TED2012
Atul Gawande: How do we heal medicine?
Atul Gawande: Hvordan helbreder vi lægeverdenen?
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Vores sundhedssystem er i stykker. Læger kan udføre ekstraordinære (og dyre) behandlinger, men de har tabt fokus på det væsentlige: At behandle folk. Læge og forfatter Atul Gawande foreslår at vi træder et skridt tilbage og kigger på nye måder at behandle på -- med færre cowboys og flere mekanikere.
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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Jeg begyndte
00:18
in writing and research
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på skrivning og forskning
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as a surgical trainee,
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som kirurgisk praktikant,
00:23
as someone who was a long ways away
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som én, der var lang vej
00:25
from becoming any kind of an expert at anything.
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fra at blive ekspert inden for noget som helst.
00:28
So the natural question you ask then at that point
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Det spørgsmål du helt naturligt så vil stille
00:31
is, how do I get good at what I'm trying to do?
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er, hvordan bliver jeg godt til det, jeg forsøger at gøre?
00:33
And it became a question of,
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Og det blev til et et spørgsmål om
00:35
how do we all get good
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hvordan bliver vi alle gode
00:37
at what we're trying to do?
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til det vi prøver at gøre?
00:40
It's hard enough to learn to get the skills,
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Det er svært nok at lære færdighederne,
00:44
try to learn all the material you have to absorb
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prøve at lære alt det materiale, du skal læse
00:47
at any task you're taking on.
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inden for en hvilken som helst opgave.
00:49
I had to think about how I sew and how I cut,
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Jeg skulle tænke over, hvordan jeg syede og skar,
00:52
but then also how I pick the right person
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men derudover også hvordan jeg skal vælge den rette person
00:54
to come to an operating room.
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til at være på en operationsstue.
00:56
And then in the midst of all this
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Og så, midt i alt dette,
00:58
came this new context
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kom denne nye kontekst
01:00
for thinking about what it meant to be good.
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med at tænke over, hvad det vil sige at være dygtig.
01:02
In the last few years
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Inden for de sidste par år
01:04
we realized we were in the deepest crisis
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har vi indset, at vi befinder os i den største krise
01:07
of medicine's existence
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lægekunsten har oplevet,
01:09
due to something you don't normally think about
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på grund af noget, du normalt ikke tænker over
01:11
when you're a doctor
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når du er en læge,
01:13
concerned with how you do good for people,
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som bekymrer sig om at gøre godt for andre mennesker,
01:16
which is the cost
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og det er prisen
01:18
of health care.
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på sundhedssystemet.
01:20
There's not a country in the world
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Der er ikke det land i verden
01:23
that now is not asking
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som i dag ikke spørger sig
01:25
whether we can afford what doctors do.
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om vi kan betaler for det som lægerne gør.
01:28
The political fight that we've developed
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Den politiske kamp som har udviklet sig
01:31
has become one around
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handler om
01:33
whether it's the government that's the problem
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hvorvidt det er regeringen som er problemet
01:36
or is it insurance companies that are the problem.
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eller det er forsikringsselskaberne som er problemet.
01:41
And the answer is yes and no;
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Svaret er ja og nej.
01:45
it's deeper than all of that.
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Det ligger dybere end alt dette.
01:47
The cause of our troubles
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Grunden til vores besvær
01:49
is actually the complexity that science has given us.
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er faktisk kompleksiteten som videnskaben har givet os.
01:52
And in order to understand this,
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Og for at forstå dette,
01:54
I'm going to take you back a couple of generations.
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Vil jeg tage jer et par generationer tilbage i tiden.
01:58
I want to take you back
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Jeg vil tage jer tilbage
02:00
to a time when Lewis Thomas was writing in his book, "The Youngest Science."
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til en tid hvor Lewis Thomas skrev sin bog: "Den yngste videnskab."
02:03
Lewis Thomas was a physician-writer,
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Lewis Thomas var en læge-forfatter,
02:05
one of my favorite writers.
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en af mine favorit forfattere.
02:07
And he wrote this book to explain, among other things,
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Og har skrev denne bog for at forklare, blandt mange ting,
02:10
what it was like to be a medical intern
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hvordan det var at være intern mediciner
02:13
at the Boston City Hospital
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på Boston City Hospital
02:15
in the pre-penicillin year
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i årene før penicillinen
02:17
of 1937.
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i 1937.
