ABOUT THE SPEAKER
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.

Why you should listen

Atul Gawande is author of several best-selling books, including Complications: A Surgeon's Notes on an Imperfect ScienceBetter: 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

More profile about the speaker
Atul Gawande | Speaker | TED.com
TED2012

Atul Gawande: How do we heal medicine?

Atul Gawande: 我們如何治療醫學界的問題?

Filmed:
2,001,183 views

我們的醫療體制失控了。醫生可以成為異樣的(昂貴的)治療, 但他們失去了他們的初衷:把病人治好。 身兼醫生和作家的Atul Gawande建議我們退後一步並看待新的改善方法- 用越來越少的牛仔和更多的維修人員。
- 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

Double-click the English transcript below to play the video.

00:15
I got my start開始
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當我開始從事
00:18
in writing寫作 and research研究
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寫作和研究時
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as a surgical外科 trainee實習生,
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我還是一個
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as someone有人 who was a long ways方法 away
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對任何事都一竅不通的
00:25
from becoming變得 any kind of an expert專家 at anything.
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外科實習醫生。
00:28
So the natural自然 question you ask then at that point
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所以在這個情形時, 你自然而然會問
00:31
is, how do I get good at what I'm trying to do?
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我要如何在我想做的事物上精益求精?
00:33
And it became成為 a question of,
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然後問題就變成
00:35
how do we all get good
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“我們”該如何
00:37
at what we're trying to do?
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把“我們”想做的事情做好?
00:40
It's hard enough足夠 to learn學習 to get the skills技能,
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學習各種技巧,吸收大量的知識,
00:44
try to learn學習 all the material材料 you have to absorb吸收
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並且應用在你負責的工作上
00:47
at any task任務 you're taking服用 on.
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是一件困難的事。
00:49
I had to think about how I sew and how I cut,
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外科醫生必須考慮縫合和切割傷口,
00:52
but then also how I pick the right person
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我同時也要挑選適合的團隊
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to come to an operating操作 room房間.
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進入手術房
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And then in the midst中間 of all this
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面對這所有的過程
00:58
came來了 this new context上下文
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我一直思考
01:00
for thinking思維 about what it meant意味著 to be good.
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到底甚麼樣才稱做把事情做好。
01:02
In the last few少數 years年份
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最近這幾年
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we realized實現 we were in the deepest最深 crisis危機
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我們的醫療體系
01:07
of medicine's醫學的 existence存在
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面臨嚴重的危機
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due應有 to something you don't normally一般 think about
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因為身為一個醫生
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when you're a doctor醫生
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你所關心的是
01:13
concerned關心 with how you do good for people,
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如何盡全力去醫治病人
01:16
which哪一個 is the cost成本
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而不是去在意
01:18
of health健康 care關心.
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醫療成本。
01:20
There's not a country國家 in the world世界
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但現在世界上每個國家
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that now is not asking
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都想知道
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whether是否 we can afford給予 what doctors醫生 do.
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是否自己能夠支付醫療行為的代價。
01:28
The political政治 fight鬥爭 that we've我們已經 developed發達
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這也形成政治上的爭論
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has become成為 one around
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問題總圍繞在
01:33
whether是否 it's the government政府 that's the problem問題
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政府是否該為此負責?
01:36
or is it insurance保險 companies公司 that are the problem問題.
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還是保險公司才是罪魁禍首?
01:41
And the answer回答 is yes and no;
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你可以說是,也可以說不是;
01:45
it's deeper更深 than all of that.
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但這個問題的答案不是這麼表面的。
01:47
The cause原因 of our troubles麻煩
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造成現今困境的原因
01:49
is actually其實 the complexity複雜 that science科學 has given特定 us.
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可以說是科學發展日趨複雜的結果。
01:52
And in order訂購 to understand理解 this,
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為了瞭解這個觀點
01:54
I'm going to take you back a couple一對 of generations.
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讓我們回到幾個世代之前。
01:58
I want to take you back
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我們回到
02:00
to a time when Lewis劉易斯 Thomas托馬斯 was writing寫作 in his book, "The Youngest最年輕的 Science科學."
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醫生兼作家Lewis Thomas
02:03
Lewis劉易斯 Thomas托馬斯 was a physician-writer醫生作家,
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寫"最稚齡的科學."這本書的時候。
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one of my favorite喜愛 writers作家.
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他是我最喜歡的作家之一。
02:07
And he wrote this book to explain說明, among其中 other things,
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他的書中描述了
02:10
what it was like to be a medical intern實習生
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當時在波士頓醫院
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at the Boston波士頓 City Hospital醫院
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身為實習醫生時的情況。
02:15
in the pre-penicillin預青黴素 year
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那是在西元1937年
02:17
of 1937.
