TEDMED 2012
Ivan Oransky: Are we over-medicalized?
Ivan Oransky: Kategoriziramo li prečesto sve kao bolest?
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Reutersov urednik zdravstvene tematike Ivan Oransky upozorava da patimo od epidemije besmislenih pred-stanja -- pred-dijebetesa, pred-raka i mnogih drugih. U ovom zanimljivom govoru s TEDMED konferencije on pokazuje kako zdravstveni sustav može naći rješenje... učeći važnu lekciju iz bejzbola.
Ivan Oransky - Health reporter
Ivan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions. Full bio
Ivan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions. Full bio
Double-click the English transcript below to play the video.
00:16
Those of you who have seen the film "Moneyball,"
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Onima koji su vidjeli film "Igra pobjednika"
00:20
or have read the book by Michael Lewis,
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ili su čitali knjigu Michaela Lewisa
00:22
will be familiar with the story of Billy Beane.
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bit će poznata priča o Billyju Beaneu.
00:25
Billy was supposed to be a tremendous ballplayer; all the scouts told him so.
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Billy je trebao biti veliki igrač baseballa; svi lovci na talente rekli su mu to.
00:29
They told his parents that
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Rekli su njegovim roditeljima da
00:31
they predicted that he was going to be a star.
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predviđaju da će biti zvijezda.
00:33
But what actually happened when he signed the contract -- and by the way, he didn't
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Ali što se zapravo dogodilo kada je potpisao ugovor – usput rečeno, on nije
00:38
want to sign that contract, he wanted to go to
college --
college --
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htio potpisati taj ugovor, htio je ići na fakultet –
00:40
which is what my mother, who actually does
love me,
love me,
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što je moja majka, koja me zapravo voli,
00:43
said that I should do too, and I did --
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rekla da bih ja trebao učiniti, a to sam i učinio –
00:46
well, he didn't do very well. He struggled
mightily.
mightily.
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a on nije dobro prošao. Žestoko se trudio.
00:49
He got traded a couple of times, he ended up in the Minors for most of his career,
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Mijenjali su ga nekoliko puta, bio je u maloj ligi većinu svoje karijere
00:53
and he actually ended up in management. He ended up as a General Manager of the
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i zapravo na kraju završio u menadžmentu. Završio je kao glavni direktor
00:57
Oakland A's.
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Oakland A kluba.
00:58
Now for many of you in this room, ending up in management, which is also what I've done,
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Za mnoge od vas završiti kao direktor, kao što sam i ja učinio,
01:02
is seen as a success.
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zapravo je uspjeh.
01:04
I can assure you that for a kid trying to make it in the Bigs,
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Uvjeravam vas da za dijete koje pokušava dospjeti do velike lige
01:07
going into management ain't no success story. It's a failure.
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posao direktora nije uspjeh. To je promašaj.
01:12
And what I want to talk to you about today, and share with you, is that our
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A ono o čemu vam želim pričati danas i što želim podijeliti s vama jest da je naš
01:16
healthcare system, our medical system, is
just as bad at predicting
just as bad at predicting
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zdravstveni sustav, naš sustav medicine jednako loš u predviđanju
01:21
what happens to people in it -- patients,
others --
others --
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što će se dogoditi ljudima u njemu – pacijentima, drugima –
01:25
as those scouts were at predicting what would happen to Billy Beane.
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kao što su bili loši i oni lovci na talente koji su predviđali što će se dogoditi s Billyjem Beaneom.
01:30
And yet, every day
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Ali ipak, svaki dan
01:32
thousands of people in this country
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tisućama ljudi u ovoj državi
01:34
are diagnosed with preconditions.
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dijagnosticirani su preduvjeti za bolest.
01:38
We hear about pre-hypertension, we hear about pre-dementia,
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Slušamo o predhipertenziji, slušamo o preddemenciji,
01:42
we hear about pre-anxiety, and I'm pretty sure that I diagnosed myself with
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slušamo o predanksioznosti i poprilično sam siguran da sam si sam to dijagnosticirao
01:48
that in the green room.
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u zelenoj sobi.
01:49
We also refer to subclinical conditions.
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Također mislimo i na subklinička stanja.
01:53
There's subclinical atherosclerosis, subclinical hardening of the arteries,
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Postoji subklinička arteroskleroza, subkliničko otvrdnjavanje arterija,
01:58
obviously linked to heart attacks, potentially.
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potencijalno, ali očigledno povezano sa srčanim udarima.
02:02
One of my favorites is called
subclinical acne.
subclinical acne.
