TED2012
Atul Gawande: How do we heal medicine?
Atul Gawande: 我們如何治療醫學界的問題？
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我們的醫療體制失控了。醫生可以成為異樣的（昂貴的）治療, 但他們失去了他們的初衷：把病人治好。 身兼醫生和作家的Atul Gawande建議我們退後一步並看待新的改善方法- 用越來越少的牛仔和更多的維修人員。
Atul Gawande - Surgeon, writer, public health innovator
Surgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching. Full bio
Surgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching. Full bio
Double-click the English transcript below to play the video.
00:15
I got my start
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當我開始從事
00:18
in writing and research
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寫作和研究時
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as a surgical trainee,
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我還是一個
00:23
as someone who was a long ways away
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對任何事都一竅不通的
00:25
from becoming any kind of an expert at anything.
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外科實習醫生。
00:28
So the natural question you ask then at that point
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所以在這個情形時, 你自然而然會問
00:31
is, how do I get good at what I'm trying to do?
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我要如何在我想做的事物上精益求精？
00:33
And it became a question of,
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然後問題就變成
00:35
how do we all get good
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“我們”該如何
00:37
at what we're trying to do?
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把“我們”想做的事情做好？
00:40
It's hard enough to learn to get the skills,
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學習各種技巧，吸收大量的知識，
00:44
try to learn all the material you have to absorb
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並且應用在你負責的工作上
00:47
at any task you're taking on.
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是一件困難的事。
00:49
I had to think about how I sew and how I cut,
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外科醫生必須考慮縫合和切割傷口，
00:52
but then also how I pick the right person
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我同時也要挑選適合的團隊
00:54
to come to an operating room.
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進入手術房
00:56
And then in the midst of all this
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面對這所有的過程
00:58
came this new context
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我一直思考
01:00
for thinking about what it meant to be good.
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到底甚麼樣才稱做把事情做好。
01:02
In the last few years
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最近這幾年
01:04
we realized we were in the deepest crisis
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我們的醫療體系
01:07
of medicine's existence
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面臨嚴重的危機
01:09
due to something you don't normally think about
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因為身為一個醫生
01:11
when you're a doctor
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你所關心的是
01:13
concerned with how you do good for people,
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如何盡全力去醫治病人
01:16
which is the cost
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而不是去在意
01:18
of health care.
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醫療成本。
01:20
There's not a country in the world
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但現在世界上每個國家
01:23
that now is not asking
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都想知道
01:25
whether we can afford what doctors do.
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是否自己能夠支付醫療行為的代價。
01:28
The political fight that we've developed
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這也形成政治上的爭論
01:31
has become one around
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問題總圍繞在
01:33
whether it's the government that's the problem
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政府是否該為此負責?
01:36
or is it insurance companies that are the problem.
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還是保險公司才是罪魁禍首？
01:41
And the answer is yes and no;
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你可以說是，也可以說不是；
01:45
it's deeper than all of that.
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但這個問題的答案不是這麼表面的。
01:47
The cause of our troubles
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造成現今困境的原因
01:49
is actually the complexity that science has given us.
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可以說是科學發展日趨複雜的結果。
01:52
And in order to understand this,
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為了瞭解這個觀點
01:54
I'm going to take you back a couple of generations.
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讓我們回到幾個世代之前。
01:58
I want to take you back
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我們回到
02:00
to a time when Lewis Thomas was writing in his book, "The Youngest Science."
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醫生兼作家Lewis Thomas
02:03
Lewis Thomas was a physician-writer,
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寫"最稚齡的科學."這本書的時候。
02:05
one of my favorite writers.
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他是我最喜歡的作家之一。
02:07
And he wrote this book to explain, among other things,
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他的書中描述了
02:10
what it was like to be a medical intern
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當時在波士頓醫院
02:13
at the Boston City Hospital
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身為實習醫生時的情況。
02:15
in the pre-penicillin year
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那是在西元1937年
02:17
of 1937.
