TED2012
Atul Gawande: How do we heal medicine?
Atul Gavande (Atul Gawande): Kako lečimo medicinu?
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Naši zdravstveni sistemi su porušeni. Lekari su sposobni da urade izvanredne (i skupe) terapije, ali gube svoj osnovni fokus: stvarno lečenje ljudi. Lekar i pisac Atul Gavande predlaže da se vratimo korak nazad i da pogledamo na nove načine rada u medicini – sa manje kauboja i sa više pit posada.
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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Moj početak je bio
00:18
in writing and research
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u pisanju i istraživanju
00:20
as a surgical trainee,
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u svojstvu pripravnika na hirurgiji,
00:23
as someone who was a long ways away
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nekoga ko je bio veoma daleko
00:25
from becoming any kind of an expert at anything.
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od postajanja bilo kakvog stručnjaka
u bilo čemu.
u bilo čemu.
00:28
So the natural question you ask then at that point
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Pitanje koje se tu samo nameće je -
00:31
is, how do I get good at what I'm trying to do?
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kako postajem dobar u tome
što pokušavam da uradim?
što pokušavam da uradim?
00:33
And it became a question of,
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To se pretvorilo u pitanje -
00:35
how do we all get good
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kako postajemo dobri
00:37
at what we're trying to do?
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u onom što pokušavamo da uradimo?
00:40
It's hard enough to learn to get the skills,
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Dovoljno je teško učenje veštine,
00:44
try to learn all the material you have to absorb
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pokušaj učenja celog gradiva
koje morate savladati
koje morate savladati
00:47
at any task you're taking on.
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pri bilo čemu čega se latite.
00:49
I had to think about how I sew and how I cut,
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Morao sam da razmislim
kako šijem i kako sečem,
kako šijem i kako sečem,
00:52
but then also how I pick the right person
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ali takođe i kako odaberem pravu osobu
00:54
to come to an operating room.
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za operacijsku dvoranu.
00:56
And then in the midst of all this
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I tada, u sred svega toga
00:58
came this new context
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pojavio se ovaj novi kontekst
01:00
for thinking about what it meant to be good.
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za razmišljanje o tome
šta znači biti dobar.
šta znači biti dobar.
01:02
In the last few years
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U poslednjih nekoliko godina
01:04
we realized we were in the deepest crisis
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shvatili smo da smo u najdubljoj krizi
01:07
of medicine's existence
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medicinskog postojanja
01:09
due to something you don't normally think about
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zbog nečega o čemu
normalno ne razmišljate
normalno ne razmišljate
01:11
when you're a doctor
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kada ste lekar,
01:13
concerned with how you do good for people,
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obuzet mišlju kako činiti ljudima dobro,
01:16
which is the cost
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a to su troškovi
01:18
of health care.
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zdravstvene zaštite.
01:20
There's not a country in the world
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Nema zemlje na svetu
01:23
that now is not asking
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koja se danas ne pita
01:25
whether we can afford what doctors do.
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možemo li priuštiti to što lekari rade.
01:28
The political fight that we've developed
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Politička borba koju smo razvili
01:31
has become one around
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se vrti oko toga
01:33
whether it's the government that's the problem
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da li je problem u vladi
01:36
or is it insurance companies that are the problem.
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ili u osiguravajućim kompanijama.
01:41
And the answer is yes and no;
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A odgovor je i da i ne.
01:45
it's deeper than all of that.
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Dublje je od svega toga.
01:47
The cause of our troubles
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Uzrok naših nevolja
01:49
is actually the complexity that science has given us.
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je zapravo u složenosti
koju nam je nauka donela.
koju nam je nauka donela.
01:52
And in order to understand this,
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Da bi to razumeli
01:54
I'm going to take you back a couple of generations.
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osvrnuću se na par generacija ranije.
01:58
I want to take you back
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Vratiću vas
02:00
to a time when Lewis Thomas was writing in his book, "The Youngest Science."
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u vreme kada je Luis Tomas napisao
svoju knjigu "Najmlađa nauka."
svoju knjigu "Najmlađa nauka."
02:03
Lewis Thomas was a physician-writer,
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Luis Tomas je lekar-pisac,
02:05
one of my favorite writers.
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jedan od mojih omiljenih pisaca.
02:07
And he wrote this book to explain, among other things,
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Napisao je ovu knjigu da objasni,
između ostalog,
između ostalog,
02:10
what it was like to be a medical intern
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kakav je osećaj biti medicinski pripravnik
02:13
at the Boston City Hospital
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u Bostonskoj gradskoj bolnici
02:15
in the pre-penicillin year
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u pre-penicilinskoj godini
02:17
of 1937.
