TED@BCG Singapore
Stefan Larsson: What doctors can learn from each other
史提芬拉森: 醫生可以互相學習嘅地方
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唔同嘅醫院因為唔同嘅程序有唔同嘅結果。只係病人呢樣嘢，令到揀醫生好似一個高風險嘅估猜遊戲。史提芬拉森想知道，醫生評估同分享佢哋臀部替換手術嘅成果時，會有咩效果。例如邊個技術證明最有效？如果醫生可以互相學習，一直同其他醫生報告返手術個案，醫療可唔可以進步同埋更平？（喺 TED@BCG 錄影）
Stefan Larsson - Value-based health care advocate
A doctor by training, Stefan Larsson of BCG researches how transparency of medical outcomes and costs could radically transform the healthcare industry. Full bio
A doctor by training, Stefan Larsson of BCG researches how transparency of medical outcomes and costs could radically transform the healthcare industry. Full bio
Double-click the English transcript below to play the video.
00:12
Five years ago, I was on a sabbatical,
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五年前，我放咗一年假
00:15
and I returned to the medical university
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之後我返去我以前讀過嘅醫學院
00:17
where I studied.
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00:19
I saw real patients and I wore the white coat
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十七年嚟，自從我做咗顧問之後
我第一次見到病人同著住白袍
00:24
for the first time in 17 years,
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00:26
in fact since I became a management consultant.
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嗰個月裡面，有兩樣令到我好驚訝
00:30
There were two things that surprised me
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00:32
during the month I spent.
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00:34
The first one was that the common theme
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第一樣，嚟嚟去去都只係講同一樣嘢
00:36
of the discussions we had were hospital budgets
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唔係醫院預算，就係開源節流
00:39
and cost-cutting,
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00:41
and the second thing, which really bothered me,
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第二樣，真係令我非常煩
00:43
actually, was that several of the colleagues I met,
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就喺之前識得嘅幾個同事
00:46
former friends from medical school,
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以前讀醫學院嘅同學
00:48
who I knew to be some of the smartest,
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佢哋都好醒目
00:50
most motivated, engaged and passionate people
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好有鬥志、有承擔、滿腔熱血
00:53
I'd ever met,
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00:55
many of them had turned cynical, disengaged,
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但係，佢哋好多都睇穿人性嘅羞惡
已經無曬擔戴
00:59
or had distanced themselves
from hospital management.
from hospital management.
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又或者已經對醫院管理置之不理
01:02
So with this focus on cost-cutting,
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所以呢，當醫院講緊節流
01:05
I asked myself, are we forgetting the patient?
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我就問自己
我哋係唔係忘記咗病人呢？
01:09
Many countries that you represent
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在座各位你哋嘅國家，同我嘅國家
01:11
and where I come from
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01:13
struggle with the cost of healthcare.
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都要處理醫療嘅開支問題
01:16
It's a big part of the national budgets.
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呢樣係佔咗國家預算嘅一大筆
01:19
And many different reforms aim
at holding back this growth.
at holding back this growth.
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好多唔同嘅改革
都想限制醫療嘅開支增長
都想限制醫療嘅開支增長
01:22
In some countries, we have long waiting times
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有啲國家，病人做手術要排好耐
01:24
for patients for surgery.
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01:27
In other countries, new drugs
are not being reimbursed,
are not being reimbursed,
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有啲國家，新藥唔可以報銷
01:29
and therefore don't reach patients.
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所以新藥病人用唔到
01:32
In several countries, doctors and nurses
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有啲國家，醫生同護士某程度上
01:34
are the targets, to some extent, for the governments.
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係政府落手嘅對象
01:38
After all, the costly decisions in health care
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畢竟，醫療開支係由醫生同護士做決定
01:42
are taken by doctors and nurses.
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你揀好貴嘅實驗測試
01:44
You choose an expensive lab test,
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你選擇幫又老又殘嘅病人做手術
01:47
you choose to operate on an old and frail patient.
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01:51
So, by limiting the degrees of freedom of physicians,
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就係咁，政府想限制醫生
01:55
this is a way to hold costs down.