02:20
It was a time when medicine was cheap
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Det var en tid hvor medicin var billig
02:24
and very ineffective.
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og meget ineffektiv.
02:28
If you were in a hospital, he said,
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Hvis du var på et hospital, skrev han,
02:31
it was going to do you good
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ville det gøre dig godt
02:34
only because it offered you
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men kun fordi det tilbød dig
02:36
some warmth, some food, shelter,
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noget varme, noget mad, ly,
02:40
and maybe the caring attention
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og måske medfølende opmærksomhed
02:42
of a nurse.
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fra en sygeplejerske.
02:44
Doctors and medicine
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Læger og medicin
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made no difference at all.
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gjorde ingen forskel overhovedet.
02:50
That didn't seem to prevent the doctors
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Dette forhindrede ikke lægerne
02:52
from being frantically busy in their days,
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fra at være afsindigt travle i deres arbejde
02:54
as he explained.
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som han forklarede.
02:56
What they were trying to do
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Hvad de prøvede at gøre
02:58
was figure out whether you might have one of the diagnoses
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var at finde ud af om du havde en af de diagnoser
03:01
for which they could do something.
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som man kunne gøre noget ved.
03:04
And there were a few.
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Og der var få.
03:06
You might have a lobar pneumonia, for example,
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Du kunne for eksempel have lungebetændelse
03:09
and they could give you an antiserum,
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og de kunne give dig et antiserum,
03:11
an injection of rabid antibodies
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og injektioner af kanin antistoffer
03:15
to the bacterium streptococcus,
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mod bakterien streptococcus
03:18
if the intern sub-typed it correctly.
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hvis lægen kunne bestemme undertypen rigtigt.
03:22
If you had an acute congestive heart failure,
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Hvis du havde akut hjertesvigt,
03:25
they could bleed a pint of blood from you
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kunne de tape en halv liter blod fra dig,
03:28
by opening up an arm vein,
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ved at åbne en pulsåre på armen
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giving you a crude leaf preparation of digitalis
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og give dig knuste blade fra planten fingerbøl
03:34
and then giving you oxygen by tent.
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og lægge dig i et ilttelt.
03:39
If you had early signs of paralysis
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Hvis du havde tidlige tegn på lammelse
03:41
and you were really good at asking personal questions,
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og var du virkelig god til at spørge om personlige spørgsmål,
03:44
you might figure out
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kunne du finde ud af
03:46
that this paralysis someone has is from syphilis,
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at lammelsen skyldes syfilis,
03:49
in which case you could give this nice concoction
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hvorefter du kunne ordinere en hyggelig blanding
03:52
of mercury and arsenic --
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af kviksølv og arsenik --
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as long as you didn't overdose them and kill them.
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så længe de ikke overdoserede og slog patienten ihjel.
04:01
Beyond these sorts of things,
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Udover denne slags ting
04:03
a medical doctor didn't have a lot that they could do.
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var der ikke meget en læge kunne gøre.
04:08
This was when the core structure of medicine
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Det var dengang kernestrukturen af lægeverden
04:10
was created --
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blev skabt --
04:12
what it meant to be good at what we did
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hvad det var at være god til, hvad vi ville
04:15
and how we wanted to build medicine to be.
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og hvad vi ønskede hvad lægekunsten skulle udvikle sig til.
04:17
It was at a time
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Det var en tid
04:19
when what was known you could know,
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hvor hvad der var kendt vidste du,
04:21
you could hold it all in your head, and you could do it all.
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du kunne have det hele i dit hovede og du kunne det hele.
04:24
If you had a prescription pad,
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Hvis du havde en receptblok,
04:26
if you had a nurse,
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hvis du havde en sygeplejerske,
04:28
if you had a hospital
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hvis du havde et hospital
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that would give you a place to convalesce, maybe some basic tools,
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kunne det give dig et sted hvor folk kunne komme sig, måske nogle simple redskaber,
04:33
you really could do it all.
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Så kunne du gøre det hele.
04:35
You set the fracture, you drew the blood,
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Du rettede benbruddet, du tappede blodet,
04:38
you spun the blood,
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præparerede det
04:40
looked at it under the microscope,
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og kiggede på det under mikroskopet,
04:42
you plated the culture, you injected the antiserum.
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du dyrkede kulturer, du indsprøjtede antiserum.
04:45
This was a life as a craftsman.
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Det var en håndværkers liv.
