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TEDGlobal 2011

Abraham Verghese: A doctor's touch

エイブラハム・バルギーズ:医師の手が持つ力

July 14, 2011

近代医療は、人の手が持つ力という、昔からある強力なツールを失いつつあります。医師であり作家でもあるエイブラハム・バルギーズは、患者がもはやパソコン上のデータに過ぎなくなった現代社会の奇妙さを描き、昔ながらの一対一の診察への回帰を呼びかけます。

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

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Double-click the English subtitles below to play the video.
A few months ago,
ほんの数ヶ月前
00:15
a 40 year-old woman came to an emergency room
私の近所のとある病院に
00:17
in a hospital close to where I live,
40代の女性が意識不明で
00:20
and she was brought in confused.
担ぎ込まれました
00:22
Her blood pressure was an alarming
血圧は
00:24
230 over 170.
危険領域に達し
00:26
Within a few minutes, she went into cardiac collapse.
数分後 心肺停止状態となりました
00:29
She was resuscitated, stabilized,
すぐさま 蘇生処置がほどこされ
00:32
whisked over to a CAT scan suite
救命室の隣のCATスキャンへ
00:35
right next to the emergency room,
運ばれました
00:37
because they were concerned about blood clots in the lung.
肺に血栓の疑いがあったのです
00:39
And the CAT scan revealed
スキャンの結果
00:42
no blood clots in the lung,
血栓こそありませんでしたが
00:44
but it showed bilateral, visible, palpable breast masses,
なんと両方の乳房に明らかな
00:46
breast tumors,
癌の腫瘍が見られ
00:51
that had metastasized widely
体中に
00:53
all over the body.
転移していました
00:55
And the real tragedy was, if you look through her records,
ひどい話ですが カルテによると
00:57
she had been seen
過去数年間に
01:00
in four or five other health care institutions
数箇所の医療機関で
01:02
in the preceding two years.
受診歴があるのです
01:04
Four or five opportunities
ということは こうなる前に
01:06
to see the breast masses, touch the breast mass,
乳房のしこりが発見され
01:08
intervene at a much earlier stage
早期に対処が
01:10
than when we saw her.
できたかもしれないということです
01:13
Ladies and gentlemen,
みなさん
01:15
that is not an unusual story.
珍しい例ではありません
01:17
Unfortunately, it happens all the time.
残念ながらどこででもありえます
01:19
I joke, but I only half joke,
半分はジョークですが
01:22
that if you come to one of our hospitals missing a limb,
脚を失った状態で 病院に来ても
01:24
no one will believe you till they get a CAT scan, MRI
CATスキャン MRIといった検査を受けるまで
01:27
or orthopedic consult.
誰も気づかないでしょう
01:30
I am not a Luddite.
先端技術が嫌いなわけじゃありません
01:32
I teach at Stanford.
スタンフォードで教えてますし
01:34
I'm a physician practicing with cutting-edge technology.
こうした技術も利用しています
01:36
But I'd like to make the case to you
しかし この17分間でご紹介したいのは
01:38
in the next 17 minutes
患者と話をし
01:40
that when we shortcut the physical exam,
触れて診察を行う代りに
01:42
when we lean towards ordering tests
検査に偏重し 患者との
01:46
instead of talking to and examining the patient,
ふれあいを省略すると
01:48
we not only overlook simple diagnoses
まだ初期段階の 治癒可能な
01:51
that can be diagnosed at a treatable, early stage,
症状を見過ごしてしまうだけではなく
01:54
but we're losing much more than that.
もっと大切な「儀式」が
01:57
We're losing a ritual.
失われてしまうのです
01:59
We're losing a ritual that I believe is transformative, transcendent,
これには 医師と患者の関係に
02:01
and is at the heart
変化をおこし 強力にする
02:04
of the patient-physician relationship.
力があるのです
02:06
This may actually be heresy to say this at TED,
TEDでご紹介するのは
02:08
but I'd like to introduce you
場違いかもしれませんが
02:11
to the most important innovation,
今後10年間における
02:13
I think, in medicine
もっとも重要な
02:15
to come in the next 10 years,
イノベーションは
02:17
and that is the power of the human hand --
人の手の持つ力でしょう
02:19
to touch, to comfort, to diagnose
触れて 癒し 診察する
02:21
and to bring about treatment.
