TEDxOslo
Christer Mjåset: 4 questions you should always ask your doctor
克里斯特‧米塞特: 必問醫生的四個問題
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「醫生，這真的有必要嗎？」神經外科醫生克里斯特‧米塞特透過讓人震驚的過度治療統計數據，解釋了在談到醫療和手術時，問這個問題及其他幾個簡單問題能發揮多強大的力量，並分享病人如何能和醫生更充分地合作來獲得他們所需的醫療照護。
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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我是神經外科醫生，
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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今天我是來告訴大家，
像我這樣的人需要你們的協助。
像我這樣的人需要你們的協助。
00:20
And in a few moments, I will tell you how.
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等一下我就會告訴大家怎麼做。
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，首先讓我先談談我的一位病人。
00:26
This was a woman in her 50s,
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她是一位五十多歲的女子，
00:28
she was in generally good shape,
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身體狀況大致不錯，
00:31
but she had been in and out
of hospital a few times
of hospital a few times
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但她因為治療乳癌
00:33
due to curative breast cancer treatment.
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已經進出過醫院好幾次了。
00:37
Now she had gotten a prolapse
from a cervical disc,
from a cervical disc,
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現在她因頸椎的椎間盤突出，
00:40
giving her radiating pain of a tense kind,
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而讓她的右手臂有很劇烈的
00:44
out into the right arm.
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放射性疼痛。
00:47
Looking at her MRI
before the consultation,
before the consultation,
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在諮詢之前我先看了她的磁振造影，
00:49
I decided to suggest an operation.
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我決定要建議她動手術。
00:52
Now, neck operations like these
are standardized, and they're quick.
are standardized, and they're quick.
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像這樣的頸部手術是
標準化且很快速的。
標準化且很快速的。
00:57
But they carry a certain risk.
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但仍然有一些風險。
00:58
You make an incision right here,
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從這裡切開，
01:01
and you dissect carefully
past the trachea,
past the trachea,
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小心地切過去，繞過氣管，
01:03
the esophagus,
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繞過食道，
01:05
and you try not to cut
into the internal carotid artery.
into the internal carotid artery.
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試著不要切到頸內動脈。
01:08
(Laughter)
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（笑聲）
01:09
Then you bring in the microscope,
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接著顯微鏡登場，
01:12
and you carefully remove
the disc and the prolapse
the disc and the prolapse
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然後小心地移除椎間盤
壓迫神經根管的地方，
壓迫神經根管的地方，
01:14
in the nerve root canal,
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不能損害到就在底下幾毫米的
脊髓神經及神經根。
脊髓神經及神經根。
01:15
without damaging the cord
and the nerve root
and the nerve root
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01:17
lying only millimeters underneath.
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01:20
The worst case scenario
is the damage to the cord,
is the damage to the cord,
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最糟糕的狀況就是傷到脊髓神經，
01:23
which can result in paralysis
from the neck down.
from the neck down.
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可能會造成脖子以下癱瘓。
01:28
Explaining this to the patient,
she fell silent.
she fell silent.
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我向病人解釋這些之後，她沉默了。
01:31
And after a few moments,
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一會兒之後，
01:32
she uttered a few very decisive words
for me and for her.
for me and for her.
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她說出了對我及對她來說
都非常果敢的話。
都非常果敢的話。
01:37
"Doctor, is this really necessary?"
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「醫生，這真的有必要嗎？」
01:41
(Laughter)
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（笑聲）
01:44
And you know what I realized,
right there and then?
right there and then?
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各位知道我在那當下領悟了什麼嗎？
01:47
It was not.
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沒有必要。
01:49
In fact, when I get patients
like this woman,
like this woman,
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事實上，當我看到
像這名女子的病人時，
像這名女子的病人時，
01:52
I tend to advise not to operate.
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我會傾向建議不要動手術。
01:55
So what made me do it this time?
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那麼，這次我為什麼會這麼做？
01:59
Well, you see,
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嗯，要知道，
02:00
this prolapse was so delicate,
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這個突出是如此的微妙，
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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在她進入諮詢室之前，
我就可以看見自己
把它從神經根管中拔出來。
把它從神經根管中拔出來。
02:06
before she entered the consultation room.
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02:09
I have to admit it,
I wanted to operate on her.
I wanted to operate on her.
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我得承認，我想要幫她動手術。
02:13
I'd love to operate on her.