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1937.
02:20
It was a time when medicine was cheap
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Bilo je to vreme kada je lek bio jeftin
02:24
and very ineffective.
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i vrlo nedelotvoran.
02:28
If you were in a hospital, he said,
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On je rekao da ako ste bili u bolnici,
02:31
it was going to do you good
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to vam je činilo dobro
02:34
only because it offered you
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samo zato što vam je ponudilo
02:36
some warmth, some food, shelter,
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neku toplinu, hranu, krov nad glavom,
02:40
and maybe the caring attention
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a možda i brižnu pažnju
02:42
of a nurse.
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bolničarke.
02:44
Doctors and medicine
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Lekari i medicina
02:48
made no difference at all.
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nisu bili od pomoći.
02:50
That didn't seem to prevent the doctors
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To izgleda lekare nije sprečilo
02:52
from being frantically busy in their days,
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da budu izbezumljeno zaposleni
u svom poslu,
u svom poslu,
02:54
as he explained.
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kako je objasnio.
02:56
What they were trying to do
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Pokušavali su da prepoznaju
02:58
was figure out whether you might have one of the diagnoses
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da li možda imate jednu od dijagnoza
03:01
for which they could do something.
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za koju su mogli da učine nešto.
03:04
And there were a few.
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Bilo ih je nekoliko.
03:06
You might have a lobar pneumonia, for example,
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Možda imate lobusnu upalu pluća,
na primer,
na primer,
03:09
and they could give you an antiserum,
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i mogli su vam dati antiserum,
03:11
an injection of rabid antibodies
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inekciju s antitelima besnila
03:15
to the bacterium streptococcus,
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protiv bakterija streptokoka,
03:18
if the intern sub-typed it correctly.
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ako je pripravnik to ispravno upisao.
03:22
If you had an acute congestive heart failure,
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Ako ste imali akutnu srčanu insufienciju,
03:25
they could bleed a pint of blood from you
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mogli su da vam puste pola litre krvi
03:28
by opening up an arm vein,
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otvaranjem vene na ruci,
03:31
giving you a crude leaf preparation of digitalis
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dajući vam preparat
od sirovog lista digitalisa
od sirovog lista digitalisa
03:34
and then giving you oxygen by tent.
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i onda kiseonik, kiseoničkim šatorom.
03:39
If you had early signs of paralysis
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Ako su postojali rani znaci paralize,
03:41
and you were really good at asking personal questions,
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a bili ste jako dobri
u postavljanju intimnih pitanja
u postavljanju intimnih pitanja
03:44
you might figure out
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mogli ste da pronađete
03:46
that this paralysis someone has is from syphilis,
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da je uzrok te paralize sifilis,
03:49
in which case you could give this nice concoction
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u kom slučaju biste mogli da date
ovu lepu mešavinu
ovu lepu mešavinu
03:52
of mercury and arsenic --
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žive i arsena -
03:56
as long as you didn't overdose them and kill them.
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sve dok ih ne predozirate i ubijete.
04:01
Beyond these sorts of things,
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Osim tih stvari,
04:03
a medical doctor didn't have a lot that they could do.
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lekari nisu mogli mnogo da urade.
04:08
This was when the core structure of medicine
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Tada je stvoreno
04:10
was created --
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jezgro medicine -
04:12
what it meant to be good at what we did
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šta je tada značilo biti dobar
u svom radu
u svom radu
04:15
and how we wanted to build medicine to be.
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i kakvu medicinu smo želeli da izgradimo.
04:17
It was at a time
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Bilo je to u vreme
04:19
when what was known you could know,
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kada ste ono što je bilo poznato,
mogli da znate,
mogli da znate,
04:21
you could hold it all in your head, and you could do it all.
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da sve držite u glavi i da sve uradite.
04:24
If you had a prescription pad,
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Ako ste imali formular za recept,
04:26
if you had a nurse,
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medicinsku sestru,
04:28
if you had a hospital
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bolnicu
04:30
that would give you a place to convalesce, maybe some basic tools,
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kao mesto za oporavak,
možda neke osnovne instrumente,
možda neke osnovne instrumente,
04:33
you really could do it all.
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mogli ste da uradite sve.
