or have read the book by Michael Lewis,

在場看過電影「魔球」

will be familiar with the story of Billy Beane.

或者看過麥可．路易斯書的人

Billy was supposed to be a tremendous ballplayer; all the scouts told him so.

對比利．比恩的故事並不陌生吧

They told his parents that

所有的球探都告訴比利他原本會是個傑出的球員

they predicted that he was going to be a star.

他們告訴他的父母

But what actually happened when he signed the contract -- and by the way, he didn't

他們預測比利將成為明日之星

want to sign that contract, he wanted to go to college --

但當他簽了合約後的事實是－

which is what my mother, who actually does love me,

順帶一提，他並不想要簽那個合約，他想上大學

said that I should do too, and I did --

這就是為什麼愛我的媽媽

well, he didn't do very well. He struggled mightily.

說我也應該去上大學，然後我去了－

He got traded a couple of times, he ended up in the Minors for most of his career,

嗯…他沒有做得很好，而且做得非常辛苦。

and he actually ended up in management. He ended up as a General Manager of the

他被交易了幾次，他的職業生涯大多在小聯盟裡

Oakland A's.

最終他成為了球隊經理

Now for many of you in this room, ending up in management, which is also what I've done,

他擔任了奧克蘭運動家隊的的經理

is seen as a success.

回到在座的各位來說，和我一樣以管理階層的身份離開

I can assure you that for a kid trying to make it in the Bigs,

被認為是成功的

going into management ain't no success story. It's a failure.

我能向你保證對於那些想打進大聯盟的孩子們來說

And what I want to talk to you about today, and share with you, is that our

進入到管理階層並不是成功的故事，那是失敗。

healthcare system, our medical system, is just as bad at predicting

而我今天想跟你們分享的是

what happens to people in it -- patients, others --

我們的保健、醫藥系統

as those scouts were at predicting what would happen to Billy Beane.

對於預測人們或是病人發生了什麼事

And yet, every day

就和球探們預測比利．比恩的未來一樣不準

thousands of people in this country

然後，每一天

are diagnosed with preconditions.

這個國家裡有成千上萬的人

We hear about pre-hypertension, we hear about pre-dementia,

被診斷出生病的前兆

we hear about pre-anxiety, and I'm pretty sure that I diagnosed myself with

我們到到有高血壓的前兆、痴呆的前兆

that in the green room.

焦慮症的前兆 我非常確定在那個綠色的房間裡

We also refer to subclinical conditions.

我認為我患了焦慮症

There's subclinical atherosclerosis, subclinical hardening of the arteries,

我們也被暗示有症狀不顯著的病症

obviously linked to heart attacks, potentially.

可能是症狀不顯著的動脈粥樣硬化、動脈硬化

One of my favorites is called subclinical acne.

明顯地被聯結為潛在的心臟病

If you look up subclinical acne, you may find a website, which I did,

我最愛的一種稱為症狀不顯著的粉刺

which says that this is the easiest type of acne to treat.

如果你查詢這個症狀，你會和我一樣發現一個網站

You don't have the pustules or the redness and inflammation.

裡頭提到了這是最容易治療的粉刺種類

Maybe that's because you don't actually have acne.

你沒有膿皰、紅腫或發炎

I have a name for all of these conditions, it's another precondition:

或許這是因為你其實根本就沒有粉刺

I call them preposterous.

我為這些病症取了一個名字，這又是另一個前兆了：

In baseball, the game follows the pre-game.

我稱它為荒唐病

Season follows the pre-season.

在棒球裡，正式比賽在熱身賽之後

But with a lot of these conditions, that actually isn't the case, or at least it isn't the

球季在賽前季之後

case all the time. It's as if there's a rain delay, every single time in many cases.

但是在許多情況中根本不會有病

We have pre-cancerous lesions,

至少是大部份的時候都不會有病 那就好像隨時隨地都有遇雨停賽的可能

which often don't turn into cancer.