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盤尼西林發明前的年代。
02:20
It was a time when medicine醫學 was cheap低廉
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那個時候,醫藥費很便宜
02:24
and very ineffective不靈.
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但也沒什麼效果。
02:28
If you were in a hospital醫院, he said,
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他說,當時的醫院
02:31
it was going to do you good
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對病人的幫助
02:34
only because it offered提供 you
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僅僅在於提供病人
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some warmth熱情, some food餐飲, shelter庇護,
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一些溫暖,食物和庇護
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and maybe the caring愛心 attention注意
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也許還有來自護士的
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of a nurse護士.
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悉心照料。
02:44
Doctors醫生 and medicine醫學
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醫生和藥物
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made製作 no difference區別 at all.
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對病情沒有多大影響。
02:50
That didn't seem似乎 to prevent避免 the doctors醫生
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但即使如此,
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from being存在 frantically瘋狂 busy in their days,
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當時的醫師
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as he explained解釋.
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仍然非常忙碌。
02:56
What they were trying to do
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他們試圖
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was figure數字 out whether是否 you might威力 have one of the diagnoses診斷
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想要從病人的診斷書中
03:01
for which哪一個 they could do something.
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看看有什麼是他們能做的。
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And there were a few少數.
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當然,很少。
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You might威力 have a lobar pneumonia肺炎, for example,
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舉例來說,如果你是一個肺炎病人
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and they could give you an antiserum抗血清,
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醫生會給你抗血清的藥,
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an injection注射 of rabid瘋狂的 antibodies抗體
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注射藥性強的抗體
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to the bacterium細菌 streptococcus鏈球菌,
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對抗鏈球菌。
03:18
if the intern實習生 sub-typed子類型化 it correctly正確地.
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前提是實習醫生的血型分類正確。
03:22
If you had an acute急性 congestive充血性 heart failure失敗,
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如果你有充血性心臟衰竭,
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they could bleed流血 a pint品脫 of blood血液 from you
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醫生可能會從你的手臂靜脈
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by opening開盤 up an arm vein靜脈,
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抽出一品脫的血,
03:31
giving you a crude原油 leaf preparation製備 of digitalis洋地黃
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給你天然植物調配的強心劑,
03:34
and then giving you oxygen by tent帳篷.
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再提供你氧氣帳。
03:39
If you had early signs跡象 of paralysis麻痺
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如果病人有癱瘓的早期徵兆,
03:41
and you were really good at asking personal個人 questions問題,
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當醫生緊密的追蹤病人的私生活時
03:44
you might威力 figure數字 out
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可能會發現
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that this paralysis麻痺 someone有人 has is from syphilis梅毒,
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癱瘓的原因來自梅毒感染
03:49
in which哪一個 case案件 you could give this nice不錯 concoction藥汁
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這時病人會被注射適量的
03:52
of mercury and arsenic --
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汞和砷的混合劑–
03:56
as long as you didn't overdose過量 them and kill them.
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如果注射過量,可能連病人一起殺死了。
04:01
Beyond these sorts排序 of things,
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除了這些治療之外
04:03
a medical doctor醫生 didn't have a lot that they could do.
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醫生能做的很有限。
04:08
This was when the core核心 structure結構體 of medicine醫學
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在那樣的年代,
04:10
was created創建 --
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醫生們盡力做好份內工作
04:12
what it meant意味著 to be good at what we did
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建立期望中的醫療行為
04:15
and how we wanted to build建立 medicine醫學 to be.
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醫藥體系的核心架構於是開始形成。
04:17
It was at a time
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在當時,
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when what was known已知 you could know,
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醫生可以記住所有的醫學知識
04:21
you could hold保持 it all in your head, and you could do it all.
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也能夠獨立從事所有已知的醫療行為
04:24
If you had a prescription處方 pad,
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所以如果一個醫生有配製處方的藥室
04:26
if you had a nurse護士,
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有一個護士
04:28
if you had a hospital醫院
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有一個可以讓病人休息的場所或醫院
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that would give you a place地點 to convalesce療養, maybe some basic基本 tools工具,
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或許再加上一些基本的工具
04:33
you really could do it all.
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就可以完成所有的治療。
04:35
You set the fracture斷裂, you drew德魯 the blood血液,
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你可以處理骨折、抽血、
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you spun the blood血液,
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分析病人血液,
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looked看著 at it under the microscope顯微鏡,
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並且用顯微鏡觀察,
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you plated the culture文化, you injected注射 the antiserum抗血清.
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你可以作組織培養、可以注射抗血清。
04:45
This was a life as a craftsman.