04:35
You set the fracture, you drew the blood,
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Popravili ste prelom, pustili krv,
04:38
you spun the blood,
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centrifugirali krv,
04:40
looked at it under the microscope,
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pogledali je pod mikroskopom,
04:42
you plated the culture, you injected the antiserum.
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zasejali kulturu, ubrizgali antiserum.
04:45
This was a life as a craftsman.
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To je bio život nalik zanatlijskom.
04:50
As a result, we built it around
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Rezultat je bio da smo to izgradili
04:53
a culture and set of values
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oko kulture i sklopa vrednosti
04:55
that said what you were good at
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koje su govorile da si bio dobar
04:58
was being daring,
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u tome što si odvažan,
05:00
at being courageous,
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hrabar,
05:02
at being independent and self-sufficient.
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nezavisan i samodovoljan.
05:06
Autonomy was our highest value.
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Samostalnost je bila
naša najveća vrednost.
naša najveća vrednost.
05:12
Go a couple generations forward
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Pomaknimo se par generacija napred
05:14
to where we are, though,
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do današnjeg vremena
05:16
and it looks like a completely different world.
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u sasvim drugačiji svet.
05:18
We have now found treatments
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Pronašli smo terapije
05:21
for nearly all of the tens of thousands of conditions
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za skoro sve od desetina hiljada bolesti
05:25
that a human being can have.
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koje ljudsko biće može da ima.
05:27
We can't cure it all.
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Ne možemo ih sve izlečiti.
05:29
We can't guarantee that everybody will live a long and healthy life.
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Ne možemo da garantujemo
da će svi imati dug i zdrav život,
da će svi imati dug i zdrav život,
05:32
But we can make it possible
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ali ga možemo omogućiti
05:34
for most.
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većini.
05:37
But what does it take?
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Šta je za to potrebno?
05:39
Well, we've now discovered
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Do sada smo pronašli
05:41
4,000 medical and surgical procedures.
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4.000 medicinskih i hirurških postupaka.
05:45
We've discovered 6,000 drugs
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Pronašli smo 6000 lekova
05:48
that I'm now licensed to prescribe.
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koje sada ovlašćeno mogu da propisujem.
05:51
And we're trying to deploy this capability,
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Pokušavamo te mogućnosti da primenimo
05:53
town by town,
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u svakom gradu,
05:55
to every person alive --
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na svakoj živoj osobi -
05:59
in our own country,
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u našoj zemlji,
06:01
let alone around the world.
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da i ne spominjem svet.
06:03
And we've reached the point where we've realized,
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Došli smo do tačke u kojoj smo shvatili,
06:06
as doctors,
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kao lekari,
06:08
we can't know it all.
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da ne možemo znati sve.
06:10
We can't do it all
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Ne možemo učiniti sve
06:13
by ourselves.
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sami.
06:15
There was a study where they looked
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U jednom istraživanju su posmatrali
06:17
at how many clinicians it took to take care of you
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koliko se kliničara brine o vama
06:19
if you came into a hospital,
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ako ste došli u bolnicu,
06:21
as it changed over time.
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jer se to vremenom promenilo.
06:23
And in the year 1970,
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U 1970. godini,
06:25
it took just over two full-time equivalents of clinicians.
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bilo je potrebno nešto više
od dva stalna kliničara.
od dva stalna kliničara.
06:28
That is to say,
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To govori
06:30
it took basically the nursing time
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da je vremenski preovladavala bolnička nega
06:33
and then just a little bit of time for a doctor
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uz nešto malo učešća lekara
06:35
who more or less checked in on you
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koji je uglavnom obavljao kontrolu
06:37
once a day.
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jednom dnevno.
06:39
By the end of the 20th century,
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Krajem 20. veka,
06:42
it had become more than 15 clinicians
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to je preraslo u više od 15 kliničara
06:45
for the same typical hospital patient --
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za istog tipičnog pacijenta u bolnici -
06:48
specialists, physical therapists,
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specijalisti, fizioterapeuti,
06:51
the nurses.
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sestre.
06:54
We're all specialists now,
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Svi smo danas specijalisti,
06:56
even the primary care physicians.
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čak i lekari opšte prakse.
06:58
Everyone just has
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Svako ima samo
07:00
a piece of the care.
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deo nege.
07:03
But holding onto that structure we built
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Ali držeći se čvrsto te strukture
koju smo izgradili
koju smo izgradili
07:05
around the daring, independence,
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oko smelosti, nezavisnosti,
07:07
self-sufficiency
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samodovoljnosti
07:09
of each of those people
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svih tih ljudi,
07:12
has become a disaster.