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從而削減開支
01:58
And ultimately, some physicians will say today
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到最後，有啲醫生就話
02:01
that they don't have the full liberty
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佢哋就算覺得有啲決定對病人有益
02:03
to make the choices they think
are right for their patients.
are right for their patients.
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佢哋都落實唔到
02:07
So no wonder that some of my old colleagues
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所以，都好難怪我有啲舊同事咁沮喪
02:09
are frustrated.
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02:12
At BCG, we looked at this,
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喺 BCG，我哋討論到呢個問題
02:14
and we asked ourselves,
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我哋問自己
02:16
this can't be the right way of managing healthcare.
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咁樣做醫療管理係行唔通？
02:19
And so we took a step back and we said,
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所以我哋退後一步諗︰
02:23
"What is it that we are trying to achieve?"
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我哋想達到咩目標？
02:25
Ultimately, in the healthcare system,
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我哋希望喺醫療系統裡面
02:27
we're aiming at improving health for the patients,
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用有限或負擔得起嘅預算
02:31
and we need to do so at a limited,
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最終可以改善病人健康
02:34
or affordable, cost.
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02:36
We call this value-based healthcare.
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我哋叫呢個做
以成本效益為本嘅醫療
以成本效益為本嘅醫療
02:38
On the screen behind me, you see what we mean
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我身後嘅屏幕，大家可以見到何謂價值
02:40
by value:
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既可以幫到病人
02:42
outcomes that matter to patients
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02:44
relative to the money we spend.
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我哋開支又可以控制喺合埋水平
02:47
This was described beautifully in a book in 2006
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2006 年一本書描述得好好
02:50
by Michael Porter and Elizabeth Teisberg.
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書嘅作者係 Michael Porter
同 Elizabeth Teisberg
同 Elizabeth Teisberg
02:54
On this picture, you have my father-in-law
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呢張相，你見我岳父同佢身邊三個女
02:57
surrounded by his three beautiful daughters.
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03:01
When we started doing our research at BCG,
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當時我哋喺 BCG 開始做研究
03:04
we decided not to look so much at the costs,
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我哋決定唔好太介意使費幾多
03:06
but to look at the quality instead,
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反而要注重研究質量
03:09
and in the research, one of the things
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研究裏面，有一樣嘢令我哋讚嘆嘅
03:11
that fascinated us was the variation we saw.
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係我哋見到分別
03:14
You compare hospitals in a country,
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你比較一個國家嘅醫院
03:17
you'll find some that are extremely good,
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你會發現有啲醫院做得好好
03:19
but you'll find a large number
that are vastly much worse.
that are vastly much worse.
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但其他好多醫院就水皮
03:22
The differences were dramatic.
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分別非常之大
03:25
Erik, my father-in-law,
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Erik 我嘅岳父
03:27
he suffers from prostate cancer,
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佢有前列腺癌
03:29
and he probably needs surgery.
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佢需要做手術
佢宜家住喺歐洲，佢可以選擇去德國
03:32
Now living in Europe, he can
choose to go to Germany
choose to go to Germany
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03:34
that has a well-reputed healthcare system.
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德國有出名嘅醫療系統
03:38
If he goes there and goes to the average hospital,
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如果佢選擇去嗰度
住一間中等水平嘅醫院
03:42
he will have the risk of becoming incontinent
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佢手術後大小失禁嘅機會係 50%
03:46
by about 50 percent,
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03:48
so he would have to start wearing diapers again.
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如果真係咁嘅話，佢就又要再著過尿片
03:51
You flip a coin. Fifty percent risk. That's quite a lot.
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你掟個銀仔，50% 風險都幾多
03:55
If he instead would go to Hamburg,
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但係，如果佢決定去漢堡
03:57
and to a clinic called the Martini-Klinik,
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一間叫 Martini-Klinik 嘅診所
04:00
the risk would be only one in 20.
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風險就會降到 5%
04:03
Either you a flip a coin,
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一係你就 50% 風險
04:04
or you have a one in 20 risk.
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一係就 5% 風險
04:06
That's a huge difference, a seven-fold difference.
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差別好大，兩者相差十倍
04:10
When we look at many hospitals
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只有當我哋去睇好多醫院
睇唔同嘅病
睇唔同嘅病
04:12
for many different diseases,
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04:13
we see these huge differences.
