AtulGawande_2012[阿图尔-葛王德][拿什么拯救你_我们的医疗].pdf

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1、www.XiYuS锡育软件I got my start in writing and research as a surgical trainee,assomeone who was a long ways away from becoming any kindof an expert at anything.我的职业生涯 从写作、研究开始 当时还是个外科实习医生 像很多人一样,需要经历漫漫长路 才能成为某个领域的专家00:12So the natural question you ask then at that point is,how do Iget good at what Im tr

2、ying to do?因而,在当时那个阶段你自然要问 我该如何做好自己所尝试做的这一领域？00:25And it became a question of,how do we all get good at whatwere trying to do?这个问题会演变成 我们怎样才能做好 我们正在努力做的这件事？00:30Its hard enough to learn to get the skills,try to learn all thematerial you have to absorb at any task youre taking on.要掌握技术着实不易 需要对所学内容都吸收

3、消化无论做什么00:37I had to think about how I sew and how I cut,but then alsohow I pick the right person to come to an operating room.就拿我来说,我必须学会如何缝合、如何开刀 还得知道如何选择对的人 进入手术室00:46And then in the midst of all this came this new context forthinking about what it meant to be good.在以上思考过程中 还隐藏这一个问题 那就是:究竟什么才是造福于

4、人？00:53In the last few years we realized we were in the deepest crisisof medicines existence due to something you dont normallythink about when youre a doctor concerned with how youdo good for people,which is the cost of health care.在过去几年中 我们意识到自己深陷 医学危机 原因在于有些事情 作为医生很难考虑到 关于如何造福于人 例如,医疗卫生的 成本问题00:5

5、9start in:开始 trainee:n.练习生,实习生;受训者;新兵;训练中的动物 midst:n.当中，中间/prep.在中间(等于amidst)concerned with:关心;涉及;忙于;与有关Theres not a country in the world that now is not askingwhether we can afford what doctors do.世界上没有一个国家 不在问 自己是否能支付医疗行为的代价01:17The political fight that weve developed has become onearound whether

6、its the government thats the problem or isit insurance companies that are the problem.这也引发了政治上的争论 争论焦点围绕着 究竟是政府 还是保险公司才是罪魁祸首01:25And the answer is yes and no;its deeper than all of that.答案既“是”,也“否”还有更深层次的回答01:38The cause of our troubles is actually the complexity thatscience has given us.造成麻烦的根源 其实是

7、科学带来的复杂性01:44And in order to understand this,Im going to take you back acouple of generations.为了让大家更好地理解这个观点 让我带大家回顾几代人之前的情况01:49I want to take you back to a time when Lewis Thomas waswriting in his book,The Youngest Science.我想带大家回到 刘易斯-托马斯写下最年轻的科学的那个时代01:55Lewis Thomas was a physician-writer,one of

8、 my favoritewriters.刘易斯-托马斯是一位医生兼作家 也是我最喜爱的作家之一02:00And he wrote this book to explain,among other things,whatit was like to be a medical intern at the Boston City Hospitalin the pre-penicillin year of 1937.他在书中描述了 作一名实习医生的生活 在当时的波士顿市立医院 在盘尼西林尚未发现的年代 那是1937年02:04It was a time when medicine was cheap

9、and very ineffective.当时药物很便宜 但疗效也不好02:17If you were in a hospital,he said,it was going to do you goodonly because it offered you some warmth,some food,shelter,and maybe the caring attention of a nurse.他写道:如果你去看病 医院对你的唯一帮助 就是提供了 给你提供了温暖、食物、住所,或许还有来自护士的 关怀02:25Lewis:n.吊楔 ineffective:adj.无效的,失效的;不起作用的D

10、octors and medicine made no difference at all.医生和药物的作用 无关紧要02:41That didnt seem to prevent the doctors from beingfrantically busy in their days,as he explained.即使这样 当时的医生们还是忙得不可开交 对此,他解释道02:47What they were trying to do was figure out whether youmight have one of the diagnoses for which they could d

11、osomething.他们努力想做的 就是弄清楚患者是否适用于某种诊断 是他们可以治疗的02:53And there were a few.这样的病症不多03:01You might have a lobar pneumonia,for example,and theycould give you an antiserum,an injection of rabidantibodies to the bacterium streptococcus,if the internsub-typed it correctly.比如说,你患有大叶性肺炎 医生可以对你进行抗血清治疗 为你注射狂犬病抗体 以

