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
Filmed:
Readability: 4.2
1,719,216 views
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
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,
0
0
2000
ほんの数ヶ月前
00:17
a 40 year-old woman came to an emergency room
1
2000
3000
私の近所のとある病院に
00:20
in a hospital close to where I live,
2
5000
2000
40代の女性が意識不明で
00:22
and she was brought in confused.
3
7000
2000
担ぎ込まれました
00:24
Her blood pressure was an alarming
4
9000
2000
血圧は
00:26
230 over 170.
5
11000
3000
危険領域に達し
00:29
Within a few minutes, she went into cardiac collapse.
6
14000
3000
数分後 心肺停止状態となりました
00:32
She was resuscitated, stabilized,
7
17000
3000
すぐさま 蘇生処置がほどこされ
00:35
whisked over to a CAT scan suite
8
20000
2000
救命室の隣のCATスキャンへ
00:37
right next to the emergency room,
9
22000
2000
運ばれました
00:39
because they were concerned about blood clots in the lung.
10
24000
3000
肺に血栓の疑いがあったのです
00:42
And the CAT scan revealed
11
27000
2000
スキャンの結果
00:44
no blood clots in the lung,
12
29000
2000
血栓こそありませんでしたが
00:46
but it showed bilateral, visible, palpable breast masses,
13
31000
5000
なんと両方の乳房に明らかな
00:51
breast tumors,
14
36000
2000
癌の腫瘍が見られ
00:53
that had metastasized widely
15
38000
2000
体中に
00:55
all over the body.
16
40000
2000
転移していました
00:57
And the real tragedy was, if you look through her records,
17
42000
3000
ひどい話ですが カルテによると
01:00
she had been seen
18
45000
2000
過去数年間に
01:02
in four or five other health care institutions
19
47000
2000
数箇所の医療機関で
01:04
in the preceding two years.
20
49000
2000
受診歴があるのです
01:06
Four or five opportunities
21
51000
2000
ということは こうなる前に
01:08
to see the breast masses, touch the breast mass,
22
53000
2000
乳房のしこりが発見され
01:10
intervene at a much earlier stage
23
55000
3000
早期に対処が
01:13
than when we saw her.
24
58000
2000
できたかもしれないということです
01:15
Ladies and gentlemen,
25
60000
2000
みなさん
01:17
that is not an unusual story.
26
62000
2000
珍しい例ではありません
01:19
Unfortunately, it happens all the time.
27
64000
3000
残念ながらどこででもありえます
01:22
I joke, but I only half joke,
28
67000
2000
半分はジョークですが
01:24
that if you come to one of our hospitals missing a limb,
29
69000
3000
脚を失った状態で 病院に来ても
01:27
no one will believe you till they get a CAT scan, MRI
30
72000
3000
CATスキャン MRIといった検査を受けるまで
01:30
or orthopedic consult.
31
75000
2000
誰も気づかないでしょう
01:32
I am not a Luddite.
32
77000
2000
先端技術が嫌いなわけじゃありません
01:34
I teach at Stanford.
33
79000
2000
スタンフォードで教えてますし
01:36
I'm a physician practicing with cutting-edge technology.
34
81000
2000
こうした技術も利用しています
01:38
But I'd like to make the case to you
35
83000
2000
しかし この17分間でご紹介したいのは
01:40
in the next 17 minutes
36
85000
2000
患者と話をし
01:42
that when we shortcut the physical exam,
37
87000
4000
触れて診察を行う代りに
01:46
when we lean towards ordering tests
38
91000
2000
検査に偏重し 患者との
01:48
instead of talking to and examining the patient,
39
93000
3000
ふれあいを省略すると
01:51
we not only overlook simple diagnoses
40
96000
3000
まだ初期段階の 治癒可能な
01:54
that can be diagnosed at a treatable, early stage,
41
99000
3000
症状を見過ごしてしまうだけではなく
01:57
but we're losing much more than that.
42
102000
2000
もっと大切な「儀式」が
01:59
We're losing a ritual.
43
104000
2000
失われてしまうのです
02:01
We're losing a ritual that I believe is transformative, transcendent,
44
106000
3000
これには 医師と患者の関係に
02:04
and is at the heart
45
109000
2000
変化をおこし 強力にする
02:06
of the patient-physician relationship.
46
111000
2000
力があるのです
02:08
This may actually be heresy to say this at TED,
47
113000
3000
TEDでご紹介するのは
02:11
but I'd like to introduce you
48
116000
2000
場違いかもしれませんが
02:13
to the most important innovation,
49
118000
2000
今後10年間における
02:15
I think, in medicine
50
120000
2000
もっとも重要な
02:17
to come in the next 10 years,
51
122000
2000
イノベーションは
02:19
and that is the power of the human hand --
52
124000
2000
人の手の持つ力でしょう
02:21
to touch, to comfort, to diagnose
53
126000
3000
触れて 癒し 診察する
02:24
and to bring about treatment.
54
129000
2000
そして治療を行う
02:26
I'd like to introduce you first to this person
55
131000
3000
まずはこの人物をご紹介します
02:29
whose image you may or may not recognize.
56
134000
2000
お気づきの方もいるでしょう
02:31
This is Sir Arthur Conan Doyle.