我們有癌症的徵兆

And yet,

但是最終通常都不會變成癌症

if you take, for example, subclinical osteoporosis, a bone thinning disease,

還有

the precondition,

以症狀不顯著的骨質疏鬆症為例

otherwise known as osteopenia,

這是一種骨質薄化的病症

you would have to treat 270 women for three years

如果你將它視為骨質減少

in order to prevent one broken bone.

你必須在三年內治療270位女性

That's an awful lot of women

以免其中一位跌斷了骨頭

when you multiply by the number of women who were diagnosed

當你計算有多少女性

with this osteopenia.

被診斷為骨質減少時 所得到的數字

And so is it any wonder,

將會非常驚人

given all of the costs and the side effects

是否有人懷疑過

of the drugs that we're using to treat these preconditions, that every year

花費這些錢

we're spending more than two trillion dollars on healthcare and yet

還有為了治療這些徵兆而服用的藥物所帶來的副作用

100,000 people a year -- and that's a conservative estimate -- are dying

我們已在健康管理上花費超過兩萬億美元

not because of the conditions they have,

而且保守估計每年還有十萬人面臨死亡

but because of the treatments that we're giving them and the complications of those treatments?

他們不是因為有了什麼疾病

We've medicalized everything

而是因為我們給他的治療所產生的併發症 讓他面臨死亡

in this country.

在這個國家

Women in the audience, I have some

我們一直用醫藥的方式來處理每件事

pretty bad news that you already know,

在場的女性朋友

and that's that every aspect of your life

有幾個壞消息是您已經知道的

has been medicalized.

那就是您生命中的每一個面向

Strike one is when you hit puberty.

都已被醫藥化了

You now have something that happens to you once a month that has been medicalized.

第一個階段是在你年輕的時候

It's a condition;

有一個東西是每個月出現一次 那也已經被醫藥化了

it has to be treated. Strike two

這是一種已經被治療的症狀

is if you get pregnant.

第二個階段是

That's been medicalized as well.

如果你懷孕了

You have to have a high-tech experience

這件事也被醫藥化了

of pregnancy, otherwise something might go wrong.

你必須要經歷高科技的懷孕過程

Strike three is menopause.

否則可能會有問題

We all know what happened when millions of women were given hormone replacement therapy

第三個階段是更年期

for menopausal symptoms

我們都知道幾十年來上百萬位婦女

for decades until all of a sudden we realized, because a study came out, a big one,

被以荷爾蒙替代療法來治療更年期的症狀

NIH-funded.

直到某一刻國家衛生研究所發表了一篇研究

It said,

我們才突然驚醒

actually, a lot of that hormone replacement therapy may be doing more harm than good

這份研究報告指出

for many of those women.

事實上，對許多婦女來說

Just in case,

荷爾蒙替代療法可能造成更多的傷害

I don't want to leave the men out --

遠多於它所帶來的幫助

I am one, after all --

比方說

I have really bad news for all of you in this room,

我不想讓男人離開

and for everyone

畢竟我也是個男人

listening and watching elsewhere:

我有一個壞消息要告訴在座的男性

You all have

以及在任何地方的觀眾朋友

a universally fatal condition.

你們都有

So, just take a moment.

致命的病症

It's called pre-death.

因此，請深呼吸片刻

Every single one of you has it, because you have the risk factor for it,

這叫作死亡前兆

which is being alive.

每一個人都有這個病症 因為你們都有一個可能致死的危險因子

But I have some good news for you, because

那就是活著

I'm a journalist, I like to end things in a happy way or a forward-thinking way.

但是我有一個好消息要告訴你

And that good news is that if you can survive to the end of my talk, which

因為我是個新聞工作者 我喜歡讓事情以快樂或是正向思考的方式來作結

we'll see if that happens for everyone,

這個好消息是如果你能夠在我的演講後倖存

you will be a pre-vivor.

稍後見分曉

I made up pre-death.

你就會是一位有「倖存前兆」的人

If I used someone else's pre-death, I apologize,

我虛構了死亡前兆這個詞

I think I made it up.

如果我用了某個人創造的這個詞

I didn't make up pre-vivor.

