TEDxOslo
Christer Mjåset: 4 questions you should always ask your doctor
克里斯特·莫塞特: 四个你应该问医生的问题
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“医生，这个真的必要吗？”基于过度医疗的惊人调查数据，神经外科医生克里斯特·莫塞特（Christer Mjåset）解释了这个问题和医疗及手术方面的其它几个简单问题的力量，并且分享了患者如何可以更好的与医生合作来获得他们所需的照顾。
Christer Mjåset - Neurosurgeon
Christer Mjåset, M.D. is a neurosurgeon, author, columnist and lecturer who currently works as a Harkness fellow in Health Care Policy and Practice at Harvard T.H. Chan School of Public Health in Boston studying value-based health care models. Full bio
Christer Mjåset, M.D. is a neurosurgeon, author, columnist and lecturer who currently works as a Harkness fellow in Health Care Policy and Practice at Harvard T.H. Chan School of Public Health in Boston studying value-based health care models. Full bio
Double-click the English transcript below to play the video.
00:12
I am a neurosurgeon,
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我是一个神经外科医生，
00:15
and I'm here to tell you today
that people like me need your help.
that people like me need your help.
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我今天要告诉你们，
像我一样的人需要你们的帮助。
像我一样的人需要你们的帮助。
00:20
And in a few moments, I will tell you how.
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过一会儿，我会告诉你们怎么做。
00:22
But first, let me start off by telling you
about a patient of mine.
about a patient of mine.
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但是首先，让我跟你们
聊一下我的一个病人。
聊一下我的一个病人。
00:26
This was a woman in her 50s,
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她是一个五十多岁的女士，
00:28
she was in generally good shape,
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身材基本上保持的不错，
00:31
but she had been in and out
of hospital a few times
of hospital a few times
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但是她已经为了根治乳腺癌
00:33
due to curative breast cancer treatment.
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多次进出医院。
00:37
Now she had gotten a prolapse
from a cervical disc,
from a cervical disc,
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现在她的颈椎间盘有脱落，
00:40
giving her radiating pain of a tense kind,
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带给她放射性的疼痛，
一直影响到她的右胳膊。
00:44
out into the right arm.
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00:47
Looking at her MRI
before the consultation,
before the consultation,
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在诊疗之前我看了
她的核磁共振成像，
她的核磁共振成像，
00:49
I decided to suggest an operation.
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我决定建议她进行手术。
00:52
Now, neck operations like these
are standardized, and they're quick.
are standardized, and they're quick.
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现在这种脖颈手术已经
很标准化，而且手术时间短，
很标准化，而且手术时间短，
00:57
But they carry a certain risk.
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但是仍带有一定的风险。
00:58
You make an incision right here,
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要在这里做一个切口，
01:01
and you dissect carefully
past the trachea,
past the trachea,
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然后剖开，小心的穿过气管，
01:03
the esophagus,
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食道，
01:05
and you try not to cut
into the internal carotid artery.
into the internal carotid artery.
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还要尽量不切到颈内动脉。
01:08
(Laughter)
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（笑声）
01:09
Then you bring in the microscope,
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然后要利用显微镜，
01:12
and you carefully remove
the disc and the prolapse
the disc and the prolapse
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仔细的在神经根管中
01:14
in the nerve root canal,
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移除间盘和脱垂，
01:15
without damaging the cord
and the nerve root
and the nerve root
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同时不能损害
在下方仅几毫米处的
在下方仅几毫米处的
01:17
lying only millimeters underneath.
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索状组织和神经根。
01:20
The worst case scenario
is the damage to the cord,
is the damage to the cord,
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最坏的情况就是损害了索状组织，
01:23
which can result in paralysis
from the neck down.
from the neck down.
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会导致颈部以下的瘫痪。
01:28
Explaining this to the patient,
she fell silent.
she fell silent.
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我把这些解释给病人时，她沉默了。
01:31
And after a few moments,
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然后过了一会，
01:32
she uttered a few very decisive words
for me and for her.
for me and for her.
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她对我和她自己说了
一句非常果断的话。
一句非常果断的话。
01:37
"Doctor, is this really necessary?"