57
136000
2000
アーサー・コナン・ドイルです
02:33
Since we're in Edinburgh, I'm a big fan of Conan Doyle.
58
138000
3000
私はコナン・ドイルの大ファンです
02:36
You might not know that Conan Doyle went to medical school
59
141000
2000
ここエジンバラで 彼は医学を
02:38
here in Edinburgh,
60
143000
2000
学んだ経験もあります
02:40
and his character, Sherlock Holmes,
61
145000
2000
シャーロック・ホームズは
02:42
was inspired by Sir Joseph Bell.
62
147000
3000
ジョセフ・ベルにインスパイアされました
02:45
Joseph Bell was an extraordinary teacher by all accounts.
63
150000
3000
あらゆる点で ジョセフ・ベルは優れた教師で
02:48
And Conan Doyle, writing about Bell,
64
153000
3000
コナン・ドイルは
02:51
described the following exchange
65
156000
2000
ベルと生徒とのやりとりについて
02:53
between Bell and his students.
66
158000
2000
こんな逸話を残しています
02:55
So picture Bell sitting in the outpatient department,
67
160000
3000
想像してください ベルは外来で
02:58
students all around him,
68
163000
2000
生徒は彼を取り巻き
03:00
patients signing up in the emergency room
69
165000
2000
受付を済ませた患者が
03:02
and being registered and being brought in.
70
167000
3000
処置室にやって来ます
03:05
And a woman comes in with a child,
71
170000
2000
彼女は子供を連れていました
03:07
and Conan Doyle describes the following exchange.
72
172000
3000
コナン・ドイルはこんな会話を残しています
03:10
The woman says, "Good Morning."
73
175000
4000
「おはようございます」患者は言いました
03:14
Bell says, "What sort of crossing did you have
74
179000
3000
「バーンティスランドからのフェリーは
03:17
on the ferry from Burntisland?"
75
182000
3000
いかがだったかな？」ベルは言います
03:20
She says, "It was good."
76
185000
2000
「よかったですよ」患者は答えます
03:22
And he says, "What did you do with the other child?"
77
187000
3000
「もう一人のお子さんはどうしたのかな？」ベルは言います
03:25
She says, "I left him with my sister at Leith."
78
190000
3000
「リースの姉に預けて来ました」
03:28
And he says,
79
193000
2000
彼は続けます
03:30
"And did you take the shortcut down Inverleith Row
80
195000
2000
「ここに来る時に 植物園を通って
03:32
to get here to the infirmary?"
81
197000
2000
近道をしたんじゃないかね？」
03:34
She says, "I did."
82
199000
2000
「そうです」患者は答えます
03:36
And he says, "Would you still be working at the linoleum factory?"
83
201000
4000
「今も リノリウム工場で働いているのかね？」
03:40
And she says, "I am."
84
205000
2000
「そうです」患者は答えます
03:42
And Bell then goes on to explain to the students.
85
207000
2000
ベルは生徒達に説明し始めました
03:44
He says, "You see, when she said, 'Good morning,'
86
209000
3000
「彼女が挨拶した時
03:47
I picked up her Fife accent.
87
212000
2000
ファイフ訛りと気づいてね
03:49
And the nearest ferry crossing from Fife is from Burntisland.
88
214000
3000
ファイフから最寄のフェリーはバーンティスランドだ
03:52
And so she must have taken the ferry over.
89
217000
3000
だからフェリーを使ったに違いないと
03:55
You notice that the coat she's carrying
90
220000
2000
そして 彼女が持っているコートを見ると
03:57
is too small for the child who is with her,
91
222000
3000
連れている子供のものにしては小さすぎると
04:00
and therefore, she started out the journey with two children,
92
225000
3000
なので 最初は２人連れて出発し
04:03
but dropped one off along the way.
93
228000
3000
途中で一人を預けたのだろうと
04:06
You notice the clay on the soles of her feet.
94
231000
2000
靴底の土に気づいてね
04:08
Such red clay is not found within a hundred miles of Edinburgh,
95
233000
4000
エジンバラの周辺には こんな赤土は存在しない
04:12
except in the botanical gardens.
96
237000
2000
植物園を除いてはね
04:14
And therefore, she took a short cut down Inverleith Row
97
239000
3000
だから 彼女は植物園を通って
04:17
to arrive here.
98
242000
2000
近道したんだなと
04:19
And finally, she has a dermatitis
99
244000
2000
最後に 彼女の右手の指には
04:21
on the fingers of her right hand,
100
246000
2000
皮膚炎が見られる
04:23
a dermatitis that is unique
101
248000
2000
この皮膚炎はバーンティスランドの
04:25
to the linoleum factory workers in Burntisland."
102
250000
3000
リノリウム工場の工員に独特のものなんだ」
04:28
And when Bell actually strips the patient,
103
253000
2000
ベルは実際に服を脱がせ
04:30
begins to examine the patient,
104
255000
2000
診察を始める前に
04:32
you can only imagine how much more he would discern.
105
257000
3000
なんと多くの情報を得ていたことか
04:35
And as a teacher of medicine, as a student myself,
106
260000
3000
医学の教師であり また生徒でもある私は
04:38
I was so inspired by that story.