そして治療を行う
02:24
I'd like to introduce you first to this person
まずはこの人物をご紹介します
02:26
whose image you may or may not recognize.
お気づきの方もいるでしょう
02:29
This is Sir Arthur Conan Doyle.
アーサー・コナン・ドイルです
02:31
Since we're in Edinburgh, I'm a big fan of Conan Doyle.
私はコナン・ドイルの大ファンです
02:33
You might not know that Conan Doyle went to medical school
ここエジンバラで 彼は医学を
02:36
here in Edinburgh,
学んだ経験もあります
02:38
and his character, Sherlock Holmes,
シャーロック・ホームズは
02:40
was inspired by Sir Joseph Bell.
ジョセフ・ベルにインスパイアされました
02:42
Joseph Bell was an extraordinary teacher by all accounts.
あらゆる点で ジョセフ・ベルは優れた教師で
02:45
And Conan Doyle, writing about Bell,
コナン・ドイルは
02:48
described the following exchange
ベルと生徒とのやりとりについて
02:51
between Bell and his students.
こんな逸話を残しています
02:53
So picture Bell sitting in the outpatient department,
想像してください ベルは外来で
02:55
students all around him,
生徒は彼を取り巻き
02:58
patients signing up in the emergency room
受付を済ませた患者が
03:00
and being registered and being brought in.
処置室にやって来ます
03:02
And a woman comes in with a child,
彼女は子供を連れていました
03:05
and Conan Doyle describes the following exchange.
コナン・ドイルはこんな会話を残しています
03:07
The woman says, "Good Morning."
「おはようございます」患者は言いました
03:10
Bell says, "What sort of crossing did you have
「バーンティスランドからのフェリーは
03:14
on the ferry from Burntisland?"
いかがだったかな?」ベルは言います
03:17
She says, "It was good."
「よかったですよ」患者は答えます
03:20
And he says, "What did you do with the other child?"
「もう一人のお子さんはどうしたのかな?」ベルは言います
03:22
She says, "I left him with my sister at Leith."
「リースの姉に預けて来ました」
03:25
And he says,
彼は続けます
03:28
"And did you take the shortcut down Inverleith Row
「ここに来る時に 植物園を通って
03:30
to get here to the infirmary?"
近道をしたんじゃないかね?」
03:32
She says, "I did."
「そうです」患者は答えます
03:34
And he says, "Would you still be working at the linoleum factory?"
「今も リノリウム工場で働いているのかね?」
03:36
And she says, "I am."
「そうです」患者は答えます
03:40
And Bell then goes on to explain to the students.
ベルは生徒達に説明し始めました
03:42
He says, "You see, when she said, 'Good morning,'
「彼女が挨拶した時
03:44
I picked up her Fife accent.
ファイフ訛りと気づいてね
03:47
And the nearest ferry crossing from Fife is from Burntisland.
ファイフから最寄のフェリーはバーンティスランドだ
03:49
And so she must have taken the ferry over.
だからフェリーを使ったに違いないと
03:52
You notice that the coat she's carrying
そして 彼女が持っているコートを見ると
03:55
is too small for the child who is with her,
連れている子供のものにしては小さすぎると
03:57
and therefore, she started out the journey with two children,
なので 最初は2人連れて出発し
04:00
but dropped one off along the way.
途中で一人を預けたのだろうと
04:03
You notice the clay on the soles of her feet.
靴底の土に気づいてね
04:06
Such red clay is not found within a hundred miles of Edinburgh,
エジンバラの周辺には こんな赤土は存在しない
04:08
except in the botanical gardens.
植物園を除いてはね
04:12
And therefore, she took a short cut down Inverleith Row
だから 彼女は植物園を通って
04:14
to arrive here.
近道したんだなと
04:17
And finally, she has a dermatitis
最後に 彼女の右手の指には
04:19
on the fingers of her right hand,
皮膚炎が見られる
04:21
a dermatitis that is unique
この皮膚炎はバーンティスランドの
04:23
to the linoleum factory workers in Burntisland."
