I had just driven home,

當時我剛開車回到家，

it was around midnight in the dead of Montreal winter,

就在蒙特婁寒冬中的午夜時分，

I had been visiting my friend, Jeff, across town,

我剛拜訪完住在 鎮上另一邊的朋友傑夫。

and the thermometer on the front porch read minus 40 degrees --

門廊前的溫度計顯示零下40度 －

and don't bother asking if that's Celsius or Fahrenheit,

就別問我是攝氏還是華氏了，

minus 40 is where the two scales meet --

零下40度剛好是 攝氏等於華氏的溫度 －

it was very cold.

非常地寒冷。

And as I stood on the front porch fumbling in my pockets,

當我站在門廊前翻著口袋時，

I found I didn't have my keys.

發現鑰匙不在自己身上。

In fact, I could see them through the window,

事實上，我還能從窗外看到那串鑰匙，

lying on the dining room table where I had left them.

它就被我擱在餐桌上靜靜地躺著。

So I quickly ran around and tried all the other doors and windows,

所以我快速繞了一圈， 試了試所有的門和窗戶，

and they were locked tight.

發現每一扇都鎖得緊緊的。

I thought about calling a locksmith -- at least I had my cellphone,

我想著要不要找鎖匠來 － 至少手機還在身上，

but at midnight, it could take a while for a locksmith to show up,

但在這種午夜時分， 要找鎖匠來可有得等了，

and it was cold.

天氣又這麼冷。

I couldn't go back to my friend Jeff's house for the night

我也不能再回去傑夫那借住一晚，

because I had an early flight to Europe the next morning,

因為隔天一早我就得飛到歐洲，

and I needed to get my passport and my suitcase.

我得拿到我的護照和行李。

So, desperate and freezing cold,

所以，在這個令人絕望 又冷得要命的時刻，

I found a large rock and I broke through the basement window,

我找到一塊大石後， 砸破地下室的玻璃，

cleared out the shards of glass,

清了清玻璃碎片後

I crawled through,

就爬了進去，

I found a piece of cardboard and taped it up over the opening,

然後找了一片厚紙板 貼在窗戶破掉的地方，

figuring that in the morning, on the way to the airport,

心裡估算著明天早上往機場的路上

I could call my contractor and ask him to fix it.

可以打電話給我的承包商， 請他幫我修好玻璃。

This was going to be expensive,

維修費一定很貴，

but probably no more expensive than a middle-of-the-night locksmith,

但應該不會比午夜時分 請鎖匠來開鎖還貴，

so I figured, under the circumstances, I was coming out even.

所以我想，在當時的情況下， 這個決定也沒讓我虧到。

Now, I'm a neuroscientist by training

因為我是個受過訓練的神經學家，

and I know a little bit about how the brain performs under stress.

對於大腦在壓力之下的運作略有了解，

It releases cortisol that raises your heart rate,

我知道它會釋出皮質醇， 增加你的心跳、

it modulates adrenaline levels

調解腎上腺素、

and it clouds your thinking.

並讓你思緒渾沌不清。

So the next morning,

所以第二天早上，

when I woke up on too little sleep,

當我從嚴重不足的睡眠中醒來後，

worrying about the hole in the window,

就開始擔心玻璃上的那個破洞，

and a mental note that I had to call my contractor,

心裡一直惦記著要打電話給承包商，

and the freezing temperatures,

天氣又冷得要命，

and the meetings I had upcoming in Europe,

還有即將要在歐洲開的那些會議，

and, you know, with all the cortisol in my brain,

而你知道的，因為有許多皮質醇在大腦裡，

my thinking was cloudy,

我的思緒一片渾沌，

but I didn't know it was cloudy because my thinking was cloudy.

而正因它一片渾沌， 我根本沒發現它一片渾沌

(Laughter)

(笑聲)

And it wasn't until I got to the airport check-in counter,

而當我到達機場的報到櫃台時，

that I realized I didn't have my passport.

我才發現自己竟然沒帶護照。

(Laughter)

(笑聲)

So I raced home in the snow and ice, 40 minutes,

所以我在冰雪中疾馳回家， 花了40分鐘，

got my passport, raced back to the airport,

拿到護照後再火速回到機場，

I made it just in time,

在最後關頭總算趕上，

but they had given away my seat to someone else,

但他們已經把我的座位 先讓給別人了，

so I got stuck in the back of the plane, next to the bathrooms,

於是我只能被擠到 飛機的最後方、廁所旁的位子，

in a seat that wouldn't recline, on an eight-hour flight.

座椅還無法向後倾斜， 而且得撐8小時。

Well, I had a lot of time to think during those eight hours and no sleep.