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”医生，这个手术真的必要吗？“
01:41
(Laughter)
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（笑声）
01:44
And you know what I realized,
right there and then?
right there and then?
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你们知道那一刻我意识到什么吗？
01:47
It was not.
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这个手术并不必要。
01:49
In fact, when I get patients
like this woman,
like this woman,
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实际上，当我面对
像这位女士的病人时，
像这位女士的病人时，
01:52
I tend to advise not to operate.
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我倾向于建议她们不做手术。
01:55
So what made me do it this time?
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为什么我这次却建议她做呢？
01:59
Well, you see,
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是这样的，
02:00
this prolapse was so delicate,
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这个脱垂非常精巧，
02:03
I could practically see myself
pulling it out of the nerve root canal
pulling it out of the nerve root canal
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在她进入诊疗室之前，
我几乎可以看见自己
我几乎可以看见自己
02:06
before she entered the consultation room.
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正在把脱垂从神经根管中取出。
02:09
I have to admit it,
I wanted to operate on her.
I wanted to operate on her.
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我不得不承认，
我想给她做手术。
我想给她做手术。
02:13
I'd love to operate on her.
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我非常希望给她做手术。
02:15
Operating, after all,
is the most fun part of my job.
is the most fun part of my job.
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毕竟，手术是我工作中
最有趣的部分。
最有趣的部分。
02:18
(Laughter)
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（笑声）
02:22
I think you can relate to this feeling.
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我觉得你们可以体会这种感受。
02:24
My architect neighbor says
he loves to just sit and draw
he loves to just sit and draw
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我的建筑师邻居
说他就喜欢坐在那
说他就喜欢坐在那
02:28
and design houses.
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设计房子。
02:30
He'd rather do that all day
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宁可坐在那一天，
02:31
than talk to the client
paying for the house
paying for the house
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他也不想跟客户讨论
付款买房的事项，
付款买房的事项，
02:35
that might even give him
restrictions on what to do.
restrictions on what to do.
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这甚至有可能限制他的设计。
02:39
But like every architect,
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就像每个建筑师，
02:40
every surgeon needs
to look their patient in the eye
to look their patient in the eye
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每个外科医生需要
看着病人的眼睛，
看着病人的眼睛，
02:43
and together with the patient,
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然后跟病人一起
02:44
they need to decide on what is best
for the person having the operation.
for the person having the operation.
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决定对病人来说最好的手术。
02:50
And that might sound easy.
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这个听起来可能简单。
02:51
But let's look at some statistics.
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但是让我们来看一些统计数据。
02:56
The tonsils are the two lumps
in the back of your throat.
in the back of your throat.
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扁桃体是
在你喉咙后面的两个肿块。
在你喉咙后面的两个肿块。
02:59
They can be removed surgically,
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它们可以通过手术切除，
03:01
and that's called a tonsillectomy.
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即扁桃体切除手术。
03:03
This chart shows the operation rate
of tonsillectomies in Norway
of tonsillectomies in Norway
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这个儿童数据表展示了
在挪威不同地区
在挪威不同地区
03:07
in different regions.
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进行扁桃体手术的比例。
03:09
What might strike you
is that there is twice the chance
is that there is twice the chance
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可能会吓到你的是，
在芬马克郡的孩子
在芬马克郡的孩子
03:13
that your kid --
because this is for children --
because this is for children --
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需要做扁桃体切除手术的几率是
03:16
will get a tonsillectomy in Finnmark
than in Trondheim.
than in Trondheim.
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特隆赫姆的孩子的两倍。
03:20
The indications
in both regions are the same.
in both regions are the same.
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在这两个地方
患病的迹象是相同的。
患病的迹象是相同的。
03:24
There should be
no difference, but there is.
no difference, but there is.
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所以不应该有区别，但是现在有。
03:26
Here's another chart.
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这是另一个表。
03:28
The meniscus helps stabilize the knee
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半月板有助于稳定膝盖，
03:30
and can be torn or fragmented acutely,
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但是容易被撕裂或发生急性碎裂，
03:32
topically during sports like soccer.
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特别是在像足球这种运动过程中。
03:35
What you see here is the operation rate
for this condition.
for this condition.