リノリウム工場の工員に独特のものなんだ」
04:25
And when Bell actually strips the patient,
ベルは実際に服を脱がせ
04:28
begins to examine the patient,
診察を始める前に
04:30
you can only imagine how much more he would discern.
なんと多くの情報を得ていたことか
04:32
And as a teacher of medicine, as a student myself,
医学の教師であり また生徒でもある私は
04:35
I was so inspired by that story.
この話に大変感銘を受けました
04:38
But you might not realize
しかしながら
04:40
that our ability to look into the body
医師の知覚という単純な手段で
04:42
in this simple way, using our senses,
体の中が調べられるようになったのは
04:44
is quite recent.
ごく近年のことです
04:46
The picture I'm showing you is of Leopold Auenbrugger
こちらは レオポルト・アウエンブルッカー
04:48
who, in the late 1700s,
1,700年代 彼により
04:51
discovered percussion.
打診法が開発されました
04:53
And the story is that Leopold Auenbrugger
きっかけは 彼の父親が
04:55
was the son of an innkeeper.
居酒屋の主人であったことです
04:58
And his father used to go down into the basement
父親はワイン樽をコツコツ叩いて
05:01
to tap on the sides of casks of wine
ワインの残量を測っていました
05:04
to determine how much wine was left
ワインの追加注文のタイミングを
05:06
and whether to reorder.
決めるためです
05:08
And so when Auenbrugger became a physician,
アウエンブルッカーは医師となり
05:10
he began to do the same thing.
同じことをはじめました
05:12
He began to tap on the chests of his patients,
患者の胸部や腹部を叩く診察法を
05:14
on their abdomens.
はじめました
05:17
And basically everything we know about percussion,
打診はいわば当時の超音波診断ですが
05:19
which you can think of as an ultrasound of its day --
今日知られている全て -臓器肥大も
05:21
organ enlargement, fluid around the heart, fluid in the lungs,
心嚢水も肺水腫も
05:25
abdominal changes --
腹部の異変なども全て
05:28
all of this he described in this wonderful manuscript
この優れた著書に記されています
05:30
"Inventum Novum," "New Invention,"
「新発見」
05:32
which would have disappeared into obscurity,
この手法は忘れさられるところでした
05:35
except for the fact that this physician, Corvisart,
著名なフランスの医師 コルヴィザール-
05:37
a famous French physician --
彼はこちらの紳士の
05:40
famous only because he was physician to this gentleman --
主治医であったことのみで有名でしたが-
05:42
Corvisart repopularized and reintroduced the work.
彼は打診法を復活させました
05:45
And it was followed a year or two later
1〜2 年後にラエンエックにより
05:49
by Laennec discovering the stethoscope.
聴診器が発明されるに至ります
05:51
Laennec, it is said, was walking in the streets of Paris
彼がある日 パリを歩いていた時のこと
05:54
and saw two children playing with a stick.
棒で遊んでいる二人の子供を見かけました
05:57
One was scratching at the end of the stick,
一人が端っこを引っかいて
05:59
another child listened at the other end.
もう一人が別の端っこで音を聞いていました
06:02
And Laennec thought this would be a wonderful way
ラエンネックは思いつきました
06:04
to listen to the chest or listen to the abdomen
これは 体内の音を聴くのに 良い方法だと
06:06
using what he called "the cylinder."
これをシリンダーと彼は名付け
06:08
Later he renamed it the stethoscope.
のちに 聴診器と改名し
06:10
And that is how stethoscope and auscultation was born.
こうして聴診器と聴診が生まれたのです
06:12
So within a few years,
18世紀の終わりから
06:16
in the late 1800s, early 1900s,
19世紀初頭の数年間で
06:18
all of a sudden,
急激に
06:20
the barber surgeon had given way
手術を行う理髪店は
06:22
to the physician who was trying to make a diagnosis.
診察を行う医師に取って代わられました
06:25
If you'll recall, prior to that time,
当時の人々は
06:28
no matter what ailed you, you went to see the barber surgeon
どんな症状であっても こうした理髪店に行っていました
06:30
who wound up cupping you,
そこでは吸引療法
06:33
bleeding you, purging you.
血抜き療法 洗浄療法
06:35
And, oh yes, if you wanted,
そして お望みなら
06:37
he would give you a haircut -- short on the sides, long in the back --
もちろん髪も切ってくれました
06:39
and pull your tooth while he was at it.