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這是像工匠或技師一樣的工作。
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As a result結果, we built內置 it around
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當時的醫師們勇於冒險
04:53
a culture文化 and set of values
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充滿勇氣
04:55
that said what you were good at
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獨立工作
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was being存在 daring大膽,
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且自給自足,
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at being存在 courageous勇敢,
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最終,我們建立了
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at being存在 independent獨立 and self-sufficient自給.
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醫療體系獨有的文化和價值標準。
05:06
Autonomy自治 was our highest最高 value.
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獨立自主是我們高度推崇的價值。
05:12
Go a couple一對 generations forward前鋒
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回到現在,
05:14
to where we are, though雖然,
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我們處在一個
05:16
and it looks容貌 like a completely全然 different不同 world世界.
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完全不同的環境。
05:18
We have now found發現 treatments治療
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我們幾乎能夠治療
05:21
for nearly幾乎 all of the tens of thousands數千 of conditions條件
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人類會發生的
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that a human人的 being存在 can have.
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數以千計的病症。
05:27
We can't cure治愈 it all.
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當然,我們沒辦法克服所有疾病
05:29
We can't guarantee保證 that everybody每個人 will live生活 a long and healthy健康 life.
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我們也沒有辦法保證每個人活得更久更健康。
05:32
But we can make it possible可能
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但我們盡可能
05:34
for most.
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做到最好。
05:37
But what does it take?
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但是這要付出的代價是甚麼?
05:39
Well, we've我們已經 now discovered發現
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我們現在已經擁有
05:41
4,000 medical and surgical外科 procedures程序.
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4000種內外科療法
05:45
We've我們已經 discovered發現 6,000 drugs毒品
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我可以開立的處方藥
05:48
that I'm now licensed領有牌照 to prescribe規定.
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有6000種。
05:51
And we're trying to deploy部署 this capability能力,
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我們還試著將醫療
05:53
town by town,
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挨家挨戶的
05:55
to every一切 person alive --
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深入我們我們國家
05:59
in our own擁有 country國家,
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甚至於全世界
06:01
let alone單獨 around the world世界.
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去治療所有的人。
06:03
And we've我們已經 reached到達 the point where we've我們已經 realized實現,
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但是現在,我們已經知道
06:06
as doctors醫生,
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身為醫生
06:08
we can't know it all.
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我們沒辦法靠自己
06:10
We can't do it all
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知道所有的醫學知識
06:13
by ourselves我們自己.
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完成所有醫療行為。
06:15
There was a study研究 where they looked看著
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有一個研究統計
06:17
at how many許多 clinicians臨床醫生 it took to take care關心 of you
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究竟需要多少醫護人員
06:19
if you came來了 into a hospital醫院,
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去照顧一個進到醫院的病人,
06:21
as it changed over time.
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結果隨著年代不同而有很大差異。
06:23
And in the year 1970,
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1970年代,
06:25
it took just over two full-time全職 equivalents當量 of clinicians臨床醫生.
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只需要兩個全職醫護人員。
06:28
That is to say,
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也就是說,
06:30
it took basically基本上 the nursing看護 time
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除了基礎護理的時間外,
06:33
and then just a little bit of time for a doctor醫生
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只要一個醫生
06:35
who more or less checked檢查 in on you
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一天一次
06:37
once一旦 a day.
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確認一下病人情況。
06:39
By the end結束 of the 20th century世紀,
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到了20世紀末,
06:42
it had become成為 more than 15 clinicians臨床醫生
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一個同樣的病人
06:45
for the same相同 typical典型 hospital醫院 patient患者 --
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需要專科醫生、物理治療師
06:48
specialists專家, physical物理 therapists治療師,
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護士等
06:51
the nurses護士.
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超過15個醫護人員處理。
06:54
We're all specialists專家 now,
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現在所有的醫生的都是專科醫生,
06:56
even the primary care關心 physicians醫師.
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甚至基礎治療的醫生也不例外。
06:58
Everyone大家 just has
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每個醫護
07:00
a piece of the care關心.
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提供一小部分照顧。
07:03
But holding保持 onto that structure結構體 we built內置
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每個醫師都
07:05
around the daring大膽, independence獨立,
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充滿勇氣、獨立工作、
07:07
self-sufficiency自給自足
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且自信滿滿。
07:09
of each of those people
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這些都醫師養成教育所重視的價值
07:12
has become成為 a disaster災害.
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但反而讓醫療體系變成一場災難。
07:14
We have trained熟練, hired僱用 and rewarded獎勵 people
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我們訓練、雇用並獎勵醫護人員
07:18
to be cowboys牛仔.
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希望他們像牛仔一樣勇敢能幹。
07:21
But it's pit crews船員 that we need,
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但其實我們需要的是賽車維修隊,
07:24
pit crews船員 for patients耐心.