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你们会看见的是
这种情况下的手术比例。
这种情况下的手术比例。
03:39
And you see that the operation
rate in Møre og Romsdal
rate in Møre og Romsdal
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在默勒市的比例
03:43
is five times the operation
rate in Stavanger.
rate in Stavanger.
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是在斯塔万格市的五倍。
03:47
Five times.
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五倍。
03:49
How can this be?
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为什么会这样？
03:50
Did the soccer players in Møre og Romsdal
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是在默勒的足球运动员
03:52
play more dirty
than elsewhere in the country?
than elsewhere in the country?
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比国家其它地方玩得更野蛮吗？
03:54
(Laughter)
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（笑声)
03:56
Probably not.
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可能不是。
03:59
I added some information now.
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我现在加入一些信息。
04:01
What you see now
is the procedures performed
is the procedures performed
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现在你们看见的
浅蓝色的是在公立医院
浅蓝色的是在公立医院
04:03
in public hospitals, in light blue,
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执行的治疗程序，
04:05
the ones in private clinics
are light green.
are light green.
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在私人诊所的是浅绿色的。
04:08
There is a lot of activity
in the private clinics
in the private clinics
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在默勒的私人诊所治疗记录
04:11
in Møre og Romsdal, isn't there?
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有很多，对吗？
04:14
What does this indicate?
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这表明了什么？
04:15
A possible economic motivation
to treat the patients.
to treat the patients.
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原因可能是治疗病人的经济动机。
04:20
And there's more.
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不仅如此。
04:23
Recent research has shown
that the difference of treatment effect
that the difference of treatment effect
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最近的研究展示了常规的物理治疗
04:27
between regular physical therapy
and operations for the knee --
and operations for the knee --
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和膝盖手术的治疗效果
04:30
there is no difference.
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并没有不同。
04:32
Meaning that most
of the procedures performed
of the procedures performed
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意思是在这个我刚展示的图表中，
04:36
on the chart I've just shown
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大部分被执行的手术
04:38
could have been avoided,
even in Stavanger.
even in Stavanger.
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是本可以被避免的，
甚至是在斯塔万格。
甚至是在斯塔万格。
04:41
So what am I trying to tell you here?
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所以我在试图告诉你们什么呢？
04:44
Even though most indications
for treatments in the world
for treatments in the world
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尽管世界上大部分的治疗指示
04:49
are standardized,
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已经标准化了，
04:50
there is a lot of unnecessary variation
of treatment decisions,
of treatment decisions,
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但是有很多是没必要的
治疗手段的变形，
治疗手段的变形，
04:54
especially in the Western world.
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特别是在西方国家。
04:57
Some people are not getting
the treatment that they need,
the treatment that they need,
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一些人没有得到他们需要的治疗，
05:01
but an even greater portion of you
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而你们当中很多人
05:04
are being overtreated.
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在被过度治疗。
05:08
"Doctor, is this really necessary?"
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“医生，这个手术真的必要吗？”
05:11
I've only heard that question
once in my career.
once in my career.
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我在我的职业生涯中
只听见过一次这个问题。
只听见过一次这个问题。
05:14
My colleagues say they never heard
these words from a patient.
these words from a patient.
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我的同事们说他们从未
听过病人这样问。
听过病人这样问。
05:19
And to turn it the other way around,
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换一种方式说，
如果你问这种问题，
你们觉得有几次
你们觉得有几次
05:21
how often do you think
you'll get a "no" from a doctor
you'll get a "no" from a doctor
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会听见一个医生说”没必要“？
05:23
if you ask such a question?
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05:26
Researchers have investigated this,
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调查人员对此进行了调查，
05:28
and they come up
with about the same "no" rate
with about the same "no" rate
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他们得到了不论在哪里
05:30
wherever they go.
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都大概相同的比例。
05:32
And that is 30 percent.
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是30%。
05:33
Meaning, three out of 10 times,
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意思是，10 次里有 3 次
05:37
your doctor prescribes
or suggests something
or suggests something
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你的医生会给你开出或者建议
05:41
that is completely unnecessary.
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完全没必要的东西。
05:46
And you know what they claim
the reason for this is?
the reason for this is?
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你们知道他们声称的原因是什么？
05:50
Patient pressure.
