I come to you as someone who has been really interested

我今天不是以專家的身分來，

in how I get better at what I do

我來是因為我一直很想知道

and how we all do.

要怎麼讓自己做得更好，

I think it's not just how good you are now,

我們要怎麼做得更好。

I think it's how good you're going to be that really matters.

這件事不只關於你現在多好，

I was visiting this birth center in the north of India.

你會變得多好才是重點。

I was watching the birth attendants,

我之前在北印度一間婦產中心

and I realized I was witnessing in them an extreme form of this very struggle,

觀察接生人員，

which is how people improve in the face of complexity --

我意識到自己目睹他們 用一種很極端的方式使勁掙扎，

or don't.

就是人在面對複雜情況的時候 進步的那個樣子，

The women here are delivering in a region

或沒進步的樣子。

where the typical birth center has a one-in-20 death rate for the babies,

女性在這區一般產房生產

and the moms are dying at a rate ten times higher than they do elsewhere.

要面對二十分之一的嬰兒死亡率，

Now, we've known the critical practices

母親的死亡率比其他地方高出十倍。

that stop the big killers in birth for decades,

現在我們已經知道

and the thing about it is that even in this place --

數十年來讓嬰兒活產的關鍵措施。

in this place especially,

但問題是即使在這裡，

the simplest things are not simple.

尤其是這裡，

We know for example you should wash hands and put on clean gloves,

最簡單的事情都辦不到。

but here,

例如我們應該要洗手、戴乾淨手套，

the tap is in another room,

但是這裡，

and they don't have clean gloves.

水龍頭在別的房間，

To reuse their gloves,

而且他們沒有乾淨的手套。

they wash them in this basin of dilute bleach,

為了重覆使用手套，

but you can see there's still blood on the gloves from the last delivery.

他們用這盆稀釋的漂白水洗，

Ten percent of babies are born with difficulty breathing everywhere.

但是大家可以看到， 手套上還有之前接生的血漬。

We know what to do.

10% 的嬰兒出生時會呼吸困難， 不管在哪都一樣。

You dry the baby with a clean cloth to stimulate them to breathe.

我們知道怎麼應對。

If they don't start to breathe,

用一塊乾淨的布擦乾嬰兒， 刺激他們呼吸，

you suction out their airways.

如果他們還沒開始呼吸，

And if that doesn't work, you give them breaths with the baby mask.

就抽吸他們的呼吸道。

But these are skills that they've learned mostly from textbooks,

如果還不行， 就給他們戴嬰兒氧氣罩。

and that baby mask is broken.

這些方法他們幾乎都在課本上學過，

In this one disturbing image for me

但是嬰兒氧氣罩壞了。

is a picture that brings home just how dire the situation is.

這個畫面讓我很難受，

This is a baby 10 minutes after birth,

完全顯示出情況有多慘。

and he's alive,

這個小孩剛出生十分鐘，

but only just.

他還活著，

No clean cloth,

但只剩一絲殘息。

has not been dried,

沒有乾淨的布，

not warming skin to skin,

沒有被擦乾，

an unsterile clamp across the cord.

身體還沒完全變暖，

He's an infection waiting to happen,

未殺菌的鉗子剪斷臍帶。

and he's losing his temperature by the minute.

他可能快被感染，

Successful child delivery requires a successful team of people.

每分鐘都在失溫。

A whole team has to be skilled and coordinated;

成功接生需要一組成功團隊。

the nurses who do the deliveries in a place like this,

每個人都應該技巧熟練、合作無間，

the doctor who backs them up,

要有能在這種地方接生的護理師，

the supply clerk who's responsible for 22 critical drugs and supplies

要有能夠支援的醫生，

being in stock and at the bedside,

要有負責打點 22 種重要藥物 和醫療用品的補給員，

the medical officer in charge,

確保有現貨放在床邊，

responsible for the quality of the whole facility.

要有醫務官負責

The thing is they are all experienced professionals.

所有設備的品質。

I didn't meet anybody who hadn't been part of thousands of deliveries.

