about how we can tap

我來和大家聊一聊

a really underutilized resource in health care,

我們如何解決一個醫保方面

which is the patient,

一直沒有被利用到的資源問題，

or, as I like to use the scientific term,

這個問題就是病人，

people.

或者按照科學術語——

Because we are all patients, we are all people.

人。

Even doctors are patients at some point.

因為我們都是病人，但我們也都是普通人。

So I want to talk about that

在某種程度上，醫生也是病人。

as an opportunity

我想藉此機會

that we really have failed to engage with very well in this country

說明

and, in fact, worldwide.

我們其實在密切關心我們的國家，甚至整個世界方面

If you want to get at the big part --

做得並不好。

I mean from a public health level, where my training is --

如果你想從大的方面來看——

you're looking at behavioral issues.

從公眾健康的層面來看，我將要

You're looking at things where people are actually given information,

討論的是一個行為學問題，

and they're not following through with it.

你會發現人們得到的信息

It's a problem that manifests itself in diabetes,

並非全部都能理解。

obesity, many forms of heart disease,

這個問題在糖尿病，

even some forms of cancer -- when you think of smoking.

肥胖症和很多其他的疾病上都得到了證實，

Those are all behaviors where people know what they're supposed to do.

當考慮到吸煙問題，在某些癌症上也存在這樣的問題。

They know what they're supposed to be doing,

對於這些疾病的預防，人們都知道應該怎樣去做才有好處。

but they're not doing it.

儘管他們知道應該怎麼做，

Now behavior change is something

但他們並沒有那麼做。

that is a long-standing problem in medicine.

這樣一來，行為變化就成了

It goes all the way back to Aristotle.

醫學上一個長期存在的問題。

And doctors hate it, right?

這就回到了亞里士多德的行為學觀點：人的行為總是一再重復的。

I mean, they complain about it all the time.

顯然醫生很討厭這種行為，對嗎？

We talk about it in terms of engagement, or non-compliance.

因為醫生們總是抱怨。

When people don't take their pills,

我們可以從約定和不服從的方面來看，

when people don't follow doctors' orders --

如果人們不吃藥，

these are behavior problems.

不遵醫囑。

But for as much as clinical medicine

這些都是行為問題。

agonizes over behavior change,

和臨床醫學一樣，

there's not a lot of work done

醫生們對於行為的改變的問題都很頭痛，

in terms of trying to fix that problem.

但是在試圖解決這個問題上，

So the crux of it

人們並沒有做什麼努力。

comes down to this notion of decision-making --

因此解決這個問題的關鍵

giving information to people in a form

落到了做決定的方法上——

that doesn't just educate them

應該以某種方式給人們提供信息，

or inform them,

這種方式不僅僅是教育

but actually leads them to make better decisions,

或者告知他們，

better choices in their lives.

而實際上是引導他們在生活中做出更好的決定

One part of medicine, though,

和選擇。

has faced the problem of behavior change pretty well,

其中行為改變的問題在

and that's dentistry.

體現最明顯到的一個醫學分支

Dentistry might seem -- and I think it is --

便是牙科。

many dentists would have to acknowledge

我認為，

it's somewhat of a mundane backwater of medicine.

當然很多牙醫自己也承認，

Not a lot of cool, sexy stuff happening in dentistry.

牙科學在某種程度上是醫學的一個普遍的死角。

But they have really taken this problem of behavior change

那些又酷又帥的醫生並非無緣無故的混在牙科。

and solved it.

他們確實把行為變化做爲一個問題來研究

It's the one great preventive health success

並解決這些問題。

we have in our health care system.

這在我們的醫保體系中的確

People brush and floss their teeth.

是個很好的健康預防的成功案例。

They don't do it as much as they should, but they do it.

人們都刷牙並且用牙線剔牙。

So I'm going to talk about one experiment

他們並沒有按照所需要的那麼多次來刷牙，但是他們確實刷牙了。

that a few dentists in Connecticut

接下來我想和大家分享一個實驗，

cooked up about 30 years ago.