04:50
As a result, we built it around
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Som resultat, opbyggede vi
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a culture and set of values
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en kultur og et sæt af værdier
04:55
that said what you were good at
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som siger hvad du var god til
04:58
was being daring,
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var at at være dristig,
05:00
at being courageous,
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at være modig,
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at being independent and self-sufficient.
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at være uafhængig og selvtilstrækkelig.
05:06
Autonomy was our highest value.
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Autonomi var vores højeste værdi.
05:12
Go a couple generations forward
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Gå et par generationer frem
05:14
to where we are, though,
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til hvor vi er nu
05:16
and it looks like a completely different world.
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og det ligner en fuldstændig anden verden.
05:18
We have now found treatments
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Vi har nu fundet behandlinger
05:21
for nearly all of the tens of thousands of conditions
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for næsten alle de titusinder af tilstande
05:25
that a human being can have.
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som et menneske kan have.
05:27
We can't cure it all.
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Vi kan ikke kurere alt.
05:29
We can't guarantee that everybody will live a long and healthy life.
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Vi kan ikke garantere at alle vil leve et langt og sundt liv.
05:32
But we can make it possible
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Men vi kan gøre det muligt
05:34
for most.
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for de fleste.
05:37
But what does it take?
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Hvordan er det muligt?
05:39
Well, we've now discovered
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Vi har nu udformet
05:41
4,000 medical and surgical procedures.
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4.000 medicinske og kirurgiske procedure.
05:45
We've discovered 6,000 drugs
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Vi har opfundet 6.000 medikamenter
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that I'm now licensed to prescribe.
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som jeg nu har tilladelse til at ordinere.
05:51
And we're trying to deploy this capability,
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Vi prøver at udbrede denne formåen,
05:53
town by town,
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by efter by,
05:55
to every person alive --
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til alle personer i live --
05:59
in our own country,
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i vores eget land,
06:01
let alone around the world.
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samt i resten af verden.
06:03
And we've reached the point where we've realized,
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Og vi har nået det punkt hvor vi har erkendt,
06:06
as doctors,
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som læger,
06:08
we can't know it all.
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at vi ikke kan vide det hele.
06:10
We can't do it all
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Vi kan ikke selv
06:13
by ourselves.
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gøre alt.
06:15
There was a study where they looked
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Det var en undersøgelse hvor de kiggede
06:17
at how many clinicians it took to take care of you
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på hvor mange klinikere som skulle til at tage sig af dig
06:19
if you came into a hospital,
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hvis du kom på hospitalet,
06:21
as it changed over time.
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som det har ændret sig over tid.
06:23
And in the year 1970,
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Og i året 1970
06:25
it took just over two full-time equivalents of clinicians.
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tog det hvad der svarer til to fuldtidsklinikere.
06:28
That is to say,
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Det vil sige
06:30
it took basically the nursing time
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at det tog noget tid til pleje
06:33
and then just a little bit of time for a doctor
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og så en lille smule tid for lægen
06:35
who more or less checked in on you
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som kom forbi dig
06:37
once a day.
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en gang om dagen.
06:39
By the end of the 20th century,
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I slutningen af det 20'ende århundrede
06:42
it had become more than 15 clinicians
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kræver det nu mere end 15 klinikere
06:45
for the same typical hospital patient --
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for den samme type hospitalspatient --
06:48
specialists, physical therapists,
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specialister, fysioterapeuter,
06:51
the nurses.
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sygeplejerskerne.
06:54
We're all specialists now,
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Vi er alle specialister nu
06:56
even the primary care physicians.
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selv de praktiserende læger.
06:58
Everyone just has
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Alle har kun
07:00
a piece of the care.
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en lille del af plejen.
07:03
But holding onto that structure we built
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Men at holde fast i strukturen vi byggede
07:05
around the daring, independence,
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omkring den frygtløshed, uafhængighed,
07:07
self-sufficiency
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selvtilstrækkelighed
07:09
of each of those people
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hos hver at disse mennesker
07:12
has become a disaster.
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er blevet en katastrofe.
07:14
We have trained, hired and rewarded people
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Vi har uddannet, ansat og belønnet folk
07:18
to be cowboys.
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til at være cowboys.
07:21
But it's pit crews that we need,
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Men det er mekanikere, vi har brug for,
07:24
pit crews for patients.
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mekanikere for patienter.