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Jedno od meni najdražih stanja naziva se subkliničkim aknama.
02:05
If you look up subclinical acne, you may find a website, which I did,
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Ako potražite subkliničke akne možete pronaći web stranicu, koju sam ja našao,
02:09
which says that this is the easiest type of acne to treat.
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koja kaže da je ovo najjednostavniji oblik akni za liječenje.
02:13
You don't have the pustules or the redness and inflammation.
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Nemate gnoj niti crvenilo ni upalu.
02:20
Maybe that's because you don't actually
have acne.
have acne.
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Možda zato što zapravo nemate akne.
02:23
I have a name for all of these conditions, it's another precondition:
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Imam naziv za sva ova stanja, još jedno predstanje:
02:30
I call them preposterous.
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zovem ih besmislicom.
02:32
In baseball, the game follows the pre-game.
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U baseballu igra prati predigru.
02:38
Season follows the pre-season.
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Sezona prati predsezonu.
02:40
But with a lot of these conditions, that actually isn't the case, or at least it isn't the
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Ali s mnogima od ovih stanja to nije slučaj ili bar nije
02:45
case all the time. It's as if there's a rain delay, every single time in many cases.
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uvijek slučaj. To je svaki put poput zakašnjele kiše u mnogim slučajevima.
02:49
We have pre-cancerous lesions,
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Imamo predtumorske ozljede
02:51
which often don't turn into cancer.
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koje često ne postanu tumori.
02:55
And yet,
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Ali, na primjer,
02:56
if you take, for example, subclinical
osteoporosis, a bone thinning disease,
osteoporosis, a bone thinning disease,
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ako uzmete subkliničku osteoporozu, bolest omekšanja kostiju,
03:00
the precondition,
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preduvjet
03:02
otherwise known as osteopenia,
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za bolest poznatu kao osteopenija,
03:04
you would have to treat 270
women for three years
women for three years
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morali biste liječiti 270 žena tri godine
03:08
in order to prevent one broken bone.
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kako biste spriječili jednu slomljenu kost.
03:10
That's an awful lot of women
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To je jako puno žena,
03:12
when you multiply by the number of women
who were diagnosed
who were diagnosed
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kada se pomnože sa brojem žena kojima je dijagnosticirana
03:15
with this osteopenia.
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osteopenija.
03:17
And so is it any wonder,
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I je li ikakvo čudo,
03:19
given all of the costs and the side effects
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gledajući trošak i sve nuspojave
03:21
of the drugs that we're using to treat these preconditions, that every year
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lijekova koje koristimo kako bi tretirali preduvjet za bolest, da svake godine
03:25
we're spending more than two trillion dollars on healthcare and yet
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trošimo više od dva bilijuna dolara na zdravstveno osiguranje, a ipak
03:29
100,000 people a year -- and that's a conservative estimate -- are dying
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100,000 ljudi godišnje – i to je blaga procjena – umire
03:32
not because of the conditions they have,
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ne zbog stanja koje imaju
03:34
but because of the treatments that we're giving them and the complications of those treatments?
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već zbog liječenja koje im je pruženo i komplikacija nastalih tim liječenjem?
03:39
We've medicalized everything
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Sve kategoriziramo kao nešto što treba liječiti
03:41
in this country.
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u ovoj državi.
03:42
Women in the audience, I have
some
some
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Žene u publici, imam
03:46
pretty bad news that you already know,
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poprilično loše vijesti koje već znate,
03:48
and that's that every aspect of your
life
life
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a to je da je svaki dio vašeg života
03:50
has been medicalized.
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bio kategoriziran kao nešto što se treba liječiti.
03:52
Strike one is when you hit puberty.
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Počevši od vašeg puberteta.
03:54
You now have something that happens to you once a month that has been medicalized.
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Sada imate nešto što se dogodi jednom mjesečno i kategorizirano je.
03:59
It's a condition;
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To je stanje,
03:59
it has to be treated. Strike two
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treba se tretirati. Zatim,
04:01
is if you get pregnant.
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ako ste bile trudne.
04:03
That's been medicalized as
well.
well.
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To je također kategorizirano.
04:06
You have to have a high-tech experience
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Tijekom trudnoće sve mora biti
04:08
of pregnancy, otherwise something might go wrong.
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modernizirano jer u protivnom nešto može poći po zlu.
04:10
Strike three is menopause.
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Zatim ide menopauza.