12、此对抗链球菌 前提是实习医生分类正确03:03TED演讲者：Atul Gawande|阿图尔-葛王德演讲标题：Atul Gawande:How do we heal medicine?|拿什么拯救你，我们的医疗?内容概要：Surgeon by day and public health journalist by night,Atul Gawande explores howdoctors can dramatically improve their practice using something as simple as a checklist.我们的医疗系统破败不堪。医生们开出昂贵无比的

13、诊断书和处方，但他们却忽视了核心问题:真真切切地治疗患者。医生、作家阿图尔-葛王德建议我们退一步思考，换一个角度看待医疗行业摈弃个人主义，建立团队合作If you had an acute congestive heart failure,they could bleeda pint of blood from you by opening up an arm vein,givingyou a crude leaf preparation of digitalis and then giving youoxygen by tent.如果你不幸突发急性充血性心脏衰竭 医生可以给你放一品脱的血 从

14、割开的手臂静脉里 他们会为你准备一剂粗糙的洋地黄叶制剂 然后让你在氧幕里吸氧03:19frantically:adv.疯狂似地;狂暴地 diagnoses:n.诊断;调查分析;评价(diagnosis的复数形式)lobar:adj.叶的;肺叶的pneumonia:n.肺炎 antiserum:n.免疫抗血清 rabid:adj.激烈的;狂暴的;偏激的;患狂犬病的 antibodies:n.免疫抗体(antibody的复数)bacterium:n.微细菌;杆菌属 streptococcus:n.链球菌;链球菌属 congestive:adj.充血的,充血性的vein:n.血管;叶脉;地质岩脉;纹

15、理;翅脉;性情/vt.使成脉络;象脉络般分布于 digitalis:n.洋地黄;植毛地黄If you had early signs of paralysis and you were really goodat asking personal questions,you might figure out that thisparalysis someone has is from syphilis,in which case youcould give this nice concoction of mercury and arsenic-aslong as you didnt overdo

16、se them and kill them.如果你出现瘫痪的前期症状 如果你很善于问个人问题 你或许会发现 这个病人的瘫痪很有可能是梅毒引发的 因此你可以开出 汞和砷的混合药剂 只要不过量使用,不会置他们于死地03:36Beyond these sorts of things,a medical doctor didnt have alot that they could do.除此之外 医师能做的事并不多03:58This was when the core structure of medicine was created-what it meant to be good at what

17、we did and how wewanted to build medicine to be.也就在那个时代,医疗的核心 形成了 那就是如何做好我们所做的事 以及如何建立医疗体系04:05It was at a time when what was known you could know,youcould hold it all in your head,and you could do it all.当时 医生能知道当时所有的医疗技术 一个人就可以记住所有的医疗知识,也能实施所有的医疗行为04:14If you had a prescription pad,if you had a nu

18、rse,if you had ahospital that would give you a place to convalesce,maybesome basic tools,you really could do it all.如果你有处方权 如果你有一名护士 如果你有一所医院 或许可以给你一个栖身之所,得到一些基本的工具 你凭一己之力可以完成所有的事04:21paralysis:n.麻痹;无力;停顿 syphilis:n.性病梅毒 concoction:n.混合;调合;调合物 mercury:n.化汞，水银/天水星/温度表/精神，元气 arsenic:n.砷;砒霜;三氧化二砷/adj.砷

19、的;含砷的 overdose:vt.配药过量;使过分沉溺/n.药量过多(等于overdosage)/vi.服药过量;过分沉溺 at a time:一次;每次;在某时 convalesce:vi.渐愈;渐渐康复You set the fracture,you drew the blood,you spun theblood,looked at it under the microscope,you plated theculture,you injected the antiserum.你可以处理骨折,可以抽血 可以验血 可以用显微镜观察 你可以组织切片,可以注射抗血清04:32This was

20、 a life as a craftsman.这是工匠一般的生活04:42As a result,we built it around a culture and set of values thatsaid what you were good at was being daring,at beingcourageous,at being independent and self-sufficient.最终,我们成功 建立起了医疗文化和价值体系 医生最应擅长的事 就是行事大胆 充满勇气 并且要独立工作,自给自足04:47Autonomy was our highest value.自主是至高