07:26
There's evidence all around us:
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Der er beviser nok omkring os:
07:28
40 percent of our coronary artery disease patients
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40 procent af patienter med blodpropper i kranspulsåren
07:31
in our communities
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i vores samfund
07:33
receive incomplete or inappropriate care.
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modtager mangelfuld eller forkert behandling.
07:37
60 percent
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60 procent
07:39
of our asthma, stroke patients
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af vores astma- og hjerteslagspatienter
07:42
receive incomplete or inappropriate care.
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modtager mangelfuld eller forkert behandling.
07:46
Two million people come into hospitals
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to millioner kommer på hospitalet
07:49
and pick up an infection
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og pådrager sig en infektion
07:51
they didn't have
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som de ikke havde før
07:53
because someone failed to follow
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fordi nogle ikke fulgte
07:56
the basic practices of hygiene.
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de basal principper for hygiejne.
07:59
Our experience
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Vores erfaring
08:01
as people who get sick,
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med folk som bliver syge,
08:03
need help from other people,
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har behov for hjælp fra andre folk,
08:05
is that we have amazing clinicians
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er at vi har forbløffende klinikere
08:08
that we can turn to --
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som vi kan henvende os til --
08:10
hardworking, incredibly well-trained and very smart --
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hårdtarbejdende, utroligt veltrænede og meget kloge --
08:13
that we have access to incredible technologies
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at vi har adgang til fantastiske teknologier
08:16
that give us great hope,
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som giver os meget håb.
08:18
but little sense
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Men lidt fornemmelse
08:20
that it consistently all comes together for you
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for at det forenes på pålidelig vis for dig
08:24
from start to finish
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fra start til slut
08:27
in a successful way.
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på en succesfuld måde.
08:30
There's another sign
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Det er et andet tegn
08:32
that we need pit crews,
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på at vi skal bruge mekanikere,
08:34
and that's the unmanageable cost
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og det er de uhåndterlige udgifter
08:37
of our care.
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for sundhedsvæsnet.
08:40
Now we in medicine, I think,
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Vi indenfor lægevidenskab, tror jeg,
08:42
are baffled by this question of cost.
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er ligeglade med dette spørgsmål om pris.
08:44
We want to say, "This is just the way it is.
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Vi ønsker bare at sige: "Sådan er det bare.
08:48
This is just what medicine requires."
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Det er hvad behandling koster."
08:50
When you go from a world
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Når du går fra en verden
08:52
where you treated arthritis with aspirin,
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hvor du behandlede gigt med aspirin,
08:55
that mostly didn't do the job,
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som sjældent virkede,
08:58
to one where, if it gets bad enough,
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til en hvor, hvis det er slemt nok,
09:00
we can do a hip replacement, a knee replacement
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kan erstatte hofter eller knæ.
09:02
that gives you years, maybe decades,
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Hvilket giver dig år, måske årtier
09:05
without disability,
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uden funktionsnedsættelse,
09:07
a dramatic change,
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en dramatisk forandring,
09:09
well is it any surprise
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men er det en overraskelse
09:11
that that $40,000 hip replacement
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at en hofteoperation til $40.000
09:14
replacing the 10-cent aspirin
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som erstatning til en 10 cents aspirin
09:16
is more expensive?
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er meget dyrere?
09:18
It's just the way it is.
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Sådan er det bare.
09:21
But I think we're ignoring certain facts
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Men jeg tror at vi ikke kan ignorere nogle sandheder,
09:23
that tell us something about what we can do.
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som fortæller os noget om hvad vi kan gøre.
09:28
As we've looked at the data
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Da vi kiggede på data
09:30
about the results that have come
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for at finde resultater der er kommet
09:33
as the complexity has increased,
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efter kompleksiteten er steget
09:35
we found
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fandt vi
09:37
that the most expensive care
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at de dyreste behandlinger
09:39
is not necessarily the best care.
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ikke nødvendigvis er de bedste.
09:42
And vice versa,
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Og omvendt,
09:44
the best care
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den bedste behandling
09:46
often turns out to be the least expensive --
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viser sig ofte at være den billigste --
09:49
has fewer complications,
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har færre komplikationer,
09:52
the people get more efficient at what they do.
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og folk er mere effektive med hvad de gør.
09:55
And what that means
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Hvilket betyder
09:57
is there's hope.
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at der er håb.