04:14
We all know what happened when millions of women were given hormone replacement therapy
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Svi znamo što se dogodilo kada su milijuni žena dobivali hormonske zamjene
04:18
for menopausal symptoms
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za simptome menopauze
04:21
for decades until all of a sudden we realized, because a study came out, a big one,
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desetljećima sve dok odjednom nismo shvatili, zato što je napravljeno istraživanje, veliko istraživanje,
04:26
NIH-funded.
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koje je financirao Nacionalni institut za zdravlje.
04:27
It said,
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Otkriveno je
04:28
actually, a lot of that hormone replacement therapy may be doing more harm than good
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da dosta tih terapija hormonskim zamjenama čini više štete nego dobra
04:32
for many of those women.
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većini žena.
04:34
Just in case,
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Za svaki slučaj,
04:36
I don't want to leave the men out --
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ne izostavimo muškarce –
04:38
I am one, after all --
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na kraju, i ja sam jedan –
04:40
I have really bad news for all of you in
this room,
this room,
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imam lošu vijest za sve vas u sobi,
04:42
and for everyone
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i za sve
04:43
listening and watching elsewhere:
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koji slušaju i gledaju drugdje.
04:45
You all have
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Svi imate
04:46
a universally fatal condition.
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univerzalno smrtonosno stanje.
04:49
So, just take a moment.
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Uzmite si trenutak.
04:52
It's called pre-death.
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To se naziva pred-smrt.
04:54
Every single one of you has it, because
you have the risk factor for it,
you have the risk factor for it,
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Svaki od vas ima to stanje zato što svi imate rizični faktor za njega,
04:59
which is being alive.
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a to je da ste živi.
05:01
But I have some good news for you,
because
because
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Ali imam dobre vijesti za vas, zato što
05:04
I'm a journalist, I like to end things in a happy way or a forward-thinking way.
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sam novinar i volim završiti stvari sretno ili na optimističan način.
05:08
And that good news is that if you can survive to the end of my talk, which
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A dobra vijest je ta da ako možete preživjeti do kraja mog govora što
05:12
we'll see if that happens for everyone,
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ćemo vidjeti hoće li se dogoditi svima,
05:14
you will be a pre-vivor.
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svi ćete biti predživitelji.
05:17
I made up pre-death.
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Izmislio sam pred-smrt.
05:22
If I used someone else's pre-death, I apologize,
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Ako sam koristio tuđu pred-smrt, ispričavam se,
05:26
I think I made it up.
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mislim da sam ju izmislio.
05:28
I didn't make up pre-vivor.
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Nisam izmislio predživitelje.
05:30
Pre-vivor is what a particular cancer advocacy group would like everyone who
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Predživitelj je ime koje bi određene grupe zagovornika tumora
05:35
just has a risk factor,
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voljele upotrijebiti za sve
05:36
but hasn't actually had that cancer,
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koji imaju rizični faktor,
05:39
to call themselves.
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ali nemaju zapravo tumor.
05:40
You are a pre-vivor.
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Vi ste predživitelj.
05:42
We've had HBO here this morning. I'm wondering if Mark Burnett is anywhere in the
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Gledali smo HBO ovdje ujutro. Pitam se je li Mark Burnett negdje
05:46
audience, I'd like to suggest
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u publici jer bih htio predložiti
05:48
a reality TV show called "Pre-vivor."
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reality show koji se zove “Predživitelji”.
05:52
If you develop a disease, you're off
the island.
the island.
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Ako se razvije bolest, odlazite s otoka.
05:55
But the problem is, we have a system
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Problem je taj što imamo sustav
06:01
that is completely --
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koji se potpuno
06:02
basically promoted this.
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temelji na tome.
06:04
We've selected, at every point in this system,
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Odabrali smo kao svaku točku ovog sustava
06:07
to do what we do, and to give everyone a
precondition and then eventually
precondition and then eventually
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raditi što radimo i svima dati preduvjet za bolest, a zatim i
06:11
a condition, in some cases.
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stanje u nekim slučajevima.
06:13
Start with the doctor-patient
relationship. Doctors, most of them,
relationship. Doctors, most of them,
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Počnimo s odnosom liječnika i pacijenta. Liječnici, većina njih,
06:18
are in a fee-for-service system. They are
basically incentivized to do more --
basically incentivized to do more --
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u naplatnom su sustavu. Oni su zapravo potaknuti da čine više –
06:23
procedures, tests,
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zahvata, pretraga,
06:24
prescribe medications.
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propisivanja lijekova.
06:26
Patients come to them,
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Pacijenti dolaze k njima,
06:27
they want to do something. We're
Americans, we can't just stand
Americans, we can't just stand
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oni žele nešto učiniti. Mi smo Amerikanci, ne možemo samo mirno stajati,
06:31
there, we have to do something. And so
they want a drug.
they want a drug.