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盤尼西林發明前的年代。
02:20
It was a time when medicine was cheap
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那個時候，醫藥費很便宜
02:24
and very ineffective.
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但也沒什麼效果。
02:28
If you were in a hospital, he said,
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他說，當時的醫院
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it was going to do you good
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對病人的幫助
02:34
only because it offered you
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僅僅在於提供病人
02:36
some warmth, some food, shelter,
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一些溫暖，食物和庇護
02:40
and maybe the caring attention
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也許還有來自護士的
02:42
of a nurse.
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悉心照料。
02:44
Doctors and medicine
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醫生和藥物
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made no difference at all.
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對病情沒有多大影響。
02:50
That didn't seem to prevent the doctors
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但即使如此，
02:52
from being frantically busy in their days,
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當時的醫師
02:54
as he explained.
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仍然非常忙碌。
02:56
What they were trying to do
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他們試圖
02:58
was figure out whether you might have one of the diagnoses
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想要從病人的診斷書中
03:01
for which they could do something.
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看看有什麼是他們能做的。
03:04
And there were a few.
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當然，很少。
03:06
You might have a lobar pneumonia, for example,
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舉例來說，如果你是一個肺炎病人
03:09
and they could give you an antiserum,
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醫生會給你抗血清的藥，
03:11
an injection of rabid antibodies
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注射藥性強的抗體
03:15
to the bacterium streptococcus,
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對抗鏈球菌。
03:18
if the intern sub-typed it correctly.
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前提是實習醫生的血型分類正確。
03:22
If you had an acute congestive heart failure,
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如果你有充血性心臟衰竭，
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they could bleed a pint of blood from you
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醫生可能會從你的手臂靜脈
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by opening up an arm vein,
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抽出一品脫的血，
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giving you a crude leaf preparation of digitalis
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給你天然植物調配的強心劑，
03:34
and then giving you oxygen by tent.
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再提供你氧氣帳。
03:39
If you had early signs of paralysis
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如果病人有癱瘓的早期徵兆，
03:41
and you were really good at asking personal questions,
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當醫生緊密的追蹤病人的私生活時
03:44
you might figure out
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可能會發現
03:46
that this paralysis someone has is from syphilis,
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癱瘓的原因來自梅毒感染
03:49
in which case you could give this nice concoction
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這時病人會被注射適量的
03:52
of mercury and arsenic --
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汞和砷的混合劑–
03:56
as long as you didn't overdose them and kill them.
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如果注射過量，可能連病人一起殺死了。
04:01
Beyond these sorts of things,
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除了這些治療之外
04:03
a medical doctor didn't have a lot that they could do.
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醫生能做的很有限。
04:08
This was when the core structure of medicine
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在那樣的年代，
04:10
was created --
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醫生們盡力做好份內工作
04:12
what it meant to be good at what we did
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建立期望中的醫療行為
04:15
and how we wanted to build medicine to be.
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醫藥體系的核心架構於是開始形成。
04:17
It was at a time
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在當時，
04:19
when what was known you could know,
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醫生可以記住所有的醫學知識
04:21
you could hold it all in your head, and you could do it all.
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也能夠獨立從事所有已知的醫療行為
04:24
If you had a prescription pad,
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所以如果一個醫生有配製處方的藥室
04:26
if you had a nurse,
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有一個護士
04:28
if you had a hospital
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有一個可以讓病人休息的場所或醫院
04:30
that would give you a place to convalesce, maybe some basic tools,
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或許再加上一些基本的工具
04:33
you really could do it all.
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就可以完成所有的治療。
04:35
You set the fracture, you drew the blood,
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你可以處理骨折、抽血、
04:38
you spun the blood,
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分析病人血液，
04:40
looked at it under the microscope,
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並且用顯微鏡觀察，
04:42
you plated the culture, you injected the antiserum.
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你可以作組織培養、可以注射抗血清。
04:45
This was a life as a craftsman.
