TEDMED 2012
Ivan Oransky: Are we over-medicalized?
伊万.欧兰斯基：是否我们过分医疗化了？
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路透社健康编辑伊万.欧兰斯基警告说，一些荒谬的先决条件已经成为了一种让我们感到十分痛苦的流行病，比如说- 糖尿病前期，癌症前期，还有更多其他的。在这个TEDMED谈话中，他展示了医疗保险系统如何能找到解决方案...从棒球中学到的重要一课。
Ivan Oransky - Health reporter
Ivan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions. Full bio
Ivan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions. Full bio
Double-click the English transcript below to play the video.
00:16
Those of you who have seen the film "Moneyball,"
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在座看过电影“点球成金”的
00:20
or have read the book by Michael Lewis,
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又或者读过麦克·路易斯的书的，
00:22
will be familiar with the story of Billy Beane.
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会对比利·比恩的故事很熟悉。
00:25
Billy was supposed to be a tremendous ballplayer; all the scouts told him so.
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比利应该是一个非常好的球员；所以的球探都这么跟他说。
00:29
They told his parents that
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他们告诉他的父母，
00:31
they predicted that he was going to be a star.
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他们预测他会变成一个明星。
00:33
But what actually happened when he signed the contract -- and by the way, he didn't
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但事实上当他签约后 -- 其实他并不想
00:38
want to sign that contract, he wanted to go to
college --
college --
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签约，他想去上大学 --
00:40
which is what my mother, who actually does
love me,
love me,
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而这是真的爱我的母亲
00:43
said that I should do too, and I did --
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说我应该做的，而我也这么做了 --
00:46
well, he didn't do very well. He struggled
mightily.
mightily.
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但其实他没做多好。他挣扎着去适应。
00:49
He got traded a couple of times, he ended up in the Minors for most of his career,
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他被交易了几次，并在小联盟打了他大部分的职业球赛，
00:53
and he actually ended up in management. He ended up as a General Manager of the
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最终来到了管理层。它做了奥克兰运动家球队
00:57
Oakland A's.
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的总经理。
00:58
Now for many of you in this room, ending up in management, which is also what I've done,
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对于在座的大多数人来说，像我一样成为管理层的一部分
01:02
is seen as a success.
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会被看做是成功。
01:04
I can assure you that for a kid trying to make it in the Bigs,
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我可以向你保证，对于一个试图在大联盟打出名声的孩子来说，
01:07
going into management ain't no success story. It's a failure.
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进入管理层不是一个成功的故事。它是一种失败。
01:12
And what I want to talk to you about today, and share with you, is that our
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而我今天想和你说的，便是
01:16
healthcare system, our medical system, is
just as bad at predicting
just as bad at predicting
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我们的医保系统，医疗系统，在对于预测
01:21
what happens to people in it -- patients,
others --
others --
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将发生在人身上的事情也很差 -- 病患，其他的 --
01:25
as those scouts were at predicting what would happen to Billy Beane.
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就像那些预测比利·比恩会成功的球探一样。
01:30
And yet, every day
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但每一天
01:32
thousands of people in this country
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在这个国家里仍然有上千个人
01:34
are diagnosed with preconditions.
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被诊断出疾病前兆。
01:38
We hear about pre-hypertension, we hear about pre-dementia,
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我们听到高血压前兆，痴呆症前兆，
01:42
we hear about pre-anxiety, and I'm pretty sure that I diagnosed myself with
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焦虑症前兆，而我确定我在那绿色的房间里
01:48
that in the green room.
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给了自己这个诊断。
01:49
We also refer to subclinical conditions.
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同样的，我们也提到亚临床症状。
01:53
There's subclinical atherosclerosis, subclinical hardening of the arteries,
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我们有亚临床动脉硬化，
01:58
obviously linked to heart attacks, potentially.
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潜在的联系到心力衰竭。
02:02
One of my favorites is called
subclinical acne.
subclinical acne.
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我最喜欢的叫做亚临床粉刺。
02:05
If you look up subclinical acne, you may find a website, which I did,
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如果你搜索亚临床粉刺，你可能会像我一样找到一个网站，
02:09
which says that this is the easiest type of acne to treat.