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我很想幫她動手術。
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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畢竟，手術是我工作中
最有趣的部分。
最有趣的部分。
02:18
(Laughter)
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（笑聲）
02:22
I think you can relate to this feeling.
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我想你們可以體會這種感覺。
02:24
My architect neighbor says
he loves to just sit and draw
he loves to just sit and draw
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我那個當建築師的鄰居說，
他喜歡的就只是
坐下來繪製和設計房子。
坐下來繪製和設計房子。
02:28
and design houses.
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02:30
He'd rather do that all day
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他寧可整天做這件事，
02:31
than talk to the client
paying for the house
paying for the house
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也不想跟付錢買房子的客戶交談，
02:35
that might even give him
restrictions on what to do.
restrictions on what to do.
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這個客戶可能還會框限他的想法。
02:39
But like every architect,
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但就像建築師一樣，
每一位外科醫生
每一位外科醫生
02:40
every surgeon needs
to look their patient in the eye
to look their patient in the eye
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都得坦誠地與病人交流且和病人一起
02:43
and together with the patient,
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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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決定動手術是否是最好的選擇。
02:50
And that might sound easy.
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聽起來可能很簡單。
02:51
But let's look at some statistics.
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但，讓我們來看些統計數字。
02:56
The tonsils are the two lumps
in the back of your throat.
in the back of your throat.
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扁桃腺是喉嚨後面的兩塊隆起。
02:59
They can be removed surgically,
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可以用手術將它們切除，
03:01
and that's called a tonsillectomy.
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那稱為扁桃腺切除術。
03:03
This chart shows the operation rate
of tonsillectomies in Norway
of tonsillectomies in Norway
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這張圖上顯示的是在挪威不同區域的
扁桃腺切除術施行率。
03:07
in different regions.
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03:09
What might strike you
is that there is twice the chance
is that there is twice the chance
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各位可能會感到驚訝的是，
03:13
that your kid --
because this is for children --
because this is for children --
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你的孩子——
這是針對孩子的統計——
這是針對孩子的統計——
03:16
will get a tonsillectomy in Finnmark
than in Trondheim.
than in Trondheim.
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在芬馬克要動扁桃腺切除術的機率
是在特隆赫姆的兩倍。
是在特隆赫姆的兩倍。
03:20
The indications
in both regions are the same.
in both regions are the same.
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這兩個區域的適應症都是一樣的。
03:24
There should be
no difference, but there is.
no difference, but there is.
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動手術的機率理應沒差別，其實不然。
03:26
Here's another chart.
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這是另一張圖。
03:28
The meniscus helps stabilize the knee
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半月板的功能是穩定膝蓋，
03:30
and can be torn or fragmented acutely,
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有可能局部或全部被撕裂或破裂，
03:32
topically during sports like soccer.
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比如會因為踢足球等運動造成。
03:35
What you see here is the operation rate
for this condition.
for this condition.
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各位在這裡看到的是
針對這種狀況的開刀率。
針對這種狀況的開刀率。
03:39
And you see that the operation
rate in Møre og Romsdal
rate in Møre og Romsdal
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可以發現，在默勒－魯姆斯達爾郡的
03:43
is five times the operation
rate in Stavanger.
rate in Stavanger.
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開刀率是斯塔萬格的五倍。
03:47
Five times.
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五倍之多。
03:49
How can this be?
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怎麼會這樣？
默勒－魯姆斯達爾郡的足球員踢球時
比全國其他的球員更會耍小動作嗎？
比全國其他的球員更會耍小動作嗎？
03:50
Did the soccer players in Møre og Romsdal
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03:52
play more dirty
than elsewhere in the country?
than elsewhere in the country?
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03:54
(Laughter)
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（笑聲）
03:56
Probably not.
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可能不是。
03:59
I added some information now.
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現在我再增加一些資訊。
04:01
What you see now
is the procedures performed
is the procedures performed
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各位現在可以看到，淺藍色的
是在公立醫院中所進行的手術，
是在公立醫院中所進行的手術，
04:03
in public hospitals, in light blue,
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04:05
the ones in private clinics
are light green.
are light green.
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私人診所則用淺綠色表示。
04:08
There is a lot of activity
in the private clinics
in the private clinics
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在默勒－魯姆斯達爾郡的私人診所
有很多活動，對吧？
04:11
in Møre og Romsdal, isn't there?
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04:14
What does this indicate?