おまけに歯だって抜いてくれます
06:42
He made no attempt at diagnosis.
ただ 診察は全くありません
06:44
In fact, some of you might well know
事実 ご存知の方もいるでしょうか
06:46
that the barber pole, the red and white stripes,
理髪店の赤と白の縞模様のポールは
06:48
represents the blood bandages of the barber surgeon,
血に染まった包帯からきたものなんです
06:51
and the receptacles on either end
両端の物体は
06:54
represent the pots in which the blood was collected.
血液を集める容器を表しています
06:56
But the arrival of auscultation and percussion
聴診と打診の登場は
06:59
represented a sea change,
転換期を象徴するものでした
07:02
a moment when physicians were beginning to look inside the body.
医師が患者の体内に注目しはじめたのです
07:04
And this particular painting, I think,
個人的には こちらの絵は
07:07
represents the pinnacle, the peak, of that clinical era.
そうした決定的な時代の頂点を表しています
07:10
This is a very famous painting:
とても有名な絵で
07:13
"The Doctor" by Luke Fildes.
ルーク・フィルデス作 「医師」
07:15
Luke Fildes was commissioned to paint this by Tate,
彼はテート美術館の創立者である
07:18
who then established the Tate Gallery.
テート氏の依頼により描きました
07:21
And Tate asked Fildes to paint a painting
社会的に影響力のある絵画を頼む と
07:23
of social importance.
依頼されたのです
07:25
And it's interesting that Fildes picked this topic.
医師がテーマに選ばれた興味深い話があります
07:27
Fildes' oldest son, Philip,
フィルデスの長男のフィリップは
07:30
died at the age of nine on Christmas Eve
9つのとき 短期間の病を経て
07:33
after a brief illness.
クリスマス・イヴに亡くなりました
07:36
And Fildes was so taken by the physician
息子の横で数日に及び
07:38
who held vigil at the bedside for two, three nights,
寝ずの看病を続けた医師に感動したフィルデスは
07:41
that he decided that he would try and depict
医師の姿を描こうと
07:45
the physician in our time --
決めたのです
07:47
almost a tribute to this physician.
この医師に捧げるためでした
07:49
And hence the painting "The Doctor," a very famous painting.
「医師」はとても有名で
07:51
It's been on calendars, postage stamps in many different countries.
各国でカレンダーや切手のデザインになってます
07:54
I've often wondered, what would Fildes have done
よく思うんです もしフィルデスが
07:57
had he been asked to paint this painting
2011年にこの絵画を依頼されたなら
08:00
in the modern era,
一体何を
08:02
in the year 2011?
描くのだろうと
08:04
Would he have substituted a computer screen
患者のかわりにパソコン画面を
08:07
for where he had the patient?
もってくるのでは?
08:11
I've gotten into some trouble in Silicon Valley
シリコンバレーで批判を受けました
08:13
for saying that the patient in the bed
「患者はもはや
08:15
has almost become an icon
パソコン上のデータに
08:17
for the real patient who's in the computer.
過ぎなくなった」と言ったのです
08:20
I've actually coined a term for that entity in the computer.
そうしたデータに名前まで付けました
08:23
I call it the iPatient.
アイ・ペイシャントです
08:26
The iPatient is getting wonderful care all across America.
全米でデータは手厚いケアを受ける一方
08:28
The real patient often wonders,
本物の患者は思います
08:31
where is everyone?
「みんなどこ?」
08:33
When are they going to come by and explain things to me?
「いつになったら僕のところに説明にくるの?」
08:35
Who's in charge?
「担当者は誰?」
08:38
There's a real disjunction between the patient's perception
一流の治療の定義は患者と
08:40
and our own perceptions as physicians of the best medical care.
我々医師の間ではかけ離れたものになっています
08:43
I want to show you a picture
こちらをご覧いただきましょう
08:46
of what rounds looked like
私が研修医の頃の
08:48
when I was in training.
回診の様子です
08:50
The focus was around the patient.
中心には患者がいました
08:52
We went from bed to bed. The attending physician was in charge.