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上面说这种粉刺最容易被治疗。
02:13
You don't have the pustules or the redness and inflammation.
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你不会有脓包，红肿或炎症。
02:20
Maybe that's because you don't actually
have acne.
have acne.
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但这也有可能是因为你并没有粉刺。
02:23
I have a name for all of these conditions, it's another precondition:
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我给这些病症起了个名字，它也是一种前兆症：
02:30
I call them preposterous.
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我叫它们 ”荒谬绝伦“。
02:32
In baseball, the game follows the pre-game.
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在棒球中，正式比赛在热身赛后开始。
02:38
Season follows the pre-season.
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赛季在赛前季后。
02:40
But with a lot of these conditions, that actually isn't the case, or at least it isn't the
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但对于这些疾病来说，这大多数情况
02:45
case all the time. It's as if there's a rain delay, every single time in many cases.
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并不成立。在很多病例中它就像在球赛被下雨取消了一般。
02:49
We have pre-cancerous lesions,
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我们有癌前病变，
02:51
which often don't turn into cancer.
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但它们经常不会转化为癌症。
02:55
And yet,
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然而，
02:56
if you take, for example, subclinical
osteoporosis, a bone thinning disease,
osteoporosis, a bone thinning disease,
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如果你拿亚临床骨质疏松症做例子，
03:00
the precondition,
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它的前兆症状，
03:02
otherwise known as osteopenia,
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被称为骨质减少，
03:04
you would have to treat 270
women for three years
women for three years
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你必须为270个女人提供长达3年的治疗，
03:08
in order to prevent one broken bone.
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来防止一个断裂的骨头。
03:10
That's an awful lot of women
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当你用时间乘以被诊断为骨质减少的
03:12
when you multiply by the number of women
who were diagnosed
who were diagnosed
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女人人数时，
03:15
with this osteopenia.
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这个数字是相当庞大的。
03:17
And so is it any wonder,
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所以，看看每年
03:19
given all of the costs and the side effects
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我们花费在这些病症前兆上的
03:21
of the drugs that we're using to treat these preconditions, that every year
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药物的费用以及它们导致的副作用，
03:25
we're spending more than two trillion dollars on healthcare and yet
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我们每年都要在医保上花费2万亿美元以上的钱，
03:29
100,000 people a year -- and that's a conservative estimate -- are dying
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但每年仍然有10万人 死亡-- 而这只是一个保守的估计，
03:32
not because of the conditions they have,
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不是因为他们所有的病症，
03:34
but because of the treatments that we're giving them and the complications of those treatments?
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而是因为我们所给他们的疗程以及这些疗程带来的并发症。
03:39
We've medicalized everything
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我们医疗化了这个国家
03:41
in this country.
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的一切。
03:42
Women in the audience, I have
some
some
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在座的女性们，我有一些
03:46
pretty bad news that you already know,
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你已经知道的坏消息，
03:48
and that's that every aspect of your
life
life
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那就是你们生活的每一部分
03:50
has been medicalized.
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都被医疗化了。
03:52
Strike one is when you hit puberty.
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第一次是当你来到青春期。
03:54
You now have something that happens to you once a month that has been medicalized.
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你现在有了一个被医疗化的，每月都发作一次的东西。
03:59
It's a condition;
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它变成了一个病症；
03:59
it has to be treated. Strike two
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它必须被治疗。第二次是
04:01
is if you get pregnant.
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当你怀孕的时候。
04:03
That's been medicalized as
well.
well.
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那也被医疗化了。
04:06
You have to have a high-tech experience
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你必须使用高科技
04:08
of pregnancy, otherwise something might go wrong.
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来保护孕期，不然有些地方可能会出错。
04:10
Strike three is menopause.
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第三次是更年期。
04:14
We all know what happened when millions of women were given hormone replacement therapy
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我们都知道，几十年来我们给了几百万的女人激素取代疗法
04:18
for menopausal symptoms
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来治疗更年期症状，
04:21
for decades until all of a sudden we realized, because a study came out, a big one,
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直到我们突然明白了一个由国家卫生研究所 （NIH）资助的研究
04:26
NIH-funded.