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postalo je katastrofa.
07:14
We have trained, hired and rewarded people
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Obučili smo, zaposlili i nagradili ljude
07:18
to be cowboys.
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da budu kauboji,
07:21
But it's pit crews that we need,
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a trebaju nam pit posade
07:24
pit crews for patients.
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za pacijente.
07:26
There's evidence all around us:
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Svuda oko nas su dokazi:
07:28
40 percent of our coronary artery disease patients
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40% koronarnih pacijenata
07:31
in our communities
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u našim zajednicama
07:33
receive incomplete or inappropriate care.
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dobijaju nepotpunu
ili neodgovarajuću negu.
ili neodgovarajuću negu.
07:37
60 percent
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60%
07:39
of our asthma, stroke patients
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naših astmatičara,
bolesnika s moždanim udarom
bolesnika s moždanim udarom
07:42
receive incomplete or inappropriate care.
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dobija nepotpunu ili neadekvatnu negu.
07:46
Two million people come into hospitals
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Dva miliona ljudi koji dođu u bolnice
07:49
and pick up an infection
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pokupe neku infekciju
07:51
they didn't have
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koju nisu imali
07:53
because someone failed to follow
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zato što neko nije uspeo da prati
07:56
the basic practices of hygiene.
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osnovna pravila higijene.
07:59
Our experience
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Kao ljudi koji se razboljevamo
08:01
as people who get sick,
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i trebamo pomoć drugih ljudi,
08:03
need help from other people,
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naše iskustvo je
08:05
is that we have amazing clinicians
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da imamo neverovatne kliničare
08:08
that we can turn to --
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kojima se možemo obratiti -
08:10
hardworking, incredibly well-trained and very smart --
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radne, neverovatno dobro obučene
i vrlo pametne -
i vrlo pametne -
08:13
that we have access to incredible technologies
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da imamo pristup
neverovatnim tehnologijama
neverovatnim tehnologijama
08:16
that give us great hope,
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koje nam daju veliku nadu,
08:18
but little sense
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ali premalo smisla
08:20
that it consistently all comes together for you
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za doslednu primenu svega toga zajedno
08:24
from start to finish
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od početka do kraja
08:27
in a successful way.
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na uspešan način.
08:30
There's another sign
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Postoji još jedan znak
08:32
that we need pit crews,
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da su nam potrebne pit posade,
08:34
and that's the unmanageable cost
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a to su nesavladivi troškovi
08:37
of our care.
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naše nege.
08:40
Now we in medicine, I think,
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Mislim da smo u medicini
08:42
are baffled by this question of cost.
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zapanjeni troškovima.
08:44
We want to say, "This is just the way it is.
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Želimo reći: "To je tako.
08:48
This is just what medicine requires."
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To medicina zahteva."
08:50
When you go from a world
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Kad pređete iz sveta
08:52
where you treated arthritis with aspirin,
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u kome se artritis lečio aspirinom,
08:55
that mostly didn't do the job,
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koji većinom nije delovao,
08:58
to one where, if it gets bad enough,
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u svet u kome, pri pogoršanju,
09:00
we can do a hip replacement, a knee replacement
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možemo da zamenimo kuk, koleno,
09:02
that gives you years, maybe decades,
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što vam pruža godine, možda i decenije
09:05
without disability,
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bez invaliditeta,
09:07
a dramatic change,
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to je dramatična promena.
09:09
well is it any surprise
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Da li uopšte iznenađuje
09:11
that that $40,000 hip replacement
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da je 40.000 $ za zamenu kuka
09:14
replacing the 10-cent aspirin
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umesto 10 centi za aspirin
09:16
is more expensive?
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skuplje?
09:18
It's just the way it is.
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To je tako.
09:21
But I think we're ignoring certain facts
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No, mislim da zanemarujemo
određene činjenice
određene činjenice
09:23
that tell us something about what we can do.
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koje nam ponešto govore
o tome šta možemo da uradimo.
o tome šta možemo da uradimo.
09:28
As we've looked at the data
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Kad smo pogledali podatke
09:30
about the results that have come
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o novijim rezultatima
09:33
as the complexity has increased,
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kako je složenost rasla,
09:35
we found
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pronašli smo
09:37
that the most expensive care
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da nije najskuplja nega
09:39
is not necessarily the best care.
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nužno i najbolja.
09:42
And vice versa,
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I obrnuto,
09:44
the best care
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najbolja nega
09:46
often turns out to be the least expensive --
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često ispadne najjeftinija -
09:49
has fewer complications,
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ima manje komplikacija,
09:52
the people get more efficient at what they do.