10:00
Because [if] to have the best results,
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Hvis man for at få de bedste resultater
10:03
you really needed the most expensive care
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virkeligt havde behov for den mest kostbare behandling
10:06
in the country, or in the world,
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i landet, i verden,
10:08
well then we really would be talking about rationing
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så havde vi virkeligt behov for at tale om rationering
10:11
who we're going to cut off from Medicare.
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af hvem som skal dækkes af Medicare.
10:15
That would be really our only choice.
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Det ville være vores eneste valg.
10:19
But when we look at the positive deviants --
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Men når vi kigger på de positive afvigelser --
10:21
the ones who are getting the best results
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dem som får de bedste resultater
10:24
at the lowest costs --
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til den laveste pris --
10:26
we find the ones that look the most like systems
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så opdager vi at dem som minder mest om systemer
10:29
are the most successful.
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er de mest succesfulde.
10:31
That is to say, they found ways
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Hvilket vil sige, at de fandt veje
10:34
to get all of the different pieces,
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for at få alle de forskellige dele,
10:36
all of the different components,
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alle de forskellige komponenter,
10:38
to come together into a whole.
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samlet til en helhed.
10:41
Having great components is not enough,
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At have fantastiske komponenter er ikke nok,
10:44
and yet we've been obsessed in medicine with components.
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og stadigvæk syntes vi at være besat af komponenter indenfor medicin.
10:48
We want the best drugs, the best technologies,
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Vi vil have de bedste medikamenter, de bedste teknologier,
10:51
the best specialists,
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de bedste specialister,
10:54
but we don't think too much
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men vi tænker ikke meget på
10:56
about how it all comes together.
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hvordan det hele skal fungere sammen.
10:59
It's a terrible design strategy actually.
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Det er faktisk en forfærdelig designstrategi.
11:03
There's a famous thought experiment
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Her er et berømt tankeeksperiment,
11:06
that touches exactly on this
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som rammer plet,
11:08
that said, what if you built a car
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som siger: "Hvad hvis du byggede en bil
11:10
from the very best car parts?
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af alle de bedste bildele?"
11:13
Well it would lead you to put in Porsche brakes,
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Du starter med at bruge Porche bremser,
11:16
a Ferrari engine,
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en Ferrari motor,
11:18
a Volvo body, a BMW chassis.
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et Volvo karrosseri, et BMW chassis.
11:21
And you put it all together and what do you get?
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Og du samle det hele og hvad vil du få ud af det?
11:24
A very expensive pile of junk that does not go anywhere.
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En meget dyr bunke skrot, som ikke kører nogen steder.
11:28
And that is what medicine can feel like sometimes.
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Og det er hvad lægeverden nogen gange føles som.
11:33
It's not a system.
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Det er ikke et system.
11:36
Now a system, however,
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Nu med systemer,
11:38
when things start to come together,
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når ting fungere sammen,
11:41
you realize it has certain skills
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så opdager du at bestemte færdigheder
11:44
for acting and looking that way.
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for at betragte det sådan.
11:47
Skill number one
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Færdighed nummer et
11:49
is the ability to recognize success
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er evnen til at genkende en succes
11:51
and the ability to recognize failure.
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og evnen til at genkende en fiasko.
11:54
When you are a specialist,
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Når du er specialist,
11:56
you can't see the end result very well.
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kan du ikke se slutresultatet sårligt godt.
11:59
You have to become really interested in data,
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Du skal blive virkeligt interesseret i data,
12:02
unsexy as that sounds.
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lige så usexet som det lyder.
12:04
One of my colleagues is a surgeon in Cedar Rapids, Iowa,
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En af mine kollegaer er kirurg i Cedar Rapids, Iowa,
12:07
and he got interested in the question of,
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og han blev interesseret i spørgsmålet om
12:11
well how many CT scans did they do
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hvor mange CT- skanninger de lavede
12:13
for their community in Cedar Rapids?
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for deres distrikt i Cedar Rapids.
12:15
He got interested in this
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Han blev interesseret i dette
12:17
because there had been government reports,
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fordi der havde været regeringsrapporter,
12:19
newspaper reports, journal articles
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avisartikler og tidsskriftartikler
12:21
saying that there had been too many CT scans done.
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som sagde at der havde været alt for mange CT-skanninger.
12:24
He didn't see it in his own patients.
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Han så det ikke med sine egne patienter.
12:28
And so he asked the question, "How many did we do?"
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Så han stillede spørgsmålet: "Hvor mange udfører vi?"
12:30
and he wanted to get the data.
