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  • A few years ago, I broke into my own house.

    幾年前,我闖進自己家裡。

  • 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?」

  • These are things to talk about and think about now,

    這些都是值得思考的事,

  • with your family and your loved ones.

    所以趕快和家人及你所愛的人好好想想。

  • You might change your mind in the heat of the moment,

    你還是可能一時激動改變心意,

  • but at least you're practiced with this kind of thinking.

    但至少你已練習過這樣的思考。

  • Remember, our brain under stress releases cortisol,

    請記住,我們的大腦會在壓力下釋放皮質醇,

  • and one of the things that happens at that moment

    在此情況下會發生的事

  • is a whole bunch on systems shut down.

    就是整個系統一起停工。

  • There's an evolutionary reason for this.

    在生物演化上這是有道理的。

  • Face-to-face with a predator, you don't need your digestive system,

    當獵食者就在你面前時,你不需要你的消化系統、

  • or your libido, or your immune system,

    也不需要性慾、或是免疫系統,

  • because if you're body is expending metabolism on those things

    因為如果你的身體將代謝反應擴展到這些事情上,

  • and you don't react quickly,

    你無法快速反應,

  • you might become the lion's lunch, and then none of those things matter.

    可能讓你變成獅子的午餐,然後這些事情就再也不重要了。

  • Unfortunately,

    很不幸地,

  • one of the things that goes out the window during those times of stress

    能讓我們在這種高壓時刻脫離險境的東西之一,

  • is rational, logical thinking,

    就是理性、邏輯思考,

  • as Danny Kahneman and his colleagues have shown.

    正如丹尼爾.卡尼曼和他的同事證明的。