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一個針對病人的維修團隊。
07:26
There's evidence證據 all around us:
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我們身邊就有例子可以證明:
07:28
40 percent百分 of our coronary冠狀動脈 artery動脈 disease疾病 patients耐心
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在我們社會上
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in our communities社區
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40%的冠狀動脈病人
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receive接收 incomplete殘缺 or inappropriate不當 care關心.
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沒有得到適當的治療。
07:37
60 percent百分
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60%的
07:39
of our asthma哮喘, stroke行程 patients耐心
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氣喘或中風病人
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receive接收 incomplete殘缺 or inappropriate不當 care關心.
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沒有接受完整或適當的照護。
07:46
Two million百萬 people come into hospitals醫院
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高達兩百萬的人進出醫院後
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and pick up an infection感染
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被感染了
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they didn't have
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原先沒有的病菌。
07:53
because someone有人 failed失敗 to follow跟隨
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只因為醫護疏忽了
07:56
the basic基本 practices做法 of hygiene衛生.
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基礎衛生工作。
07:59
Our experience經驗
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我們的經驗是
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as people who get sick生病,
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當有人生病
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need help from other people,
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需要別人的幫助時
08:05
is that we have amazing驚人 clinicians臨床醫生
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我們有優秀的醫生
08:08
that we can turn to --
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我們可以化身為
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hardworking用功, incredibly令人難以置信 well-trained訓練有素 and very smart聰明 --
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認真工作, 受過非常良好訓練, 而且很聰明的醫生
08:13
that we have access訪問 to incredible難以置信 technologies技術
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我們可以接觸到先進的醫學科技
08:16
that give us great hope希望,
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讓我們擁抱更好的希望
08:18
but little sense
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但請注意
08:20
that it consistently始終如一 all comes together一起 for you
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所有的一切都為你而準備好的
08:24
from start開始 to finish
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從開始到結束
08:27
in a successful成功 way.
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由一個成功的方式到來
08:30
There's another另一個 sign標誌
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也有另外一個現象是
08:32
that we need pit crews船員,
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我們需要維修人員
08:34
and that's the unmanageable不可收拾 cost成本
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而對我們的服務而言
08:37
of our care關心.
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這是個無法控制好的預算
08:40
Now we in medicine醫學, I think,
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現今的醫藥界, 我想
08:42
are baffled困惑 by this question of cost成本.
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我們正為了預算的問題而苦惱
08:44
We want to say, "This is just the way it is.
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我們想說:“這就是這樣。
08:48
This is just what medicine醫學 requires要求."
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這就是醫藥界需要的呀“
08:50
When you go from a world世界
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當你的想法是
08:52
where you treated治療 arthritis關節炎 with aspirin阿司匹林,
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用阿斯匹靈來治關節炎
08:55
that mostly大多 didn't do the job工作,
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雖然並沒有什麼用
08:58
to one where, if it gets得到 bad enough足夠,
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轉換到另一種想法是, 當關節炎變非常非常糟了
09:00
we can do a hip臀部 replacement替代, a knee膝蓋 replacement替代
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我們可以做髖關節替換手術, 膝蓋替換手術
09:02
that gives you years年份, maybe decades幾十年,
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然後可以讓你好幾年, 也許好幾十年
09:05
without disability失能,
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都不會不良於行
09:07
a dramatic戲劇性 change更改,
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一個戲劇化的轉變
09:09
well is it any surprise
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四萬美金的髖關節替換手術
09:11
that that $40,000 hip臀部 replacement替代
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取代了10美分的阿斯匹靈
09:14
replacing更換 the 10-cent-cent aspirin阿司匹林
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這不是很讓人驚訝嗎?
09:16
is more expensive昂貴?
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是不是更貴呢?
09:18
It's just the way it is.
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事情就是這樣的
09:21
But I think we're ignoring無視 certain某些 facts事實
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但我想我們忽略了某些
09:23
that tell us something about what we can do.
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告訴我們可以做的事的事實
09:28
As we've我們已經 looked看著 at the data數據
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我們看著那些
09:30
about the results結果 that have come
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越來越複雜的
09:33
as the complexity複雜 has increased增加,
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成果數據時
09:35
we found發現
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我們發現
09:37
that the most expensive昂貴 care關心
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最貴的醫療照護
09:39
is not necessarily一定 the best最好 care關心.
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並不見得是最好的照護
09:42
And vice versa反之亦然,
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而反者亦然
09:44
the best最好 care關心
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最好的照料
09:46
often經常 turns out to be the least最小 expensive昂貴 --
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通常都是那些不貴的
09:49
has fewer complications並發症,
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沒有什麼糾紛的
09:52
the people get more efficient高效 at what they do.
