about a piece of the culture of medicine that has to change.

去改變醫界一部份的文化

And I think it starts with one physician, and that's me.

我想該從一位醫生開始，就是我。

And maybe I've been around long enough

我想我在這一行夠久了

that I can afford to give away some of my false prestige

我承受得了失去一些虛名

to be able to do that.

來做這樣的改變。

Before I actually begin the meat of my talk,

在我開始進入主題之前

let's begin with a bit of baseball.

我們來談點棒球。

Hey, why not?

嗯! 有何不可?

We're near the end, we're getting close to the World Series.

球季就快結束，就要打到世界大賽了。

We all love baseball, don't we?

我們都愛棒球，不是嗎？

(Laughter)

(笑聲)

Baseball is filled with some amazing statistics.

棒球有許多驚人的統計數據

And there's hundreds of them.

有上百個

"Moneyball" is about to come out, and it's all about statistics

電影《魔球》就要上映，裡頭都在講統計數據

and using statistics to build a great baseball team.

和如何用統計數據來組成一隊棒球隊。

I'm going to focus on one stat

我要來談其中一項數據

that I hope a lot of you have heard of.

我希望在座有許多人聽過。

It's called batting average.

叫做打擊率。

So we talk about a 300, a batter who bats 300.

我們說打擊率有三成的打者。

That means that ballplayer batted safely, hit safely

是指這位打者,打擊很穩定

three times out of 10 at bats.

每十次就有三次會打安打。

That means hit the ball into the outfield,

能把球打去外野

it dropped, it didn't get caught,

球會落在外野，不會被接殺

and whoever tried to throw it to first base didn't get there in time

不管誰試著要把球傳往一壘也來不及刺殺

and the runner was safe.

跑者會安全上壘。

Three times out of 10.

每十次中有三次可以打安打。

Do you know what they call a 300 hitter

各位知道在大聯盟裡

in Major League Baseball?

怎麼說這些打擊率三成的打者

Good, really good,

好，真的很好。

maybe an all-star.

可以說是明星球員。

Do you know what they call

各位知道他們又是如何稱呼

a 400 baseball hitter?

一位打擊率四成的打者嗎？

That's somebody who hit, by the way,

也就是一位每十次打擊

four times safely out of every 10.

就有四次打出安打的打者。

Legendary --

是傳奇

as in Ted Williams legendary --

是像Ted Williams那樣的傳奇

the last Major League Baseball player

他是在球季大聯盟賽中最新傳奇球員,

to hit over 400 during a regular season.

擁有超過四成打擊率的打者

Now let's take this back into my world of medicine

現在回來談我的世界--醫療領域。

where I'm a lot more comfortable,

這個主題我比較在行,

or perhaps a bit less comfortable

但可能也有點困擾

after what I'm going to talk to you about.

特別是在我的演說之後。

Suppose you have appendicitis

假設各位得了盲腸炎

and you're referred to a surgeon

而且交由一位執行盲腸炎手術

who's batting 400 on appendectomies.

有四成成功率的外科醫生。

(Laughter)

(笑聲)

Somehow this isn't working out, is it?

這聽起來不太行，對吧?

Now suppose you live

現在假設你住在

in a certain part of a certain remote place

一個特定的偏遠地區

and you have a loved one

你所鍾愛的人

who has blockages in two coronary arteries

她的兩條冠狀動脈都有堵塞

and your family doctor refers that loved one to a cardiologist

你的家庭醫師將你所鐘愛的人引介給一位心臟科醫師

who's batting 200 on angioplasties.

該醫師在心血管手術上有兩成的成功率。

But, but, you know what?

但是，等等 你知道嗎?

She's doing a lot better this year. She's on the comeback trail.

她今年的成功率提高，她的水準又回來了。

And she's hitting a 257.

她有兩成五七的成功率。

Somehow this isn't working.

但是這樣還是不能被接受。

But I'm going to ask you a question.

我現在要問各位一個問題

What do you think a batting average

各位認為所謂的"成功率"

for a cardiac surgeon or a nurse practitioner

對一位心臟外科醫生或是職業護士

or an orthopedic surgeon,

或是整形外科醫生

an OBGYN, a paramedic

一位婦產科醫生，或一位合格的醫護人員

is supposed to be?