好吧，至少在這8小時中 我有很多時間思考，反正也別想睡了。

(Laughter)

(笑聲)

And I started wondering, are there things that I can do,

然後我開始想，我能不能先做些什麼，

systems that I can put into place,

或是設置好什麼機制，

that will prevent bad things from happening?

來幫助我避免壞事發生？

Or at least if bad things happen,

或至少發生了壞事之後，

will minimize the likelihood of it being a total catastrophe.

能把造成重大損害的可能性降到最低，

So I started thinking about that,

所以我開始思考這些事，

but my thoughts didn't crystallize until about a month later.

但我的思緒直到一個月後才漸漸清晰。

I was having dinner with my colleague, Danny Kahneman, the Nobel Prize winner,

那時我正和我的同事，諾貝爾經濟學獎 得主丹尼爾‧卡尼曼一起吃晚餐，

and I somewhat embarrassedly told him about having broken my window,

我有點不好意思地 提到破窗進入自己家裡、

and, you know, forgotten my passport,

還有忘記帶護照等等的事，

and Danny shared with me

於是丹尼爾和我分享

that he'd been practicing something called prospective hindsight.

他正在實行一種叫做 「前瞻性後見之明」的東西。

(Laughter)

(笑聲)

It's something that he had gotten from the psychologist Gary Klein,

這東西是他從心理學家 蓋瑞．克萊恩那裡得來的，

who had written about it a few years before,

幾年前他曾寫過相關著作，

also called the pre-mortem.

又將其稱為「事前剖析」。

Now, you all know what the postmortem is.

各位一定都知道事後剖析是什麼。

Whenever there's a disaster,

每當有災難降臨，

a team of experts come in and they try to figure out what went wrong, right?

一組專家就會來到事發現場， 設法釐清出了什麼問題，對吧？

Well, in the pre-mortem, Danny explained,

那麼，事前剖析，根據丹尼爾的解釋，

you look ahead and you try to figure out all the things that could go wrong,

就是你先往前看， 設法找出所有可能出錯的事，

and then you try to figure out what you can do

接著再嘗試找出對應的解決方式

to prevent those things from happening, or to minimize the damage.

來防止這些事發生或將傷害降到最低。

So what I want to talk to you about today

所以今天要和各位聊的，

are some of the things we can do in the form of a pre-mortem.

是我們能用「事前剖析」來做些什麼。

Some of them are obvious, some of them are not so obvious.

有些顯而易見，有些不那麼明顯。

I'll start with the obvious ones.

我先從顯而易見的開始。

Around the home, designate a place for things that are easily lost.

在房子四處，給每個容易 遺失的東西一個專屬位置。

Now, this sounds like common sense, and it is,

這聽起來像是常識，也確實是，

but there's a lot of science to back this up,

但它有許多理論基礎可為其佐證，

based on the way our spatial memory works.

像是我們空間記憶的運作方式。

There's a structure in the brain called the hippocampus,

大腦裡有個結構叫做海馬體，

that evolved over tens of thousands of years,

它經過成千上萬年的演化而來，

to keep track of the locations of important things --

負責追蹤每個重要物品的位置 －

where the well is, where fish can be found,

例如井的位置、哪裡可以捕到魚、

that stand of fruit trees,

果樹的位置、

where the friendly and enemy tribes live.

或是同盟及敵對的部落在哪裡等等。

The hippocampus is the part of the brain

海馬體是大腦裡的一部分，

that in London taxicab drivers becomes enlarged.

倫敦的計程車司機 這個部分比常人還大。

It's the part of the brain that allows squirrels to find their nuts.

松鼠可以順利找到松果 也是靠大腦的這個部分。

And if you're wondering, somebody actually did the experiment

如果你有興趣， 有人的確做過這個實驗，

where they cut off the olfactory sense of the squirrels,

在他們切斷松鼠的嗅覺之後，

and they could still find their nuts.

發現牠們仍能找到松果。

They weren't using smell, they were using the hippocampus,

牠們用的不是嗅覺，而是海馬體，

this exquisitely evolved mechanism in the brain for finding things.

大腦裡一個為了找到東西 而高度演化而成的機制。

But it's really good for things that don't move around much,

但它對靜止不動的物體比較有用，

not so good for things that move around.

對會移動的東西就沒那麼有效。

So this is why we lose car keys and reading glasses and passports.

這就是為什麼我們很容易 遺失鑰匙、老花眼鏡和護照。

So in the home, designate a spot for your keys --

所以在家時，幫你的鑰匙 找個固定位置 －

a hook by the door, maybe a decorative bowl.

例如掛在門上、或放在裝飾性的碗裡。

For your passport, a particular drawer.

至於護照，擺在某個特定的抽屜裡。

For your reading glasses, a particular table.

老花眼鏡則可以固定放在某個桌子上。

If you designate a spot and you're scrupulous about it,

如果東西都放到定位而且你夠留意，

your things will always be there when you look for them.