107
263000
2000
この話に大変感銘を受けました
04:40
But you might not realize
108
265000
2000
しかしながら
04:42
that our ability to look into the body
109
267000
2000
医師の知覚という単純な手段で
04:44
in this simple way, using our senses,
110
269000
2000
体の中が調べられるようになったのは
04:46
is quite recent.
111
271000
2000
ごく近年のことです
04:48
The picture I'm showing you is of Leopold Auenbrugger
112
273000
3000
こちらは レオポルト・アウエンブルッカー
04:51
who, in the late 1700s,
113
276000
2000
1,700年代 彼により
04:53
discovered percussion.
114
278000
2000
打診法が開発されました
04:55
And the story is that Leopold Auenbrugger
115
280000
3000
きっかけは 彼の父親が
04:58
was the son of an innkeeper.
116
283000
3000
居酒屋の主人であったことです
05:01
And his father used to go down into the basement
117
286000
3000
父親はワイン樽をコツコツ叩いて
05:04
to tap on the sides of casks of wine
118
289000
2000
ワインの残量を測っていました
05:06
to determine how much wine was left
119
291000
2000
ワインの追加注文のタイミングを
05:08
and whether to reorder.
120
293000
2000
決めるためです
05:10
And so when Auenbrugger became a physician,
121
295000
2000
アウエンブルッカーは医師となり
05:12
he began to do the same thing.
122
297000
2000
同じことをはじめました
05:14
He began to tap on the chests of his patients,
123
299000
3000
患者の胸部や腹部を叩く診察法を
05:17
on their abdomens.
124
302000
2000
はじめました
05:19
And basically everything we know about percussion,
125
304000
2000
打診はいわば当時の超音波診断ですが
05:21
which you can think of as an ultrasound of its day --
126
306000
4000
今日知られている全て －臓器肥大も
05:25
organ enlargement, fluid around the heart, fluid in the lungs,
127
310000
3000
心嚢水も肺水腫も
05:28
abdominal changes --
128
313000
2000
腹部の異変なども全て
05:30
all of this he described in this wonderful manuscript
129
315000
2000
この優れた著書に記されています
05:32
"Inventum Novum," "New Invention,"
130
317000
3000
「新発見」
05:35
which would have disappeared into obscurity,
131
320000
2000
この手法は忘れさられるところでした
05:37
except for the fact that this physician, Corvisart,
132
322000
3000
著名なフランスの医師 コルヴィザール－
05:40
a famous French physician --
133
325000
2000
彼はこちらの紳士の
05:42
famous only because he was physician to this gentleman --
134
327000
3000
主治医であったことのみで有名でしたが－
05:45
Corvisart repopularized and reintroduced the work.
135
330000
4000
彼は打診法を復活させました
05:49
And it was followed a year or two later
136
334000
2000
1〜2 年後にラエンエックにより
05:51
by Laennec discovering the stethoscope.
137
336000
3000
聴診器が発明されるに至ります
05:54
Laennec, it is said, was walking in the streets of Paris
138
339000
3000
彼がある日 パリを歩いていた時のこと
05:57
and saw two children playing with a stick.
139
342000
2000
棒で遊んでいる二人の子供を見かけました
05:59
One was scratching at the end of the stick,
140
344000
3000
一人が端っこを引っかいて
06:02
another child listened at the other end.
141
347000
2000
もう一人が別の端っこで音を聞いていました
06:04
And Laennec thought this would be a wonderful way
142
349000
2000
ラエンネックは思いつきました
06:06
to listen to the chest or listen to the abdomen
143
351000
2000
これは 体内の音を聴くのに 良い方法だと
06:08
using what he called "the cylinder."
144
353000
2000
これをシリンダーと彼は名付け
06:10
Later he renamed it the stethoscope.
145
355000
2000
のちに 聴診器と改名し
06:12
And that is how stethoscope and auscultation was born.
146
357000
4000
こうして聴診器と聴診が生まれたのです
06:16
So within a few years,
147
361000
2000
18世紀の終わりから
06:18
in the late 1800s, early 1900s,
148
363000
2000
19世紀初頭の数年間で
06:20
all of a sudden,
149
365000
2000
急激に
06:22
the barber surgeon had given way
150
367000
3000
手術を行う理髪店は
06:25
to the physician who was trying to make a diagnosis.
151
370000
3000
診察を行う医師に取って代わられました
06:28
If you'll recall, prior to that time,
152
373000
2000
当時の人々は
06:30
no matter what ailed you, you went to see the barber surgeon
153
375000
3000
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
06:33
who wound up cupping you,
154
378000
2000
そこでは吸引療法
06:35
bleeding you, purging you.
155
380000
2000
血抜き療法 洗浄療法
06:37
And, oh yes, if you wanted,
156
382000
2000
そして お望みなら
06:39
he would give you a haircut -- short on the sides, long in the back --
157
384000
3000
もちろん髪も切ってくれました
06:42
and pull your tooth while he was at it.
158
387000
2000
おまけに歯だって抜いてくれます
06:44
He made no attempt at diagnosis.