應該是多少?

1,000, very good.

十成，很好.。

Now truth of the matter is,

但事實上,

nobody knows in all of medicine

沒有人知道在醫界

what a good surgeon

一位好的外科醫生

or physician or paramedic

一位醫生，或護理人員

is supposed to bat.

應該"成功率"是多少.。

What we do though is we send each one of them, including myself,

而我們所做的是，讓他們每一位，包括我自己

out into the world

在世人眼前

with the admonition, be perfect.

是訓練有素的，是完美的。

Never ever, ever make a mistake,

從不會犯錯的.。

but you worry about the details, about how that's going to happen.

但你還是會擔心，這是如何達成。

And that was the message that I absorbed

這是我在醫學院時

when I was in med school.

所得到的訊息。

I was an obsessive compulsive student.

我是一位有學習強迫症的學生

In high school, a classmate once said

在高中時，曾有同學說

that Brian Goldman would study for a blood test.

我會去學習血液檢驗學

(Laughter)

(笑聲)

And so I did.

我的確去學了。

And I studied in my little garret

我在多倫多總醫院

at the nurses' residence at Toronto General Hospital,

護士宿舍的小閣樓學習

not far from here.

離這裡不遠。

And I memorized everything.

我強記每一件事

I memorized in my anatomy class

我背下解剖課時

the origins and exertions of every muscle,

每一塊肌肉的來源，伸展方式

every branch of every artery that came off the aorta,

每一條從主動脈延伸出來的小動脈和分支系統

differential diagnoses obscure and common.

細分診斷上的隱蔽症狀，和通常症狀。

I even knew the differential diagnosis

我甚至知道鑑別診斷上

in how to classify renal tubular acidosis.

要如何區分不同的腎小管酸中毒症

And all the while,

這段時間

I was amassing more and more knowledge.

我累積越來越多知識。

And I did well, I graduated with honors,

我表現良好，高分畢業

cum laude.

拿到優等。

And I came out of medical school

我從醫學院畢業

with the impression

以為如果

that if I memorized everything and knew everything,

我記得每件事，知道每件事

or as much as possible,

或幾乎記得所有全部的事,

as close to everything as possible,

還有跟每件事情有關的也都記得,

that it would immunize me against making mistakes.

那我犯醫療錯誤機會就微乎其微。

And it worked

有好一段時間

for a while,

我的確沒有犯任何錯

until I met Mrs. Drucker.

直到我遇見Drucker女士。

I was a resident at a teaching hospital here in Toronto

我當時是多倫多一間教學醫院的住院醫生

when Mrs. Drucker was brought to the emergency department

當Drucker女士被送來

of the hospital where I was working.

我所工作醫院的急診室時。

At the time I was assigned to the cardiology service

當時我在心臟科的輪調時

on a cardiology rotation.

被分配到心臟門診

And it was my job,

我的工作是

when the emergency staff called for a cardiology consult,

當急診室人員尋求心臟科的諮詢時

to see that patient in emerg.

去急診室診斷病人

and to report back to my attending.

再回來報告給我的主治。

And I saw Mrs. Drucker, and she was breathless.

我見到Drucker女士，她當時呼吸困難

And when I listened to her, she was making a wheezy sound.

當我跟她交談時,聽到她有喘息的聲音。

And when I listened to her chest with a stethoscope,

當我用聽診器聽她的胸腔時

I could hear crackly sounds on both sides

我可以聽到兩邊都傳來爆裂的聲音

that told me that she was in congestive heart failure.

這告訴我, 這是充血性心臟衰竭。

This is a condition in which the heart fails,

這是造成心臟衰竭的原因之一

and instead of being able to pump all the blood forward,

心臟不能將血液往前輸送

some of the blood backs up into the lung, the lungs fill up with blood,

有部分的血液流回肺臟，肺裡充滿的血液,

and that's why you have shortness of breath.

這也是造成呼吸短促的原因。

And that wasn't a difficult diagnosis to make.

這在診斷上並不困難。

I made it and I set to work treating her.