重點是他們全都是 有經驗的專業人員。

But against the complexities that they face,

我碰過的每一個都接生過好幾千次。

they seem to be at their limits.

但是面對這複雜的情況，

They were not getting better anymore.

他們就像已經做到極限，

It's how good you're going to be that really matters.

沒辦法做得更好。

It presses on a fundamental question.

你能做得多好，才是重點。

How do professionals get better at what they do?

這又涉及一個基本的問題。

How do they get great?

專業人員要怎麼做得更好？

And there are two views about this.

要怎麼做到最好？

One is the traditional pedagogical view.

關於這個有兩種觀點。

That is that you go to school,

第一種是傳統教學的觀點。

you study, you practice, you learn, you graduate,

就是你上學、

and then you go out into the world

研讀、練習、學習、畢業，

and you make your way on your own.

然後出校園進入世界，

A professional is someone who is capable of managing their own improvement.

用自己的方式走自己的路。

That is the approach that virtually all professionals have learned by.

專業人員有能力讓自己進步。

That's how doctors learn,

各行各業都學過怎麼做。

that's how lawyers do,

醫生就是這麼學的，

scientists ...

還有律師也是，

musicians.

科學家……

And the thing is, it works.

音樂家。

Consider for example legendary Juilliard violin instructor Dorothy DeLay.

重點是，這些方法有用。

She trained an amazing roster of violin virtuosos:

例如茱莉亞學院的小提琴 傳奇教師桃樂絲．狄蕾。

Midori, Sarah Chang, Itzhak Perlman.

她訓練過的小提琴大師 名單熠熠生輝：

Each of them came to her as young talents,

五嶋綠、張永宙、伊扎克．帕爾曼。

and they worked with her over years.

每個好手在年輕時就拜師學藝，

What she worked on most, she said,

跟著她很多年。

was inculcating in them habits of thinking and of learning

她說，自己做最多的是

so that they could make their way in the world without her

灌輸他們思考和學習的習慣，

when they were done.

如此一來他們學成後， 無需她隨侍在側，

Now, the contrasting view comes out of sports.

就可以自己闖蕩世界。

And they say "You are never done,

體育界持相反觀點。

everybody needs a coach."

他們說：「永遠學不完，

Everyone.

每個人都要教練。」

The greatest in the world needs a coach.

無一例外。

So I tried to think about this as a surgeon.

世界上最厲害的運動員也需要教練。

Pay someone to come into my operating room,

我把這件事套在外科上思考。

observe me and critique me.

付錢請人到我的開刀房，

That seems absurd.

觀察我、評論我，

Expertise means not needing to be coached.

好像有點奇怪。

So then which view is right?

專家意謂著不需再受教。

I learned that coaching came into sports as a very American idea.

哪個觀點正確？

In 1875,

我發現運動界開始提倡找教練 是很美式的做法。

Harvard and Yale played one of the very first American-rules football games.

1875 年的時候，

Yale hired a head coach;

哈佛和耶魯對打 當時少見的橄欖球賽。

Harvard did not.

耶魯聘了一位總教練；

The results?

哈佛沒有。

Over the next three decades,

結果呢？

Harvard won just four times.

之後三十年

Harvard hired a coach.

哈佛只贏了四次。

(Laughter)

哈佛之後也請了教練。

And it became the way that sports works.

（笑聲）

But is it necessary then?

這件事就變成體育界常態。

Does it transfer into other fields?

但是真的有必要嗎？

I decided to ask, of all people,

其它領域也適用嗎？

Itzhak Perlman.

我決定去問

He had trained the Dorothy DeLay way

伊扎克．帕爾曼。

and became arguably the greatest violinist of his generation.

他在桃樂絲．狄蕾門下受訓，

One of the beautiful things about getting to write for "The New Yorker"

成為他那一代 可說是最成功的小提琴家。

is I call people up, and they return my phone calls.

幫《紐約客》寫文章 最棒的一件事情是

(Laughter)

我打給電話找人，他們會回電。

And Perlman returned my phone call.

（笑聲）

So we ended up having an almost two-hour conversation

帕爾曼先生回了我電話。

about how he got to where he got in his career.