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ljudi u svom poslu postanu efikasniji.
09:55
And what that means
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A to znači
09:57
is there's hope.
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da ima nade.
10:00
Because [if] to have the best results,
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Jer ako je za najbolje rezultate,
10:03
you really needed the most expensive care
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stvarno potrebna najskuplja nega
10:06
in the country, or in the world,
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u zemlji ili u svetu,
10:08
well then we really would be talking about rationing
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onda bismo stvarno
govorili o racionalizaciji
govorili o racionalizaciji
10:11
who we're going to cut off from Medicare.
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u smislu kome ćemo uskratiti
pružanje medicinske nege.
pružanje medicinske nege.
10:15
That would be really our only choice.
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To bi nam zaista bio jedini izbor.
10:19
But when we look at the positive deviants --
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No, kada pogledamo pozitivna odstupanja -
10:21
the ones who are getting the best results
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onih koji dobijaju najbolje rezultate
10:24
at the lowest costs --
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po najnižim troškovima -
10:26
we find the ones that look the most like systems
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pronalazimo da su slučajevi
najviše nalik sistemima
najviše nalik sistemima
10:29
are the most successful.
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najuspešniji.
10:31
That is to say, they found ways
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Naime, našli su načine
10:34
to get all of the different pieces,
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da sve različite delove,
10:36
all of the different components,
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svih različitih komponenti,
10:38
to come together into a whole.
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sastave u celinu.
10:41
Having great components is not enough,
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Imati sjajne delove nije dovoljno,
10:44
and yet we've been obsessed in medicine with components.
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a ipak smo u medicini
bili opsednuti s komponentama.
bili opsednuti s komponentama.
10:48
We want the best drugs, the best technologies,
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Želimo najbolje lekove,
najbolje tehnologije,
najbolje tehnologije,
10:51
the best specialists,
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najbolje specijaliste,
10:54
but we don't think too much
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ali ne razmišljamo previše
10:56
about how it all comes together.
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o tome kako to deluje zajedno.
10:59
It's a terrible design strategy actually.
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To je u stvari očajna
dizajnerska strategija.
dizajnerska strategija.
11:03
There's a famous thought experiment
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Postoji poznati misaoni eksperiment,
11:06
that touches exactly on this
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koji govori upravo o tome
11:08
that said, what if you built a car
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šta se dešava ako sastavite
11:10
from the very best car parts?
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automobil od najboljih delova?
11:13
Well it would lead you to put in Porsche brakes,
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Recimo da stavite Poršeove kočnice,
11:16
a Ferrari engine,
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Ferarijev motor,
11:18
a Volvo body, a BMW chassis.
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Volvovu karoseriju, BMW-ovu šasiju.
11:21
And you put it all together and what do you get?
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Spojite sve to i šta dobijete?
11:24
A very expensive pile of junk that does not go anywhere.
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Vrlo skupu hrpu smeća
koja ne može da se vozi.
koja ne može da se vozi.
11:28
And that is what medicine can feel like sometimes.
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Tako medicina ponekad deluje.
11:33
It's not a system.
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To nije sistem.
11:36
Now a system, however,
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Međutim, sistem,
11:38
when things start to come together,
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kada se stvari počnu objedinjavati,
11:41
you realize it has certain skills
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pokazuje određena umeća
11:44
for acting and looking that way.
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u svom delovanju.
11:47
Skill number one
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Umeće broj jedan
11:49
is the ability to recognize success
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je sposobnost da prepozna uspeh
11:51
and the ability to recognize failure.
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i neuspeh.
11:54
When you are a specialist,
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Kada ste specijalista,
11:56
you can't see the end result very well.
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ne možete da vidite
krajnji rezultat vrlo dobro.
krajnji rezultat vrlo dobro.
11:59
You have to become really interested in data,
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Morate biti zaista
zainteresovani za podatke,
zainteresovani za podatke,
12:02
unsexy as that sounds.
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što baš nije privlačno.
12:04
One of my colleagues is a surgeon in Cedar Rapids, Iowa,
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Jedan moj kolega,
hirurg u Sidar Rapidsu u Ajovi,
hirurg u Sidar Rapidsu u Ajovi,
12:07
and he got interested in the question of,
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se zainteresovao
12:11
well how many CT scans did they do
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koliko je CT skeniranja urađeno
12:13
for their community in Cedar Rapids?