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得出来的结果。
04:27
It said,
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研究说，
04:28
actually, a lot of that hormone replacement therapy may be doing more harm than good
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其实太多的激素取代疗法对于很多女人来说
04:32
for many of those women.
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坏处可能多于好处。
04:34
Just in case,
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为了以防万一，
04:36
I don't want to leave the men out --
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我不想把男人置身事外 --
04:38
I am one, after all --
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毕竟我也是其中一份子 --
04:40
I have really bad news for all of you in
this room,
this room,
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对于在座的给位以及正在收听和
04:42
and for everyone
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收看的观众，
04:43
listening and watching elsewhere:
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我有很坏的消息：
04:45
You all have
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你们都有
04:46
a universally fatal condition.
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一个普遍的致命病症。
04:49
So, just take a moment.
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所以，请深呼吸一下。
04:52
It's called pre-death.
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他叫死亡前兆。
04:54
Every single one of you has it, because
you have the risk factor for it,
you have the risk factor for it,
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你们每个人都有，因为你们都有它的危险因素，
04:59
which is being alive.
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那就是活着。
05:01
But I have some good news for you,
because
because
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但我也有些好消息，因为我是
05:04
I'm a journalist, I like to end things in a happy way or a forward-thinking way.
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一个新闻记者，我喜欢以一种开心和积极的心态来结尾。
05:08
And that good news is that if you can survive to the end of my talk, which
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这个好的信息便是，如果你可以成功的活到我的演讲的结束，
05:12
we'll see if that happens for everyone,
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这点我相信大家都可以，
05:14
you will be a pre-vivor.
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你会是一个前存者 (pre-vivor)。
05:17
I made up pre-death.
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死亡前兆是我编的。
05:22
If I used someone else's pre-death, I apologize,
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如有雷同，对不起，
05:26
I think I made it up.
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但我想这的确是我编的。
05:28
I didn't make up pre-vivor.
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但我没有编出前存者 (pre-vivor)。
05:30
Pre-vivor is what a particular cancer advocacy group would like everyone who
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前存者（其实指癌症高危人群） 是一个癌症宣传组织，
05:35
just has a risk factor,
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它是指某些人有癌症高发因素，
05:36
but hasn't actually had that cancer,
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但却还没发展成癌症
05:39
to call themselves.
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他们就这么称呼他们自己。
05:40
You are a pre-vivor.
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你们都是前存者（癌症高危人群）。
05:42
We've had HBO here this morning. I'm wondering if Mark Burnett is anywhere in the
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家庭票房（HBO）今早还在这里。我不知道Mark Burnett（英国著名电视制作人）是否
05:46
audience, I'd like to suggest
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现在在观众席中。我建议开办一个
05:48
a reality TV show called "Pre-vivor."
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叫做“前存者”的真人秀节目。
05:52
If you develop a disease, you're off
the island.
the island.
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谁患上了一种疾病，就要从岛上退出。
05:55
But the problem is, we have a system
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但问题是，我们的系统
06:01
that is completely --
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完完全全的 --
06:02
basically promoted this.
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时时刻刻地在促进它的发生。
06:04
We've selected, at every point in this system,
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我们在这个系统的每个时刻都选择了
06:07
to do what we do, and to give everyone a
precondition and then eventually
precondition and then eventually
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我们在做什么，于是它给了每一个人一个前兆
06:11
a condition, in some cases.
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而最终，其中某些前兆转变为病症。
06:13
Start with the doctor-patient
relationship. Doctors, most of them,
relationship. Doctors, most of them,
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让我们从医患关系说起。大多数医生，
06:18
are in a fee-for-service system. They are
basically incentivized to do more --
basically incentivized to do more --
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服从一种一次一付的医疗付费系统。越是给的多，他们就做得越多。
06:23
procedures, tests,
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比如步骤，检测，
06:24
prescribe medications.
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还有开处方。
06:26
Patients come to them,
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病人来找医生，
06:27
they want to do something. We're
Americans, we can't just stand
Americans, we can't just stand
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就是想要到一些东西。我们美国人不能只是傻傻地站在那儿吧，
06:31
there, we have to do something. And so
they want a drug.
they want a drug.