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這是像工匠或技師一樣的工作。
04:50
As a result, we built it around
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當時的醫師們勇於冒險
04:53
a culture and set of values
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充滿勇氣
04:55
that said what you were good at
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獨立工作
04:58
was being daring,
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且自給自足，
05:00
at being courageous,
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最終，我們建立了
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at being independent and self-sufficient.
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醫療體系獨有的文化和價值標準。
05:06
Autonomy was our highest value.
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獨立自主是我們高度推崇的價值。
05:12
Go a couple generations forward
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回到現在，
05:14
to where we are, though,
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我們處在一個
05:16
and it looks like a completely different world.
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完全不同的環境。
05:18
We have now found treatments
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我們幾乎能夠治療
05:21
for nearly all of the tens of thousands of conditions
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人類會發生的
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that a human being can have.
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數以千計的病症。
05:27
We can't cure it all.
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當然，我們沒辦法克服所有疾病
05:29
We can't guarantee that everybody will live a long and healthy life.
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我們也沒有辦法保證每個人活得更久更健康。
05:32
But we can make it possible
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但我們盡可能
05:34
for most.
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做到最好。
05:37
But what does it take?
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但是這要付出的代價是甚麼？
05:39
Well, we've now discovered
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我們現在已經擁有
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4,000 medical and surgical procedures.
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4000種內外科療法
05:45
We've discovered 6,000 drugs
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我可以開立的處方藥
05:48
that I'm now licensed to prescribe.
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有6000種。
05:51
And we're trying to deploy this capability,
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我們還試著將醫療
05:53
town by town,
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挨家挨戶的
05:55
to every person alive --
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深入我們我們國家
05:59
in our own country,
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甚至於全世界
06:01
let alone around the world.
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去治療所有的人。
06:03
And we've reached the point where we've realized,
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但是現在，我們已經知道
06:06
as doctors,
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身為醫生
06:08
we can't know it all.
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我們沒辦法靠自己
06:10
We can't do it all
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知道所有的醫學知識
06:13
by ourselves.
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完成所有醫療行為。
06:15
There was a study where they looked
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有一個研究統計
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at how many clinicians it took to take care of you
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究竟需要多少醫護人員
06:19
if you came into a hospital,
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去照顧一個進到醫院的病人，
06:21
as it changed over time.
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結果隨著年代不同而有很大差異。
06:23
And in the year 1970,
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1970年代，
06:25
it took just over two full-time equivalents of clinicians.
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只需要兩個全職醫護人員。
06:28
That is to say,
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也就是說，
06:30
it took basically the nursing time
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除了基礎護理的時間外，
06:33
and then just a little bit of time for a doctor
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只要一個醫生
06:35
who more or less checked in on you
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一天一次
06:37
once a day.
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確認一下病人情況。
06:39
By the end of the 20th century,
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到了20世紀末，
06:42
it had become more than 15 clinicians
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一個同樣的病人
06:45
for the same typical hospital patient --
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需要專科醫生、物理治療師
06:48
specialists, physical therapists,
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護士等
06:51
the nurses.
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超過15個醫護人員處理。
06:54
We're all specialists now,
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現在所有的醫生的都是專科醫生，
06:56
even the primary care physicians.
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甚至基礎治療的醫生也不例外。
06:58
Everyone just has
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每個醫護
07:00
a piece of the care.
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提供一小部分照顧。
07:03
But holding onto that structure we built
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每個醫師都
07:05
around the daring, independence,
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充滿勇氣、獨立工作、
07:07
self-sufficiency
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且自信滿滿。
07:09
of each of those people
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這些都醫師養成教育所重視的價值
07:12
has become a disaster.
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但反而讓醫療體系變成一場災難。
07:14
We have trained, hired and rewarded people
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我們訓練、雇用並獎勵醫護人員
07:18
to be cowboys.
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希望他們像牛仔一樣勇敢能幹。
07:21
But it's pit crews that we need,
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但其實我們需要的是賽車維修隊，
07:24
pit crews for patients.