ベッドからベッドへ 主治医が回ります
08:54
Too often these days,
最近では
08:57
rounds look very much like this,
回診の様子はこうです
08:59
where the discussion is taking place
議論は患者から遠く離れた
09:01
in a room far away from the patient.
会議室で行われます
09:03
The discussion is all about images on the computer, data.
議論の中心はパソコン上のイメージとデータのみ
09:06
And the one critical piece missing
不可欠な要素である
09:09
is that of the patient.
患者本人が抜け落ちています
09:11
Now I've been influenced in this thinking
では 私が影響を受けた
09:13
by two anecdotes that I want to share with you.
2つのエピソードをご紹介したいと思います
09:16
One had to do with a friend of mine who had a breast cancer,
一つ目は乳がんを患った友人の話です
09:19
had a small breast cancer detected --
小さな乳がんが発見され
09:22
had her lumpectomy in the town in which I lived.
私の住む地元で摘出手術を受けました
09:25
This is when I was in Texas.
私がテキサスにいた頃です
09:27
And she then spent a lot of time researching
その後 術後のケアのため
09:29
to find the best cancer center in the world
彼女は世界で一番のがんセンターを
09:32
to get her subsequent care.
探しはじめました
09:35
And she found the place and decided to go there, went there.
お目当ての場所が見つかり 彼女はそこに行ったんです
09:37
Which is why I was surprised a few months later
なので数ヵ月後 町に戻った彼女を見かけて
09:40
to see her back in our own town,
私は驚きました
09:43
getting her subsequent care with her private oncologist.
ここで 地元の癌専門医に通っていたのです
09:46
And I pressed her, and I asked her,
彼女に聞きました
09:49
"Why did you come back and get your care here?"
「なぜここでケアを受けることにしたの?」
09:51
And she was reluctant to tell me.
彼女はためらいながらも言いました
09:54
She said, "The cancer center was wonderful.
「がんセンターはステキだったわ
09:56
It had a beautiful facility,
施設も立派だし 巨大な
09:59
giant atrium, valet parking,
吹き抜けに バレー・パーキング
10:01
a piano that played itself,
自動のピアノだってあるの
10:03
a concierge that took you around from here to there.
あちこち連れてってくれる世話人もいるしね」
10:05
But," she said,
「でもね
10:08
"but they did not touch my breasts."
そこでは 胸に一度も触わらなかったの」
10:10
Now you and I could argue
胸に触る必要さえなかったと
10:14
that they probably did not need to touch her breasts.
言えなくもありません
10:16
They had her scanned inside out.
彼女のデータはスキャンされ
10:18
They understood her breast cancer at the molecular level;
彼女の乳がんは分子レベルで把握され
10:20
they had no need to touch her breasts.
触る必要さえなかったわけです
10:23
But to her, it mattered deeply.
でも 彼女にとっては
10:25
It was enough for her to make the decision
病院を変えさせるくらい
10:28
to get her subsequent care with her private oncologist
重要な要素だったのです
10:32
who, every time she went,
今の医者は毎回
10:35
examined both breasts including the axillary tail,
両方の乳房をわきの下も含め
10:37
examined her axilla carefully,
じっくり診察し
10:40
examined her cervical region, her inguinal region,
首まわり 股のあたりもじっくりと
10:42
did a thorough exam.
診察します
10:44
And to her, that spoke of a kind of attentiveness that she needed.
彼女は こうした手厚いケアを求めていたのです
10:46
I was very influenced by that anecdote.
この話に私は大いに影響を受けました
10:50
I was also influenced by another experience that I had,
もう一つ影響を受けた経験をお話しましょう
10:52
again, when I was in Texas, before I moved to Stanford.
スタンフォードに移る前 テキサス時代の話です
10:55
I had a reputation
当時 私には
10:58
as being interested in patients
慢性疲労患者の専門医
11:00
with chronic fatigue.
という評判がありました
11:02
This is not a reputation you would wish on your worst enemy.
好ましい評判ではありません
11:05
I say that because these are difficult patients.
というのも なにせ手強い相手です
11:09
They have often been rejected by their families,
こうした患者は家族から見放され
11:12
have had bad experiences with medical care
医療機関では苦い経験をし
11:15
and they come to you fully prepared
私の所に来る頃には
11:17
for you to join the long list of people
もう期待などない状態
11:20
who's about to disappoint them.