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za zajednicu u Sidar Rapidsu?
12:15
He got interested in this
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Zainteresovao se zato
12:17
because there had been government reports,
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što su u vladinim izveštajima,
12:19
newspaper reports, journal articles
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u novinama i člancima u časopisima
12:21
saying that there had been too many CT scans done.
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navodili da je bilo previše CT skeniranja.
12:24
He didn't see it in his own patients.
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Nije to video kod svojih pacijenata.
12:28
And so he asked the question, "How many did we do?"
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Hteo je da dobije podatke,
pa je postavio pitanje:
pa je postavio pitanje:
12:30
and he wanted to get the data.
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"Koliko smo ih napravili?"
12:32
It took him three months.
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Trebalo mu je tri meseca.
12:34
No one had asked this question in his community before.
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Niko u zajednici nije postavio
to pitanje ranije.
to pitanje ranije.
12:37
And what he found was that,
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Pronašao je da je
12:39
for the 300,000 people in their community,
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za 300.000 ljudi u zajednici,
12:41
in the previous year
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prethodne godine
12:43
they had done 52,000 CT scans.
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napravljeno 52.000 CT skeniranja.
12:48
They had found a problem.
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Pronašli su problem.
12:51
Which brings us to skill number two a system has.
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To nas dovodi do drugog umeća
koje ima sistem.
koje ima sistem.
12:56
Skill one, find where your failures are.
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Prvo umeće je pronaći kvarove.
12:59
Skill two is devise solutions.
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Drugo je osmisliti rešenja.
13:03
I got interested in this
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Zainteresovao sam se za to
13:05
when the World Health Organization came to my team
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kada je Svetska zdravstvena
organizacija zatražila
organizacija zatražila
13:07
asking if we could help with a project
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od mog tima da pomognemo projektu
13:09
to reduce deaths in surgery.
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u smanjivanju smrtnosti u hirurgiji.
13:11
The volume of surgery had spread
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Količina operacija se širom sveta
13:13
around the world,
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proširila,
13:15
but the safety of surgery
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ali ne i njihova
13:17
had not.
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bezopasnost.
13:19
Now our usual tactics for tackling problems like these
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Naše uobičajene taktike
za rešavanje takvih problema
za rešavanje takvih problema
13:22
are to do more training,
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su povećavanje obuke,
13:24
give people more specialization
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dati ljudima više specijalizacije
13:27
or bring in more technology.
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ili uvesti više tehnologije.
13:30
Well in surgery, you couldn't have people who are more specialized
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U hirurgiji, ne možete imati
specijalizovanije
specijalizovanije
13:33
and you couldn't have people who are better trained.
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i obučenije ljude,
13:36
And yet we see unconscionable levels
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a ipak vidimo nesavesne slučajeve
13:39
of death, disability
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smrti, invalidnosti
13:43
that could be avoided.
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koje bi se mogle izbeći.
13:45
And so we looked at what other high-risk industries do.
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Obratili smo se drugim
visokorizičnim industrijama.
visokorizičnim industrijama.
13:47
We looked at skyscraper construction,
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Pregledali smo gradnju nebodera,
13:49
we looked at the aviation world,
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vazduhoplovni svet
13:52
and we found
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i pronašli smo
13:54
that they have technology, they have training,
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da osim tehnologije i obuke,
13:56
and then they have one other thing:
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imaju još jednu stvar:
13:59
They have checklists.
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kontrolne liste.
14:02
I did not expect
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Nisam očekivao
14:04
to be spending a significant part
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da ću kao harvardski hirurg
14:06
of my time as a Harvard surgeon
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provoditi značajan deo svog vremena
14:08
worrying about checklists.
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brinući se o kontrolnim listama.
14:11
And yet, what we found
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No ipak smo pronašli
14:13
were that these were tools
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da su to načini
14:16
to help make experts better.
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koji pomažu boljem delovanju stručnjaka.
14:19
We got the lead safety engineer for Boeing to help us.
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Pomoć smo potražili od Boingovog
glavnog inženjera za sigurnost.
glavnog inženjera za sigurnost.
14:23
Could we design a checklist for surgery?
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Da li bismo mogli da napravimo
kontrolnu listu za operaciju?
kontrolnu listu za operaciju?
14:26
Not for the lowest people on the totem pole,
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Ne za najniže u hijerarhiji,
14:28
but for the folks
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već za ljude
14:30
who were all the way around the chain,
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koji su u celom lancu,
14:32
the entire team including the surgeons.