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人們可以經由他們的行為中變得更有效率
09:55
And what that means手段
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這也意味著
09:57
is there's hope希望.
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希望是存在的
10:00
Because [if] to have the best最好 results結果,
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因為(如果)要有最好的結局
10:03
you really needed需要 the most expensive昂貴 care關心
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你絕對需要最貴的醫療照護
10:06
in the country國家, or in the world世界,
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在這個國家, 或在這個世界
10:08
well then we really would be talking about rationing配給
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那 我們真的需要討論到配給的問題
10:11
who we're going to cut off from Medicare醫保.
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哪些人我們需要停止提供醫療照護
10:15
That would be really our only choice選擇.
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而這是我們的唯一選擇
10:19
But when we look at the positive deviants離經叛道 --
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但當我們看著那些有正面反應的異變者 --
10:21
the ones那些 who are getting得到 the best最好 results結果
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那些用著最低廉的價格
10:24
at the lowest最低 costs成本 --
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得到最好的照護的人們 --
10:26
we find the ones那些 that look the most like systems系統
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我們會發現最成功的案例
10:29
are the most successful成功.
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是最系統性的
10:31
That is to say, they found發現 ways方法
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那也意味著, 他們找到
10:34
to get all of the different不同 pieces,
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把所有不一樣的事物
10:36
all of the different不同 components組件,
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所有不同的要件
10:38
to come together一起 into a whole整個.
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全部統整在一起的方法
10:41
Having great components組件 is not enough足夠,
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有最好的要件還不夠
10:44
and yet然而 we've我們已經 been obsessed痴迷 in medicine醫學 with components組件.
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雖然過去我們為了一些醫藥界的要件而著迷
10:48
We want the best最好 drugs毒品, the best最好 technologies技術,
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我們想要最好的藥品, 最好的醫學科技,
10:51
the best最好 specialists專家,
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最好的專科醫生
10:54
but we don't think too much
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但我們沒有好好想過
10:56
about how it all comes together一起.
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如何把這些要件組合在一起
10:59
It's a terrible可怕 design設計 strategy戰略 actually其實.
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這實際上是個不好的設計方式
11:03
There's a famous著名 thought experiment實驗
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有個有名的思想實驗
11:06
that touches觸摸 exactly究竟 on this
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剛好跟我們討論的東西有關連
11:08
that said, what if you built內置 a car汽車
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實驗是, 如果你組一台車
11:10
from the very best最好 car汽車 parts部分?
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用最好的零組件
11:13
Well it would lead you to put in Porsche保時捷 brakes剎車,
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你用了保時捷的煞車
11:16
a Ferrari法拉利 engine發動機,
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法拉利的引擎
11:18
a Volvo沃爾沃 body身體, a BMW寶馬 chassis機殼.
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富豪的車身, BMW的 底盤
11:21
And you put it all together一起 and what do you get?
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然後你組裝完後你得到的是?
11:24
A very expensive昂貴 pile of junk破爛 that does not go anywhere隨地.
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一堆昂貴的卻根本也不能用的垃圾
11:28
And that is what medicine醫學 can feel like sometimes有時.
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而有時醫藥界正是如此
11:33
It's not a system系統.
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這不是系統性的
11:36
Now a system系統, however然而,
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系統性的治療,是
11:38
when things start開始 to come together一起,
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當事情能組合在一起時
11:41
you realize實現 it has certain某些 skills技能
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你會發現它
11:44
for acting演戲 and looking that way.
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有些特定的功能
11:47
Skill技能 number one
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第一個功能是
11:49
is the ability能力 to recognize認識 success成功
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發現成功的能力
11:51
and the ability能力 to recognize認識 failure失敗.
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和發現弱點的能力
11:54
When you are a specialist專家,
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當你是個專科醫生
11:56
you can't see the end結束 result結果 very well.
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你沒辦法準確的看到最後的結果
11:59
You have to become成為 really interested有興趣 in data數據,
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你必須變得對於數據很有興趣
12:02
unsexyunsexy as that sounds聲音.
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但這聽起來很無聊
12:04
One of my colleagues同事 is a surgeon外科醫生 in Cedar雪松 Rapids急流, Iowa愛荷華州,
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我有個同事是在愛荷華州的Cedar Rapids 那邊當外科醫生
12:07
and he got interested有興趣 in the question of,
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而他對於以下這個問題很有興趣
12:11
well how many許多 CTCT scans掃描 did they do
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他們為了Cedar Rapids 這個社區
12:13
for their community社區 in Cedar雪松 Rapids急流?
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做了多少電腦斷層掃描?
