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  • Science.

    科學

  • The very word for many of you conjures unhappy memories of boredom

    這詞喚起你們當中許多人

  • in high school biology or physics class.

    高中生物和物理課裡 無聊、不愉快的回憶。

  • But let me assure that what you did there

    但我保證,

  • had very little to do with science.

    你們當時的經歷與科學大相逕庭。

  • That was really the "what" of science.

    那其實是科學的 「是什麼」的那部分。

  • It was the history of what other people had discovered.

    是前人發現的歷史記載。

  • What I'm most interested in as a scientist

    身為科學家,我最感興趣的 是科學的「如何」那部分。

  • is the "how" of science.

    因為科學是求知的進程。

  • Because science is knowledge in process.

    我們觀察,

  • We make an observation, guess an explanation for that observation,

    猜個說法用來解釋所觀察到的現象,

  • and then make a prediction that we can test

    然後預測假設,

  • with an experiment or other observation.

    再用實驗或其他的觀察 來測試這個預測。

  • A couple of examples.

    舉兩個例子。

  • First of all, people noticed that the Earth was below, the sky above,

    第一個,前人注意到 地在下而天在上,

  • and both the Sun and the Moon seemed to go around them.

    看似太陽和月亮都圍繞著天地轉。

  • Their guessed explanation

    他們猜的解釋是

  • was that the Earth must be the center of the universe.

    地球想必是宇宙的中心。

  • The prediction: everything should circle around the Earth.

    預測:每樣東西都應該繞著地球轉。

  • This was first really tested

    首次有人真正檢視這說法

  • when Galileo got his hands on one of the first telescopes,

    是伽里略從第一批 望遠鏡中拿到了一台,

  • and as he gazed into the night sky,

    並著手觀測星空的時候,

  • what he found there was a planet, Jupiter,

    他發現木星這個行星

  • with four moons circling around it.

    有四個繞著它轉的衛星。

  • He then used those moons to follow the path of Jupiter

    他用這些衛星來追蹤木星的軌跡,

  • and found that Jupiter also was not going around the Earth

    並且發現木星也沒繞著地球轉,

  • but around the Sun.

    而是繞著太陽轉。

  • So the prediction test failed.

    因此那個假設並未通過測試,

  • And this led to the discarding of the theory

    所以導致大家捨棄了 地球是宇宙中心的理論。

  • that the Earth was the center of the universe.

    另一個例子:艾薩克·牛頓爵士 注意到東西落地。

  • Another example: Sir Isaac Newton noticed that things fall to the Earth.

    他猜測的解釋是重力,

  • The guessed explanation was gravity,

    預測每個東西都會落地。

  • the prediction that everything should fall to the Earth.

    當然,並非每個東西都會落地。

  • But of course, not everything does fall to the Earth.

    我們因此就棄捨重力論嗎?

  • So did we discard gravity?

    當然不。我們把理論修正為: 重力曳引東西落地,

  • No. We revised the theory and said, gravity pulls things to the Earth

    除非另有個力道相等 而方向相反的作用力。

  • unless there is an equal and opposite force in the other direction.

    這讓我們學到新知識。

  • This led us to learn something new.

    我們開始更加注意鳥和鳥的翅膀,

  • We began to pay more attention to the bird and the bird's wings,

    試想所有沿著這條思路 而引出的新發現。

  • and just think of all the discoveries

    因此,失敗的測試、例外與離群值,

  • that have flown from that line of thinking.

    教導我們原先未知的,

  • So the test failures, the exceptions, the outliers

    並且引領我們發現新知。

  • teach us what we don't know and lead us to something new.

    科學如此前進。

  • This is how science moves forward. This is how science learns.

    科學如此學習。

  • Sometimes in the media, and even more rarely,

    雖然罕見,

  • but sometimes even scientists will say

    有時媒體甚至連科學家都說

  • that something or other has been scientifically proven.

    這或那個已經被科學所證明了。

  • But I hope that you understand that science never proves anything

    但我希望你們明白

  • definitively forever.

    科學從未終極永遠地證明過什麼。

  • Hopefully science remains curious enough

    希望科學家保有足夠的好奇心

  • to look for

    去探尋,

  • and humble enough to recognize

    並且謙卑得足以辨認,

  • when we have found

    在我們發現下一個離群值

  • the next outlier,

    或例外時,

  • the next exception,

    像是木星的衛星那樣,

  • which, like Jupiter's moons,

    教導我們原先並未真正明瞭的。

  • teaches us what we don't actually know.

    此刻我們暫時先變換個主題。

  • We're going to change gears here for a second.

    蛇杖,醫學的標誌,

  • The caduceus, or the symbol of medicine,

    對不同的人而言,代表不同的意思,

  • means a lot of different things to different people,

    但大多數的公共醫學論述

  • but most of our public discourse on medicine

    把它轉成了工程問題。

  • really turns it into an engineering problem.