如有雷同，純屬巧合

Pre-vivor is what a particular cancer advocacy group would like everyone who

我並沒有虛構倖存前兆者

just has a risk factor,

倖存前兆者是一個多麼特殊的癌症提倡團體

but hasn't actually had that cancer,

希望每個人都有危險因子

to call themselves.

但是事實上

You are a pre-vivor.

他們連這個癌症的名字都沒有

We've had HBO here this morning. I'm wondering if Mark Burnett is anywhere in the

你是一個倖存前兆者

audience, I'd like to suggest

我們今早在這裡看了HBO電影台

a reality TV show called "Pre-vivor."

我很好奇如果馬克伯內特在場

If you develop a disease, you're off the island.

我會建議他拍一場叫「倖存前兆者」的實鏡電視秀

But the problem is, we have a system

如果你生了病，你就得離開這座島

that is completely --

但是問題是

basically promoted this.

我們有一種非常徹底且基本的宣傳機制

We've selected, at every point in this system,

我們是被選出來的

to do what we do, and to give everyone a precondition and then eventually

在這個機制的每一分一毫都被安排好了

a condition, in some cases.

我們要做的事、給每個人一個前兆

Start with the doctor-patient relationship. Doctors, most of them,

接著其中一部份則成了病症

are in a fee-for-service system. They are basically incentivized to do more --

以醫病關係來作說明

procedures, tests,

大部份的醫生都在收費服務的機制裡

prescribe medications.

基本上他們樂於做更多手續、測驗

Patients come to them,

開立處方箋

they want to do something. We're Americans, we can't just stand

病人前來就醫

there, we have to do something. And so they want a drug.

他們想要某種東西 我們是美國人，我們不會只是站在那裡

They want a treatment. They want to be told, this is what you have and this is how

我們需要做點什麼 因此他們得到了藥物與治療

you treat it. If the doctor doesn't give you that,

他們想要聽到這是你目前可以用的藥 以及你如何治療病症

you go somewhere else.

如果醫生沒有給你這些東西

That's not very good for doctors' business.

你就會另外找一家醫院

Or even worse,

這對醫生的生意來說不太好

if you are diagnosed with something eventually, and the doctor didn't order that test,

更糟的可能是

you get sued.

如果最後你被診斷出某種疾病

We have pharmaceutical companies that are constantly trying to expand

而之前的醫生沒有做那些檢驗，你就會告他

the indications, expand the number of people who are eligible for a given treatment,

我們有不斷嘗試開發出適用各種病症藥品的製藥廠

because that obviously helps their bottom line. We have advocacy groups,

擴展能夠得到合適處方藥物的病人

like the one that's come up with pre-vivor,

因為那很顯然的滿足了最基本的需求

who want to make more and more people feel they are at risk, or might have a condition,

我們有像「倖存前兆者」的提倡團體

so that they can raise more funds

試著想要讓更多人覺得他們身處危機、患有病症

and raise visibility, et cetera.

因此他們可以得到更多的贊助

But this isn't actually,

提升能見度等等

despite what journalists typically do, this isn't actually about blaming

然而這並非屬實

particular players.

不管新聞工作者怎麼做

We are all responsible.

都不是在責備特別的球員

I'm responsible.

我們都很盡責

I actually root for the Yankees, I mean talk about

我也很盡責

rooting for the worst possible

其實我支持洋基隊

offender when it comes to doing everything you can do.

我的意思是當你可以做任何事情的時候

Thank you.

支持最有可能的罪犯

But everyone is responsible.

謝謝

I went to medical school,

但是每個人都是負責任的

and I didn't have a course called How to Think Skeptically,

我曾去過醫學院

or How Not to Order Tests.

卻沒有一堂叫做「如何保持懷疑態度的思考」

We have this system

或是「如何避免做檢驗」

where that's what you do.

我們的體制如此

And it actually took being a journalist

而你只能在其中做該做的事

to understand all these incentives. You know, economists like to say,

這其實讓身為記者的我了解所有這些動機

there are no bad people,

你知道經濟學者可能會說

there are just bad incentives.