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Og han ønskede at få fat i data.
12:32
It took him three months.
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Det tog ham tre måneder.
12:34
No one had asked this question in his community before.
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Ingen havde spurgt om dette i hans distrikt før.
12:37
And what he found was that,
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Og hvad han fandt var at
12:39
for the 300,000 people in their community,
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for de 300.000 mennesker i deres distrikt,
12:41
in the previous year
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var der i det forrige år
12:43
they had done 52,000 CT scans.
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udført 52.000 CT-skanninger.
12:48
They had found a problem.
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De havde fundet et problem.
12:51
Which brings us to skill number two a system has.
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Hvilket bringer os til færdighed nummer to som et system har.
12:56
Skill one, find where your failures are.
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Færdighed et, find ud af hvor dine fiaskoer er.
12:59
Skill two is devise solutions.
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Færdighed nummer to er at finde løsninger.
13:03
I got interested in this
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Jeg blev interesseret i dette
13:05
when the World Health Organization came to my team
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da WHO kom til mit team
13:07
asking if we could help with a project
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og spurgte om vi kunne hjælpe med et projekt
13:09
to reduce deaths in surgery.
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for at reducere dødsfald i kirurgi.
13:11
The volume of surgery had spread
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Mængden af kirurgi har spredt
13:13
around the world,
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sig rundt i verdenen,
13:15
but the safety of surgery
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men sikkerheden i kirurgi
13:17
had not.
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har ikke.
13:19
Now our usual tactics for tackling problems like these
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Nu er vores sædvanlige taktik med at takle problemer som disse
13:22
are to do more training,
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at lave mere træning,
13:24
give people more specialization
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give vores folk mere specialisering
13:27
or bring in more technology.
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eller bruge mere teknologi.
13:30
Well in surgery, you couldn't have people who are more specialized
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Med kirurgi kan du bare ikke finde folk som er mere specialiserede
13:33
and you couldn't have people who are better trained.
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og du kan ikke finde folk som er bedre trænnet.
13:36
And yet we see unconscionable levels
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Og stadigvæk ser vi disse uforståelige niveauer
13:39
of death, disability
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af dødsfald, bivirkninger
13:43
that could be avoided.
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som kunne være undgået.
13:45
And so we looked at what other high-risk industries do.
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Så vi kiggede på hvad andre høj-risiko industrier gør.
13:47
We looked at skyscraper construction,
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Vi kiggede på skyskraber konstruktion,
13:49
we looked at the aviation world,
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vi kiggede på luftfartsindustrien,
13:52
and we found
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og vi fandt
13:54
that they have technology, they have training,
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at de havde teknologi, de havde træning
13:56
and then they have one other thing:
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og de havde endnu en ting:
13:59
They have checklists.
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De havde checklister.
14:02
I did not expect
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Jeg forventede ikke
14:04
to be spending a significant part
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at jeg skulle bruge en væsentlig del
14:06
of my time as a Harvard surgeon
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af min tid som en Harvard kirurg
14:08
worrying about checklists.
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med at bekymre mig om checklister.
14:11
And yet, what we found
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Men dog fandt vi
14:13
were that these were tools
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at disse var redskabet
14:16
to help make experts better.
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til at gøre eksperter bedre.
14:19
We got the lead safety engineer for Boeing to help us.
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Vi fik en sikkerhedsingeniør fra Boing til at hjælpe os.
14:23
Could we design a checklist for surgery?
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Kunne vi designe en checkliste for kirurger?
14:26
Not for the lowest people on the totem pole,
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Ikke for de nederste folk på totempælen,
14:28
but for the folks
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men for folkene
14:30
who were all the way around the chain,
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fra top til bund,
14:32
the entire team including the surgeons.
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hele holdet inklusiv kirurgerne.
14:34
And what they taught us
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Og hvad de lærte os
14:36
was that designing a checklist
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var at, det at designe en checkliste
14:38
to help people handle complexity
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som skal hjælp folk at håndtere kompleksitet
14:40
actually involves more difficulty than I had understood.
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faktisk indeholder flere vanskeligheder end jeg havde forestillet mig.
14:43
You have to think about things
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Du må forestille dig disse ting
14:45
like pause points.
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som pauser.
14:47
You need to identify the moments in a process
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Du har behov for at identificerer øjeblikke i processen
14:50
when you can actually catch a problem before it's a danger
332
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hvor du kan fange et problem før det udvikler sig til en fare
14:52
and do something about it.