159
389000
2000
ただ 診察は全くありません
06:46
In fact, some of you might well know
160
391000
2000
事実 ご存知の方もいるでしょうか
06:48
that the barber pole, the red and white stripes,
161
393000
3000
理髪店の赤と白の縞模様のポールは
06:51
represents the blood bandages of the barber surgeon,
162
396000
3000
血に染まった包帯からきたものなんです
06:54
and the receptacles on either end
163
399000
2000
両端の物体は
06:56
represent the pots in which the blood was collected.
164
401000
3000
血液を集める容器を表しています
06:59
But the arrival of auscultation and percussion
165
404000
3000
聴診と打診の登場は
07:02
represented a sea change,
166
407000
2000
転換期を象徴するものでした
07:04
a moment when physicians were beginning to look inside the body.
167
409000
3000
医師が患者の体内に注目しはじめたのです
07:07
And this particular painting, I think,
168
412000
3000
個人的には こちらの絵は
07:10
represents the pinnacle, the peak, of that clinical era.
169
415000
3000
そうした決定的な時代の頂点を表しています
07:13
This is a very famous painting:
170
418000
2000
とても有名な絵で
07:15
"The Doctor" by Luke Fildes.
171
420000
3000
ルーク・フィルデス作 「医師」
07:18
Luke Fildes was commissioned to paint this by Tate,
172
423000
3000
彼はテート美術館の創立者である
07:21
who then established the Tate Gallery.
173
426000
2000
テート氏の依頼により描きました
07:23
And Tate asked Fildes to paint a painting
174
428000
2000
社会的に影響力のある絵画を頼む と
07:25
of social importance.
175
430000
2000
依頼されたのです
07:27
And it's interesting that Fildes picked this topic.
176
432000
3000
医師がテーマに選ばれた興味深い話があります
07:30
Fildes' oldest son, Philip,
177
435000
3000
フィルデスの長男のフィリップは
07:33
died at the age of nine on Christmas Eve
178
438000
3000
9つのとき 短期間の病を経て
07:36
after a brief illness.
179
441000
2000
クリスマス・イヴに亡くなりました
07:38
And Fildes was so taken by the physician
180
443000
3000
息子の横で数日に及び
07:41
who held vigil at the bedside for two, three nights,
181
446000
4000
寝ずの看病を続けた医師に感動したフィルデスは
07:45
that he decided that he would try and depict
182
450000
2000
医師の姿を描こうと
07:47
the physician in our time --
183
452000
2000
決めたのです
07:49
almost a tribute to this physician.
184
454000
2000
この医師に捧げるためでした
07:51
And hence the painting "The Doctor," a very famous painting.
185
456000
3000
「医師」はとても有名で
07:54
It's been on calendars, postage stamps in many different countries.
186
459000
3000
各国でカレンダーや切手のデザインになってます
07:57
I've often wondered, what would Fildes have done
187
462000
3000
よく思うんです もしフィルデスが
08:00
had he been asked to paint this painting
188
465000
2000
2011年にこの絵画を依頼されたなら
08:02
in the modern era,
189
467000
2000
一体何を
08:04
in the year 2011?
190
469000
3000
描くのだろうと
08:07
Would he have substituted a computer screen
191
472000
4000
患者のかわりにパソコン画面を
08:11
for where he had the patient?
192
476000
2000
もってくるのでは？
08:13
I've gotten into some trouble in Silicon Valley
193
478000
2000
シリコンバレーで批判を受けました
08:15
for saying that the patient in the bed
194
480000
2000
「患者はもはや
08:17
has almost become an icon
195
482000
3000
パソコン上のデータに
08:20
for the real patient who's in the computer.
196
485000
3000
過ぎなくなった」と言ったのです
08:23
I've actually coined a term for that entity in the computer.
197
488000
3000
そうしたデータに名前まで付けました
08:26
I call it the iPatient.
198
491000
2000
アイ・ペイシャントです
08:28
The iPatient is getting wonderful care all across America.
199
493000
3000
全米でデータは手厚いケアを受ける一方
08:31
The real patient often wonders,
200
496000
2000
本物の患者は思います
08:33
where is everyone?
201
498000
2000
「みんなどこ？」
08:35
When are they going to come by and explain things to me?
202
500000
3000
「いつになったら僕のところに説明にくるの？」
08:38
Who's in charge?
203
503000
2000
「担当者は誰？」
08:40
There's a real disjunction between the patient's perception
204
505000
3000
一流の治療の定義は患者と
08:43
and our own perceptions as physicians of the best medical care.
205
508000
3000
我々医師の間ではかけ離れたものになっています
08:46
I want to show you a picture
206
511000
2000
こちらをご覧いただきましょう
08:48
of what rounds looked like
207
513000
2000
私が研修医の頃の
08:50
when I was in training.
208
515000
2000
回診の様子です
08:52
The focus was around the patient.
209
517000
2000
中心には患者がいました
08:54
We went from bed to bed. The attending physician was in charge.
210
519000
3000
ベッドからベッドへ 主治医が回ります
08:57
Too often these days,
211
522000
2000
最近では
08:59
rounds look very much like this,
212
524000
2000
回診の様子はこうです
09:01
where the discussion is taking place
213
526000
2000
議論は患者から遠く離れた
09:03
in a room far away from the patient.
214
528000
3000
会議室で行われます
09:06
The discussion is all about images on the computer, data.