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一個針對病人的維修團隊。
07:26
There's evidence all around us:
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我們身邊就有例子可以證明：
07:28
40 percent of our coronary artery disease patients
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在我們社會上
07:31
in our communities
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40%的冠狀動脈病人
07:33
receive incomplete or inappropriate care.
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沒有得到適當的治療。
07:37
60 percent
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60%的
07:39
of our asthma, stroke patients
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氣喘或中風病人
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receive incomplete or inappropriate care.
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沒有接受完整或適當的照護。
07:46
Two million people come into hospitals
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高達兩百萬的人進出醫院後
07:49
and pick up an infection
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被感染了
07:51
they didn't have
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原先沒有的病菌。
07:53
because someone failed to follow
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只因為醫護疏忽了
07:56
the basic practices of hygiene.
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基礎衛生工作。
07:59
Our experience
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我們的經驗是
08:01
as people who get sick,
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當有人生病
08:03
need help from other people,
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需要別人的幫助時
08:05
is that we have amazing clinicians
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我們有優秀的醫生
08:08
that we can turn to --
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我們可以化身為
08:10
hardworking, incredibly well-trained and very smart --
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認真工作, 受過非常良好訓練, 而且很聰明的醫生
08:13
that we have access to incredible technologies
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我們可以接觸到先進的醫學科技
08:16
that give us great hope,
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讓我們擁抱更好的希望
08:18
but little sense
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但請注意
08:20
that it consistently all comes together for you
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所有的一切都為你而準備好的
08:24
from start to finish
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從開始到結束
08:27
in a successful way.
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由一個成功的方式到來
08:30
There's another sign
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也有另外一個現象是
08:32
that we need pit crews,
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我們需要維修人員
08:34
and that's the unmanageable cost
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而對我們的服務而言
08:37
of our care.
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這是個無法控制好的預算
08:40
Now we in medicine, I think,
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現今的醫藥界, 我想
08:42
are baffled by this question of cost.
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我們正為了預算的問題而苦惱
08:44
We want to say, "This is just the way it is.
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我們想說：“這就是這樣。
08:48
This is just what medicine requires."
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這就是醫藥界需要的呀“
08:50
When you go from a world
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當你的想法是
08:52
where you treated arthritis with aspirin,
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用阿斯匹靈來治關節炎
08:55
that mostly didn't do the job,
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雖然並沒有什麼用
08:58
to one where, if it gets bad enough,
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轉換到另一種想法是, 當關節炎變非常非常糟了
09:00
we can do a hip replacement, a knee replacement
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我們可以做髖關節替換手術, 膝蓋替換手術
09:02
that gives you years, maybe decades,
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然後可以讓你好幾年, 也許好幾十年
09:05
without disability,
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都不會不良於行
09:07
a dramatic change,
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一個戲劇化的轉變
09:09
well is it any surprise
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四萬美金的髖關節替換手術
09:11
that that $40,000 hip replacement
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取代了10美分的阿斯匹靈
09:14
replacing the 10-cent aspirin
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這不是很讓人驚訝嗎？
09:16
is more expensive?
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是不是更貴呢？
09:18
It's just the way it is.
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事情就是這樣的
09:21
But I think we're ignoring certain facts
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但我想我們忽略了某些
09:23
that tell us something about what we can do.
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告訴我們可以做的事的事實
09:28
As we've looked at the data
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我們看著那些
09:30
about the results that have come
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越來越複雜的
09:33
as the complexity has increased,
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成果數據時
09:35
we found
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我們發現
09:37
that the most expensive care
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最貴的醫療照護
09:39
is not necessarily the best care.
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並不見得是最好的照護
09:42
And vice versa,
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而反者亦然
09:44
the best care
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最好的照料
09:46
often turns out to be the least expensive --
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通常都是那些不貴的
09:49
has fewer complications,
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沒有什麼糾紛的
09:52
the people get more efficient at what they do.
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人們可以經由他們的行為中變得更有效率
09:55
And what that means
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這也意味著
09:57
is there's hope.