    國會和保險公司的董事會

  • We have the hallways of Congress,

    試圖找出支付醫療款項的方法。

  • and the boardrooms of insurance companies that try to figure out how to pay for it.

    倫理學家和流行病學家

  • The ethicists and epidemiologists

    試圖找到分配醫藥的最佳方式。

  • try to figure out how best to distribute medicine,

    而醫院和醫生們則完全沉迷於

  • and the hospitals and physicians are absolutely obsessed

    他們的儀軌和清單裡,

  • with their protocols and checklists,

    試圖找出最佳、最安全的行醫方式。

  • trying to figure out how best to safely apply medicine.

    這些都是好事。

  • These are all good things.

    然而,在某種程度上他們全都假設

  • However, they also all assume

    醫學教科書已蓋棺論定。

  • at some level

    我們以多快能獲得治療 來衡量我們的醫療品質。

  • that the textbook of medicine is closed.

    在這種氣氛下,我一點也不訝異

  • We start to measure the quality of our health care

    許多機構所提供的醫療

  • by how quickly we can access it.

    變得像是 Jiffy Lube 汽車維修連鎖店那樣。

  • It doesn't surprise me that in this climate,

    (笑聲)

  • many of our institutions for the provision of health care

    唯一的問題是

  • start to look a heck of a lot like Jiffy Lube.

    當我自醫學院畢業時,

  • (Laughter)

    沒拿到像這樣的小玩意,

  • The only problem is that when I graduated from medical school,

    汽車技工把它插進車裡,

  • I didn't get one of those little doohickeys

    用來找出車子哪裡出了問題。

  • that your mechanic has to plug into your car

    因為醫學的教科書尚未編寫完整,

  • and find out exactly what's wrong with it,

    醫學是科學,

  • because the textbook of medicine

    醫學是正在進程中的知識。

  • is not closed.

    我們觀察,

  • Medicine is science.

    為所觀察到的現象猜個解釋,

  • Medicine is knowledge in process.

    然後做個可以測試的預測。

  • We make an observation,

    多數的醫療預測在民眾的身上測試。

  • we guess an explanation of that observation,

    你們可能記得

  • and then we make a prediction that we can test.

    從前上的無聊生物課裡說到,

  • Now, the testing ground of most predictions in medicine

    人口的分佈

  • is populations.

    傾向集中於平均值

  • And you may remember from those boring days in biology class

    也就是高斯或常態分佈。

  • that populations tend to distribute

    因此,在醫學上

  • around a mean

    猜了個解釋後,我們預測假設,

  • as a Gaussian or a normal curve.

    然後在民眾身上測試。

  • Therefore, in medicine,

    這意味著我們的醫學知識,

  • after we make a prediction from a guessed explanation,

    我們的知識和學問

  • we test it in a population.

    來自人群,

  • That means that what we know in medicine,

    它最遠只延伸到

  • our knowledge and our know-how,

    下一個離群值、

  • comes from populations

    下一個例外;

  • but extends only as far

    就像木星的衛星,

  • as the next outlier,

    能教導我們原先未確切明白的道理。

  • the next exception,

    我是個外科醫生,

  • which, like Jupiter's moons,

    照顧惡性肉瘤癌症的患者。

  • will teach us what we don't actually know.

    肉瘤是種罕見的癌症。

  • Now, I am a surgeon

    是肌肉與骨骼的癌變。

  • who looks after patients with sarcoma.

    我必須說,

  • Sarcoma is a very rare form of cancer.

    我的每個病人都是個離群值,

  • It's the cancer of flesh and bones.

    是個特例。

  • And I would tell you that every one of my patients is an outlier,

    我為肉瘤患者動的手術,

  • is an exception.

    不曾有任何一個遵循著

  • There is no surgery I have ever performed for a sarcoma patient

    隨機控制的臨床試驗,

  • that has ever been guided by a randomized controlled clinical trial,

    也就是我們以為是 人口常態分佈的最佳醫療方式。

  • what we consider the best kind of population-based evidence in medicine.

    人們總說要跳脫框框, 採取創造性思維,

  • People talk about thinking outside the box,

    但肉瘤沒有既定的框框。

  • but we don't even have a box in sarcoma.

    我們的肉瘤被不確定、

  • What we do have as we take a bath in the uncertainty

    未知、特例和離群值所包圍,

  • and unknowns and exceptions and outliers that surround us in sarcoma

    我認為易用的是

  • is easy access to what I think are those two most important values

    普世科學的兩個最重要的價值:

  • for any science:

    謙卑和好奇心。

  • humility and curiosity.