215
531000
3000
議論の中心はパソコン上のイメージとデータのみ
09:09
And the one critical piece missing
216
534000
2000
不可欠な要素である
09:11
is that of the patient.
217
536000
2000
患者本人が抜け落ちています
09:13
Now I've been influenced in this thinking
218
538000
3000
では 私が影響を受けた
09:16
by two anecdotes that I want to share with you.
219
541000
3000
２つのエピソードをご紹介したいと思います
09:19
One had to do with a friend of mine who had a breast cancer,
220
544000
3000
一つ目は乳がんを患った友人の話です
09:22
had a small breast cancer detected --
221
547000
3000
小さな乳がんが発見され
09:25
had her lumpectomy in the town in which I lived.
222
550000
2000
私の住む地元で摘出手術を受けました
09:27
This is when I was in Texas.
223
552000
2000
私がテキサスにいた頃です
09:29
And she then spent a lot of time researching
224
554000
3000
その後 術後のケアのため
09:32
to find the best cancer center in the world
225
557000
3000
彼女は世界で一番のがんセンターを
09:35
to get her subsequent care.
226
560000
2000
探しはじめました
09:37
And she found the place and decided to go there, went there.
227
562000
3000
お目当ての場所が見つかり 彼女はそこに行ったんです
09:40
Which is why I was surprised a few months later
228
565000
3000
なので数ヵ月後 町に戻った彼女を見かけて
09:43
to see her back in our own town,
229
568000
3000
私は驚きました
09:46
getting her subsequent care with her private oncologist.
230
571000
3000
ここで 地元の癌専門医に通っていたのです
09:49
And I pressed her, and I asked her,
231
574000
2000
彼女に聞きました
09:51
"Why did you come back and get your care here?"
232
576000
3000
「なぜここでケアを受けることにしたの？」
09:54
And she was reluctant to tell me.
233
579000
2000
彼女はためらいながらも言いました
09:56
She said, "The cancer center was wonderful.
234
581000
3000
「がんセンターはステキだったわ
09:59
It had a beautiful facility,
235
584000
2000
施設も立派だし 巨大な
10:01
giant atrium, valet parking,
236
586000
2000
吹き抜けに バレー・パーキング
10:03
a piano that played itself,
237
588000
2000
自動のピアノだってあるの
10:05
a concierge that took you around from here to there.
238
590000
3000
あちこち連れてってくれる世話人もいるしね」
10:08
But," she said,
239
593000
2000
「でもね
10:10
"but they did not touch my breasts."
240
595000
4000
そこでは 胸に一度も触わらなかったの」
10:14
Now you and I could argue
241
599000
2000
胸に触る必要さえなかったと
10:16
that they probably did not need to touch her breasts.
242
601000
2000
言えなくもありません
10:18
They had her scanned inside out.
243
603000
2000
彼女のデータはスキャンされ
10:20
They understood her breast cancer at the molecular level;
244
605000
3000
彼女の乳がんは分子レベルで把握され
10:23
they had no need to touch her breasts.
245
608000
2000
触る必要さえなかったわけです
10:25
But to her, it mattered deeply.
246
610000
3000
でも 彼女にとっては
10:28
It was enough for her to make the decision
247
613000
4000
病院を変えさせるくらい
10:32
to get her subsequent care with her private oncologist
248
617000
3000
重要な要素だったのです
10:35
who, every time she went,
249
620000
2000
今の医者は毎回
10:37
examined both breasts including the axillary tail,
250
622000
3000
両方の乳房をわきの下も含め
10:40
examined her axilla carefully,
251
625000
2000
じっくり診察し
10:42
examined her cervical region, her inguinal region,
252
627000
2000
首まわり 股のあたりもじっくりと
10:44
did a thorough exam.
253
629000
2000
診察します
10:46
And to her, that spoke of a kind of attentiveness that she needed.
254
631000
4000
彼女は こうした手厚いケアを求めていたのです
10:50
I was very influenced by that anecdote.
255
635000
2000
この話に私は大いに影響を受けました
10:52
I was also influenced by another experience that I had,
256
637000
3000
もう一つ影響を受けた経験をお話しましょう
10:55
again, when I was in Texas, before I moved to Stanford.
257
640000
3000
スタンフォードに移る前 テキサス時代の話です
10:58
I had a reputation
258
643000
2000
当時 私には
11:00
as being interested in patients
259
645000
2000
慢性疲労患者の専門医
11:02
with chronic fatigue.
260
647000
3000
という評判がありました
11:05
This is not a reputation you would wish on your worst enemy.
261
650000
4000
好ましい評判ではありません
11:09
I say that because these are difficult patients.
262
654000
3000
というのも なにせ手強い相手です
11:12
They have often been rejected by their families,
263
657000
3000
こうした患者は家族から見放され
11:15
have had bad experiences with medical care
264
660000
2000
医療機関では苦い経験をし
11:17
and they come to you fully prepared
265
662000
3000
私の所に来る頃には
11:20
for you to join the long list of people
266
665000
2000
もう期待などない状態
11:22
who's about to disappoint them.
