
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nije bio ništa više od kostura
16:32
encased in shrinking skin,
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u oklopu skupljajuće kože,
16:34
unable to speak,
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nije mogao govoriti
16:36
his mouth crusted with candida
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njegova usta obložena kandidom
16:38
that was resistant to the usual medications.
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koja je bila otporna na uobičajene lijekove.
16:41
When he saw me
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Kada me vidio
16:43
on what turned out to be his last hours on this earth,
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u svojim zadnjim satima na Zemlji,
16:45
his hands moved as if in slow motion.
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njegove ruke su se pomakle kao u usporenom filmu.
16:48
And as I wondered what he was up to,
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I dok sam se pitao što to radi,
16:50
his stick fingers made their way
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njegovi su se štapićasti prsti pomakli
16:52
up to his pajama shirt,
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do košulje njegove piđame
16:54
fumbling with his buttons.
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petljajući s gumbima.
16:57
I realized that he was wanting
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Shvatio sam da je htio
16:59
to expose his wicker-basket chest to me.
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otkriti svoja prsa, koja su izgledala poput pletene košare.
17:02
It was an offering, an invitation.
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Bila je to ponuda, poziv.
17:05
I did not decline.
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Nisam odbio.
17:07
I percussed. I palpated. I listened to the chest.
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Perkutirao sam. Palpirao sam. Poslušao sam pluća.
17:10
I think he surely must have known by then
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Mislim da je do tada morao znati kako je
17:12
that it was vital for me
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ovo bilo toliko vitalno za mene
17:14
just as it was necessary for him.
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koliko je bilo nužno za njega.
17:16
Neither of us could skip this ritual,
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Nijedan od nas dvojice nije mogao preskočiti ovaj ritual,
17:19
which had nothing to do with detecting rales in the lung,
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koji nije imao nikakve veze s otkrivanjem hropaca na plućima,
17:22
or finding the gallop rhythm of heart failure.
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ili traženjem galopnog ritma srčanog zastoja.
17:25
No, this ritual was about the one message
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Ne, ovaj ritual je bio o poruci
17:28
that physicians have needed to convey to their patients.
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koju su liječnici trebali prenijeti svojim pacijentima.
17:31
Although, God knows, of late, in our hubris,
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Iako sam Bog zna da se čini da smo u zadnje vrijeme,
17:33
we seem to have drifted away.
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odlutali u našoj oholosti.
17:35
We seem to have forgotten --
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Kao da smo zaboravili,
17:37
as though, with the explosion of knowledge,
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kao da s eksplozijom znanja,
17:39
the whole human genome mapped out at our feet,
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cijeli ljudski genom stoji mapiran pred nama,
17:42
we are lulled into inattention,
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uljuljkani smo u nepažnju,
17:44
forgetting that the ritual is cathartic to the physician,
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zaboravljajući da ritual pruža katarzu liječniku,
17:47
necessary for the patient --
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da je nužan za pacijenta,
17:49
forgetting that the ritual has meaning
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zaboravljajući da ritual ima značenje
17:51
and a singular message to convey to the patient.
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i jednu jedinu poruku koju treba prenijeti pacijentu.
17:55
And the message, which I didn't fully understand then,
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A poruka, koju nisam u potpunosti tada shvatio,
17:58
even as I delivered it,
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čak i kad sam je prenosio,
18:00
and which I understand better now is this:
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a koju shvaćam sada bolje je ova:
18:03
I will always, always, always be there.
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Uvijek, uvijek, uvijek ću biti uz tebe.
18:06
I will see you through this.
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Pratit ću te kroz ovo.
18:08
I will never abandon you.
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Nikad te neću napustiti.
18:10
I will be with you through the end."
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Bit ću s tobom do kraja.“
18:12
Thank you very much.
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Puno vam hvala.
18:14
(Applause)
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(Pljesak)
ABOUT THE SPEAKER
Abraham Verghese - Physician and authorIn our era of the patient-as-data-point, Abraham Verghese believes in the old-fashioned physical exam, the bedside chat, the power of informed observation.
Why you should listen
Before he finished medical school, Abraham Verghese spent a year on the other end of the medical pecking order, as a hospital orderly. Moving unseen through the wards, he saw the patients with new eyes, as human beings rather than collections of illnesses. The experience has informed his work as a doctor -- and as a writer. "Imagining the Patient’s Experience" was the motto of the Center for Medical Humanities & Ethics, which he founded at the University of Texas San Antonio, where he brought a deep-seated empathy. He’s now a professor for the Theory and Practice of Medicine at Stanford, where his old-fashioned weekly rounds have inspired a new initiative, the Stanford 25, teaching 25 fundamental physical exam skills and their diagnostic benefits to interns.
He’s also a best-selling writer, with two memoirs and a novel, Cutting for Stone, a moving story of two Ethiopian brothers bound by medicine and betrayal.
He says: “I still find the best way to understand a hospitalized patient is not by staring at the computer screen but by going to see the patient; it's only at the bedside that I can figure out what is important.”
In 2011, Verghese was elected to the Institute of Medicine, which advises the government and private institutions on medicine and health on a national level.
Abraham Verghese | Speaker | TED.com