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og gøre noget ved det.
14:54
You have to identify
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Du må identificere
14:56
that this is a before-takeoff checklist.
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at dette er en før-start-checkliste.
14:59
And then you need to focus on the killer items.
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Og du skal fokusere på det vigtige.
15:02
An aviation checklist,
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En fly checkliste,
15:04
like this one for a single-engine plane,
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som denne for et enmotorsfly,
15:06
isn't a recipe for how to fly a plane,
339
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er ikke en opskrift på hvordan man flyver et fly,
15:08
it's a reminder of the key things
340
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det er en huskeliste over de nøgle punkter,
15:10
that get forgotten or missed
341
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som kan glemmes eller tabes
15:13
if they're not checked.
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hvis de ikke er checkede.
15:15
So we did this.
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Så vi gjorde dette.
15:17
We created a 19-item two-minute checklist
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Vi lavede en 19 punkts tominutters checkliste
15:20
for surgical teams.
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for kirurgiske teams.
15:22
We had the pause points
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Vi havde pauser
15:24
immediately before anesthesia is given,
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lige inden bedøvelsen blev givet,
15:27
immediately before the knife hits the skin,
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lige inden skalpelen rammer huden,
15:30
immediately before the patient leaves the room.
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lige inden patienten forlader operationsstuen.
15:33
And we had a mix of dumb stuff on there --
350
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3000
Og vi havde en blanding af banale ting her --
15:36
making sure an antibiotic is given in the right time frame
351
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At være sikker på at antibiotika bliver givet indenfor de rigtige tidsramme,
15:39
because that cuts the infection rate by half --
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fordi det halvere antallet af infektioner --
15:41
and then interesting stuff,
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og så det interessante,
15:43
because you can't make a recipe for something as complicated as surgery.
354
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3000
fordi du ikke kan lave en opskrift på noget så kompliceret som kirurgi.
15:46
Instead, you can make a recipe
355
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2000
I stedet for kan du lave en opskrift
15:48
for how to have a team that's prepared for the unexpected.
356
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3000
på hvordan holdet skal være forberedt på det uforudsete.
15:51
And we had items like making sure everyone in the room
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Og vi havde ting som at være sikker på at alle i rummet
15:54
had introduced themselves by name at the start of the day,
358
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3000
havde introduceret dem selv med navn ved dagen start,
15:57
because you get half a dozen people or more
359
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2000
fordi du har et halvt dusin folk eller mere
15:59
who are sometimes coming together as a team
360
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3000
hvor nogen sommetider er sammen som et hold
16:02
for the very first time that day that you're coming in.
361
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3000
for den første gang den dag hvor du kommer ind.
16:05
We implemented this checklist
362
950000
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Vi indførte denne checkliste
16:07
in eight hospitals around the world,
363
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3000
på otte hospitaler rund om i verden,
16:10
deliberately in places from rural Tanzania
364
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2000
spændende fra landlige områder i Tanzania
16:12
to the University of Washington in Seattle.
365
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3000
til University of Washington i Seattle.
16:15
We found that after they adopted it
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Vi fandt at efter de indførte den
16:18
the complication rates fell
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2000
faldt raten af komplikationer
16:20
35 percent.
368
965000
2000
med 35 procent.
16:22
It fell in every hospital it went into.
369
967000
3000
Den faldt på samtlige hospitaler hvor den blev indført.
16:25
The death rates fell
370
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2000
Dødsraten faldt
16:27
47 percent.
371
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3000
med 47 procent.
16:30
This was bigger than a drug.
372
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2000
Dette var meget mere end med et medikament.
16:32
(Applause)
373
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6000
(Bifald)
16:38
And that brings us
374
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Og det bringer os
16:40
to skill number three,
375
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3000
til færdighed nummer tre,
16:43
the ability to implement this,
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2000
evnen til at indføre dette,
16:45
to get colleagues across the entire chain
377
990000
3000
at få kollegaer fra top til bund
16:48
to actually do these things.
378
993000
3000
til rent faktisk at gøre disse ting.
16:51
And it's been slow to spread.
379
996000
2000
Og det har været langsomt til at spredes.
16:53
This is not yet our norm in surgery --
380
998000
4000
Det er ikke vores norm i kirurgi --
16:57
let alone making checklists
381
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2000
at lave checklister
16:59
to go onto childbirth and other areas.