267
667000
2000
なんですから
11:24
And I learned very early on with my first patient
268
669000
3000
まさに最初のこうした患者を診察した時
11:27
that I could not do justice
269
672000
2000
彼らが持ってくる
11:29
to this very complicated patient
270
674000
2000
これまでの診察記録は
11:31
with all the records they were bringing
271
676000
2000
初診の45分間で
11:33
in a new patient visit of 45 minutes.
272
678000
2000
症状を把握するには
11:35
There was just no way.
273
680000
2000
全く役に立たないことが分かりました
11:37
And if I tried, I'd disappoint them.
274
682000
3000
また同じ事の繰り返しです
11:40
And so I hit on this method
275
685000
2000
そこで ある方法を思いつきました
11:42
where I invited the patient
276
687000
2000
初診では 全ての時間を使って
11:44
to tell me the story for their entire first visit,
277
689000
3000
患者に自分の状態を語ってもらうのです
11:47
and I tried not to interrupt them.
278
692000
3000
中断せずじっと聞くことにしました
11:50
We know the average American physician
279
695000
2000
アメリカでは平均的な医師は
11:52
interrupts their patient in 14 seconds.
280
697000
3000
患者の話に14秒で割って入ります
11:55
And if I ever get to heaven,
281
700000
2000
もし私が天国にいけるなら
11:57
it will be because I held my piece for 45 minutes
282
702000
3000
患者の話を中断することなく
12:00
and did not interrupt my patient.
283
705000
2000
45分聞き続けたからでしょう
12:02
I then scheduled the physical exam for two weeks hence,
284
707000
3000
２週間後に仕切りなおして 診察をします
12:05
and when the patient came for the physical,
285
710000
2000
その時には
12:07
I was able to do a thorough physical,
286
712000
2000
じっくりと診断ができます
12:09
because I had nothing else to do.
287
714000
2000
他にする事が無いのですから
12:11
I like to think that I do a thorough physical exam,
288
716000
3000
徹底的に診察するのは
12:14
but because the whole visit was now about the physical,
289
719000
3000
その回が診察のための回だからという理由でなく
12:17
I could do an extraordinarily thorough exam.
290
722000
3000
とてつもなく詳細に診察するためです
12:20
And I remember my very first patient in that series
291
725000
4000
こうした診察回に最初に訪れた患者は
12:24
continued to tell me more history
292
729000
2000
最初 自身の症状をとうとうと
12:26
during what was meant to be the physical exam visit.
293
731000
3000
語り始めました この回は診察のための回というのに
12:29
And I began my ritual.
294
734000
2000
そこで私も手順に従って
12:31
I always begin with the pulse,
295
736000
2000
まず脈を図ります
12:33
then I examine the hands, then I look at the nail beds,
296
738000
3000
そして患者の手を 爪床をチェックします
12:36
then I slide my hand up to the epitrochlear node,
297
741000
2000
手を滑らせながら肘のリンパ腺へ－
12:38
and I was into my ritual.
298
743000
2000
いつもの手順です
12:40
And when my ritual began,
299
745000
2000
私の手順が始まると
12:42
this very voluble patient
300
747000
2000
このおしゃべりな患者が
12:44
began to quiet down.
301
749000
2000
静かになり
12:46
And I remember having a very eerie sense
302
751000
3000
不思議な感覚を覚えました
12:49
that the patient and I
303
754000
3000
患者と私は なにか
12:52
had slipped back into a primitive ritual
304
757000
2000
原始的な儀式を行っているという感覚
12:54
in which I had a role
305
759000
2000
私には役割があり
12:56
and the patient had a role.
306
761000
2000
そして患者にも役割がある
12:58
And when I was done,
307
763000
2000
診察が終わった際
13:00
the patient said to me with some awe,
308
765000
2000
患者は畏敬の念とともに言いました
13:02
"I have never been examined like this before."
309
767000
3000
こんな風に診察されたのは始めてです
13:05
Now if that were true,
310
770000
2000
さて これが事実なら
13:07
it's a true condemnation of our health care system,
311
772000
2000
現代の医療システムに
13:09
because they had been seen in other places.
312
774000
3000
問題があるということです
13:12
I then proceeded to tell the patient,
313
777000
2000
そして 私は患者が服を着た後
13:14
once the patient was dressed,
314
779000
2000
診察結果を説明します
13:16
the standard things that the person must have heard in other institutions,
315
781000
3000
他の医療機関でも聞いたであろう内容です
13:19
which is, "This is not in your head.
316
784000
2000
「あなたの思い込みではなく
13:21
This is real.
317
786000
2000
病気は存在します
13:23
The good news, it's not cancer, it's not tuberculosis,
318
788000
3000
良いニュースは 癌や結核 はたまた
13:26
it's not coccidioidomycosis or some obscure fungal infection.
319
791000
3000
なにか恐ろしい感染症ではありません
13:29
The bad news is we don't know exactly what's causing this,
320
794000
3000
悪いニュースは一体何が原因かわからないことです
13:32
but here's what you should do, here's what we should do."
321
797000
3000
では まずあなたがすべき事と 私達がすべき事です…」
13:35
And I would lay out all the standard treatment options
322
800000
3000
こうして私は患者に通常の治療法を説明します
13:38
that the patient had heard elsewhere.