這是一個30年前在美國康州

So this is an old experiment, but it's a really good one,

做的實驗。

because it was very simple,

看起來這的確是個老試驗了，但他確實很能說明問題。

so it's an easy story to tell.

因為它很簡單，

So these Connecticut dentists decided

也很容易說明。

that they wanted to get people to brush their teeth and floss their teeth more often,

這些康州牙醫的目的是

and they were going to use one variable:

讓人們更頻繁的刷牙並且使用牙線清理牙齒。

they wanted to scare them.

他們需要用一個變量來分析這個實驗。

They wanted to tell them how bad it would be

他們想要嚇唬人們。

if they didn't brush and floss their teeth.

他們想要告訴人們

They had a big patient population.

如果不刷牙和不用牙線洗牙將會有多麼糟糕。

They divided them up into two groups.

他們有很多病人可以參與這個實驗。

They had a low-fear population,

實驗人員將這些病人分成兩組。

where they basically gave them a 13-minute presentation,

一組是低恐慌人群，

all based in science,

實驗員給這組人看了一段13分鐘的講解，

but told them that, if you didn't brush and floss your teeth,

都是基於科學的，

you could get gum disease. If you get gum disease, you will lose your teeth,

但是只告訴他們，如果不刷牙不用牙線洗牙，

but you'll get dentures, and it won't be that bad.

那麽可能會的牙周病，如果得了牙周病，就會失去牙齒，

So that was the low-fear group.

但是還可以戴假牙，情況就沒那麼可怕。

The high-fear group, they laid it on really thick.

這就是低恐慌人群實驗。

They showed bloody gums.

下面是高恐慌人群組，實驗人員在這一組下了猛料。

They showed puss oozing out from between their teeth.

他們給這一組看了血淋淋的牙齦，

They told them that their teeth were going to fall out.

看了牙縫參差不齊的口腔，

They said that they could have infections

告訴被實驗者的牙齒即將脫落，

that would spread from their jaws to other parts of their bodies,

告訴他們可能會得傳染病

and ultimately, yes, they would lose their teeth.

而且病菌可能從他們的嘴巴擴散到身體的其他部位，

They would get dentures, and if you got dentures,

最總，他們將會失去牙齒。

you weren't going to be able to eat corn-on-the-cob,

雖然也可以戴假牙，但是帶假牙

you weren't going to be able to eat apples,

就不能再吃烤甜玉米，

you weren't going to be able to eat steak.

不能吃蘋果，

You'll eat mush for the rest of your life.

不能吃牛排；

So go brush and floss your teeth.

下半輩子將只能吃濃粥度日。

That was the message. That was the experiment.

所以趕緊去刷牙去剔牙線吧。

Now they measured one other variable.

情況就是這樣，實驗就是這麽進行的。

They wanted to capture one other variable,

接著他們測試了另一個變量。

which was the patients' sense of efficacy.

他們想要得到的變量是

This was the notion of whether the patients felt

病人們自己的主觀能動性。

that they actually would go ahead and brush and floss their teeth.

這是一種意識，就是病人們是否意識到

So they asked them at the beginning,

他們實際上願意去刷牙並剔牙縫。

"Do you think you'll actually be able to stick with this program?"

所以實驗的開始醫生就會問病人們：

And the people who said, "Yeah, yeah. I'm pretty good about that,"

「你們確定可以堅持到底嗎？」

they were characterized as high efficacy,

如果有人回答：「沒問題，我可以做到」，

and the people who said,

他們就屬於能夠發揮主觀能動性的一組，

"Eh, I never get around to brushing and flossing as much as I should,"

如果有人回答：

they were characterized as low efficacy.

「額，我們從來沒考慮過要刷那麼多次牙並且剔牙線」，

So the upshot was this.

那麽，他們就屬於缺乏主觀能動性的一組。

The upshot of this experiment

由此得到的結論是這樣的。

was that fear was not really a primary driver

實驗表明

of the behavior at all.