21、无上的价值观05:03Go a couple generations forward to where we are,though,and it looks like a completely different world.往后推几代人 来看今天 世界好像完全变了个样05:09We have now found treatments for nearly all of the tens ofthousands of conditions that a human being can have.我们现在的治疗手段 几乎能处理上万种 人类可能患上的疑难杂症05:15We cant cure it

22、 all.尽管不能治愈所有疾病05:24We cant guarantee that everybody will live a long andhealthy life.我们不能保证每个人都长命百岁、无病无患05:26fracture:n.破裂,断裂;外科骨折/vi.破裂;折断/vt.使破裂 spun:adj.纺成的/v.纺(spin的过去分词);旋转 plated:adj.镀金的;电镀的;装甲的/v.电镀;给装甲(plate的过去式及过去分词形式)injected:充血的/注入的 craftsman:n.工匠;手艺人;技工daring:adj.大胆的,勇敢的/n.胆量,勇气/v.敢(dar

23、e的现在分词)courageous:adj.有胆量的,勇敢的 self-sufficient:adj.自给自足的;极为自负的;过于自信的 Autonomy:n.自治，自治权 treatments:n.临床治疗(treatment的复数);处理But we can make it possible for most.但是我们可以让多数人 过上健康长寿的生活05:29But what does it take?但是,实现这一结果的代价是什么呢？05:34Well,weve now discovered 4,000 medical and surgicalprocedures.如今我们已经发现了 4

24、000种药物介入和外科手术05:36Weve discovered 6,000 drugs that Im now licensed toprescribe.我们研制了6000种药物 这还仅仅是我现在处方权允许的范围05:42And were trying to deploy this capability,town by town,toevery person alive-in our own country,let alone around theworld.我们正在尝试把这些治疗手段和药物,推广到更多地方 挨家挨户地 深入大众 覆盖我们国家的每一寸土地 乃至全球各个角落05:48And

25、weve reached the point where weve realized,asdoctors,we cant know it all.我们已经到了这样的地步 作为医生 我们认识到自己不能知晓一切06:00We cant do it all by ourselves.也不能一一做到 仅凭一己之力是不行的06:07There was a study where they looked at how many cliniciansit took to take care of you if you came into a hospital,as itchanged over time.曾

26、经有一项研究 调查了不同时代下,照顾一名患者在医院里 需要多少医务人员06:12And in the year 1970,it took just over two full-time在1970年 一般需要两名全职临床医务人员06:20And in the year 1970,it took just over two full-timeequivalents of clinicians.That is to say,it took basically the nursing time and then justa little bit of time for a doctor who mor

27、e or less checked inon you once a day.也就是说 基本上是护士照料时间 加上医生的一点点时间 医生的时间只用来做查房 一般一天一次06:25procedures:n.程序;规程(procedure的复数)licensed:adj.得到许可的(等于licenced)/v.许可;批准(license的过去分词)letalone:更不必说;听任;不打扰 clinicians:临床医生(clinician的名词复数)full-time:adj.专职的;全日制的;全部时间的equivalents:n.化学当量(equivalent的复数);同等设备;等同物 That

28、is to say:就是;即;换言之 more or less:或多或少By the end of the 20th century,it had become more than 15clinicians for the same typical hospital patient-specialists,physical therapists,the nurses.到了20世纪末年 这一数字上升到15名临床医务人员 照顾同样一名典型的住院患者 包括专科医生、普科医生 以及护士06:36Were all specialists now,even the primary care physici

29、ans.如今我们都是专科医生 即便是基本卫生医疗单位的医生06:51Everyone just has a piece of the care.每个人也只 提供自己专业范围内的一点点关怀06:55www.XiYuS锡育软件But holding onto that structure we built around the daring,independence,self-sufficiency of each of those people hasbecome a disaster.但是为了坚持我们建立的医疗价值体系 针对“勇敢”、“独立”“自给自足”对所有这些人而言就会变成一场灾难07:0

30、0We have trained,hired and rewarded people to be cowboys.我们培训、雇佣、奖励医生 把他们变成牛仔那样07:11But its pit crews that we need,pit crews for patients.但是我们真正需要的是赛车维修队 针对病人的维修队07:18Theres evidence all around us:40 percent of our coronaryartery disease patients in our communities receiveincomplete or inappropriate