323
803000
3000
他でも聞いた内容なのです
13:41
And I always felt
324
806000
2000
よく思うのが
13:43
that if my patient gave up the quest
325
808000
2000
もし 私の患者が ありもしない
13:45
for the magic doctor, the magic treatment
326
810000
3000
名医や特効薬を探すのはやめて
13:48
and began with me on a course towards wellness,
327
813000
3000
私と治療へのプロセスを歩み始めてくれるなら
13:51
it was because I had earned the right
328
816000
2000
それは 徹底的な診察の結果として
13:53
to tell them these things
329
818000
2000
治療法を説明するに必要な
13:55
by virtue of the examination.
330
820000
2000
信頼を築いたからだと思います
13:57
Something of importance had transpired in the exchange.
331
822000
4000
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
14:01
I took this to my colleagues
332
826000
2000
スタンフォードで
14:03
at Stanford in anthropology
333
828000
2000
人類学を教える同僚たちに
14:05
and told them the same story.
334
830000
2000
この話をしてみました
14:07
And they immediately said to me,
335
832000
2000
彼らはすぐに答えました
14:09
"Well you are describing a classic ritual."
336
834000
2000
「それは古典的な儀式のことだね」と
14:11
And they helped me understand
337
836000
2000
彼らによると 儀式とは
14:13
that rituals are all about transformation.
338
838000
3000
つまるところ 変化であると
14:16
We marry, for example,
339
841000
2000
例えば 私たちは
14:18
with great pomp and ceremony and expense
340
843000
3000
豪華な結婚式を行います
14:21
to signal our departure
341
846000
2000
寂しい独り身から
14:23
from a life of solitude and misery and loneliness
342
848000
2000
永遠の祝福への出発を
14:25
to one of eternal bliss.
343
850000
3000
お祝いしているわけです
14:28
I'm not sure why you're laughing.
344
853000
2000
なぜ みなさん笑っているのでしょうか？
14:30
That was the original intent, was it not?
345
855000
2000
もともとはそういう意味だったでしょ？
14:32
We signal transitions of power
346
857000
2000
儀式こそがこうした変化を知らせる
14:34
with rituals.
347
859000
2000
シグナルなのです
14:36
We signal the passage of a life with rituals.
348
861000
2000
人生の節々でこうしたシグナルを出します
14:38
Rituals are terribly important.
349
863000
2000
儀式はとても大事なものなのです
14:40
They're all about transformation.
350
865000
2000
儀式とは変化を表すものです
14:42
Well I would submit to you
351
867000
2000
ある人が
14:44
that the ritual
352
869000
2000
とある人を訪れ
14:46
of one individual coming to another
353
871000
2000
牧師やラビには
14:48
and telling them things
354
873000
2000
言いたくないことを伝え
14:50
that they would not tell their preacher or rabbi,
355
875000
3000
驚くべきことに
14:53
and then, incredibly on top of that,
356
878000
2000
服を脱ぎ
14:55
disrobing and allowing touch --
357
880000
3000
体を触らせるという儀式－
14:58
I would submit to you that that is a ritual of exceeding importance.
358
883000
4000
こうした儀式がとても重要なのです
15:02
And if you shortchange that ritual
359
887000
2000
服を着せたまま診察したり
15:04
by not undressing the patient,
360
889000
2000
ガウンの上から聴診したり
15:06
by listening with your stethoscope on top of the nightgown,
361
891000
3000
徹底的な診察をせず
15:09
by not doing a complete exam,
362
894000
2000
こうしたことで 儀式を省略すると
15:11
you have bypassed on the opportunity
363
896000
2000
患者と医師の関係をつなぐ機会を
15:13
to seal the patient-physician relationship.
364
898000
4000
失うことになるのです
15:17
I am a writer,
365
902000
2000
私が書いた
15:19
and I want to close by reading you a short passage that I wrote
366
904000
4000
短い一節を読みまして 終わりにします
15:23
that has to do very much with this scene.
367
908000
2000
ご覧のようなシーンと関係します
15:25
I'm an infectious disease physician,
368
910000
2000
私は感染症の専門医で
15:27
and in the early days of HIV, before we had our medications,
369
912000
3000
エイズが認識されはじめ まだ治療法も無い頃
15:30
I presided over so many scenes like this.
370
915000
4000
こうした光景に立ち会うことが多々ありました
15:34
I remember, every time I went to a patient's deathbed,
371
919000
3000
患者の臨終の床に立ち会う際
15:37
whether in the hospital or at home,
372
922000
2000
それが患者の自宅でも病院でも
15:39
I remember my sense of failure --
373
924000
4000
常に挫折を感じていました－
15:43
the feeling of I don't know what I have to say;
374
928000
2000
何を言わなければいけないのかー
15:45
I don't know what I can say;
375
930000
2000
何を言っていいのかー
15:47
I don't know what I'm supposed to do.
376
932000
2000
何をすべきかも分かりません
15:49
And out of that sense of failure,
377
934000
2000
そうした挫折感から
15:51
I remember, I would always examine the patient.
378
936000
3000
いつも患者を診察するようにしていました
15:54
I would pull down the eyelids.
379
939000
2000
まぶたをめくり
15:56
I would look at the tongue.
380
941000
2000
舌を見て
15:58
I would percuss the chest. I would listen to the heart.