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za ceo tim, uključujući hirurge.
14:34
And what they taught us
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Naučili su nas
14:36
was that designing a checklist
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da je pravljenje kontrolne liste
14:38
to help people handle complexity
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za pomoć ljudima
pri savladavanju složenosti
pri savladavanju složenosti
14:40
actually involves more difficulty than I had understood.
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zapravo teže nego što sam mislio.
14:43
You have to think about things
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Morate razmišljati o stvarima
14:45
like pause points.
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kao što su pauze.
14:47
You need to identify the moments in a process
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Morate prepoznati trenutke u procesu
14:50
when you can actually catch a problem before it's a danger
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pre nego što problem postane opasan
14:52
and do something about it.
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i kada se još može nešto učiniti.
14:54
You have to identify
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Morate prepoznati
14:56
that this is a before-takeoff checklist.
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da je to kontrolna lista pre poletanja.
14:59
And then you need to focus on the killer items.
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Zatim se morate usredotočiti
na smrtonosne stvari.
na smrtonosne stvari.
15:02
An aviation checklist,
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Vazduhoplovna kontrolna lista,
15:04
like this one for a single-engine plane,
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kao ova za avion s jednim motorom,
15:06
isn't a recipe for how to fly a plane,
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nije recept za upravljanje avionom,
15:08
it's a reminder of the key things
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već je podsetnik za ključne stvari
15:10
that get forgotten or missed
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koje se zaborave ili propuste
15:13
if they're not checked.
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ako se ne provere.
15:15
So we did this.
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To smo uradili.
15:17
We created a 19-item two-minute checklist
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Sastavili smo dvominutnu
kontrolnu listu sa 19 stavki
kontrolnu listu sa 19 stavki
15:20
for surgical teams.
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za hirurške ekipe.
15:22
We had the pause points
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Pauze smo dali
15:24
immediately before anesthesia is given,
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neposredno pre anestezije,
15:27
immediately before the knife hits the skin,
348
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neposredno pre upotrebe noža
15:30
immediately before the patient leaves the room.
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i neposredno pre nego što
pacijent napusti prostoriju.
pacijent napusti prostoriju.
15:33
And we had a mix of dumb stuff on there --
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Dobili smo mešavinu
nezanimljivih stvari -
nezanimljivih stvari -
15:36
making sure an antibiotic is given in the right time frame
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proveru da se antibiotik daje
u pravom vremenskom okviru,
u pravom vremenskom okviru,
15:39
because that cuts the infection rate by half --
352
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jer to prepolovi stopu infekcije -
15:41
and then interesting stuff,
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i zanimljivih stvari,
15:43
because you can't make a recipe for something as complicated as surgery.
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3000
jer ne možete napraviti recept
za nešto tako složeno kao operacija.
za nešto tako složeno kao operacija.
15:46
Instead, you can make a recipe
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Umesto toga, možete napraviti recept
15:48
for how to have a team that's prepared for the unexpected.
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za to kako imati ekipu pripremljenu
za neočekivano.
za neočekivano.
15:51
And we had items like making sure everyone in the room
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Imali smo stavke kao što je kontrola
da li su se svi u sobi
da li su se svi u sobi
15:54
had introduced themselves by name at the start of the day,
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predstavili po imenu na početku dana,
15:57
because you get half a dozen people or more
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jer imate pola tuceta ili više ljudi
15:59
who are sometimes coming together as a team
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koji su ponekad zajedno kao ekipa
16:02
for the very first time that day that you're coming in.
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po prvi put toga dana
kada se sami priključujete.
kada se sami priključujete.
16:05
We implemented this checklist
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Sproveli smo ovu kontrolnu listu
16:07
in eight hospitals around the world,
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u osam bolnica širom sveta,
16:10
deliberately in places from rural Tanzania
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namerno u mestima od ruralne Tanzanije
16:12
to the University of Washington in Seattle.
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3000
do Univerziteta Vašington u Sijetlu.
16:15
We found that after they adopted it
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Pronašli smo da su se,
posle prihvatanja liste,
posle prihvatanja liste,
16:18
the complication rates fell
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stope komplikacija smanjile
16:20
35 percent.
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za 35%.
16:22
It fell in every hospital it went into.
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3000
Smanjile su se u svakoj bolnici
u kojoj su je uveli.
u kojoj su je uveli.
16:25
The death rates fell
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Stope smrtnosti su se smanjile
16:27
47 percent.
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za 47%.
16:30
This was bigger than a drug.