31、 care.我们身边就有这样的实例证明 我们社区中40%的冠状动脉患者 接受的治疗是不全面或不妥当的07:2360 percent of our asthma,stroke patients receive incompleteor inappropriate care.哮喘、中风病人 接受的治疗是不全面或不妥当的07:34specialists:n.专家(specialist的复数);专科医生;特种经纪人 therapists:n.治疗专家(therapist的复数)physicians:n.内科内科医生(physician的复数)self-sufficiency:n.自给自足;自负 rew

32、arded:劳经奖赏 cowboys:n.牛仔(cowboy的复数)coronary:adj.冠的;冠状的;花冠的 artery:n.动脉；干道；主流 inappropriate:adj.不适当的;不相称的 asthma:n.内科中医哮喘,气喘Two million people come into hospitals and pick up aninfection they didnt have because someone failed to followthe basic practices of hygiene.200万人在医院的时候 受到感染 这些感染是他们原本所没有的 因为有人忽

33、略了 最基本的卫生问题07:43Our experience as people who get sick,need help from otherpeople,is that we have amazing clinicians that we can turn to-hardworking,incredibly well-trained and very smart-that we have access to incredible technologies that give usgreat hope,but little sense that it consistently all c

34、omestogether for you from start to finish in a successful way.我们的经验表明 当人们生病时 需要得到别人的帮助 应该是医生们的帮助 可以让我们找到那些令人放心的医生 勤奋努力、受过良好培训、并且聪明过人 还可以得益于尖端技术 这些都会给我们莫大的希望 但极少能见到 所有这些持续地共同作用于你 贯穿整个医疗过程 并且确保成功07:56Theres another sign that we need pit crews,and thats theunmanageable cost of our care.另外一个征兆 我们需要维修队的原

35、因 是现有医疗体系高昂到无法控制的 成本问题08:27Now we in medicine,I think,are baffled by this question ofcost.我想,在我们的医疗行业 百思不得其解的就是这个成本问题08:37We want to say,This is just the way it is.我们想说:“这就是现实08:41This is just what medicine requires.这就是医药行业必需的“08:45When you go from a world where you treated arthritis withaspirin,tha

36、t mostly didnt do the job,to one where,if it getsbad enough,we can do a hip replacement,a kneereplacement that gives you years,maybe decades,withoutdisability,a dramatic change,well is it any surprise that that$40,000 hip replacement replacing the 10-cent aspirin ismore expensive?当你从 用阿司匹林治疗关节炎的地方 那

37、往往是没有效果的 到现在,对于严重病患 我们可以做手术更换人工髋关节或膝盖 那将帮助病人恢复原本可能丧失的功能 安好地度过几十年 这是一个多戏剧化的改变啊 因此,如果说 花4万美元进行个髋关节移植手术 而不是花10美分买阿司匹林来缓解 哪个更昂贵呢？08:47hygiene:n.卫生;卫生学;保健法 hardworking:adj.努力工作的;不辞辛劳的,苦干的/v.努力工作(hardwork的ing形式)well-trained:adj.训练有素的;良好训练 consistently:adv.一贯地;一致地;坚实地 unmanageable:adj.难处理的,处理不了的;难管理的;难操纵的

38、baffled:adj.带有挡板的/v.阻碍;使迷惑(baffle的过去式)arthritis:n.外科关节炎 aspirin:n.阿司匹林(解热镇痛药)disability:n.残疾;无能;无资格;不利条件Its just the way it is.这就是现实09:15But I think were ignoring certain facts that tell us somethingabout what we can do.但我认为,我们忽略了一些事实 这些事实告诉我们,我们能做的其实有很多09:18As weve looked at the data about the resu

39、lts that have comeas the complexity has increased,we found that the mostexpensive care is not necessarily the best care.我们看到一些数据 关于医疗行为的结果 尽管环境日益复杂 我们发现 最昂贵的医疗 不见得是最好的09:25And vice versa,the best care often turns out to be the leastexpensive-has fewer complications,the people get moreefficient at wh

40、at they do.反之亦然 最好的医疗 通常花不了几个钱 而且更简单 人们在那种情况下效率更高09:39And what that means is theres hope.这一发现的含义在于 我们还有希望09:52Because if to have the best results,you really needed themost expensive care in the country,or in the world,well thenwe really would be talking about rationing who were goingto cut off from