12:15
He got interested有興趣 in this
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他對這個很有興趣
12:17
because there had been government政府 reports報告,
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因為曾經有政府的報告
12:19
newspaper報紙 reports報告, journal日誌 articles用品
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報紙報導, 雜誌報導
12:21
saying that there had been too many許多 CTCT scans掃描 doneDONE.
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指出電腦斷層掃描過多的情形。
12:24
He didn't see it in his own擁有 patients耐心.
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他沒在自己的病人裡發現這個情形
12:28
And so he asked the question, "How many許多 did we do?"
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所以他想問:“我們到底做了多少電腦斷層掃描?“
12:30
and he wanted to get the data數據.
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他想得到這些數據
12:32
It took him three months個月.
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他花了三個月的時間
12:34
No one had asked this question in his community社區 before.
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在他的社區裡從來沒有人想過這個問題
12:37
And what he found發現 was that,
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然後他找到的結果是
12:39
for the 300,000 people in their community社區,
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他們社區裡的三十萬人
12:41
in the previous以前 year
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在過去的一年裡
12:43
they had doneDONE 52,000 CTCT scans掃描.
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他們做了五萬兩千份電腦斷層掃描
12:48
They had found發現 a problem問題.
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他們發現了個問題
12:51
Which哪一個 brings帶來 us to skill技能 number two a system系統 has.
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也帶出了一個系統中的第二個功能
12:56
Skill技能 one, find where your failures故障 are.
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第一種能力是, 發現你的弱點
12:59
Skill技能 two is devise設計 solutions解決方案.
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第二種能力是設計解決方法
13:03
I got interested有興趣 in this
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我對於這個有興趣
13:05
when the World世界 Health健康 Organization組織 came來了 to my team球隊
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當世界衛生組織來到我的團隊
13:07
asking if we could help with a project項目
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詢問我們是否能參加
13:09
to reduce減少 deaths死亡 in surgery手術.
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減少手術致死機率的項目時
13:11
The volume of surgery手術 had spread傳播
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手術的數量在
13:13
around the world世界,
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世界上不斷的增加
13:15
but the safety安全 of surgery手術
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但手術的安全性
13:17
had not.
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並沒有增加
13:19
Now our usual通常 tactics策略 for tackling搶斷 problems問題 like these
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現在我們對於這些問題的解決方法是
13:22
are to do more training訓練,
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做更多的訓練
13:24
give people more specialization專業化
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讓人們變得更專業
13:27
or bring帶來 in more technology技術.
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或者提供更多的醫療科技
13:30
Well in surgery手術, you couldn't不能 have people who are more specialized專門
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在手術領域裡, 你沒有辦法擁有那些再更加專科的人
13:33
and you couldn't不能 have people who are better trained熟練.
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你也沒有辦法擁有那些訓練得更好的人
13:36
And yet然而 we see unconscionable過度的 levels水平
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現在我們看到不合理的
13:39
of death死亡, disability失能
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死亡和殘障比例
13:43
that could be avoided避免.
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都是可以被避免的
13:45
And so we looked看著 at what other high-risk高風險 industries行業 do.
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所以我們調查了另一個更高風險的行業
13:47
We looked看著 at skyscraper摩天大樓 construction施工,
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我們調查摩天大樓的建造工程
13:49
we looked看著 at the aviation航空 world世界,
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我們看到航空世界
13:52
and we found發現
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然後我們發現
13:54
that they have technology技術, they have training訓練,
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他們擁有先進的科技, 他們也有良好的訓練
13:56
and then they have one other thing:
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而他們也有另外一件事
13:59
They have checklists清單.
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他們有清單
14:02
I did not expect期望
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我並不期望
14:04
to be spending開支 a significant重大 part部分
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身為一個哈佛來的外科醫生
14:06
of my time as a Harvard哈佛 surgeon外科醫生
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要花特定的時間
14:08
worrying令人擔憂 about checklists清單.
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擔心清單這件事情
14:11
And yet然而, what we found發現
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現今, 我們發現的是
14:13
were that these were tools工具
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有工具可以幫助我們
14:16
to help make experts專家 better.
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讓專業人員變得更好
14:19
We got the lead safety安全 engineer工程師 for Boeing波音 to help us.
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我們需要引進波音的工程師來幫助我們
14:23
Could we design設計 a checklist清單 for surgery手術?
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我們能設計給外科醫生的清單嗎?
14:26
Not for the lowest最低 people on the totem圖騰 pole,
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不是為了在低層的人員們而設計
14:28
but for the folks鄉親
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而是為了那些
14:30
who were all the way around the chain,
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在工作鍊旁
14:32
the entire整個 team球隊 including包含 the surgeons外科醫生.
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整個隊伍的人員, 而其中也包含了外科醫生
14:34
And what they taught us
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而他們教我們的是
14:36
was that designing設計 a checklist清單
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設計清單可以
14:38
to help people handle處理 complexity複雜
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幫助人們更好的處理
14:40
actually其實 involves涉及 more difficulty困難 than I had understood了解.