なんですから
11:22
And I learned very early on with my first patient
まさに最初のこうした患者を診察した時
11:24
that I could not do justice
彼らが持ってくる
11:27
to this very complicated patient
これまでの診察記録は
11:29
with all the records they were bringing
初診の45分間で
11:31
in a new patient visit of 45 minutes.
症状を把握するには
11:33
There was just no way.
全く役に立たないことが分かりました
11:35
And if I tried, I'd disappoint them.
また同じ事の繰り返しです
11:37
And so I hit on this method
そこで ある方法を思いつきました
11:40
where I invited the patient
初診では 全ての時間を使って
11:42
to tell me the story for their entire first visit,
患者に自分の状態を語ってもらうのです
11:44
and I tried not to interrupt them.
中断せずじっと聞くことにしました
11:47
We know the average American physician
アメリカでは平均的な医師は
11:50
interrupts their patient in 14 seconds.
患者の話に14秒で割って入ります
11:52
And if I ever get to heaven,
もし私が天国にいけるなら
11:55
it will be because I held my piece for 45 minutes
患者の話を中断することなく
11:57
and did not interrupt my patient.
45分聞き続けたからでしょう
12:00
I then scheduled the physical exam for two weeks hence,
2週間後に仕切りなおして 診察をします
12:02
and when the patient came for the physical,
その時には
12:05
I was able to do a thorough physical,
じっくりと診断ができます
12:07
because I had nothing else to do.
他にする事が無いのですから
12:09
I like to think that I do a thorough physical exam,
徹底的に診察するのは
12:11
but because the whole visit was now about the physical,
その回が診察のための回だからという理由でなく
12:14
I could do an extraordinarily thorough exam.
とてつもなく詳細に診察するためです
12:17
And I remember my very first patient in that series
こうした診察回に最初に訪れた患者は
12:20
continued to tell me more history
最初 自身の症状をとうとうと
12:24
during what was meant to be the physical exam visit.
語り始めました この回は診察のための回というのに
12:26
And I began my ritual.
そこで私も手順に従って
12:29
I always begin with the pulse,
まず脈を図ります
12:31
then I examine the hands, then I look at the nail beds,
そして患者の手を 爪床をチェックします
12:33
then I slide my hand up to the epitrochlear node,
手を滑らせながら肘のリンパ腺へ-
12:36
and I was into my ritual.
いつもの手順です
12:38
And when my ritual began,
私の手順が始まると
12:40
this very voluble patient
このおしゃべりな患者が
12:42
began to quiet down.
静かになり
12:44
And I remember having a very eerie sense
不思議な感覚を覚えました
12:46
that the patient and I
患者と私は なにか
12:49
had slipped back into a primitive ritual
原始的な儀式を行っているという感覚
12:52
in which I had a role
私には役割があり
12:54
and the patient had a role.
そして患者にも役割がある
12:56
And when I was done,
診察が終わった際
12:58
the patient said to me with some awe,
患者は畏敬の念とともに言いました
13:00
"I have never been examined like this before."
こんな風に診察されたのは始めてです
13:02
Now if that were true,
さて これが事実なら
13:05
it's a true condemnation of our health care system,
現代の医療システムに
13:07
because they had been seen in other places.
問題があるということです
13:09
I then proceeded to tell the patient,
そして 私は患者が服を着た後
13:12
once the patient was dressed,
診察結果を説明します
13:14
the standard things that the person must have heard in other institutions,
他の医療機関でも聞いたであろう内容です
13:16
which is, "This is not in your head.
「あなたの思い込みではなく
13:19
This is real.
病気は存在します
13:21
The good news, it's not cancer, it's not tuberculosis,
良いニュースは 癌や結核 はたまた
13:23
it's not coccidioidomycosis or some obscure fungal infection.
なにか恐ろしい感染症ではありません
13:26
The bad news is we don't know exactly what's causing this,
悪いニュースは一体何が原因かわからないことです
13:29
but here's what you should do, here's what we should do."
では まずあなたがすべき事と 私達がすべき事です…」
13:32
And I would lay out all the standard treatment options
こうして私は患者に通常の治療法を説明します
13:35
that the patient had heard elsewhere.