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To je više od smanjivanja lekovima.
16:32
(Applause)
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(Aplauz)
16:38
And that brings us
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I to nas dovodi
16:40
to skill number three,
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do trećeg umeća,
16:43
the ability to implement this,
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mogućnosti sprovođenja liste,
16:45
to get colleagues across the entire chain
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da bi kolege u čitavom lancu
16:48
to actually do these things.
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zaista uradile te stvari,
16:51
And it's been slow to spread.
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2000
a ono se sporo širi.
16:53
This is not yet our norm in surgery --
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4000
To još nije naš standard u hirurgiji -
16:57
let alone making checklists
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da i ne spominjem pravljenje
kontrolnih lista
kontrolnih lista
16:59
to go onto childbirth and other areas.
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3000
za porođaje i druga područja.
17:02
There's a deep resistance
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Postoji dubok otpor
17:04
because using these tools
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2000
jer nas korišćenje takvog načina
17:06
forces us to confront
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prisiljava da se suočimo sa tim
17:08
that we're not a system,
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2000
da nismo sistem,
17:10
forces us to behave with a different set of values.
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primorava nas da se nosimo
s različitim vrednostima.
s različitim vrednostima.
17:13
Just using a checklist
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Samo korišćenje kontrolne liste
17:15
requires you to embrace different values from the ones we've had,
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zahteva prihvatanje različitih
vrednosti od dosadašnjih,
vrednosti od dosadašnjih,
17:18
like humility,
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4000
kao što je poniznost,
17:22
discipline,
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3000
disciplina,
17:25
teamwork.
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timski rad.
17:27
This is the opposite of what we were built on:
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Suprotno onom na čemu smo izgrađeni:
17:30
independence, self-sufficiency,
394
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samostalnosti, samodovoljnosti,
17:32
autonomy.
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autonomiji.
17:35
I met an actual cowboy, by the way.
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Upoznao sam pravog kauboja.
17:38
I asked him, what was it like
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Pitao sam ga, kako je
17:41
to actually herd a thousand cattle
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goniti stado od hiljadu goveda
17:43
across hundreds of miles?
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stotinama kilometara?
17:45
How did you do that?
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Kako se to radi?
17:47
And he said, "We have the cowboys stationed at distinct places all around."
401
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Rekao je: "Imamo kauboje stacionirane
u okolnim udaljenim mestima."
u okolnim udaljenim mestima."
17:50
They communicate electronically constantly,
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Oni stalno elektronski komuniciraju,
17:53
and they have protocols and checklists
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imaju protokole i kontrolne liste
17:55
for how they handle everything --
404
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kako da se late svega -
17:57
(Laughter)
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(Smeh)
17:59
-- from bad weather
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- od nevremena
18:01
to emergencies or inoculations for the cattle.
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do vanrednih stanja ili vakcina za stoku.
18:04
Even the cowboys are pit crews now.
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Čak su i kauboji sada pit posade.
18:08
And it seemed like time
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Čini se da je vreme
18:10
that we become that way ourselves.
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da i mi postanemo takvi.
18:12
Making systems work
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Stvaranje sistema koji deluju
18:14
is the great task of my generation
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je velik zadatak moje generacije
18:17
of physicians and scientists.
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lekara i naučnika.
18:19
But I would go further and say
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No, otišao bih dalje i rekao
18:21
that making systems work,
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da je stvaranje sistema koji deluju,
18:23
whether in health care, education,
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bilo u zdravstvu, obrazovanju,
18:25
climate change,
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pri klimatskim promenama,
18:27
making a pathway out of poverty,
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pri stvaranju puta izlaska iz siromaštva,
18:29
is the great task of our generation as a whole.
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velik zadatak naše generacije u celini.
18:33
In every field, knowledge has exploded,
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Na svim poljima je znanje eksplodiralo,
18:36
but it has brought complexity,
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ali je donelo složenost
18:38
it has brought specialization.
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i specijalizaciju.
18:41
And we've come to a place where we have no choice
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Došli smo do tačke
na kojoj nemamo izbora
na kojoj nemamo izbora
18:43
but to recognize,
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osim da prepoznamo,
18:45
as individualistic as we want to be,
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individualni kakvi želimo da smo,
18:48
complexity requires
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da složenost zahteva
18:51
group success.
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grupni uspeh.
18:53
We all need to be pit crews now.
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Svi moramo da smo pit posade danas.
18:57
Thank you.
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Hvala.
18:59
(Applause)
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14000
(Aplauz)
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