結果我們談了將近兩小時，

And I asked him, I said, "Why don't violinists have coaches?"

他告訴我他怎麼達到現在的境界。

And he said, "I don't know,

我問他： 「為什麼小提琴家不請教練？」

but I always had a coach."

他說：「我也不知道，

"You always had a coach?"

但我以前都有教練。」

"Oh yeah, my wife, Toby."

「你以前都有教練？」

They had graduated together from Juilliard,

「對啊，是我老婆，桃比。」

and she had given up her job as a concert violinist

他們一起從茱莉亞學院畢業，

to be his coach,

她放棄當小提琴演奏家，

sitting in the audience,

改當他的教練，

observing him and giving him feedback.

坐在觀眾席，

"Itzhak, in that middle section,

觀察他、給他意見。

you know you sounded a little bit mechanical.

「伊扎克，中間那段，

What can you differently next time?"

聽起來有點生硬。

It was crucial to everything he became, he said.

下次你可以怎麼改？」

Turns out there are numerous problems in making it on your own.

他說這件事對他的成就功不可沒。

You don't recognize the issues that are standing in your way

事實證明，自己追求進步 會有很多問題。

or if you do,

你不會意識到卡住你的問題，

you don't necessarily know how to fix them.

即使你知道問題，

And the result is that somewhere along the way,

也不見得知道該怎麼改善。

you stop improving.

結果就是成長路上的某一刻

And I thought about that,

你不再進步。

and I realized that was exactly what had happened to me as a surgeon.

我思考了這一點，

I'd entered practice in 2003,

了解到那就是我身為外科醫師 所碰到的問題。

and for the first several years,

我 2003 年開始行醫，

it was just this steady, upward improvement in my learning curve.

頭幾年

I watched my complication rates drop from one year to the next.

我在學習中一直穩定成長。

And after about five years,

我看著我病人的併發率年年下降，

they leveled out.

大概五年後

And a few more years after that,

就停在那邊。

I realized I wasn't getting any better anymore.

之後又過了幾年，

And I thought: "Is this as good as I'm going to get?"

我知道自己沒有再進步了。

So I thought a little more and I said ...

我心想：「這就是我的能耐了嗎？」

"OK,

我再想了一下之後決定：

I'll try a coach."

「好，

So I asked a former professor of mine who had retired,

我要找教練。」

his name is Bob Osteen,

所以我問了我之前的教授， 他退休了，

and he agreed to come to my operating room

叫做鮑伯．歐斯汀，

and observe me.

他答應我到我的手術房

The case --

觀察我。

I remember that first case.

第一個病例，

It went beautifully.

我記得很清楚，

I didn't think there would be anything much he'd have to say

那個手術開得很漂亮。

when we were done.

結束後，我覺得他不會有什麼好說的。

Instead, he had a whole page dense with notes.

但是他寫了一整張密密麻麻的筆記。

(Laughter)

（笑聲）

"Just small things," he said.

「一些小事而已，」他說。

(Laughter)

（笑聲）

But it's the small things that matter.

但魔鬼藏在細節裡。

"Did you notice that the light had swung out of the wound

「你有發現開刀的時候，

during the case?

燈沒有對著傷口照嗎？

You spent about half an hour

你有半小時

just operating off the light from reflected surfaces."

用反射光動手術。」

"Another thing I noticed," he said,

「我還注意到一件事，」他說，

"Your elbow goes up in the air every once in a while.

「你的手肘三不五時會往上提。

That means you're not in full control.

表示你沒有完全控制自己。

A surgeon's elbows should be down at their sides resting comfortably.

外科醫生的手肘應該要自然下垂。

So that means if you feel your elbow going in the air,

如果你覺得手肘往上提，

you should get a different instrument, or just move your feet."

就應該要換器具， 或是移動一下腳步。」

It was a whole other level of awareness.

這是完全不同程度的體認。

And I had to think,

我當時想，

you know, there was something fundamentally profound about this.