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希望是存在的
10:00
Because [if] to have the best results,
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因為（如果）要有最好的結局
10:03
you really needed the most expensive care
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你絕對需要最貴的醫療照護
10:06
in the country, or in the world,
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在這個國家, 或在這個世界
10:08
well then we really would be talking about rationing
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那 我們真的需要討論到配給的問題
10:11
who we're going to cut off from Medicare.
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哪些人我們需要停止提供醫療照護
10:15
That would be really our only choice.
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而這是我們的唯一選擇
10:19
But when we look at the positive deviants --
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但當我們看著那些有正面反應的異變者 --
10:21
the ones who are getting the best results
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那些用著最低廉的價格
10:24
at the lowest costs --
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得到最好的照護的人們 --
10:26
we find the ones that look the most like systems
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我們會發現最成功的案例
10:29
are the most successful.
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是最系統性的
10:31
That is to say, they found ways
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那也意味著, 他們找到
10:34
to get all of the different pieces,
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把所有不一樣的事物
10:36
all of the different components,
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所有不同的要件
10:38
to come together into a whole.
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全部統整在一起的方法
10:41
Having great components is not enough,
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有最好的要件還不夠
10:44
and yet we've been obsessed in medicine with components.
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雖然過去我們為了一些醫藥界的要件而著迷
10:48
We want the best drugs, the best technologies,
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我們想要最好的藥品, 最好的醫學科技,
10:51
the best specialists,
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最好的專科醫生
10:54
but we don't think too much
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但我們沒有好好想過
10:56
about how it all comes together.
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如何把這些要件組合在一起
10:59
It's a terrible design strategy actually.
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這實際上是個不好的設計方式
11:03
There's a famous thought experiment
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有個有名的思想實驗
11:06
that touches exactly on this
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剛好跟我們討論的東西有關連
11:08
that said, what if you built a car
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實驗是, 如果你組一台車
11:10
from the very best car parts?
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用最好的零組件
11:13
Well it would lead you to put in Porsche brakes,
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你用了保時捷的煞車
11:16
a Ferrari engine,
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法拉利的引擎
11:18
a Volvo body, a BMW chassis.
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富豪的車身, BMW的 底盤
11:21
And you put it all together and what do you get?
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然後你組裝完後你得到的是？
11:24
A very expensive pile of junk that does not go anywhere.
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一堆昂貴的卻根本也不能用的垃圾
11:28
And that is what medicine can feel like sometimes.
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而有時醫藥界正是如此
11:33
It's not a system.
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這不是系統性的
11:36
Now a system, however,
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系統性的治療，是
11:38
when things start to come together,
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當事情能組合在一起時
11:41
you realize it has certain skills
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你會發現它
11:44
for acting and looking that way.
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有些特定的功能
11:47
Skill number one
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第一個功能是
11:49
is the ability to recognize success
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發現成功的能力
11:51
and the ability to recognize failure.
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和發現弱點的能力
11:54
When you are a specialist,
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當你是個專科醫生
11:56
you can't see the end result very well.
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你沒辦法準確的看到最後的結果
11:59
You have to become really interested in data,
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你必須變得對於數據很有興趣
12:02
unsexy as that sounds.
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但這聽起來很無聊
12:04
One of my colleagues is a surgeon in Cedar Rapids, Iowa,
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我有個同事是在愛荷華州的Cedar Rapids 那邊當外科醫生
12:07
and he got interested in the question of,
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而他對於以下這個問題很有興趣
12:11
well how many CT scans did they do
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他們為了Cedar Rapids 這個社區
12:13
for their community in Cedar Rapids?
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做了多少電腦斷層掃描？
12:15
He got interested in this
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他對這個很有興趣
12:17
because there had been government reports,
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因為曾經有政府的報告
12:19
newspaper reports, journal articles
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報紙報導, 雜誌報導
12:21
saying that there had been too many CT scans done.
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指出電腦斷層掃描過多的情形。
12:24
He didn't see it in his own patients.
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他沒在自己的病人裡發現這個情形
12:28
And so he asked the question, "How many did we do?"