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比我能理解還要難上好幾倍的困難事物
14:43
You have to think about things
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你必須考慮這些事情
14:45
like pause暫停 points.
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像是個暫停的時刻
14:47
You need to identify鑑定 the moments瞬間 in a process處理
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你必須在危險前發現問題的存在時
14:50
when you can actually其實 catch抓住 a problem問題 before it's a danger危險
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學會如此的暫停
14:52
and do something about it.
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然後試圖解決問題
14:54
You have to identify鑑定
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你必須指認出
14:56
that this is a before-takeoff前起飛 checklist清單.
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這是個起飛或開始前的確認清單
14:59
And then you need to focus焦點 on the killer兇手 items項目.
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然後你需要專注於最重要以及最難的項目
15:02
An aviation航空 checklist清單,
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一個航空界的清單
15:04
like this one for a single-engine單引擎 plane平面,
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像是這個單引擎的飛機的清單
15:06
isn't a recipe食譜 for how to fly a plane平面,
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不是教你如何開飛機
15:08
it's a reminder提醒 of the key things
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是提醒常會被忘記或忽略的
15:10
that get forgotten忘記了 or missed錯過
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重要事物清單
15:13
if they're not checked檢查.
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如果他們沒被確認
15:15
So we did this.
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那我們就會這樣
15:17
We created創建 a 19-item-項目 two-minute兩分鐘 checklist清單
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我們給手術團隊創造了19個項目
15:20
for surgical外科 teams球隊.
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兩分鐘的確認清單
15:22
We had the pause暫停 points
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我們有暫停的時刻
15:24
immediately立即 before anesthesia麻醉 is given特定,
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就在麻醉開始前
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immediately立即 before the knife hits點擊 the skin皮膚,
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就在手術刀碰觸到皮膚前
15:30
immediately立即 before the patient患者 leaves樹葉 the room房間.
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就在病患離開手術室前
15:33
And we had a mix混合 of dumb stuff東東 on there --
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而我們有許多蠢事列在上面
15:36
making製造 sure an antibiotic抗生素 is given特定 in the right time frame
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只為了確定抗生素是在正確的時間點提供的
15:39
because that cuts削減 the infection感染 rate by half --
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因為他們能讓感染機率減半
15:41
and then interesting有趣 stuff東東,
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而有趣的是
15:43
because you can't make a recipe食譜 for something as complicated複雜 as surgery手術.
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因為你沒有辦法為了手術這樣複雜的事情列張清單
15:46
Instead代替, you can make a recipe食譜
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取而代之的是, 你可以列張
15:48
for how to have a team球隊 that's prepared準備 for the unexpected意外.
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如何讓整個團隊為了無法預期的事情作準備的清單
15:51
And we had items項目 like making製造 sure everyone大家 in the room房間
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而我們有像是確認每個在手術室裡的人
15:54
had introduced介紹 themselves他們自己 by name名稱 at the start開始 of the day,
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都有在手術開始前自我介紹的選項,
15:57
because you get half a dozen people or more
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因為你有六個或更多的人
15:59
who are sometimes有時 coming未來 together一起 as a team球隊
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是在這個手術團隊被組成前
16:02
for the very first time that day that you're coming未來 in.
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從來也不認識彼此的
16:05
We implemented實施 this checklist清單
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我們在世界上八個醫院裡
16:07
in eight hospitals醫院 around the world世界,
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實行這個清單計畫
16:10
deliberately故意 in places地方 from rural鄉村 Tanzania坦桑尼亞
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特意從塔桑尼亞的郊區
16:12
to the University大學 of Washington華盛頓 in Seattle西雅圖.
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到西雅圖的華盛頓大學
16:15
We found發現 that after they adopted採用 it
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我們發現在他們接受這項激化後
16:18
the complication並發症 rates利率 fell下跌
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糾紛發生的機率下降
16:20
35 percent百分.
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百分之三十五
16:22
It fell下跌 in every一切 hospital醫院 it went into.
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每間醫院都是如此
16:25
The death死亡 rates利率 fell下跌
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手術死亡的機率降低
16:27
47 percent百分.
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百分之四十七
16:30
This was bigger than a drug藥物.
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在藥物方面降低更多
16:32
(Applause掌聲)
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(全場鼓掌)
16:38
And that brings帶來 us
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而這也讓我們討論到
16:40
to skill技能 number three,
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第三種能力
16:43
the ability能力 to implement實行 this,
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能執行這項計畫的能力
16:45
to get colleagues同事 across橫過 the entire整個 chain
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讓每個工作鍊上的人員
16:48
to actually其實 do these things.