我做了診斷，安排治療。

I gave her aspirin. I gave her medications to relieve the strain on her heart.

我開了阿斯匹靈和一些藥物來減輕她心臟的收縮。

I gave her medications that we call diuretics, water pills,

我給她的藥物，是我們稱之為利尿劑，水丸

to get her to pee out the access fluid.

幫助她將多餘的水分排出。

And over the course of the next hour and a half or two,

接下來的一個半小時​​或兩小時

she started to feel better.

她開始覺得好轉。

And I felt really good.

我也感到高興。

And that's when I made my first mistake;

但那時我開始犯第一個錯

I sent her home.

我讓她回家。

Actually, I made two more mistakes.

事實上，我犯了兩個錯。

I sent her home

我讓她回家前

without speaking to my attending.

沒有告知我的上級主治醫生。

I didn't pick up the phone and do what I was supposed to do,

我甚至沒有把電話機拿起，做我應該做的事

which was call my attending and run the story by him

就是打電話給主治醫生，報告整件事情。

so he would have a chance to see her for himself.

他原本有機會親自前來診斷。

And he knew her,

主治認識她,

he would have been able to furnish additional information about her.

他可以提供更詳細的病情資料。

Maybe I did it for a good reason.

也許我有我的理由。

Maybe I didn't want to be a high-maintenance resident.

也許我不想成為一位老是被指導的住院醫生。

Maybe I wanted to be so successful

也許我太想成功

and so able to take responsibility

想證明我是可以獨當一面的

that I would do so

我可以做,

and I would be able to take care of my attending's patients

我有能力照護主治醫生的病人,

without even having to contact him.

而且不需要聯繫他。

The second mistake that I made was worse.

但第二個錯誤是更嚴重的。

In sending her home,

讓她出院回家,

I disregarded a little voice deep down inside

我忽視心裡一個很小的聲音

that was trying to tell me,

這個聲音試圖告訴我,

"Goldman, not a good idea. Don't do this."

「Goldman，這樣不對，別這麼做」。

In fact, so lacking in confidence was I

事實上，我當時沒什麼自信,

that I actually asked the nurse

所以我詢問了

who was looking after Mrs. Drucker,

看顧Drucker女士的護士。

"Do you think it's okay if she goes home?"

「你覺得她回家好嗎？」

And the nurse thought about it

然後護士想了一下,

and said very matter-of-factly, "Yeah, I think she'll do okay."

就事論事地說「嗯，我想她可以的。」

I can remember that like it was yesterday.

在我記憶裡, 那就像是昨天發生的事。

So I signed the discharge papers,

所以我簽了出院文件

and an ambulance came, paramedics came to take her home.

救護車來了，醫務人員帶她回家。

And I went back to my work on the wards.

我回到我的工作崗位。

All the rest of that day,

之後的那一整天。

that afternoon,

那個下午

I had this kind of gnawing feeling inside my stomach.

我一直被惱人的情緒干擾。

But I carried on with my work.

但我還是繼續工作。

And at the end of the day, I packed up to leave the hospital

那天結束，我收拾東西離開醫院

and walked to the parking lot

然後走到停車場

to take my car and drive home

取車回家

when I did something that I don't usually do.

當時我做了一件我平常不會做的事。

I walked through the emergency department on my way home.

我穿越急診室去停車場

And it was there that another nurse,

那裡有另一位護士,

not the nurse who was looking after Mrs. Drucker before, but another nurse,

不是原先那位看顧Druker女士的那位，是另一位

said three words to me

她告訴我三個字

that are the three words

就這三個字

that most emergency physicians I know dread.

大部分我認識的急診室醫生都害怕。

Others in medicine dread them as well,

其他醫界的人也害怕,

but there's something particular about emergency medicine

但對急診醫學來說這件事比較特別

because we see patients so fleetingly.

因為我們看診的病人來去匆匆。

The three words are:

那三個字是

Do you remember?

"記得嗎？"

"Do you remember that patient you sent home?"

"你記得你讓她出院的那病人嗎？"

the other nurse asked matter-of-factly.

那位護士就事論事地說

"Well she's back,"

「她又回來了」

in just that tone of voice.