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那是什麼意思？
04:15
A possible economic motivation
to treat the patients.
to treat the patients.
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有可能他們是基於
經濟上的動機去治療病人。
經濟上的動機去治療病人。
04:20
And there's more.
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還不只如此。
04:23
Recent research has shown
that the difference of treatment effect
that the difference of treatment effect
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近期研究顯示，針對膝蓋所做的
一般物理治療和手術，
一般物理治療和手術，
04:27
between regular physical therapy
and operations for the knee --
and operations for the knee --
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在治療效果上的差別——
04:30
there is no difference.
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是沒有差別。
04:32
Meaning that most
of the procedures performed
of the procedures performed
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意思就是，在剛剛那張圖上
04:36
on the chart I've just shown
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大部分所執行的手術
04:38
could have been avoided,
even in Stavanger.
even in Stavanger.
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其實是可以避免的，
在斯塔萬格也一樣。
在斯塔萬格也一樣。
04:41
So what am I trying to tell you here?
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所以，我想要告訴各位什麼？
04:44
Even though most indications
for treatments in the world
for treatments in the world
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即使全世界大部分的治療適應症
04:49
are standardized,
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都已標準化，
04:50
there is a lot of unnecessary variation
of treatment decisions,
of treatment decisions,
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在治療的決策上仍然有不必要的差異，
04:54
especially in the Western world.
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特別是在西方世界。
04:57
Some people are not getting
the treatment that they need,
the treatment that they need,
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有些人沒有得到他們需要的治療，
05:01
but an even greater portion of you
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但，更高比例的人
05:04
are being overtreated.
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是被過度治療的。
05:08
"Doctor, is this really necessary?"
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「醫生，這真的有必要嗎？」
05:11
I've only heard that question
once in my career.
once in my career.
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我在職涯中只聽過一次這個問題。
05:14
My colleagues say they never heard
these words from a patient.
these words from a patient.
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我同事說他們從來沒有
聽過病人這麼問過。
聽過病人這麼問過。
05:19
And to turn it the other way around,
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換個方向來看，
你認為如果提出這個問題，
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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會多常從醫生口中聽到「沒必要」？
05:23
if you ask such a question?
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05:26
Researchers have investigated this,
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研究者調查了這件事，
05:28
and they come up
with about the same "no" rate
with about the same "no" rate
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他們所得到的「沒必要」率
在各地都差不多。是三成。
05:30
wherever they go.
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05:32
And that is 30 percent.
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05:33
Meaning, three out of 10 times,
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也就是說，十次中有三次，
05:37
your doctor prescribes
or suggests something
or suggests something
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你的醫生開的處方或建議的治療
05:41
that is completely unnecessary.
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是完全沒必要的。
05:46
And you know what they claim
the reason for this is?
the reason for this is?
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各位知道他們為此
所宣稱的理由是什麼嗎？
所宣稱的理由是什麼嗎？
05:50
Patient pressure.
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病人壓力。
05:52
In other words, you.
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換言之，是你們。
05:54
You want something to be done.
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你們希望醫生做點什麼。
05:58
A friend of mine came to me
for medical advice.
for medical advice.
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我有一位朋友來找我詢求醫療建議。
06:01
This is a sporty guy,
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他愛運動，
06:02
he does a lot of cross-country skiing
in the winter time,
in the winter time,
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冬天時他很常越野滑雪，
06:05
he runs in the summer time.
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夏天時則是跑步。
06:07
And this time, he'd gotten a bad back ache
whenever he went jogging.
whenever he went jogging.
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這次，他只要慢跑就有嚴重的背痛。
06:11
So much that he had to stop doing it.
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痛到他只得停止跑步。
06:15
I did an examination,
I questioned him thoroughly,
I questioned him thoroughly,
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我幫他做了檢查，詳細的問診，
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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我發現，他可能是脊椎下段
06:21
in the lower part of his spine.
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發生了椎間盤退化。
06:24
Whenever it got strained, it hurt.
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只要它受到壓力就會痛。
06:28
He'd already taken up
swimming instead of jogging,
swimming instead of jogging,
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他已經用游泳取代慢跑，
已經沒其他的可做了。
已經沒其他的可做了。
06:30
there was really nothing to do,
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所以，我告訴他：「在訓練方面，
你得要仔細做選擇。
你得要仔細做選擇。
06:32
so I told him, "You need
to be more selective
to be more selective
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06:34
when it comes to training.