    若我謙卑和好奇,

  • Because if I am humble and curious,

    當病患問我問題,

  • when a patient asks me a question,

    而我沒有答案時,

  • and I don't know the answer,

    我會請教其他接觸過

  • I'll ask a colleague

    類似但是不同的肉瘤病患的同事,

  • who may have a similar albeit distinct patient with sarcoma.

    我們甚至會建立國際間的合作。

  • We'll even establish international collaborations.

    病患能透過聊天室 和支持團體彼此對談。

  • Those patients will start to talk to each other through chat rooms

    經由這樣謙卑好奇的交流,

  • and support groups.

    我們開始嘗試學習新知識。

  • It's through this kind of humbly curious communication

    例如,我的這個病人

  • that we begin to try and learn new things.

    在近膝蓋處罹癌。

  • As an example, this is a patient of mine

    經由謙卑好奇的國際合作交流,

  • who had a cancer near his knee.

    我們得知能夠移用腳踝

  • Because of humbly curious communication

    替代被移除的罹癌膝蓋,

  • in international collaborations,

    他就可以戴著假肢跑、跳與玩耍了。

  • we have learned that we can repurpose the ankle to serve as the knee

    他因國際的合作而有了這契機。

  • when we have to remove the knee with the cancer.

    他希望做這樣的手術,

  • He can then wear a prosthetic and run and jump and play.

    因他接觸過其他經歷過的病人。

  • This opportunity was available to him

    因此,醫學上的特例和離群值

  • because of international collaborations.

    教我們原本我們所不知道的,

  • It was desirable to him

    也引導我們產生新的想法。

  • because he had contacted other patients who had experienced it.

    非常重要的是,

  • And so exceptions and outliers in medicine

    所有的特例和離群值 帶給我們醫學領域的新想法

  • teach us what we don't know, but also lead us to new thinking.

    不僅適用於特例和離群值。

  • Now, very importantly,

    我們從肉瘤病患身上 不僅學到治療肉瘤患者的方法。

  • all the new thinking that outliers and exceptions lead us to in medicine

    有時候特例和離群值

  • does not only apply to the outliers and exceptions.

    教我們許多適用於普羅大眾的新知。

  • It is not that we only learn from sarcoma patients

    就像矗立在森林外的樹木,

  • ways to manage sarcoma patients.

    特例和離群值吸引我們去注意、

  • Sometimes, the outliers

    引領我們去領悟更宏觀的認識,

  • and the exceptions

    像「樹木是什麼」。

  • teach us things that matter quite a lot to the general population.

    我們常說見樹不見林,

  • Like a tree standing outside a forest,

    但人們也常會見林而忽視了樹。

  • the outliers and the exceptions draw our attention

    獨自矗立在森林之外的樹

  • and lead us into a much greater sense of perhaps what a tree is.

    使得樹木定義的關係,

  • We often talk about losing the forests for the trees,

    那些樹幹、樹根、樹枝間的關係,

  • but one also loses a tree

    更為明朗。

  • within a forest.

    即使那是棵歪斜扭曲的樹,

  • But the tree that stands out by itself

    或者那棵樹的樹幹、樹根、 與樹枝間的關係不尋常,

  • makes those relationships that define a tree,

    儘管如此,它仍吸引我們的注意力,

  • the relationships between trunk and roots and branches,

    讓我們觀察,

  • much more apparent.

    然後在普羅大眾的身上測試。

  • Even if that tree is crooked

    我說過肉瘤癌極為罕見,

  • or even if that tree has very unusual relationships

    大約只佔所有癌症案例的百分之一。

  • between trunk and roots and branches,

    你們大概也知道, 癌症被視為是一種遺傳疾病。

  • it nonetheless draws our attention

    遺傳疾病的意思是

  • and allows us to make observations

    癌基因引起癌症,

  • that we can then test in the general population.

    當癌基因被開啟

  • I told you that sarcomas are rare.

    而腫瘤抑制基因卻關閉時,

  • They make up about one percent of all cancers.

    誘發了癌症。

  • You also probably know that cancer is considered a genetic disease.

    你可能認為

  • By genetic disease we mean that cancer is caused by oncogenes

    我們對癌基因和腫瘤抑制基因的認識

  • that are turned on in cancer

    來自常見的癌症,

  • and tumor suppressor genes that are turned off to cause cancer.

    像是乳癌、前列腺癌

  • You might think that we learned about oncogenes

    和肺癌,

  • and tumor suppressor genes from common cancers

    但你錯了。

  • like breast cancer and prostate cancer

    我們首次學到癌基因和腫瘤抑制基因

  • and lung cancer,

    是從那微少、僅僅佔百分之一,

  • but you'd be wrong.

    名為肉瘤癌的癌症。

  • We learned about oncogenes and tumor suppressor genes

    佩頓·勞斯在 1966 年 獲得了諾貝爾獎,

  • for the first time

    由於他發現了雞禽裡

  • in that itty-bitty little one percent of cancers called sarcoma.