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所以他想問：“我們到底做了多少電腦斷層掃描？“
12:30
and he wanted to get the data.
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他想得到這些數據
12:32
It took him three months.
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他花了三個月的時間
12:34
No one had asked this question in his community before.
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在他的社區裡從來沒有人想過這個問題
12:37
And what he found was that,
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然後他找到的結果是
12:39
for the 300,000 people in their community,
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他們社區裡的三十萬人
12:41
in the previous year
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在過去的一年裡
12:43
they had done 52,000 CT scans.
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他們做了五萬兩千份電腦斷層掃描
12:48
They had found a problem.
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他們發現了個問題
12:51
Which brings us to skill number two a system has.
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也帶出了一個系統中的第二個功能
12:56
Skill one, find where your failures are.
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第一種能力是, 發現你的弱點
12:59
Skill two is devise solutions.
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第二種能力是設計解決方法
13:03
I got interested in this
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我對於這個有興趣
13:05
when the World Health Organization came to my team
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當世界衛生組織來到我的團隊
13:07
asking if we could help with a project
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詢問我們是否能參加
13:09
to reduce deaths in surgery.
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減少手術致死機率的項目時
13:11
The volume of surgery had spread
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手術的數量在
13:13
around the world,
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世界上不斷的增加
13:15
but the safety of surgery
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但手術的安全性
13:17
had not.
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並沒有增加
13:19
Now our usual tactics for tackling problems like these
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現在我們對於這些問題的解決方法是
13:22
are to do more training,
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做更多的訓練
13:24
give people more specialization
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讓人們變得更專業
13:27
or bring in more technology.
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或者提供更多的醫療科技
13:30
Well in surgery, you couldn't have people who are more specialized
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在手術領域裡, 你沒有辦法擁有那些再更加專科的人
13:33
and you couldn't have people who are better trained.
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你也沒有辦法擁有那些訓練得更好的人
13:36
And yet we see unconscionable levels
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現在我們看到不合理的
13:39
of death, disability
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死亡和殘障比例
13:43
that could be avoided.
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都是可以被避免的
13:45
And so we looked at what other high-risk industries do.
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所以我們調查了另一個更高風險的行業
13:47
We looked at skyscraper construction,
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我們調查摩天大樓的建造工程
13:49
we looked at the aviation world,
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我們看到航空世界
13:52
and we found
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然後我們發現
13:54
that they have technology, they have training,
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他們擁有先進的科技, 他們也有良好的訓練
13:56
and then they have one other thing:
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而他們也有另外一件事
13:59
They have checklists.
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他們有清單
14:02
I did not expect
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我並不期望
14:04
to be spending a significant part
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身為一個哈佛來的外科醫生
14:06
of my time as a Harvard surgeon
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要花特定的時間
14:08
worrying about checklists.
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擔心清單這件事情
14:11
And yet, what we found
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現今, 我們發現的是
14:13
were that these were tools
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有工具可以幫助我們
14:16
to help make experts better.
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讓專業人員變得更好
14:19
We got the lead safety engineer for Boeing to help us.
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我們需要引進波音的工程師來幫助我們
14:23
Could we design a checklist for surgery?
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我們能設計給外科醫生的清單嗎？
14:26
Not for the lowest people on the totem pole,
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不是為了在低層的人員們而設計
14:28
but for the folks
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而是為了那些
14:30
who were all the way around the chain,
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在工作鍊旁
14:32
the entire team including the surgeons.
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整個隊伍的人員, 而其中也包含了外科醫生
14:34
And what they taught us
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而他們教我們的是
14:36
was that designing a checklist
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設計清單可以
14:38
to help people handle complexity
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幫助人們更好的處理
14:40
actually involves more difficulty than I had understood.
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比我能理解還要難上好幾倍的困難事物
14:43
You have to think about things
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你必須考慮這些事情
14:45
like pause points.
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像是個暫停的時刻
14:47
You need to identify the moments in a process
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你必須在危險前發現問題的存在時
14:50
when you can actually catch a problem before it's a danger
332
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學會如此的暫停
14:52
and do something about it.