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有些活動對你是好的，
有些則不是。」
有些則不是。」
06:35
Some activities are good for you,
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06:37
some are not."
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06:39
His reply was,
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他的回應是：
06:41
"I want an MRI of my back."
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「我想要做背部磁振造影。」
06:45
"Why do you want an MRI?"
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「你為何想做磁振造影？」
06:48
"I can get it for free
through my insurance at work."
through my insurance at work."
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「我的工作有投保，不用負擔費用。」
06:51
"Come on," I said --
he was also, after all, my friend.
he was also, after all, my friend.
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「拜託，」我說——
畢竟，他也是我的朋友。
畢竟，他也是我的朋友。
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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「嗯，我認為能看看
背後有多糟也不錯。」
背後有多糟也不錯。」
07:03
"When did you start interpreting
MRI scans?" I said.
MRI scans?" I said.
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我說：「你何時開始解讀
磁振造影掃瞄結果了？」
磁振造影掃瞄結果了？」
07:06
(Laughter)
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（笑聲）
07:08
"Trust me on this.
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「這件事就相信我吧，
07:10
You're not going to need the scan."
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你不需要掃瞄。」
07:12
"Well," he said,
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他說：「嗯，」
07:14
and after a while, he continued,
"It could be cancer."
"It could be cancer."
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一會兒，他繼續說：
「有可能是癌症。」
「有可能是癌症。」
07:17
(Laughter)
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（笑聲）
07:20
He got the scan, obviously.
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很顯然，他還是做了掃瞄。
07:22
And through his insurance at work,
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透過他工作的保險，
他去找了我的一位同事，
他去找了我的一位同事，
07:24
he got to see one
of my colleagues at work,
of my colleagues at work,
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同事告訴他椎間盤退化的事，
07:26
telling him about the degenerated disc,
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07:28
that there was nothing to do,
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沒有其他可以做的，
07:30
and that he should keep on swimming
and quit the jogging.
and quit the jogging.
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所以他應該要繼續游泳，放棄慢跑。
一陣子後，我和他再次見面，他說：
07:36
After a while,
I met him again and he said,
I met him again and he said,
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「至少現在我知道它是什麼了。」
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，讓我請問各位。
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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如果這間房間中每個有這種
症狀的人都去做磁振造影會如何？
症狀的人都去做磁振造影會如何？
07:46
And what if all the people in Norway
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如果每個在挪威偶爾有背痛的人
07:49
had an MRI due to occasional back pain?
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都去做磁振造影呢？
07:54
The waiting list for an MRI
would quadruple, maybe even more.
would quadruple, maybe even more.
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磁振造影的等候名單可能會
變成四倍或更長。
變成四倍或更長。
07:58
And you would all take
the spot on that list
the spot on that list
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你們會把在等候名單上
真正癌症患者的名額給佔去了。
08:00
from someone who really had cancer.
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08:03
So a good doctor sometimes says no,
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所以，好的醫生有時會說不，
08:07
but the sensible patient
also turns down, sometimes,
also turns down, sometimes,
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但，理性的病人有時也會拒絕
08:11
an opportunity
to get diagnosed or treated.
to get diagnosed or treated.
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被診斷或治療的機會。
08:16
"Doctor, is this really necessary?"
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「醫生，這真的有必要嗎？」
08:20
I know this can be
a difficult question to ask.
a difficult question to ask.
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我知道要問這個問題很難。
08:24
In fact, if you go back 50 years,
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事實上，五十年前，
08:26
this was even considered rude.
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問這個問題可能還會被視為無禮。
08:28
(Laughter)
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（笑聲）
08:29
If the doctor had decided
what to do with you,
what to do with you,
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如果醫生決定了
要如何處理你的狀況，
要如何處理你的狀況，
08:32
that's what you did.
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你就要照做。
08:35
A colleague of mine,
now a general practitioner,
now a general practitioner,
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我的一個同事，現在是家醫科醫師，
08:37
was sent away to a tuberculosis
sanatorium as a little girl,
sanatorium as a little girl,
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她小時候被送到結核病療養院，
08:42
for six months.
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待了六個月。
08:43
It was a terrible trauma for her.
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這對她來說是很大的創傷。
08:45
She later found out, as a grown-up,
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長大後，她發現，
08:48
that her tests on tuberculosis
had been negative all along.
had been negative all along.