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我哋至知道有咁大嘅分別
04:16
But you and I don't know. We don't have the data.
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但事前你同我都唔知道。我哋冇數據
04:19
And often, the data actually doesn't exist.
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好多時，數據根本唔存在
04:21
Nobody knows.
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從來冇人知兩間醫院有分別
04:23
So going the hospital is a lottery.
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所以去醫院就好似買六合彩咁
04:27
Now, it doesn't have to be that way. There is hope.
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宜家，已經唔使再估估下
我哋有希望
04:32
In the late '70s, there were a group
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七十年代尾，有一班瑞典整形外科醫生
04:34
of Swedish orthopedic surgeons
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04:37
who met at their annual meeting,
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佢哋每年都開會
04:38
and they were discussing the different procedures
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討論佢哋臀部手術過程中
04:40
they used to operate hip surgery.
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用嘅唔同方法步驟
04:44
To the left of this slide, you see a variety
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投影片左邊，你可以見到
04:45
of metal pieces, artificial hips that you would use
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唔同嘅金屬件、人造臀部
應用喺病人身上
應用喺病人身上
04:48
for somebody who needs a new hip.
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04:51
They all realized they had
their individual way of operating.
their individual way of operating.
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佢哋都知道，佢哋各自有一套手術方法
04:55
They all argued that, "My technique is the best,"
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個個都話佢嘅技術係最優秀
04:57
but none of them actually knew,
and they admitted that.
and they admitted that.
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但冇一個知道佢哋自己嗰個係最好
05:00
So they said, "We probably need to measure quality
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所以佢哋就話︰「我哋要評估質素，
05:04
so we know and can learn from what's best."
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咁樣先知邊個最好，學最好嗰個。」
05:08
So they in fact spent two years debating,
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跟住，佢哋用咗兩年時間拗，譬如
臀部手術嘅質量點樣定義？
05:11
"So what is quality in hip surgery?"
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05:13
"Oh, we should measure this."
"No, we should measure that."
"No, we should measure that."
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「我哋評估呢個。」
「唔係，我哋評估嗰個。」
05:16
And they finally agreed.
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最後佢哋至達成共識
05:18
And once they had agreed, they started measuring,
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有咗共識之後
佢哋就開始評估，開始交換數據
05:20
and started sharing the data.
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05:23
Very quickly, they found that if you put cement
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好快，佢哋就發現
如果先將膠接劑放入病人舊骨度
05:25
in the bone of the patient
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05:27
before you put the metal shaft in,
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再將金屬桿放入去
05:29
it actually lasted a lot longer,
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咁樣會更加持久耐用
05:31
and most patients would never have to be
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而且大部分病人有生之年
都唔需要再做手術
都唔需要再做手術
05:33
re-operated on in their lifetime.
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05:35
They published the data,
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呢班人登咗呢啲數據
05:37
and it actually transformed
clinical practice in the country.
clinical practice in the country.
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將佢哋國家嘅臨床診治模式
嚟個大革新
嚟個大革新
05:40
Everybody saw this makes a lot of sense.
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人人都覺得咁樣做更加合理
05:43
Since then, they publish every year.
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嗰次之後，佢哋就年年刊登一次
05:46
Once a year, they publish the league table:
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佢哋每年都會刊登一個表：
05:47
who's best, who's at the bottom?
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話畀人知邊個係最好同最差嘅醫生
05:50
And they visit each other to try to learn,
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而且佢哋會逐個拜訪、學習
05:53
so a continuous cycle of improvement.
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所以至會不斷有改善
05:56
For many years, Swedish hip surgeons
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多年嚟，就算只有
少數瑞典臀部手術嘅醫生有評估結果
05:59
had the best results in the world,
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但佢哋做出嚟嘅手術結果
係全世界最好嘅
係全世界最好嘅
06:02
at least for those who actually were measuring,
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06:04
and many were not.
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06:07
Now I found this principle really exciting.
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我發現呢個措施真係好好
06:09
So the physicians get together,
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醫生可以走埋一齊，傾好質素嘅定義
06:11
they agree on what quality is,
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佢哋量度同交換數據
06:13
they start measuring, they share the data,
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06:17
they find who's best, and they learn from it.