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然後試圖解決問題
14:54
You have to identify
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你必須指認出
14:56
that this is a before-takeoff checklist.
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這是個起飛或開始前的確認清單
14:59
And then you need to focus on the killer items.
336
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然後你需要專注於最重要以及最難的項目
15:02
An aviation checklist,
337
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一個航空界的清單
15:04
like this one for a single-engine plane,
338
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像是這個單引擎的飛機的清單
15:06
isn't a recipe for how to fly a plane,
339
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不是教你如何開飛機
15:08
it's a reminder of the key things
340
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是提醒常會被忘記或忽略的
15:10
that get forgotten or missed
341
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重要事物清單
15:13
if they're not checked.
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如果他們沒被確認
15:15
So we did this.
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那我們就會這樣
15:17
We created a 19-item two-minute checklist
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我們給手術團隊創造了19個項目
15:20
for surgical teams.
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兩分鐘的確認清單
15:22
We had the pause points
346
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我們有暫停的時刻
15:24
immediately before anesthesia is given,
347
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就在麻醉開始前
15:27
immediately before the knife hits the skin,
348
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就在手術刀碰觸到皮膚前
15:30
immediately before the patient leaves the room.
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就在病患離開手術室前
15:33
And we had a mix of dumb stuff on there --
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而我們有許多蠢事列在上面
15:36
making sure an antibiotic is given in the right time frame
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只為了確定抗生素是在正確的時間點提供的
15:39
because that cuts the infection rate by half --
352
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因為他們能讓感染機率減半
15:41
and then interesting stuff,
353
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而有趣的是
15:43
because you can't make a recipe for something as complicated as surgery.
354
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因為你沒有辦法為了手術這樣複雜的事情列張清單
15:46
Instead, you can make a recipe
355
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取而代之的是, 你可以列張
15:48
for how to have a team that's prepared for the unexpected.
356
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如何讓整個團隊為了無法預期的事情作準備的清單
15:51
And we had items like making sure everyone in the room
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而我們有像是確認每個在手術室裡的人
15:54
had introduced themselves by name at the start of the day,
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都有在手術開始前自我介紹的選項，
15:57
because you get half a dozen people or more
359
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因為你有六個或更多的人
15:59
who are sometimes coming together as a team
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是在這個手術團隊被組成前
16:02
for the very first time that day that you're coming in.
361
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從來也不認識彼此的
16:05
We implemented this checklist
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我們在世界上八個醫院裡
16:07
in eight hospitals around the world,
363
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實行這個清單計畫
16:10
deliberately in places from rural Tanzania
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特意從塔桑尼亞的郊區
16:12
to the University of Washington in Seattle.
365
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3000
到西雅圖的華盛頓大學
16:15
We found that after they adopted it
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我們發現在他們接受這項激化後
16:18
the complication rates fell
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糾紛發生的機率下降
16:20
35 percent.
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2000
百分之三十五
16:22
It fell in every hospital it went into.
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每間醫院都是如此
16:25
The death rates fell
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手術死亡的機率降低
16:27
47 percent.
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百分之四十七
16:30
This was bigger than a drug.
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在藥物方面降低更多
16:32
(Applause)
373
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6000
（全場鼓掌）
16:38
And that brings us
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而這也讓我們討論到
16:40
to skill number three,
375
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第三種能力
16:43
the ability to implement this,
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能執行這項計畫的能力
16:45
to get colleagues across the entire chain
377
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3000
讓每個工作鍊上的人員
16:48
to actually do these things.
378
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能實際上執行這些事
16:51
And it's been slow to spread.
379
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而這散播的很慢
16:53
This is not yet our norm in surgery --
380
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這還不是我們手術界的傳統
16:57
let alone making checklists
381
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讓清單設計
16:59
to go onto childbirth and other areas.