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患者给的压力。
05:52
In other words, you.
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换句话说，是你们。
05:54
You want something to be done.
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你们希望我们一定要做点什么。
05:58
A friend of mine came to me
for medical advice.
for medical advice.
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我的一个朋友曾经来找我
咨询医疗方面的建议。
咨询医疗方面的建议。
06:01
This is a sporty guy,
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他是一个爱运动的人。
06:02
he does a lot of cross-country skiing
in the winter time,
in the winter time,
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他在冬天经常穿梭在
不同国家进行越野滑雪，
不同国家进行越野滑雪，
06:05
he runs in the summer time.
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夏天跑步。
06:07
And this time, he'd gotten a bad back ache
whenever he went jogging.
whenever he went jogging.
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这次，他在跑步时
感觉到了严重的背疼。
感觉到了严重的背疼。
06:11
So much that he had to stop doing it.
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疼得他不能再跑步。
06:15
I did an examination,
I questioned him thoroughly,
I questioned him thoroughly,
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我做了一个检查，
全面的对他进行问询，
全面的对他进行问询，
06:18
and what I found out is
that he probably had a degenerated disc
that he probably had a degenerated disc
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我发现很可能在他的脊椎下半部分
06:21
in the lower part of his spine.
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有椎间盘退变。
06:24
Whenever it got strained, it hurt.
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每次收紧的时候，都会疼痛。
06:28
He'd already taken up
swimming instead of jogging,
swimming instead of jogging,
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他已经接受用游泳代替慢跑，
06:30
there was really nothing to do,
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实际上没有什么可以做的，
所以我告诉他：
”你在训练的时候，
”你在训练的时候，
06:32
so I told him, "You need
to be more selective
to be more selective
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必须有选择性的进行。
06:34
when it comes to training.
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一些活动对你有好处，
06:35
Some activities are good for you,
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06:37
some are not."
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另一些没有。”
06:39
His reply was,
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他的回答是，
06:41
"I want an MRI of my back."
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“我想做背部的核磁共振成像。”
06:45
"Why do you want an MRI?"
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“为什么你想做这个?”
06:48
"I can get it for free
through my insurance at work."
through my insurance at work."
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“我可以用公司保险报销这个花费。”
06:51
"Come on," I said --
he was also, after all, my friend.
he was also, after all, my friend.
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“拜托，”我说 ——
毕竟，他是我的朋友。
毕竟，他是我的朋友。
06:54
"That's not the real reason."
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”那不是真正的原因。”
06:56
"Well, I think it's going to be good
to see how bad it looks back there."
to see how bad it looks back there."
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“哦，我觉得能看一下
我的后背到底多糟糕比较好。”
我的后背到底多糟糕比较好。”
07:03
"When did you start interpreting
MRI scans?" I said.
MRI scans?" I said.
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“你什么时候开始能看懂
核磁共振扫描了？”我说。
核磁共振扫描了？”我说。
07:06
(Laughter)
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（笑声）
07:08
"Trust me on this.
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“这件事你要相信我。
07:10
You're not going to need the scan."
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你不需要这个扫描。”
07:12
"Well," he said,
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”唔，”他说，
07:14
and after a while, he continued,
"It could be cancer."
"It could be cancer."
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过了一会儿，他继续说，
“可能是癌症。”
“可能是癌症。”
07:17
(Laughter)
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（笑声）
07:20
He got the scan, obviously.
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很明显，他还是做了扫描。
07:22
And through his insurance at work,
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通过他们公司的保险计划，
07:24
he got to see one
of my colleagues at work,
of my colleagues at work,
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他找了我的一个同事，
07:26
telling him about the degenerated disc,
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告诉他椎间盘退化的事，
07:28
that there was nothing to do,
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还是没什么其它可以做的，
07:30
and that he should keep on swimming
and quit the jogging.
and quit the jogging.
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他应该继续游泳，停止慢跑。
07:36
After a while,
I met him again and he said,
I met him again and he said,
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过了一段时间，
我又遇见了他，
我又遇见了他，
他说：“至少我现在知道
是怎么回事了。”
是怎么回事了。”
07:38
"At least now I know what this is."
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07:40
But let me ask you a question.