381
943000
3000
胸部を打診し 心音を聴きます
16:01
I would feel the abdomen.
382
946000
2000
そして 腹部をさすります
16:03
I remember so many patients,
383
948000
3000
私は多くの患者の
16:06
their names still vivid on my tongue,
384
951000
2000
名前や顔は今でも
16:08
their faces still so clear.
385
953000
2000
はっきり覚えています
16:10
I remember so many huge, hollowed out, haunted eyes
386
955000
4000
大きく 窪み おびえたような目が
16:14
staring up at me as I performed this ritual.
387
959000
3000
儀式を行う私を見上げていました
16:17
And then the next day,
388
962000
2000
翌日も
16:19
I would come, and I would do it again.
389
964000
2000
また私は同じ事を行うのです
16:21
And I wanted to read you this one closing passage
390
966000
3000
では 最後となる一節を読みたいと思います
16:24
about one patient.
391
969000
2000
ある患者の話です
16:26
"I recall one patient
392
971000
2000
「ある患者を思い出す
16:28
who was at that point
393
973000
2000
彼はその時点で
16:30
no more than a skeleton
394
975000
2000
皮に包まれた
16:32
encased in shrinking skin,
395
977000
2000
骸骨と化していた
16:34
unable to speak,
396
979000
2000
話すことはできず
16:36
his mouth crusted with candida
397
981000
2000
普通の薬の効かない
16:38
that was resistant to the usual medications.
398
983000
3000
カンジダで 口もカサブタだらけ
16:41
When he saw me
399
986000
2000
亡くなる数時間前のことだった
16:43
on what turned out to be his last hours on this earth,
400
988000
2000
彼は私を目にすると
16:45
his hands moved as if in slow motion.
401
990000
3000
スローモーションで手を動かし始めた
16:48
And as I wondered what he was up to,
402
993000
2000
何をしようとしているのか？
16:50
his stick fingers made their way
403
995000
2000
小枝のような指は
16:52
up to his pajama shirt,
404
997000
2000
パジャマのシャツを目指すが
16:54
fumbling with his buttons.
405
999000
3000
ボタンがつまめない
16:57
I realized that he was wanting
406
1002000
2000
診察してもらうため
16:59
to expose his wicker-basket chest to me.
407
1004000
3000
痩せた胸を出したいのだと私は気づいた
17:02
It was an offering, an invitation.
408
1007000
3000
このような提案を—勧誘を
17:05
I did not decline.
409
1010000
2000
断ることなどできない
17:07
I percussed. I palpated. I listened to the chest.
410
1012000
3000
打診し 触診し そして胸部の音を聴く
17:10
I think he surely must have known by then
411
1015000
2000
彼はその時点で気づいていたに違いないだろう
17:12
that it was vital for me
412
1017000
2000
これが自分にとって必要なだけではなく
17:14
just as it was necessary for him.
413
1019000
2000
私にも不可欠なことだと
17:16
Neither of us could skip this ritual,
414
1021000
3000
お互いに省略するわけに行かない儀式なのだ
17:19
which had nothing to do with detecting rales in the lung,
415
1024000
3000
肺の水泡を見つけるためではなく
17:22
or finding the gallop rhythm of heart failure.
416
1027000
3000
心音の異常を探すこととは全く関係なく
17:25
No, this ritual was about the one message
417
1030000
3000
医師が患者に伝えるべき
17:28
that physicians have needed to convey to their patients.
418
1033000
3000
あのメッセージを伝えるための儀式なのだ
17:31
Although, God knows, of late, in our hubris,
419
1036000
2000
傲慢になった私たちは
17:33
we seem to have drifted away.
420
1038000
2000
そこから押し流され
17:35
We seem to have forgotten --
421
1040000
2000
忘れてしまったかのようだ
17:37
as though, with the explosion of knowledge,
422
1042000
2000
知識を急速に増大させ
17:39
the whole human genome mapped out at our feet,
423
1044000
3000
人間の遺伝子地図を踏破しつくし
17:42
we are lulled into inattention,
424
1047000
2000
無関心に陥ったかのようだ
17:44
forgetting that the ritual is cathartic to the physician,
425
1049000
3000
儀式が医師の癒しであり
17:47
necessary for the patient --
426
1052000
2000
患者に欠かせないことが忘れられ
17:49
forgetting that the ritual has meaning
427
1054000
2000
儀式の持つ意味と
17:51
and a singular message to convey to the patient.
428
1056000
4000
患者に伝えるべき唯一のメッセージが忘れられている
17:55
And the message, which I didn't fully understand then,
429
1060000
3000
当時の私が伝えつつも
17:58
even as I delivered it,
430
1063000
2000
理解は十分ではなかったが
18:00
and which I understand better now is this:
431
1065000
3000
今ではよく分かるようになったメッセージである
18:03
I will always, always, always be there.
432
1068000
3000
私はいつもいつも ここにいて
18:06
I will see you through this.
433
1071000
2000
最後まで見届けます
18:08
I will never abandon you.
434
1073000
2000
決して見捨てません
18:10
I will be with you through the end."
435
1075000
2000
最後まで一緒です」
18:12
Thank you very much.
436
1077000
2000
どうもありがとうございました
18:14
(Applause)
437
1079000
12000
（拍手）
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