382
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執行到生產和其他領域
17:02
There's a deep resistance
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實際上有一定的人抗拒這項計畫
17:04
because using these tools
384
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2000
因為使用這些工具
17:06
forces us to confront
385
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強迫我們去面對
17:08
that we're not a system,
386
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2000
我們不是一個整體的系統的現實
17:10
forces us to behave with a different set of values.
387
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強迫我們去表現出不一樣的價值觀
17:13
Just using a checklist
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用這個清單
17:15
requires you to embrace different values from the ones we've had,
389
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需要我們擁有和以往不一樣的價值觀念
17:18
like humility,
390
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像是人性
17:22
discipline,
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紀律
17:25
teamwork.
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團隊合作
17:27
This is the opposite of what we were built on:
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和我們現今擁有的
17:30
independence, self-sufficiency,
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獨立, 自我滿足
17:32
autonomy.
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自治相差甚遠
17:35
I met an actual cowboy, by the way.
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順道一提, 我遇到一個真正的牛仔
17:38
I asked him, what was it like
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我問他,
17:41
to actually herd a thousand cattle
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在數百英里上畜牧一千隻的牛
17:43
across hundreds of miles?
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是怎樣的感覺？
17:45
How did you do that?
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你怎麼辦到的呀？
17:47
And he said, "We have the cowboys stationed at distinct places all around."
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他說：“我們在各地都有駐紮的牛仔“
17:50
They communicate electronically constantly,
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“他們定時用電子通訊設備溝通“
17:53
and they have protocols and checklists
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而他們有協議好也有清單確認
17:55
for how they handle everything --
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他們遇到事情要如何處理 --
17:57
(Laughter)
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（笑聲）
17:59
-- from bad weather
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-- 從惡劣的天氣
18:01
to emergencies or inoculations for the cattle.
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到緊急狀況或為牲畜接種
18:04
Even the cowboys are pit crews now.
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連牛仔都是維修人員啦
18:08
And it seemed like time
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看起來我們現在該是
18:10
that we become that way ourselves.
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變成和他們一樣的時候了
18:12
Making systems work
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讓整個體制一體的運作
18:14
is the great task of my generation
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將是我們這個醫生和科學家世代
18:17
of physicians and scientists.
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最艱鉅的任務
18:19
But I would go further and say
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但我想更深入的說
18:21
that making systems work,
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讓這個體制運作
18:23
whether in health care, education,
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不管是醫學照護, 教育
18:25
climate change,
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天氣轉變
18:27
making a pathway out of poverty,
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改變貧窮
18:29
is the great task of our generation as a whole.
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都是我們整個世代需要完成的艱鉅任務
18:33
In every field, knowledge has exploded,
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在每個領域, 知識都爆炸性的增加了
18:36
but it has brought complexity,
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但這也將一切複雜化
18:38
it has brought specialization.
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也帶來了持續的專業化。
18:41
And we've come to a place where we have no choice
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而現在我們已經沒有其他的選擇
18:43
but to recognize,
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我們必須清楚知道
18:45
as individualistic as we want to be,
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我們想要個人主義
18:48
complexity requires
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但解決困難的問題需要
18:51
group success.
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團隊的合作才能成功
18:53
We all need to be pit crews now.
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我們現在都需要維修人員
18:57
Thank you.
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謝謝大家
18:59
(Applause)
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（全場鼓掌）
ABOUT THE SPEAKER
Atul Gawande - Surgeon, writer, public health innovatorSurgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching.
Why you should listen
Atul Gawande is author of several best-selling books, including Complications: A Surgeon's Notes on an Imperfect Science, Better: A Surgeon's Notes on Performance, Being Mortal: Medicine and What Matters in the End and The Checklist Manifesto.
He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship and two National Magazine Awards. In his work in public health, he is Executive Director of Ariadne Labs, a joint center for health systems innovation and chair of Lifebox, a nonprofit organization making surgery safer globally.
In June 2018, Gawande was chosen to lead the new healthcare company set up by Amazon, JPMorgan and Berkshire Hathaway.
Photo: Aubrey Calo
Atul Gawande | Speaker | TED.com