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但是让我问你们一个问题。
07:42
What if all of you in this room
with the same symptoms had an MRI?
with the same symptoms had an MRI?
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如果这个房间里有同样症状的人
都来做核磁共振成像呢？
都来做核磁共振成像呢？
07:46
And what if all the people in Norway
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如果挪威所有人都因为偶尔的背疼
07:49
had an MRI due to occasional back pain?
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去做核磁共振成像呢？
07:54
The waiting list for an MRI
would quadruple, maybe even more.
would quadruple, maybe even more.
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核磁共振成像的排队人数
会增至四倍，甚至更多。
会增至四倍，甚至更多。
07:58
And you would all take
the spot on that list
the spot on that list
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而你们会占用了名单上那些
08:00
from someone who really had cancer.
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真的有癌症的人的名额。
08:03
So a good doctor sometimes says no,
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所以一个好的医生有时候会说不，
08:07
but the sensible patient
also turns down, sometimes,
also turns down, sometimes,
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但敏感的病人有时候也会拒绝掉
08:11
an opportunity
to get diagnosed or treated.
to get diagnosed or treated.
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一个被诊断和治疗的机会。
08:16
"Doctor, is this really necessary?"
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“医生，这个真的必要吗？”
08:20
I know this can be
a difficult question to ask.
a difficult question to ask.
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我知道这是一个
很难启齿的问题。
很难启齿的问题。
08:24
In fact, if you go back 50 years,
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实际上，如果倒退 50 年，
08:26
this was even considered rude.
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这甚至会被认为粗鲁。
08:28
(Laughter)
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（笑声）
08:29
If the doctor had decided
what to do with you,
what to do with you,
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如果医生已经决定如何治疗你，
08:32
that's what you did.
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你就要遵医嘱。
08:35
A colleague of mine,
now a general practitioner,
now a general practitioner,
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我的一个同事，
现在是一个全科医生，
现在是一个全科医生，
08:37
was sent away to a tuberculosis
sanatorium as a little girl,
sanatorium as a little girl,
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在还是个小女孩的时候
曾经被送到肺结核疗养院
曾经被送到肺结核疗养院
08:42
for six months.
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六个月。
08:43
It was a terrible trauma for her.
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对她来说是可怕的创伤。
08:45
She later found out, as a grown-up,
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在她成年后发现，
08:48
that her tests on tuberculosis
had been negative all along.
had been negative all along.
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她的肺结核测试结果
一直都是阴性的。
一直都是阴性的。
08:52
The doctor had sent her away
on nothing but wrong suspicion.
on nothing but wrong suspicion.
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医生只是基于错误的怀疑
就送她去了疗养院。
就送她去了疗养院。
08:56
No one had dared or even considered
confronting him about it.
confronting him about it.
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没有人敢或者甚至想过
去反抗他的做法。
去反抗他的做法。
09:01
Not even her parents.
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甚至她的父母都没有。
09:03
Today, the Norwegian health minister
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如今，挪威卫生部长
09:06
talks about the patient
health care service.
health care service.
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谈及患者的医疗保健服务。
09:10
The patient is supposed to get advice
from the doctor about what to do.
from the doctor about what to do.
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患者应该从医生那
得到治疗建议。
得到治疗建议。
09:16
This is great progress.
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这是巨大的进步。
09:18
But it also puts more
responsibility on you.
responsibility on you.
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但是这同样给了你们
更多的责任。
更多的责任。
09:21
You need to get in the front seat
with your doctor
with your doctor
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你们需要坐在医生面前
09:24
and start sharing
decisions on where to go.
decisions on where to go.
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一起讨论接下来的决定。
09:27
So, the next time
you're in a doctor's office,
you're in a doctor's office,
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所以，下一次
当你在医生办公室里，
当你在医生办公室里，
09:31
I want you to ask,
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我希望你们可以问，
09:32
"Doctor, is this really necessary?"
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“医生，这个真的必要吗？”
09:36
And in my female patient's case,
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在我那个女性患者的案例中，
09:38
the answer would be no,
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答案是不，
09:40
but an operation could also be justified.
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但是有的手术也有可能是合理的。
09:44
"So doctors, what are the risks
attached to this operation?"
attached to this operation?"