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跟最好嘅學習，不斷咁改善
06:21
Continuous improvement.
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06:23
Now, that's not the only exciting part.
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呢個唔止令人開心
06:26
That's exciting in itself.
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佢本身就係一樣好嘢
你諗返起計算開支嘅方程式
06:28
But if you bring back the cost side of the equation,
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06:31
and look at that,
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就會發現之前嗰啲關注質素嘅人
06:32
it turns out, those who have focused on quality,
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雖然冇將開支擺喺首位
06:35
they actually also have the lowest costs,
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06:37
although that's not been the purpose
in the first place.
in the first place.
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但佢哋嘅使費都係最低
06:40
So if you look at the hip surgery story again,
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所以，你睇返幾年前
一個臀部手術嘅研究
一個臀部手術嘅研究
06:43
there was a study done a couple years ago
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比較美國同瑞典
06:45
where they compared the U.S. and Sweden.
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研究人員統計
06:49
They looked at how many patients have needed
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幾多個病人需要喺第一次手術之後
06:51
to be re-operated on seven years after the first surgery.
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七年內要再做手術
美國嘅數字比瑞典高出三倍
06:55
In the United States, the number was three times
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06:58
higher than in Sweden.
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07:01
So many unnecessary surgeries,
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咁樣講
好多病人做咗好多不必要嘅手術
07:04
and so much unnecessary suffering
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經歷過好多不必要嘅痛苦
07:07
for all the patients who were operated on
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07:08
in that seven year period.
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07:11
Now, you can imagine how much savings
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你又可以想像社會可以慳返幾多錢
07:12
there would be for society.
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07:15
We did a study where we looked at OECD data.
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我哋做過一個研究
觀察經濟合作與發展組織
OECD 嘅數據
OECD 嘅數據
07:18
OECD does, every so often,
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OECD 定期調查成員國嘅生活質素
07:21
look at quality of care
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07:23
where they can find the data
across the member countries.
across the member countries.
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佢哋集合成員國嘅數據
07:28
The United States has, for many diseases,
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美國好多病嘅治療水平都係
低於 OECD 嘅平均
低於 OECD 嘅平均
07:30
actually a quality which is below the average
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07:32
in OECD.
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07:34
Now, if the American healthcare system
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咁樣講
如果美國醫療系統
專注多啲喺質素上面
專注多啲喺質素上面
07:36
would focus a lot more on measuring quality,
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07:38
and raise quality just to the level of average OECD,
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將水平提高到 OECD 嘅平均水平
07:43
it would save the American people
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就可以幫到美國人
每年慳返五千億美元
每年慳返五千億美元
07:45
500 billion U.S. dollars a year.
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07:49
That's 20 percent of the budget,
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亦即係慳返國家醫療預算嘅兩成
07:52
of the healthcare budget of the country.
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07:55
Now you may say that these numbers
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你可能話
呢啲數據好好，非常合邏輯
07:57
are fantastic, and it's all logical,
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08:00
but is it possible?
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但係，有冇可能做到？
08:02
This would be a paradigm shift in healthcare,
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呢個會係醫療嘅改革示例
08:05
and I would argue that not only can it be done,
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我堅信，不單止可以做到
08:08
but it has to be done.
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而且必須要做
08:10
The agents of change are the doctors and nurses
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而改革者係醫療系統嘅醫生同護士
08:14
in the healthcare system.
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08:16
In my practice as a consultant,
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我做諮詢咁耐
08:19
I meet probably a hundred or more than a hundred
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年年都會見過百個
甚至更多嘅醫生、護士
甚至更多嘅醫生、護士
08:21
doctors and nurses and other hospital
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同其他醫護員工
08:24
or healthcare staff every year.
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08:27
The one thing they have in common is
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佢哋有一個共同點：
08:29
they really care about what they achieve
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佢哋真係好緊張
為病人服務嘅質素
為病人服務嘅質素
08:31
in terms of quality for their patients.
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08:34
Physicians are, like most of you in the audience,
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醫生，正如在座咁多位一樣
08:36
very competitive.
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非常拼搏
08:39
They were always best in class.
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佢哋一直都係班內最優秀
08:41
We were always best in class.