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能實際上執行這些事
16:51
And it's been slow to spread傳播.
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而這散播的很慢
16:53
This is not yet然而 our norm規範 in surgery手術 --
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這還不是我們手術界的傳統
16:57
let alone單獨 making製造 checklists清單
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讓清單設計
16:59
to go onto childbirth分娩 and other areas.
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執行到生產和其他領域
17:02
There's a deep resistance抵抗性
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實際上有一定的人抗拒這項計畫
17:04
because using運用 these tools工具
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因為使用這些工具
17:06
forces軍隊 us to confront面對
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強迫我們去面對
17:08
that we're not a system系統,
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我們不是一個整體的系統的現實
17:10
forces軍隊 us to behave表現 with a different不同 set of values.
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強迫我們去表現出不一樣的價值觀
17:13
Just using運用 a checklist清單
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用這個清單
17:15
requires要求 you to embrace擁抱 different不同 values from the ones那些 we've我們已經 had,
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需要我們擁有和以往不一樣的價值觀念
17:18
like humility謙遜,
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像是人性
17:22
discipline學科,
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紀律
17:25
teamwork團隊合作.
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團隊合作
17:27
This is the opposite對面 of what we were built內置 on:
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和我們現今擁有的
17:30
independence獨立, self-sufficiency自給自足,
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獨立, 自我滿足
17:32
autonomy自治.
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自治相差甚遠
17:35
I met會見 an actual實際 cowboy牛仔, by the way.
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順道一提, 我遇到一個真正的牛仔
17:38
I asked him, what was it like
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我問他,
17:41
to actually其實 herd放牧 a thousand cattle黃牛
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在數百英里上畜牧一千隻的牛
17:43
across橫過 hundreds數以百計 of miles英里?
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是怎樣的感覺?
17:45
How did you do that?
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你怎麼辦到的呀?
17:47
And he said, "We have the cowboys牛仔 stationed at distinct不同 places地方 all around."
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他說:“我們在各地都有駐紮的牛仔“
17:50
They communicate通信 electronically電子 constantly經常,
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“他們定時用電子通訊設備溝通“
17:53
and they have protocols協議 and checklists清單
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而他們有協議好也有清單確認
17:55
for how they handle處理 everything --
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他們遇到事情要如何處理 --
17:57
(Laughter笑聲)
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(笑聲)
17:59
-- from bad weather天氣
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-- 從惡劣的天氣
18:01
to emergencies緊急情況 or inoculations接種 for the cattle黃牛.
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到緊急狀況或為牲畜接種
18:04
Even the cowboys牛仔 are pit crews船員 now.
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連牛仔都是維修人員啦
18:08
And it seemed似乎 like time
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看起來我們現在該是
18:10
that we become成為 that way ourselves我們自己.
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變成和他們一樣的時候了
18:12
Making製造 systems系統 work
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讓整個體制一體的運作
18:14
is the great task任務 of my generation
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將是我們這個醫生和科學家世代
18:17
of physicians醫師 and scientists科學家們.
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最艱鉅的任務
18:19
But I would go further進一步 and say
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但我想更深入的說
18:21
that making製造 systems系統 work,
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讓這個體制運作
18:23
whether是否 in health健康 care關心, education教育,
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不管是醫學照護, 教育
18:25
climate氣候 change更改,
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天氣轉變
18:27
making製造 a pathway out of poverty貧窮,
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改變貧窮
18:29
is the great task任務 of our generation as a whole整個.
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都是我們整個世代需要完成的艱鉅任務
18:33
In every一切 field領域, knowledge知識 has exploded爆炸,
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在每個領域, 知識都爆炸性的增加了
18:36
but it has brought complexity複雜,
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但這也將一切複雜化
18:38
it has brought specialization專業化.
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也帶來了持續的專業化。
18:41
And we've我們已經 come to a place地點 where we have no choice選擇
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而現在我們已經沒有其他的選擇
18:43
but to recognize認識,
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我們必須清楚知道
18:45
as individualistic個人主義的 as we want to be,
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我們想要個人主義
18:48
complexity複雜 requires要求
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但解決困難的問題需要
18:51
group success成功.
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團隊的合作才能成功
18:53
We all need to be pit crews船員 now.
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我們現在都需要維修人員
18:57
Thank you.
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謝謝大家
18:59
(Applause掌聲)
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(全場鼓掌)
Translated by Serena Chang
Reviewed by Dennis Guo

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ABOUT THE SPEAKER
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.

Why you should listen

Atul Gawande is author of several best-selling books, including Complications: A Surgeon's Notes on an Imperfect ScienceBetter: 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

More profile about the speaker
Atul Gawande | Speaker | TED.com