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“所以医生，
这个手术有哪些风险？”
这个手术有哪些风险？”
09:49
Well, five to ten percent of patients
will have worsening of pain symptoms.
will have worsening of pain symptoms.
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5 - 10% 的患者疼痛症状会加重。
09:55
One to two percent of patients
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1-2% 的患者
09:57
will have an infection in the wound
or even a rehemorrhage
or even a rehemorrhage
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会伤口感染或甚至是出血
10:00
that might end up in a re-operation.
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这就需要第二次的手术。
10:04
0.5 percent of patients
also experience permanent hoarseness
also experience permanent hoarseness
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0.5% 的患者也会经历
永久性的声音嘶哑，
永久性的声音嘶哑，
10:07
and a few, but still a few,
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还有一些
10:09
will experience reduced function
in the arms or even legs.
in the arms or even legs.
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手臂或者腿功能会衰减。
10:15
"Doctor, are there other options?"
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“医生，有其他的选择吗？”
10:18
Yes, rest and physical therapy
over some time
over some time
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是的，一段时间的休息和物理治疗
10:21
might get you perfectly well.
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可能会让你完全恢复。
10:25
"And what happens if I don't do anything?"
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“如果我什么都不做会怎么样？”
10:27
It's not recommended,
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不建议这样，
10:29
but even then, there's a slight chance
that you will get well.
that you will get well.
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但是尽管那样，
也有很小的可能你会康复。
也有很小的可能你会康复。
10:33
Four questions.
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四个问题。
10:34
Simple questions.
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简单的问题。
10:36
Consider them your new toolbox to help us.
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把它们当作你的新工具箱
来帮助我们。
来帮助我们。
10:40
Is this really necessary?
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“这真的必要吗？”
10:42
What are the risks?
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“有什么风险？”
10:44
Are there other options?
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“有没有其它选择？”
10:45
And what happens if I don't do anything?
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“如果我什么都不做会怎么样？”
10:49
Ask them when your doctor
wants to send you to an MRI,
wants to send you to an MRI,
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当医生让你做核磁共振成像时
要问医生，
要问医生，
10:53
when he prescribes antibiotics
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还有当他给你开抗生素
10:55
or suggests an operation.
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或者建议手术时也要问。
10:58
What we know from research
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从研究中我们知道
11:00
is that one out of five
of you, 20 percent,
of you, 20 percent,
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5 个人中有 1 个，
也就是 20%，
也就是 20%，
11:03
will change your opinion on what to do.
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在问了之后
会改变你们的想法。
会改变你们的想法。
11:06
And by doing that, you will
not only have made your life
not only have made your life
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做到这样，你不仅会让你的生活
11:09
a whole lot easier,
and probably even better,
and probably even better,
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变得更容易，甚至更好，
11:13
but the whole health care sector
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而且会让整个医疗保健部门
11:15
will have benefited from your decision.
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受益于你的决定。
11:19
Thank you.
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谢谢大家。
11:20
(Applause)
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（掌声）
ABOUT THE SPEAKER
Christer Mjåset - NeurosurgeonChrister Mjåset, M.D. is a neurosurgeon, author, columnist and lecturer who currently works as a Harkness fellow in Health Care Policy and Practice at Harvard T.H. Chan School of Public Health in Boston studying value-based health care models.
Why you should listen
Christer Mjåset, M.D. holds a position as a researcher at the Oslo University Hospital analyzing data from The Norwegian Spine Registry and as a lecturer at the Department of Health Management and Economics, University of Oslo, where he teaches in a leadership program for young physicians. Mjåset was president of the Norwegian Junior Doctors 2015-2019 and the Vice President of the Norwegian Medical Association 2017-2019. This work led him to be involved with the international Choosing Wisely campaign which seeks to advance a national dialogue avoiding unnecessary medical tests, treatments and procedures. From 2017-2019 he was responsible for implementing the campaign in Norway
Mjåset is a published author of five fictional books and several short stories. He won the Oslo City Cultural Scholarship for writers in 2006. He got his medical degree and bachelor’s degree in literature and philosophy at University of Oslo, both in 2000.
Christer Mjåset | Speaker | TED.com