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我们得做些什么啊。他们只是想要药物。
06:34
They want a treatment. They want to be told, this is what you have and this is how
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他们只是想要得到治疗。他们想被告知，这就是你得的病，
06:38
you treat it. If the doctor
doesn't give you that,
doesn't give you that,
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这就是你的治疗方法。如果医生没能给你这些，
06:40
you go somewhere else.
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你会到别处就医。
06:42
That's not very good for doctors'
business.
business.
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这对医生的生意是很不利的噢。
06:44
Or even worse,
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更坏的是，
06:46
if you are diagnosed with something
eventually, and the doctor didn't order that test,
eventually, and the doctor didn't order that test,
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如果你最终被诊断出来真的患有某病，而医生当时却没有要求你做相应的检测，
06:50
you get sued.
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你会起诉他。
06:52
We have pharmaceutical companies that are
constantly trying to expand
constantly trying to expand
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我们有些制药公司一直在试图扩大用药指征，
06:55
the indications, expand the number of people who are eligible for a given treatment,
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好让更多的人有理由接受它的治疗。
07:00
because that obviously helps their bottom line.
We have advocacy groups,
We have advocacy groups,
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因为这样明显会有利于他们盈利。我们有一些宣传组织，
07:03
like the one that's come up with
pre-vivor,
pre-vivor,
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就像刚刚那个想出来前存者的组织，
07:05
who want to make more and more people feel they are at risk, or might have a condition,
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他们想让越来越多的人觉得自己有高发因素，或是有症状，
07:10
so that they can raise more funds
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好让他们募得更多的资金，
07:12
and raise visibility, et cetera.
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或是提高知名度或获取其他利益。
07:14
But this isn't actually,
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这其实并不实际，
07:16
despite what journalists typically do,
this isn't actually about blaming
this isn't actually about blaming
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尽管这是典型的新闻人会干的事，但我其实并不是
07:19
particular players.
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在责怪某些人。
07:21
We are all responsible.
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我们对此都有责任。
07:22
I'm responsible.
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我也要对此负责。
07:24
I actually root for the Yankees, I mean talk
about
about
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我其实支持Yankee队，我的意思是说
07:27
rooting for the worst
possible
possible
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在有能力做任何事情的情况下
07:30
offender when it comes to doing
everything you can do.
everything you can do.
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支持最可能的罪犯
07:33
Thank you.
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谢谢。
07:34
But everyone is responsible.
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但是的确人人有责。
07:38
I went to medical school,
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我在上医学院的时候，
07:41
and I didn't have a course called How to Think Skeptically,
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并没有一门课程叫做“如何抱有怀疑态度地思考”
07:46
or How Not to Order Tests.
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或是“如何选择检测方法”
07:48
We have this system
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我们的这个体制就这样，
07:50
where that's what you do.
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你还得继续你应该做的事。
07:53
And it actually took being a journalist
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不过好像只有新闻人才懂得这些诱因。
07:55
to understand all these incentives. You know, economists like to say,
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知道吗，经济学家说，
07:59
there are no bad people,
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世上本无坏人，
08:00
there are just bad incentives.
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只有坏念头。
08:02
And that's actually true.
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这绝对是真理。
08:04
Because what we've created is a sort of Field of Dreams, when it comes to medical technology.
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因为我们已经创造出了医学界的《梦幻成真》（1989年4月21日在美国上映的一部电影）。
08:07
So when you put another MRI in
every corner, you put a robot
every corner, you put a robot
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所以当你在每个角落都装备了MRI，却在每个医院又装备机器人
08:13
in every hospital saying that everyone has to have robotic surgery.
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并且说每个人都只能进行机器人手术。
08:16
Well, we've created a system where if you
build it, they will come.
build it, they will come.
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接受现实吧，我们已经创造了这种体制，这些也是不可阻挡的现实。
08:20
But you can actually perversely
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当然你也可以倔强不屈，
08:24
tell people to come, convince them
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告诉人们将发生什么，
08:26
that they have to come.
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让他们明白这一切是必须发生的。
08:28
It was when I became a journalist that I really realized how I was part of this problem,
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我就是当了新闻人以后才真正意识到我也是这个问题的其中一员，
08:33
and how we all are part of this problem.