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moramo učiniti nešto. I zato žele lijekove.
06:34
They want a treatment. They want to be told, this is what you have and this is how
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Žele liječenje. Žele da im se kaže: Ovo je to što imate i ovako
06:38
you treat it. If the doctor
doesn't give you that,
doesn't give you that,
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se to liječi. Ako liječnik to ne učini,
06:40
you go somewhere else.
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vi odlazite negdje drugdje.
06:42
That's not very good for doctors'
business.
business.
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To nije dobro za liječnički posao.
06:44
Or even worse,
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Ili još gore,
06:46
if you are diagnosed with something
eventually, and the doctor didn't order that test,
eventually, and the doctor didn't order that test,
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ako ste na kraju dobili svoju dijagnozu, možete tužiti liječnika koji je propustio
06:50
you get sued.
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učiniti taj test.
06:52
We have pharmaceutical companies that are
constantly trying to expand
constantly trying to expand
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Imamo farmaceutske tvrtke koje neprestano žele proširiti
06:55
the indications, expand the number of people who are eligible for a given treatment,
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pokazatelje, proširiti broj ljudi koji su prikladni za određenu terapiju,
07:00
because that obviously helps their bottom line.
We have advocacy groups,
We have advocacy groups,
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jer to očigledno pomaže zaradi. Imamo grupe zagovornika,
07:03
like the one that's come up with
pre-vivor,
pre-vivor,
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poput one koja je izmislila predživiteljski status,
07:05
who want to make more and more people feel they are at risk, or might have a condition,
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koje žele učiniti da sve više i više ljudi osjeća kao da su ugroženi ili bolesni,
07:10
so that they can raise more funds
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kako bi mogli sakupiti više novca
07:12
and raise visibility, et cetera.
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i povećati vidokrug, itd.
07:14
But this isn't actually,
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Ali ovdje nije riječ o -
07:16
despite what journalists typically do,
this isn't actually about blaming
this isn't actually about blaming
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bez obzira što novinari obično rade - okrivljavanju
07:19
particular players.
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određenih igrača.
07:21
We are all responsible.
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Svi smo odgovorni.
07:22
I'm responsible.
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Ja sam odgovoran.
07:24
I actually root for the Yankees, I mean talk
about
about
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Ja zapravo navijam za Yankeese. Dakle, govorim o
07:27
rooting for the worst
possible
possible
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navijanju za najgoreg mogućeg
07:30
offender when it comes to doing
everything you can do.
everything you can do.
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prekršitelja što se tiče svega što se može učiniti.
07:33
Thank you.
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Hvala vam.
07:34
But everyone is responsible.
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Ali svi su odgovorni.
07:38
I went to medical school,
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Pohađao sam medicinsku školu
07:41
and I didn't have a course called How to Think Skeptically,
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i nisam imao predmete koji su se zvali "Kako razmišljati skeptično"
07:46
or How Not to Order Tests.
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ili "Kako ne naručiti pretragu".
07:48
We have this system
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Imamo sustav
07:50
where that's what you do.
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u kojem je to ono što radiš.
07:53
And it actually took being a journalist
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I zapravo tek nakon što sam postao novinar
07:55
to understand all these incentives. You know, economists like to say,
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shvatio sam sve te poticaje. Znate, ekonomisti vole reći
07:59
there are no bad people,
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da ne postoje loši ljudi,
08:00
there are just bad incentives.
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već samo loši poticaji.
08:02
And that's actually true.
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I to je zapravo istina.
08:04
Because what we've created is a sort of Field of Dreams, when it comes to medical technology.
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Ono što smo stvorili nekakvo je polje snova kada se radi o medicinskoj tehnologiji.
08:07
So when you put another MRI in
every corner, you put a robot
every corner, you put a robot
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Zato kada stavite još jedan MRI uređaj u svaki kut, stavljate robota
08:13
in every hospital saying that everyone has to have robotic surgery.
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u svaku bolnicu govoreći da svi moraju imati robotske operacije.
08:16
Well, we've created a system where if you
build it, they will come.
build it, they will come.
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Stvorili smo sustav gdje ako ga izgradiš, oni će doći.
08:20
But you can actually perversely
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I zapravo možete izopačeno
08:24
tell people to come, convince them
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reći ljudima da dođu, uvjeriti ih
08:26
that they have to come.
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da moraju doći.
08:28
It was when I became a journalist that I really realized how I was part of this problem,
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Nakon što sam postao novinar shvatio sam da sam ja dio ovog problema
08:33
and how we all are part of this problem.