當需要時，永遠能在定位找到東西。

What about travel?

那旅行時該怎麼辦？

Take a cell phone picture of your credit cards,

用手機幫你的信用卡拍幾張照，

your driver's license, your passport,

還有駕照、護照也拍幾張，

mail it to yourself so it's in the cloud.

然後寄給自己，照片就會在雲端留存。

If these things are lost or stolen, you can facilitate replacement.

如果這些東西掉了或被偷， 至少有東西先擋著用。

Now these are some rather obvious things.

這些都是相對明顯的事。

Remember, when you're under stress, the brain releases cortisol.

記住，當你處在壓力中， 你的大腦會釋放皮質醇。

Cortisol is toxic, and it causes cloudy thinking.

皮質醇是有害的，他會阻礙你的思考。

So part of the practice of the pre-mortem

所以「事前剖析」部分的實踐方式，

is to recognize that under stress you're not going to be at your best,

是要意識到壓力會讓你 無法處在最佳狀態，

and you should put systems in place.

所以你得將事情安排得井然有序。

And there's perhaps no more stressful a situation

而可能沒有任何狀況

than when you're confronted with a medical decision to make.

比當你面臨醫療決策時 更令人感到壓力了。

And at some point, all of us are going to be in that position,

在人生的某個時刻， 我們都面臨這樣的狀況，

where we have to make a very important decision

迫使我們必須做出重大決策，

about the future of our medical care or that of a loved one,

而這個決策可能事關 我們所愛的人未來的醫療照護，

to help them with a decision.

必須幫他們做個選擇。

And so I want to talk about that.

所以我想談談這個情境。

And I'm going to talk about a very particular medical condition.

我特別想談論的是 這個特殊的醫療情境。

But this stands as a proxy for all kinds of medical decision-making,

但這個情境可以代表所有的醫療決策，

and indeed for financial decision-making, and social decision-making --

事實上，還可以代表財務決策、社交決策 －

any kind of decision you have to make

任何一種你必須

that would benefit from a rational assessment of the facts.

針對事實進行理性評估的決策。

So suppose you go to your doctor and the doctor says,

所以假如你去看醫生，醫生告訴你：

"I just got your lab work back, your cholesterol's a little high."

「我剛拿到你的檢驗報告， 你的膽固醇偏高。」

Now, you all know that high cholesterol

在座各位都知道高膽固醇

is associated with an increased risk of cardiovascular disease,

可能會增加心血管疾病、

heart attack, stroke.

心臟病及中風的風險。

And so you're thinking

所以你開始想

having high cholesterol isn't the best thing,

高膽固醇可不是什麼好事，

and so the doctor says, "You know, I'd like to give you a drug

然後醫生接著說：「我想幫你開一種藥

that will help you lower your cholesterol, a statin."

來幫助你降低膽固醇， 叫斯達汀(statin)。」

And you've probably heard of statins,

你可能聽過斯達汀類藥物，

you know that they're among the most widely prescribed drugs

知道它們是當今世上

in the world today,

最廣泛地被開立的藥物，

you probably even know people who take them.

你甚至可能認識正在服用的人。

And so you're thinking, "Yeah! Give me the statin."

所以你想著： 「好啊！給我來點斯達汀。」

But there's a question you should ask at this point,

但這時候，你應該要問一個問題，

a statistic you should ask for

這個問題是

that most doctors don't like talking about,

大部分醫生都不願談論到的統計數據，

and pharmaceutical companies like talking about even less.

製藥公司甚至提到更少。

It's for the number needed to treat.

這個數據就是NNT「需要治療的人數」。

Now, what is this, the NNT?

那麼，這個「NNT」是什麼呢？

It's the number of people that need to take a drug

它是指某藥物或手術或療程

or undergo a surgery or any medical procedure

平均每多少人裡，

before one person is helped.

才有一人從中獲得助益。

And you're thinking, what kind of crazy statistic is that?

你可能會想，這是哪門子統計數字？

The number should be one.

這個數據應該就是 1 啊。

My doctor wouldn't prescribe something to me

我的醫生理當不會開立

if it's not going to help.

對我沒有幫助的藥物。

But actually, medical practice doesn't work that way.

但事實上，醫療的實務不是這樣運作的。

And it's not the doctor's fault,

而這不是醫生的錯，

if it's anybody's fault, it's the fault of scientists like me.

如果一定要說是誰的錯，那就是像我這樣的科學家。

We haven't figured out the underlying mechanisms well enough.

我們還不夠了解這些藥品基礎的運作機制。

But GlaxoSmithKline estimates

然而葛蘭素史克公司預測，

that 90 percent of the drugs work in only 30 to 50 percent of the people.

高達90%的藥品都只對30%至50%的人有效。

So the number needed to treat for the most widely prescribed statin,

那麼對最廣泛應用的 斯達汀來說，所需治療人數

what do you suppose it is?