他でも聞いた内容なのです
13:38
And I always felt
よく思うのが
13:41
that if my patient gave up the quest
もし 私の患者が ありもしない
13:43
for the magic doctor, the magic treatment
名医や特効薬を探すのはやめて
13:45
and began with me on a course towards wellness,
私と治療へのプロセスを歩み始めてくれるなら
13:48
it was because I had earned the right
それは 徹底的な診察の結果として
13:51
to tell them these things
治療法を説明するに必要な
13:53
by virtue of the examination.
信頼を築いたからだと思います
13:55
Something of importance had transpired in the exchange.
診察を通して 何か重要なものが生まれたのだと思います
13:57
I took this to my colleagues
スタンフォードで
14:01
at Stanford in anthropology
人類学を教える同僚たちに
14:03
and told them the same story.
この話をしてみました
14:05
And they immediately said to me,
彼らはすぐに答えました
14:07
"Well you are describing a classic ritual."
「それは古典的な儀式のことだね」と
14:09
And they helped me understand
彼らによると 儀式とは
14:11
that rituals are all about transformation.
つまるところ 変化であると
14:13
We marry, for example,
例えば 私たちは
14:16
with great pomp and ceremony and expense
豪華な結婚式を行います
14:18
to signal our departure
寂しい独り身から
14:21
from a life of solitude and misery and loneliness
永遠の祝福への出発を
14:23
to one of eternal bliss.
お祝いしているわけです
14:25
I'm not sure why you're laughing.
なぜ みなさん笑っているのでしょうか?
14:28
That was the original intent, was it not?
もともとはそういう意味だったでしょ?
14:30
We signal transitions of power
儀式こそがこうした変化を知らせる
14:32
with rituals.
シグナルなのです
14:34
We signal the passage of a life with rituals.
人生の節々でこうしたシグナルを出します
14:36
Rituals are terribly important.
儀式はとても大事なものなのです
14:38
They're all about transformation.
儀式とは変化を表すものです
14:40
Well I would submit to you
ある人が
14:42
that the ritual
とある人を訪れ
14:44
of one individual coming to another
牧師やラビには
14:46
and telling them things
言いたくないことを伝え
14:48
that they would not tell their preacher or rabbi,
驚くべきことに
14:50
and then, incredibly on top of that,
服を脱ぎ
14:53
disrobing and allowing touch --
体を触らせるという儀式-
14:55
I would submit to you that that is a ritual of exceeding importance.
こうした儀式がとても重要なのです
14:58
And if you shortchange that ritual
服を着せたまま診察したり
15:02
by not undressing the patient,
ガウンの上から聴診したり
15:04
by listening with your stethoscope on top of the nightgown,
徹底的な診察をせず
15:06
by not doing a complete exam,
こうしたことで 儀式を省略すると
15:09
you have bypassed on the opportunity
患者と医師の関係をつなぐ機会を
15:11
to seal the patient-physician relationship.
失うことになるのです
15:13
I am a writer,
私が書いた
15:17
and I want to close by reading you a short passage that I wrote
短い一節を読みまして 終わりにします
15:19
that has to do very much with this scene.
ご覧のようなシーンと関係します
15:23
I'm an infectious disease physician,
私は感染症の専門医で
15:25
and in the early days of HIV, before we had our medications,
エイズが認識されはじめ まだ治療法も無い頃
15:27
I presided over so many scenes like this.
こうした光景に立ち会うことが多々ありました
15:30
I remember, every time I went to a patient's deathbed,
患者の臨終の床に立ち会う際
15:34
whether in the hospital or at home,
それが患者の自宅でも病院でも
15:37
I remember my sense of failure --
常に挫折を感じていました-
15:39
the feeling of I don't know what I have to say;
何を言わなければいけないのかー
15:43
I don't know what I can say;
何を言っていいのかー
15:45
I don't know what I'm supposed to do.
何をすべきかも分かりません
15:47
And out of that sense of failure,
そうした挫折感から
15:49
I remember, I would always examine the patient.
いつも患者を診察するようにしていました
15:51
I would pull down the eyelids.
まぶたをめくり
15:54
I would look at the tongue.
舌を見て
15:56
I would percuss the chest. I would listen to the heart.