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我哋一直都係班內最優秀
08:44
And if somebody can show them that the result
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如果有人可以話畀佢哋知
佢哋醫人嘅結果比其他人差
08:47
they perform for their patients
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08:48
is no better than what others do,
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08:51
they will do whatever it takes to improve.
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佢哋會用盡一切方法改善
08:54
But most of them don't know.
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但係，佢哋大部分
都唔知道比其他人差
都唔知道比其他人差
08:56
But physicians have another characteristic.
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但係醫生有另一個特點：
08:59
They actually thrive from peer recognition.
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佢哋渴望得到行內認同
09:03
If a cardiologist calls another cardiologist
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如果一個心臓科醫生
打電話畀對手醫院嘅一個心臓科醫生
09:05
in a competing hospital
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09:07
and discusses why that other hospital
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問佢點解佢間醫院有更好結果時
09:09
has so much better results, they will share.
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嗰個醫生會分享俾佢聽
09:12
They will share the information on how to improve.
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佢哋會分享改善方法
09:15
So it is, by measuring and creating transparency,
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所以，因為有透明度，你可以不斷改善
09:19
you get a cycle of continuous improvement,
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09:22
which is what this slide shows.
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正如投影片所講一樣
09:25
Now, you may say this is a nice idea,
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咁你可能會話，諗法唔錯
09:28
but this isn't only an idea.
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1904
但係呢個唔止係諗法
09:30
This is happening in reality.
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呢樣嘢真係發生咗
09:32
We're creating a global community,
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我哋嘗試令到全世界
都可以評估同比較醫療結果
都可以評估同比較醫療結果
09:35
and a large global community,
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1863
09:37
where we'll be able to measure and compare
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2547
09:40
what we achieve.
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1714
09:41
Together with two academic institutions,
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2627
BCG 聯同兩間學術機構
09:44
Michael Porter at Harvard Business School,
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1994
哈佛商學院嘅 Michael Porter
09:46
and the Karolinska Institute in Sweden,
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1884
同瑞士嘅卡羅林斯卡醫學院
09:48
BCG has formed something we call ICHOM.
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已經成立咗一個叫 ICHOM 嘅機構
09:52
You may think that's a sneeze,
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你可能以為我打乞嗤
呢個唔係乞嗤，而係一個縮寫
09:54
but it's not a sneeze, it's an acronym.
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3127
全名係︰健康成果測量國際聯盟
09:57
It stands for the International Consortium
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2576
10:00
for Health Outcome Measurement.
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2960
10:03
We're bringing together leading physicians
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我哋令頂尖醫生同病人
一齊討論每一種疾病
一齊討論每一種疾病
10:05
and patients to discuss, disease by disease,
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10:09
what is really quality,
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咩為之質素
10:11
what should we measure,
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1987
我哋應該量度啲乜嘢
10:13
and to make those standards global.
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務求令標準國際化
10:16
They've worked -- four working groups have worked
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佢哋都做緊
舊年有四個工作小組做梗
白內障、背痛
白內障、背痛
10:18
during the past year:
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1968
10:20
cataracts, back pain,
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2844
10:23
coronary artery disease, which is,
for instance, heart attack,
for instance, heart attack,
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4226
冠心病，例如心臓病
同前列腺癌
10:27
and prostate cancer.
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2181
10:29
The four groups will publish their data
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2404
四個小組會喺今年十一月
刊登佢哋嘅數據
刊登佢哋嘅數據
10:32
in November of this year.
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1842
10:33
That's the first time we'll be comparing
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呢次會係第一次
我哋真正比較到同類嘅嘢
我哋真正比較到同類嘅嘢
10:36
apples to apples, not only within a country,
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唔止係比較國內
10:39
but between countries.
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而係比較唔同國家
10:42
Next year, we're planning to do eight diseases,
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下一年，我哋計劃研究八種疾病
10:46
the year after, 16.
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再下一年，研究十六種
10:48
In three years' time, we plan to have covered
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三年內，我哋計劃覆蓋
疾病總數嘅四成
疾病總數嘅四成
10:51
40 percent of the disease burden.
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10:54
Compare apples to apples. Who's better?
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比較同類型邊個好啲？
10:57
Why is that?