你猜猜看是多少？

How many people have to take it before one person is helped?

每多少人裡才有一人從中獲得助益？

300.

300。

This is according to research

這個數據來自一個研究，

by research practitioners Jerome Groopman and Pamela Hartzband,

由醫療研究者傑若‧古柏曼和潘蜜拉‧哈茨班德進行，

independently confirmed by Bloomberg.com.

同時被Bloomberg.com網站 獨立證實的研究。

I ran through the numbers myself.

我自己想了一下這個數字。

300 people have to take the drug for a year

300個人必須服用這種藥物一年，

before one heart attack, stroke or other adverse event is prevented.

才能阻止一次心臟病、 中風或其他病變。

Now you're probably thinking,

現在你可能在想，

"Well, OK, one in 300 chance of lowering my cholesterol.

「好吧，至少 有 1/300的機率能降低我的膽固醇。

Why not, doc? Give me the prescription anyway."

為何不要呢，醫生？還是開給我吧。」

But you should ask at this point for another statistic,

但這時你得問到另一個統計數據，

and that is, "Tell me about the side effects." Right?

也就是，「副作用是什麼？」對吧？

So for this particular drug,

以這種藥而言，

the side effects occur in five percent of the patients.

它會對5%的病患產生副作用。

And they include terrible things --

它們包含很可怕的症狀 －

debilitating muscle and joint pain, gastrointestinal distress --

例如四肢無力、關節疼痛、 腸胃不適 －

but now you're thinking, "Five percent,

但現在你可能又想，「就5%嘛，

not very likely it's going to happen to me,

不會這麼剛好發生在我身上，

I'll still take the drug."

我還是吃這個藥吧。」

But wait a minute.

但等一等。

Remember under stress you're not thinking clearly.

記得在壓力下你並沒有思考得很透徹。

So think about how you're going to work through this ahead of time,

所以事先想想你該怎麼處理這個狀況，

so you don't have to manufacture the chain of reasoning on the spot.

你就不用事到臨頭再 進行一連串的推理了。

300 people take the drug, right? One person's helped,

每300個人，對吧？才有一個有用，

five percent of those 300 have side effects,

這300人裡有5%會產生副作用，

that's 15 people.

也就是15人。

You're 15 times more likely to be harmed by the drug

這個藥對你造成傷害的可能性，

than you are to be helped by the drug.

高達對你有所幫助的15倍之多。

Now, I'm not saying whether you should take the statin or not.

現在我要說的， 不是你應該服用斯達汀與否。

I'm just saying you should have this conversation with your doctor.

而是你得和你的醫生談談。

Medical ethics requires it,

在醫學道德上這是需要的，

it's part of the principle of informed consent.

這是知情同意原則的一部份。

You have the right to have access to this kind of information

你有權得知這樣的資訊，

to begin the conversation about whether you want to take the risks or not.

來和醫生討論你是否願意承擔這些風險。

Now you might be thinking

現在你可能在想，

I've pulled this number out of the air for shock value,

我只是為了嚇嚇大家才丟出這個數字，

but in fact it's rather typical, this number needed to treat.

但實際上，這個治療所需人數是相對具有代表性的。

For the most widely performed surgery on men over the age of 50,

對於50歲以上男性最常進行的手術，做的最多的手術

removal of the prostate for cancer,

是為治療前列腺癌而切除前列腺，

the number needed to treat is 49.

治療所需人數是49。

That's right, 49 surgeries are done for every one person who's helped.

沒錯，每49個手術 才有一人真正受益。

And the side effects in that case occur in 50 percent of the patients.

而所有的病患中， 有50%可能產生副作用，

They include impotence, erectile dysfunction,

包含陽痿、勃起功能障礙，

urinary incontinence, rectal tearing,

尿失禁、直腸撕裂、

fecal incontinence.

和排糞失禁。

And if you're lucky, and you're one of the 50 percent who has these,

如果你夠幸運， 而你是這50%之一的話，

they'll only last for a year or two.

這些副作用只會維持一到兩年。

So the idea of the pre-mortem is to think ahead of time

所以「事前剖析」這個方法是事先想好

to the questions that you might be able to ask

所有你能問的問題，

that will push the conversation forward.

讓討論能進行得更順利。

You don't want to have to manufacture all of this on the spot.

你不會希望事到臨頭才處理這些問題。

And you also want to think about things like quality of life.

你也會希望能想想生活品質之類的事。

Because you have a choice oftentimes,

因為很多時候你其實有選擇機會，

do you I want a shorter life that's pain-free,

「我想要短暫一點、但沒有痛苦的人生，

or a longer life that might have a great deal of pain towards the end?

還是長一點，但可能得一路忍受痛苦的人生？」