這件事從根本來看意義深遠。

He was describing what great coaches do,

他說的話就是好教練做的事，

and what they do is they are your external eyes and ears,

他們當你身外的眼睛和耳朵，

providing a more accurate picture of your reality.

提供你更精確的現實。

They're recognizing the fundamentals.

他們看出根本原因。

They're breaking your actions down

他們分解你的動作，

and then helping you build them back up again.

再幫你重新組合起來。

After two months of coaching,

兩個月的訓練後，

I felt myself getting better again.

我發現自己又進步了。

And after a year,

一年之後，

I saw my complications drop down even further.

我病人的併發症案例降更低了。

It was painful.

過程很痛苦。

I didn't like being observed,

我不喜歡被觀察，

and at times I didn't want to have to work on things.

有時候我不想被逼著改掉習慣。

I also felt there were periods where I would get worse before I got better.

我也覺得在我進步之前， 有段時間在退步。

But it made me realize

但這件事讓我了解

that the coaches were onto something profoundly important.

這些指導影響深遠，意義重大。

In my other work,

我的另一份工作是

I lead a health systems innovation center called Ariadne Labs,

主持阿里亞尼醫藥創新中心，

where we work on problems in the delivery of health care,

我們處理產房裡碰到的問題，

including global childbirth.

包含全球嬰兒出生率。

As part of it,

其中，

we had worked with the World Health Organization

我們和世界衛生組織合作

to devise a safe childbirth checklist.

設計出一套安全生產清單。

It lays out the fundamentals.

清單上列出所有基本要件，

It breaks down the fundamentals --

瓦解基本要件──

the critical actions a team needs to go through

一連串團隊必須做的動作──

when a woman comes in in labor,

從產婦進產房來分娩、

when she's ready to push,

她準備好用力推，

when the baby is out,

到嬰兒出生，

and then when the mom and baby are ready to go home.

最後母子準備回家。

And we knew

我們知道，

that just handing out a checklist wasn't going to change very much,

一張清單不會改變太多，

and even just teaching it in the classroom wasn't necessarily going to be enough

即使是在教室裡教都不見得能

to get people to make the changes that you needed to bring it alive.

讓人做出可以讓嬰兒活下來的改變。

And I thought on my experience and said,

我考量了我的經驗後說：

"What if we tried coaching?

「要不要試看看找教練？

What if we tried coaching at a massive scale?"

要不要試看看大規模找教練來做？」

We found some incredible partners,

我們找到一些很棒的夥伴，

including the government of India,

包含印度政府，

and we ran a trial there in 120 birth centers.

我們在當地 120 間產婦中心測試。

In Uttar Pradesh, in India's largest state.

在印度最大的行政區北方邦，

Half of the centers basically we just observed,

有一半的診所，我們單純觀察，

but the other half got visits from coaches.

另一半會有教練過去。

We trained an army of doctors and nurses like this one

我們訓練一批醫師和護理師，像她，

who learned to observe the care and also the managers

他們學習觀察產房的護理 和管理階層，

and then help them build on their strengths

然後幫他們加強能力，

and address their weaknesses.

指出他們的弱點。

One of the skills for example they had to work on with people --

舉例來說，他們和人工作 必須有的一項技巧，

turned out to be fundamentally important --

事後證明這很重要，

was communication.

就是溝通。

Getting the nurses to practice speaking up when the baby mask is broken

讓護理師練習勇於發言， 比如說，嬰兒氧氣罩壞掉、

or the gloves are not in stock

手套庫存量不夠、

or someone's not washing their hands.

有人沒洗手。

And then getting others, including the managers,

然後讓其他人，包含管理階層，

to practice listening.

練習傾聽。

This small army of coaches ended up coaching 400 nurses

這一小批教練最後 訓練了四百位護理師、

and other birth attendants,

接生員、

and 100 physicians and managers.

一百名外科醫生和管理人員。

We tracked the results across 160,000 births.

我們追蹤 16 萬名新生兒，

The results ...

結果……

in the control group you had --

在控制組的是

and these are the ones who did not get coaching --

沒有受訓的人，

they delivered on only one-third of 18 basic practices

我們測量的 18 個基本要件當中，