382
1004000
3000
fora t gå i gang med fødsler eller andre områder
17:02
There's a deep resistance
383
1007000
2000
Det er en stor modstand
17:04
because using these tools
384
1009000
2000
fordi at bruge disse redskaber
17:06
forces us to confront
385
1011000
2000
tvinger os til at indse
17:08
that we're not a system,
386
1013000
2000
at vi er ikke et system,
17:10
forces us to behave with a different set of values.
387
1015000
3000
tvinger os til at agere ud fra et andet sæt af værdier.
17:13
Just using a checklist
388
1018000
2000
Bare det at bruge en checkliste
17:15
requires you to embrace different values from the ones we've had,
389
1020000
3000
kræver at du omfavner nogle andre værdier end dem vi havde,
17:18
like humility,
390
1023000
4000
som ydmyghed,
17:22
discipline,
391
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3000
disciplin,
17:25
teamwork.
392
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2000
holdarbejde.
17:27
This is the opposite of what we were built on:
393
1032000
3000
Det er det modsatte af hvad vi er opflasket med:
17:30
independence, self-sufficiency,
394
1035000
2000
Uafhængighed, selvtilstrækkelighed,
17:32
autonomy.
395
1037000
3000
autonomi.
17:35
I met an actual cowboy, by the way.
396
1040000
3000
Jeg mødte forresten en rigtig cowboy.
17:38
I asked him, what was it like
397
1043000
3000
Jeg spurgte ham hvordan det var
17:41
to actually herd a thousand cattle
398
1046000
2000
at drive tusinde stykker kvæg
17:43
across hundreds of miles?
399
1048000
2000
gennem hundrede af miles?
17:45
How did you do that?
400
1050000
2000
Hvordan gør du?
17:47
And he said, "We have the cowboys stationed at distinct places all around."
401
1052000
3000
Og han sagde:"Vi har cowboys placeret på bestemte steder hele vejen rundt."
17:50
They communicate electronically constantly,
402
1055000
3000
De kommunikere konstant elektronisk,
17:53
and they have protocols and checklists
403
1058000
2000
de har protokoller og checklister
17:55
for how they handle everything --
404
1060000
2000
for hvordan de håndtere alt --
17:57
(Laughter)
405
1062000
2000
(Latter)
17:59
-- from bad weather
406
1064000
2000
-- fra dårligt vejr
18:01
to emergencies or inoculations for the cattle.
407
1066000
3000
til nødsituationer eller vaccineringer af kvæget.
18:04
Even the cowboys are pit crews now.
408
1069000
4000
Selv cowboys er mekanikere ne.
18:08
And it seemed like time
409
1073000
2000
og det ser ud til at være på tide
18:10
that we become that way ourselves.
410
1075000
2000
at vi også selv bliver det.
18:12
Making systems work
411
1077000
2000
At få systemer til at virke
18:14
is the great task of my generation
412
1079000
3000
er den store opgave for min generation
18:17
of physicians and scientists.
413
1082000
2000
af læger og videnskabsfolk.
18:19
But I would go further and say
414
1084000
2000
Men jeg vil gå længere og sige
18:21
that making systems work,
415
1086000
2000
at få systemer til at virke
18:23
whether in health care, education,
416
1088000
2000
hvad enten der er indenfor sundhed, uddannelse,
18:25
climate change,
417
1090000
2000
klimaforandringer,
18:27
making a pathway out of poverty,
418
1092000
2000
finde vej ud af fattigdom,
18:29
is the great task of our generation as a whole.
419
1094000
4000
er den store udfordring for vores generation som helhed.
18:33
In every field, knowledge has exploded,
420
1098000
3000
Indenfor hvert eneste område er viden eksploderet
18:36
but it has brought complexity,
421
1101000
2000
men det har medført kompleksitet,
18:38
it has brought specialization.
422
1103000
3000
det har medført specialisering.
18:41
And we've come to a place where we have no choice
423
1106000
2000
Og vi er kommet dertil hvor vi ikke har noget valg
18:43
but to recognize,
424
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end at erkende,
18:45
as individualistic as we want to be,
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som de individualister vi gerne vil være,
18:48
complexity requires
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kompleksitet kræver
18:51
group success.
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gruppesucces.
18:53
We all need to be pit crews now.
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Vi bliver nødt til at at være mekanikere nu.
18:57
Thank you.
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Mange tak.
18:59
(Applause)
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(Bifald)
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