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同埋點解？
11:00
Five months ago,
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五個月前，我喺北歐最大嘅大學醫院
11:03
I led a workshop at the largest university hospital
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11:06
in Northern Europe.
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主持一個工作坊
11:07
They have a new CEO, and she has a vision:
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怇哋請咗新 CEO，佢有一個願景：
令醫院注重多啲病人嘅
醫療質素同醫療成果
醫療質素同醫療成果
11:11
I want to manage my big institution much more
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11:14
on quality, outcomes that matter to patients.
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4105
11:19
This particular day, we sat in a workshop
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嗰日，我哋喺工作坊
同一啲醫生、護士同其他員工一齊坐
11:22
together with physicians, nurses and other staff,
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11:25
discussing leukemia in children.
249
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討論兒童白血病
11:29
The group discussed,
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我哋討論咗：
我哋應該點樣評估質素？
11:31
how do we measure quality today?
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2040
11:33
Can we measure it better than we do?
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現有評估方法可唔可以改善？
11:36
We discussed, how do we treat these kids,
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2222
我哋討論：點樣醫好呢啲兒童
11:38
what are important improvements?
254
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有咩重大嘅進步？
11:40
And we discussed what are
the costs for these patients,
the costs for these patients,
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我哋又討論：啲病人要使幾多錢
11:43
can we do treatment more efficiently?
256
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我哋可唔可以更有效咁治療？
11:45
There was an enormous energy in the room.
257
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1944
當時房裏邊啲人好積極
11:47
There were so many ideas, so much enthusiasm.
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有好多想法、好熱情
11:51
At the end of the meeting,
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會議結束時，系主任企起身
11:53
the chairman of the department, he stood up.
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11:56
He looked over the group and he said --
261
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4577
佢望下小組
佢舉手，緊握拳頭
12:01
first he raised his hand, I forgot that --
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12:03
he raised his hand, clenched his fist,
263
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12:05
and then he said to the group, "Thank you.
264
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然後對小組嘅人講：
「多謝你哋，今日我哋終於可以討論
12:08
Thank you. Today, we're finally discussing
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12:11
what this hospital does the right way."
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呢間醫院應該點樣做。」
12:14
By measuring value in healthcare,
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通過評估醫療成效
12:17
that is not only costs
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其中不單止費用，仲包括治療嘅成果
12:19
but outcomes that matter to patients,
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我哋會令到醫院嘅員工
12:21
we will make staff in hospitals
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12:23
and elsewhere in the healthcare system
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以至醫療系統其他崗位
12:25
not a problem but an important part of the solution.
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唔再係煩惱
而係解決方案嘅重要一部分
12:29
I believe measuring value in healthcare
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我相信，評估醫療成效會帶嚟革命
12:31
will bring about a revolution,
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12:33
and I'm convinced that the founder
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我相信現代醫學嘅始祖
12:36
of modern medicine, the Greek Hippocrates,
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希臘嘅希波克拉底
12:39
who always put the patient at the center,
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一位永遠將病人放喺第一位嘅人
12:42
he would smile in his grave.
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會喺上天覺得欣慰
12:44
Thank you.
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多謝
（掌聲）
12:47
(Applause)
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ABOUT THE SPEAKER
Stefan Larsson - Value-based health care advocateA doctor by training, Stefan Larsson of BCG researches how transparency of medical outcomes and costs could radically transform the healthcare industry.
Why you should listen
In the developed world, health care represents 9 to 18 percent of the GDP -- and these costs are rising faster than economic growth. Stefan Larsson -- a senior partner and managing director in BCG’s Stockholm office, the global leader of BCG’s Health Care Payers and Providers sector, and a BCG Fellow since 2010 -- believes that the answer isn’t just managing costs, but improving patient outcomes.
The idea at the center of this approach: registries of health outcomes. By coming up with criteria for measuring quality of care, sharing data on how procedures and parts are working, and learning from each other constantly, doctors and nurses can become agents of change, providing better care and lower costs at the same time.
Larsson is co-founder of the International Consortium of Health Outcomes Measurement, a not-for-profit organization for global standardization of outcomes measurement, which has Michael Porter, HBS and Karolinska Institute as partners.
Stefan Larsson | Speaker | TED.com