胸部を打診し 心音を聴きます
15:58
I would feel the abdomen.
そして 腹部をさすります
16:01
I remember so many patients,
私は多くの患者の
16:03
their names still vivid on my tongue,
名前や顔は今でも
16:06
their faces still so clear.
はっきり覚えています
16:08
I remember so many huge, hollowed out, haunted eyes
大きく 窪み おびえたような目が
16:10
staring up at me as I performed this ritual.
儀式を行う私を見上げていました
16:14
And then the next day,
翌日も
16:17
I would come, and I would do it again.
また私は同じ事を行うのです
16:19
And I wanted to read you this one closing passage
では 最後となる一節を読みたいと思います
16:21
about one patient.
ある患者の話です
16:24
"I recall one patient
「ある患者を思い出す
16:26
who was at that point
彼はその時点で
16:28
no more than a skeleton
皮に包まれた
16:30
encased in shrinking skin,
骸骨と化していた
16:32
unable to speak,
話すことはできず
16:34
his mouth crusted with candida
普通の薬の効かない
16:36
that was resistant to the usual medications.
カンジダで 口もカサブタだらけ
16:38
When he saw me
亡くなる数時間前のことだった
16:41
on what turned out to be his last hours on this earth,
彼は私を目にすると
16:43
his hands moved as if in slow motion.
スローモーションで手を動かし始めた
16:45
And as I wondered what he was up to,
何をしようとしているのか?
16:48
his stick fingers made their way
小枝のような指は
16:50
up to his pajama shirt,
パジャマのシャツを目指すが
16:52
fumbling with his buttons.
ボタンがつまめない
16:54
I realized that he was wanting
診察してもらうため
16:57
to expose his wicker-basket chest to me.
痩せた胸を出したいのだと私は気づいた
16:59
It was an offering, an invitation.
このような提案を—勧誘を
17:02
I did not decline.
断ることなどできない
17:05
I percussed. I palpated. I listened to the chest.
打診し 触診し そして胸部の音を聴く
17:07
I think he surely must have known by then
彼はその時点で気づいていたに違いないだろう
17:10
that it was vital for me
これが自分にとって必要なだけではなく
17:12
just as it was necessary for him.
私にも不可欠なことだと
17:14
Neither of us could skip this ritual,
お互いに省略するわけに行かない儀式なのだ
17:16
which had nothing to do with detecting rales in the lung,
肺の水泡を見つけるためではなく
17:19
or finding the gallop rhythm of heart failure.
心音の異常を探すこととは全く関係なく
17:22
No, this ritual was about the one message
医師が患者に伝えるべき
17:25
that physicians have needed to convey to their patients.
あのメッセージを伝えるための儀式なのだ
17:28
Although, God knows, of late, in our hubris,
傲慢になった私たちは
17:31
we seem to have drifted away.
そこから押し流され
17:33
We seem to have forgotten --
忘れてしまったかのようだ
17:35
as though, with the explosion of knowledge,
知識を急速に増大させ
17:37
the whole human genome mapped out at our feet,
人間の遺伝子地図を踏破しつくし
17:39
we are lulled into inattention,
無関心に陥ったかのようだ
17:42
forgetting that the ritual is cathartic to the physician,
儀式が医師の癒しであり
17:44
necessary for the patient --
患者に欠かせないことが忘れられ
17:47
forgetting that the ritual has meaning
儀式の持つ意味と
17:49
and a singular message to convey to the patient.
患者に伝えるべき唯一のメッセージが忘れられている
17:51
And the message, which I didn't fully understand then,
当時の私が伝えつつも
17:55
even as I delivered it,
理解は十分ではなかったが
17:58
and which I understand better now is this:
今ではよく分かるようになったメッセージである
18:00
I will always, always, always be there.
私はいつもいつも ここにいて
18:03
I will see you through this.
最後まで見届けます
18:06
I will never abandon you.
決して見捨てません
18:08
I will be with you through the end."
最後まで一緒です」
18:10
Thank you very much.
どうもありがとうございました
18:12
(Applause)
(拍手)
18:14
Translator:SHIGERU MASUKAWA
Reviewer:Natsuhiko Mizutani

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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.

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.

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