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i kako smo svi dio ovog problema.
08:35
I was medicalizing every risk factor, I was writing stories, commissioning stories,
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Kategorizirao sam svaki rizični faktor, pisao sam priče, odobravao priče,
08:39
every day, that were trying to,
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svaki dan, koje su ne nužno
08:42
not necessarily make people worried, although that was what often happened.
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pokušavale zabrinuti ljude, iako se to često događalo.
08:45
But, you know, there are ways out.
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Ali, znate, postoje načini za izlazak iz ove situacije.
08:48
I saw my own internist last week,
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Posjetio sam svog internista prošli tjedan
08:50
and he said to me,
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i rekao mi je:
08:52
"You know," and he told me something that
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"Znate", i rekao mi je nešto što bi mi
08:55
everyone in this audience could have
told me for free,
told me for free,
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svi u publici mogli reći besplatno,
08:57
but I paid him for the privilege, which
is that
is that
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ali ja sam platio za tu povlasticu, a to je
09:00
I need to lose some weight.
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da trebam smršaviti.
09:02
Well, he's right. I've had honest-to-goodness high blood pressure
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I u pravu je. Istina je da imam visok krvni tlak
09:06
for a dozen years now, same
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već dvanaestak godina, ista
09:08
age my father got it,
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dob u kojoj je i moj otac dobio visok tlak
09:09
and it's a real disease. It's not pre-hypertension, it's actual
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i to je prava bolest. Nije predhipertenzija, to je prava
09:13
hypertension, high blood pressure.
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hipertenzija, visoki krvni tlak.
09:15
Well, he's right,
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Pa, u pravu je,
09:16
but he didn't say to me,
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ali nije mi rekao:
09:19
well, you have pre-obesity or
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"Znate, imate predpretilost ili
09:21
you have pre-diabetes, or anything like that. He didn't say,
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imate preddijabetes ili nešto poput toga." Nije rekao da je
09:24
better start taking this Statin, you need to lower your cholesterol.
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bolje da počnem uzimati ovaj Statin, da trebam smanjiti kolesterol.
09:28
No, he said, "Go out and lose some weight. Come back and see me in a bit,
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Ne, rekao je: "Idi i izgubi na težini. Vrati se i posjeti me uskoro
09:31
or just give me a call and let me know how you're doing."
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ili me samo nazovi i reci kako se osjećaš."
09:33
So that's, to me,
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I to je za mene
09:35
a way forward.
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plan za budućnost.
09:37
Billy Beane, by the way, learned the same
thing.
thing.
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Billy Beane je, usput, naučio isto to.
09:39
He learned,
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Naučio je
09:40
from watching this kid who he eventually hired, who was really successful for him,
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iz promatranja djeteta koje je zaposlio i koje je postalo uspješno,
09:44
that it wasn't swinging for the fences, it
wasn't swinging at every pitch
wasn't swinging at every pitch
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da nije dobro udarati prema ogradi, nije dobro udarati sve
09:49
like the sluggers do, which is what all the expensive teams like the Yankees like to --
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kao razbijač, što skupi timovi poput Yankeesa vole raditi –
09:54
they like to pick up those guys.
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vole uzimati takve likove.
09:55
This kid told him, you know, you gotta watch the guys, and you gotta go out and find
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Dijete mu je reklo: "Znate, morate promatrati dečke, morate izaći i pronaći
10:00
the guys who like to walk,
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dečke koji vole hodati
10:01
because getting on base by a walk
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zato što doći na bazu hodajući
10:02
is just as good, and in our healthcare
system
system
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je isto tako dobro, a u našem zdravstvenom sustavu
10:05
we need to figure out,
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moramo otkriti
10:07
is that really a good pitch
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je li to doista dobro bacanje
10:08
or should we let it go by and not swing at everything?
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ili ga trebamo propustiti i ne zamahnuti palicom na sve.
10:11
Thanks.
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Hvala.
ABOUT THE SPEAKER
Ivan Oransky - Health reporterIvan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions.
Why you should listen
Ivan Oransky is a doctor-turned reporter. With an MD and an internship completed, he left to cover heath and health care, bringing the insight of a trained doctor to the beat. He is now executive editor of Reuters Health, and also teaches journalism and medicine at New York University.
He is also the co-founder of Retraction Watch a blog that tracks and investigates retractions in scientific journals, and it's sister-site, Embargo Watch, doing the same for reporting on scientific papers.
Ivan Oransky | Speaker | TED.com