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意识到我们是怎样都和这个问题有关的。
08:35
I was medicalizing every risk factor, I was writing stories, commissioning stories,
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我在医疗化每个危险因素，我在写故事，授权故事，
08:39
every day, that were trying to,
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天天如此，目的就是
08:42
not necessarily make people worried, although that was what often happened.
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不让人们这么焦虑，虽然这通常都不管用。
08:45
But, you know, there are ways out.
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但是知道吗，其实有解决的方法。
08:48
I saw my own internist last week,
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上个星期我才见了我的内科医生，
08:50
and he said to me,
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他对我说，
08:52
"You know," and he told me something that
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“你知道吗”，
08:55
everyone in this audience could have
told me for free,
told me for free,
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这些话在座各位都可以告诉我而不收取任何费用，
08:57
but I paid him for the privilege, which
is that
is that
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而我却付给他钱让他来告诉我，
09:00
I need to lose some weight.
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那就是我需要减肥。
09:02
Well, he's right. I've had honest-to-goodness high blood pressure
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好吧，他是对的。我是如假包换的高血压患者，
09:06
for a dozen years now, same
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已经是老油条了，
09:08
age my father got it,
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患病年龄跟我父亲一样。
09:09
and it's a real disease. It's not pre-hypertension, it's actual
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这的确是一种疾病，这不是高血压前兆，
09:13
hypertension, high blood pressure.
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这的的确确就是高血压，高血压病。
09:15
Well, he's right,
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好吧，他是对的，
09:16
but he didn't say to me,
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但他没有告诉我说，
09:19
well, you have pre-obesity or
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额，你有肥胖症前兆或是
09:21
you have pre-diabetes, or anything like that. He didn't say,
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你有糖尿病前兆或是其他种种，他都没说，
09:24
better start taking this Statin, you need to lower your cholesterol.
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他也没说让我用抑制素来降低胆固醇。
09:28
No, he said, "Go out and lose some weight. Come back and see me in a bit,
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他只是说，‘出去走走，减减肥，回来让我好好看看你。
09:31
or just give me a call and let me know how you're doing."
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或者干脆给我打个电话让我知道你在做什么。“
09:33
So that's, to me,
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这就是对于我的
09:35
a way forward.
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一个解决的方法。
09:37
Billy Beane, by the way, learned the same
thing.
thing.
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同样地，Billy Beane（电影《点球成金》男主角）也学到了这点。
09:39
He learned,
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他学会了什么呢？
09:40
from watching this kid who he eventually hired, who was really successful for him,
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通过观察他最终雇佣的那个为他赢得巨大成功的孩子，
09:44
that it wasn't swinging for the fences, it
wasn't swinging at every pitch
wasn't swinging at every pitch
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他学会了要赢得比赛并不仅仅是把球挥出栅栏或是在球场上猛打就可以，
09:49
like the sluggers do, which is what all the expensive teams like the Yankees like to --
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就好比那些富队比如yankees会做的一样使用蛮力，
09:54
they like to pick up those guys.
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他们是用心去挑选球员，善用人才。
09:55
This kid told him, you know, you gotta watch the guys, and you gotta go out and find
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那孩子告诉他，你要看那些选手，你要到外面去看看，
10:00
the guys who like to walk,
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哪些家伙喜欢走路，
10:01
because getting on base by a walk
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因为步行上垒不失为一种好方法，
10:02
is just as good, and in our healthcare
system
system
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而在我们的医保体系里
10:05
we need to figure out,
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我们得弄明白
10:07
is that really a good pitch
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这真的是医疗的一块好球场吗？
10:08
or should we let it go by and not swing at everything?
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或者我们就应该让他维持现状而不去作任何改变？
10:11
Thanks.
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谢谢。
ABOUT THE SPEAKER
Ivan Oransky - Health reporterIvan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions.
Why you should listen
Ivan Oransky is a doctor-turned reporter. With an MD and an internship completed, he left to cover heath and health care, bringing the insight of a trained doctor to the beat. He is now executive editor of Reuters Health, and also teaches journalism and medicine at New York University.
He is also the co-founder of Retraction Watch a blog that tracks and investigates retractions in scientific journals, and it's sister-site, Embargo Watch, doing the same for reporting on scientific papers.
Ivan Oransky | Speaker | TED.com