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她的結核病檢測結果
一直都是陰性的。
一直都是陰性的。
08:52
The doctor had sent her away
on nothing but wrong suspicion.
on nothing but wrong suspicion.
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醫生只因錯誤的臆測
就把她送進療養院。
就把她送進療養院。
08:56
No one had dared or even considered
confronting him about it.
confronting him about it.
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沒有人敢，甚至沒有人
想過要和醫生對質。
想過要和醫生對質。
09:01
Not even her parents.
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連她的父母也沒有。
09:03
Today, the Norwegian health minister
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現今，挪威健康部長
09:06
talks about the patient
health care service.
health care service.
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談到病人健康照護服務。
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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病人應該要向醫生取得
如何治療的建議。
如何治療的建議。
09:16
This is great progress.
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這是很大的進展。
09:18
But it also puts more
responsibility on you.
responsibility on you.
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但這也會讓你們承擔更多的責任。
09:21
You need to get in the front seat
with your doctor
with your doctor
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你們得要和醫生一起坐到前座上，
09:24
and start sharing
decisions on where to go.
decisions on where to go.
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開始一起決定要往哪個方向走。
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，下次進入醫生辦公室時，
09:31
I want you to ask,
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我希望各位能夠問：
09:32
"Doctor, is this really necessary?"
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「醫生，這真的有必要嗎？」
09:36
And in my female patient's case,
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在我那位女病人的案例中，
09:38
the answer would be no,
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答案是不必要，
09:40
but an operation could also be justified.
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但如要動手術也是合理正當的。
09:44
"So doctors, what are the risks
attached to this operation?"
attached to this operation?"
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「那麼醫生，這項
手術的風險是什麼？」
手術的風險是什麼？」
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% 到 10% 的病人
會有更糟的疼痛症狀。
09:55
One to two percent of patients
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1% 到 2% 的病人
09:57
will have an infection in the wound
or even a rehemorrhage
or even a rehemorrhage
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傷口會感染或甚至發生大出血，
10:00
that might end up in a re-operation.
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最後可能要重新開刀。
10:04
0.5 percent of patients
also experience permanent hoarseness
also experience permanent hoarseness
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0.5 % 的病人會有永久性的沙啞，
10:07
and a few, but still a few,
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雖然是少數，但仍然有人
10:09
will experience reduced function
in the arms or even legs.
in the arms or even legs.
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會發現手臂甚至腿部的功能下降。
10:15
"Doctor, are there other options?"
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「醫生，有其他選擇嗎？」
10:18
Yes, rest and physical therapy
over some time
over some time
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是的，休息和物理治療一段時間
10:21
might get you perfectly well.
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可能會讓你康復得很好。
10:25
"And what happens if I don't do anything?"
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「如果我什麼都不做，會如何？」
10:27
It's not recommended,
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不建議這樣，
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，如果真的如此，
也有微小的機會可能會好起來。
也有微小的機會可能會好起來。
10:33
Four questions.
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四個問題。
10:34
Simple questions.
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很簡單的問題。
10:36
Consider them your new toolbox to help us.
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把它們視為你們用來
協助我們的新工具盒。
協助我們的新工具盒。
10:40
Is this really necessary?
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這真的有必要嗎？
10:42
What are the risks?
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風險是什麼？
10:44
Are there other options?
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有其他選擇嗎？
10:45
And what happens if I don't do anything?
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如果我什麼都不做，會如何？
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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對你的醫生提出上述問題，
當他要把你送去做磁振造影時、
當他要把你送去做磁振造影時、
10:53
when he prescribes antibiotics
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當他要開抗生素給你時，
或他建議你要動手術時。
10:55
or suggests an operation.
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10:58
What we know from research
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我們從研究得知，
11:00
is that one out of five
of you, 20 percent,
of you, 20 percent,
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五個人中就有一個，即兩成，
11:03
will change your opinion on what to do.
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會改變心意而做出不同的選擇。
11:06
And by doing that, you will
not only have made your life
not only have made your life
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藉由這麼做，你不僅讓你的人生
11:09
a whole lot easier,
and probably even better,
and probably even better,
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輕鬆許多，可能還會變得更好，
11:13
but the whole health care sector
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此外，整個健康照護部門
11:15
will have benefited from your decision.
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也會因為你的選擇而受益。
11:19
Thank you.
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謝謝。
11:20
(Applause)
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（掌聲）
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