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  • I think we have to do something

    我想我們該做些事

  • 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

  • it lifted.

    糟糕的感覺漸淡了。

  • I began to feel a bit better.

    我的感覺緩和了些。

  • And