用那種就事論事的聲調。

Well she was back all right.

好吧，她回來了

She was back and near death.

她回來，而且差點過世

About an hour after she had arrived home,

我讓她回家後

after I'd sent her home,

到家後的一小時

she collapsed and her family called 911

她昏倒了，她家人打緊急電話求救

and the paramedics brought her back to the emergency department

然後救護人員把她送回急診室

where she had a blood pressure of 50,

當時她的血壓只有50

which is in severe shock.

嚴重休克

And she was barely breathing and she was blue.

她幾乎沒有呼吸，臉色發青。

And the emerg. staff pulled out all the stops.

然後急診室人員使出渾身解數

They gave her medications to raise her blood pressure.

要使她血壓恢復。

They put her on a ventilator.

他們讓她戴上呼吸器。

And I was shocked

我震驚不已

and shaken to the core.

我嚇得不得了。

And I went through this roller coaster,

我像坐上雲霄飛車

because after they stabilized her,

因為後來他們穩住了她的病情

she went to the intensive care unit,

她被送到加護病房

and I hoped against hope that she would recover.

但我希望她有機會好轉。

And over the next two or three days,

在接下來的兩三天

it was clear that she was never going to wake up.

很明顯地她再也不會醒來。

She had irreversible brain damage.

她的腦部受損已經不會好轉。

And the family gathered.

她的家人聚在一起

And over the course of the next eight or nine days,

在之後八九天的治療期間

they resigned themselves to what was happening.

他們接受了這件事實。

And at about the nine day mark, they let her go --

九天後，他們放棄治療，讓她離開人間

Mrs. Drucker,

Druker女士,

a wife, a mother

一位妻子，一位母親

and a grandmother.

也是一位祖母。

They say you never forget the names

他們說你會永遠忘不了

of those who die.

那些(因你疏忽而死的)名字

And that was my first time to be acquainted with that.

那是我第一次意識到。

Over the next few weeks,

在接下來的幾週,

I beat myself up

我非常自責。

and I experienced for the first time

我也第一次經歷了

the unhealthy shame that exists

那種不健康的羞愧

in our culture of medicine --

存在於我們醫界的文化中--

where I felt alone, isolated,

在那兒我感到孤單無助

not feeling the healthy kind of shame that you feel,

不是像各位會感受到的那種的羞愧

because you can't talk about it with your colleagues.

因為你沒辦法和你的同事訴說。

You know that healthy kind,

有一種健康的羞愧是

when you betray a secret that a best friend made you promise never to reveal

當你背叛了對摯友的承諾

and then you get busted

你說出了原先答應要保守的秘密

and then your best friend confronts you

而當你的摯友找你算帳時

and you have terrible discussions,

你們爭執不休

but at the end of it all that sick feeling guides you

但最後罪感主導著你

and you say, I'll never make that mistake again.

然後你說，我絕對不會再犯相同的錯。

And you make amends and you never make that mistake again.

你做了修正承諾，然後你永不再犯同樣的錯。

That's the kind of shame that is a teacher.

這種羞愧可以教導我們

The unhealthy shame I'm talking about

而我所說那種非良性的羞愧

is the one that makes you so sick inside.

是那種會讓人愧對於心的

It's the one that says,

是那種

not that what you did was bad,

不是你做了壞事

but that you are bad.

而是你根本就是壞人。

And it was what I was feeling.

這是我當時候的感受。

And it wasn't because of my attending; he was a doll.

由於我跟隨的主治樂心助人

He talked to the family, and I'm quite sure that he smoothed things over

和他的家人好好談過，我確定他替我打了圓場

and made sure that I didn't get sued.

才能確保我不會被控告。

And I kept asking myself these questions.

我不斷問自己這些問題。

Why didn't I ask my attending? Why did I send her home?

為什麼當時我沒有聯繫主治醫生？為什麼我讓她回家？

And then at my worst moments:

我最糟的回憶是:

Why did I make such a stupid mistake?

我為什麼犯了這麼愚蠢的錯？

Why did I go into medicine?

為什麼我選擇進入醫界?

Slowly but surely,

慢慢地，但穩定地