    有種傳染性肉瘤。

  • In 1966, Peyton Rous got the Nobel Prize

    三十年後,哈羅德·瓦爾姆斯 與麥克·畢曉普發現了

  • for realizing that chickens

    那種傳染性的因子究竟是什麼。

  • had a transmissible form of sarcoma.

    它是一種攜帶基因的病毒,

  • Thirty years later, Harold Varmus and Mike Bishop discovered

    SRC 癌基因。

  • what that transmissible element was.

    我不是說 SRC 是最重要的癌基因。

  • It was a virus

    也不是說

  • carrying a gene,

    SRC 是所有的癌症中 最常被開啟的癌基因。

  • the src oncogene.

    但它是第一個被發現的癌基因。

  • Now, I will not tell you that src is the most important oncogene.

    這特例、離群值

  • I will not tell you

    吸引了我們的注意,帶領我們發現,

  • that src is the most frequently turned on oncogene in all of cancer.

    教導我們其他 有關生物學的重要知識。

  • But it was the first oncogene.

    TP53 是最重要的腫瘤抑制基因。

  • The exception, the outlier

    是幾乎所有的癌症裡 最常關閉的腫瘤抑制基因。

  • drew our attention and led us to something

    但我們不是從一般的癌症裡 學到這一點。

  • that taught us very important things about the rest of biology.

    而是當李醫生和佛美尼醫生

  • Now, TP53 is the most important tumor suppressor gene.

    在檢視家族病史時,

  • It is the most frequently turned off tumor suppressor gene

    發現這些家庭的肉瘤癌症比例

  • in almost every kind of cancer.

    遠高於一般家庭。

  • But we didn't learn about it from common cancers.

    我說過肉瘤癌極為罕見。

  • We learned about it when doctors Li and Fraumeni

    請記住,

  • were looking at families,

    一般而言一個家庭裡發生 兩件肉瘤癌的機率是百萬分之一,

  • and they realized that these families

    但那個家庭的發生率實在太高了。

  • had way too many sarcomas.

    就是因為十分罕見,

  • I told you that sarcoma is rare.

    所以吸引我們的注意,

  • Remember that a one in a million diagnosis,

    啟發我們新的思考。

  • if it happens twice in one family,

    或許你們當中的很多人會說,

  • is way too common in that family.

    也有權這樣說,

  • The very fact that these are rare

    是啊,凱文,那很棒,

  • draws our attention

    但是你所說的並非鳥的翅膀,

  • and leads us to new kinds of thinking.

    也不是繞著木星轉的衛星,

  • Now, many of you may say,

    而是人啊。

  • and may rightly say,

    離群值或特例能引致科學的進步,

  • that yeah, Kevin, that's great,

    但我們談的是人啊。

  • but you're not talking about a bird's wing.

    我只能說,

  • You're not talking about moons floating around some planet Jupiter.

    我太明白了。

  • This is a person.

    我與這些罹患罕見 而致命疾病的患者對話。

  • This outlier, this exception, may lead to the advancement of science,

    我紀錄這些對話。

  • but this is a person.

    這些對話非常令人焦慮,

  • And all I can say

    充滿著恐怖的語句,

  • is that I know that all too well.

    像是「我有個壞消息」

  • I have conversations with these patients with rare and deadly diseases.

    或是「我們一籌莫展」。

  • I write about these conversations.

    有時對話轉向一個單詞:

  • These conversations are terribly fraught.

    「末期」。

  • They're fraught with horrible phrases

    沉默能讓人非常難受。

  • like "I have bad news" or "There's nothing more we can do."

    在醫學裡,空白的位置

  • Sometimes these conversations turn on a single word:

    可能會像那些對話裡的 用字遣詞一樣重要。

  • "terminal."

    什麼是未知的?

  • Silence can also be rather uncomfortable.

    哪些試驗正在進行中?

  • Where the blanks are in medicine

    和我一同做個小練習。

  • can be just as important

    看在銀幕上的片語:「無處」。

  • as the words that we use in these conversations.

    注意空格落在何處。

  • What are the unknowns?

    如果我們把空格向右移一格,

  • What are the experiments that are being done?

    「無處」

  • Do this little exercise with me.

    變成了「此刻在這裡」,

  • Up there on the screen, you see this phrase, "no where."

    完全相反的意思,

  • Notice where the blank is.

    僅僅把空格向右移了一格。

  • If we move that blank one space over

    我永遠忘不了走進 一位患者病房的那一晚。

  • "no where"

    雖然我在手術房裡忙了一天,

  • becomes "now here,"

    仍然想去看看他。

  • the exact opposite meaning,

    幾天前我診斷出 這個男孩罹患了骨癌。