世界上沒有不好的人

And that's actually true.

只有不好的動機

Because what we've created is a sort of Field of Dreams, when it comes to medical technology.

確實如此

So when you put another MRI in every corner, you put a robot

因為我們創造了一種醫學界的《夢幻成真》

in every hospital saying that everyone has to have robotic surgery.

當你在每一個角落擺一台核磁共振儀器

Well, we've created a system where if you build it, they will come.

就等於你在每一間醫院放了一個機器人 他會告訴每個人都需要機器手術

But you can actually perversely

我們已經建立了一個機制 一旦建立了，事情就會順其而行

tell people to come, convince them

但是你也可以倔將地告訴人們

that they have to come.

說服他們

It was when I became a journalist that I really realized how I was part of this problem,

一定要這麼做

and how we all are part of this problem.

一直到我當了記者後 我才理解到原來我也是問題的一部份

I was medicalizing every risk factor, I was writing stories, commissioning stories,

而且我們大家都是這個問題的一部份

every day, that were trying to,

過去我醫藥化每一個風險因子

not necessarily make people worried, although that was what often happened.

我每天都寫了很多故事且授權故事

But, you know, there are ways out.

目的是不讓人們感到如此焦慮 雖然這種事很常發生

I saw my own internist last week,

但是你知道 事情總有解決的辦法

and he said to me,

上個星期我去見了我的內科醫生

"You know," and he told me something that

他告訴我

everyone in this audience could have told me for free,

「你知道的，你該減肥了。」

but I paid him for the privilege, which is that

每一個在場的觀眾都可以免費告訴我這件事

I need to lose some weight.

但是我卻得花錢請他跟我說

Well, he's right. I've had honest-to-goodness high blood pressure

那就是我該減肥了

for a dozen years now, same

好吧，他是對的

age my father got it,

我確實是好幾十年的高血壓患者

and it's a real disease. It's not pre-hypertension, it's actual

我父親在我這個年紀的時候也一樣

hypertension, high blood pressure.

而且這是一個真的疾病，這不是前兆而已

Well, he's right,

這是真的高血壓

but he didn't say to me,

好吧，他是對的

well, you have pre-obesity or

但是他沒有告訴我

you have pre-diabetes, or anything like that. He didn't say,

嘿，你有肥胖的前兆

better start taking this Statin, you need to lower your cholesterol.

或是你糖尿病的前兆，或是那之類的病症 他一點也沒有說

No, he said, "Go out and lose some weight. Come back and see me in a bit,

他用了一個比較好的方式告訴我 你該減少你的膽固醇攝取量

or just give me a call and let me know how you're doing."

喔，不對， 他是說：「出門去減個肥吧！之後再來和我見面

So that's, to me,

還是打個電話通知我，讓我知道你已經開始減肥了

a way forward.

對我來說

Billy Beane, by the way, learned the same thing.

這是一條可行的路

He learned,

順帶一提

from watching this kid who he eventually hired, who was really successful for him,

比利．比恩也學到了同樣的道理

that it wasn't swinging for the fences, it wasn't swinging at every pitch

他終於僱用了這個孩子，而這個孩子也真的成功了

like the sluggers do, which is what all the expensive teams like the Yankees like to --

他在這之中學到了並不只是要打出全壘打

they like to pick up those guys.

不是每一球都要像打擊率高的選手一樣每球必中 這就和洋基隊那種熱門球隊的作法一樣

This kid told him, you know, you gotta watch the guys, and you gotta go out and find

他們喜歡挑選那樣的人

the guys who like to walk,

這個孩子告訴他，你要好好觀察這些人

because getting on base by a walk

然後找出一個喜歡走路的人

is just as good, and in our healthcare system

因為步行上壘是件好事

we need to figure out,

而在我們的醫藥體系中

is that really a good pitch

我們需要認出

or should we let it go by and not swing at everything?

這是真的好球嗎？

Thanks.

還是就此遺忘，別理這件事？