41、Medicare.因为,假如我们想要获得最好的结果 要用到最贵的医疗 在一国范围内、或者在世界范围内最贵 那么我们真的要去讨论的就是配额制度 决定哪些人不能享受医疗保险09:57That would be really our only choice.那将会成为唯一的选择10:12But when we look at the positive deviants-the ones whoare getting the best results at the lowest costs-we find theones that look the most like systems are the

42、most successful.但如果我们看看积极的反面事例 确实存在以最低的成本 获得最佳效果的例子 我们发现最像“系统”的 是最成功的10:16vice versa:反之亦然 rationing:n.计划定量配给 cut off:切断;中断;使死亡;剥夺继承权 Medicare:n.(美,加)医疗保险(等于medicare)deviants:n.不正常者;偏移值;变异物/adj.不正常的;离经叛道的 lowest:adj.最低的;最小的(low的最高级);最底下的That is to say,they found ways to get all of the differentpieces

43、,all of the different components,to come together intoa whole.也就是说,我们发现了 平衡所有不同部分 不同因素的方法 让各个部分变成一个整体10:28Having great components is not enough,and yet weve beenobsessed in medicine with components.仅有好的组成部分是远远不够的 然而我们正是对医药的组成部分太过痴迷了10:38We want the best drugs,the best technologies,the bestspecialist

44、s,but we dont think too much about how it allcomes together.我们想要最好的药物、最好的技术 最好的专科医生 但我们却不曾想过 这些如何组合在一起10:45Its a terrible design strategy actually.这其实是个很糟糕的战略设计10:56Theres a famous thought experiment that touches exactly onthis that said,what if you built a car from the very best carparts?有一个很著名的思考实

45、验 验证了这个想法 实验是这样的,假如你用最好的汽车零件 能造出怎样一辆车？11:00Well it would lead you to put in Porsche brakes,a Ferrariengine,a Volvo body,a BMW chassis.你可以用保时捷的刹车 法拉利的引擎 沃尔沃的车身,宝马的底盘11:10And you put it all together and what do you get?你把这些都组装在一起会得到一辆怎样的车呢？11:18A very expensive pile of junk that does not go anywhere.答

46、案是:一堆很贵的垃圾,一辆完全不能开的车11:21And that is what medicine can feel like sometimes.有时候医药行业也是这样11:25Its not a system.它并非一个系统11:30Now a system,however,when things start to come together,you realize it has certain skills for acting and looking thatway.然而,为了组建一个体系 当所有部分都组合到一起你需要有特定的技巧 来让它运作起来,让它看起来像回事儿11:33Pors

47、che:n.保时捷(德国知名汽车厂商或其出产的轿车品牌名)chassis:n.底盘,底架 pile:n.堆;大量;建筑群/vt.累积;打桩于/vi.挤;堆积;积累Skill number one is the ability to recognize success and theability to recognize failure.首当其冲的是 辨识成功的能力 以及辨识失败的能力11:44When you are a specialist,you cant see the end result verywell.假如你是一名专科医生 如果你无法很好地设想最终结果11:51You have

48、 to become really interested in data,unsexy as thatsounds.你必须认真分析数据 这听上去非常无趣11:56One of my colleagues is a surgeon in Cedar Rapids,Iowa,andhe got interested in the question of,well how many CT scansdid they do for their community in Cedar Rapids?我的一个外科医生同事,在爱荷华州锡达拉皮兹工作 他对一个问题产生了兴趣 那就是:他们在锡达拉皮兹 做了多少个

49、CT扫描？12:01He got interested in this because there had beengovernment reports,newspaper reports,journal articlessaying that there had been too many CT scans done.他对此很感兴趣 因为政府报告 新闻报道、期刊论文 都在说现在做的CT扫描过量了12:12He didnt see it in his own patients.但他没在自己的病人中看到这个问题12:21And so he asked the question,How many

50、did we do?因此他提出这一疑问:”我们究竟做了多少CT扫描呢？“12:25and he wanted to get the data.他想得到这一数据12:27It took him three months.于是他花了3个月时间12:29No one had asked this question in his community before.此前,在他的社区,没人有过这个疑问12:31And what he found was that,for the 300,000 people in theircommunity,in the previous year they had d