恐懼並非行為的

The people who brushed and flossed their teeth

主要動機。

were not necessarily the people

按要求刷牙和剔牙的人

who were really scared about what would happen --

並不一定是

it's the people who simply felt that they had the capacity

對不刷牙肯可能帶來的後果感到恐懼的人——

to change their behavior.

而僅僅是認為自己有能力

So fear showed up as not really the driver.

來改變自己行為的人。

It was the sense of efficacy.

因此說明恐懼並不能成為改變行為的動機，

So I want to isolate this,

而這個動機應該是人們自己的主觀能動性。

because it was a great observation --

我特別拿出這個例子來看，

30 years ago, right, 30 years ago --

是因為這的確是個很棒的觀察結果，

and it's one that's laid fallow in research.

沒錯，是30年前的結論，

It was a notion that really came out

也是一直深藏在研究界中的結論。

of Albert Bandura's work,

這個想法來源於

who studied whether

Albert Bandura的著作，

people could get a sense of empowerment.

該著作研究的是

The notion of efficacy basically boils down to one -- that

人們是否有行動力。

if somebody believes that they have the capacity to change their behavior.

能動性的概念基本上歸結爲

In health care terms, you could characterize this

人們是否相信他們有改變自己行為的能力。

as whether or not somebody feels

在醫療方面，我們可以概括爲

that they see a path towards better health,

人們是否意識到

that they can actually see their way towards getting better health,

獲得健康的途徑，

and that's a very important notion.

也就是說人們可以實實在在的看到自己正在朝著越來越健康的方向發展。

It's an amazing notion.

這的確是很重要的一個觀點。

We don't really know how to manipulate it, though, that well.

也是一個驚人的觀點。

Except, maybe we do.

我們也不知道如何很好的運用這個觀點，

So fear doesn't work, right? Fear doesn't work.

除非我們嘗試者去做。

And this is a great example

所以恐懼看起來並不起作用。

of how we haven't learned that lesson at all.

這也是個很好的例子，

This is a campaign from the American Diabetes Association.

說明我們根本還沒意識到這個層面。

This is still the way we're communicating messages about health.

下面是美國糖尿病協會的一張運動。

I mean, I showed my three-year-old this slide last night,

也是目前醫療健康方面仍舊使用的一種信息交流方式。

and he's like, "Papa, why is an ambulance in these people's homes?"

可以來看這張圖，我昨天晚上給三歲的孩子看了這張幻燈片，

And I had to explain, "They're trying to scare people."

然後他說：「爸爸，為什麼救護車會在人們的家裡呢？」

And I don't know if it works.

我只能解釋：「這是在嚇唬人們而已。」

Now here's what does work:

其實我也不知道這樣是否有用。

personalized information works.

那麽怎樣才能有用呢？

Again, Bandura recognized this

答案就是給人們提供個性化的參考數據。

years ago, decades ago.

同樣，Bandura在幾十年前

When you give people specific information

就認識到了整個方法。

about their health, where they stand,

當給人們提供一些具體的信息，

and where they want to get to, where they might get to,

可以使關於他們健康的，關於目前所處情況的，

that path, that notion of a path --

和他們想要得到的以及可能得到的健康狀況的信息。

that tends to work for behavior change.

也就是通過這種途徑給人們展示個性化的信息概念，

So let me just spool it out a little bit.

將會在行為改變上起作用。

So you start with personalized data, personalized information

接著，我會把整個概念更加清晰化。

that comes from an individual,

當開始從每個個體得到個人化的數據

and then you need to connect it to their lives.

和信息後，

You need to connect it to their lives,

接著需要做的是將這些數據和信息跟每個人的生活聯繫起來。

hopefully not in a fear-based way, but one that they understand.

沒錯，需要和每個人的生活聯繫起來才行，

Okay, I know where I sit. I know where I'm situated.

當然不能以一種令人感到恐慌的方式，而是一種人們可以理解的方式聯繫起來。

And that doesn't just work for me in terms of abstract numbers --

這樣一來，人們就可以知道自己所處的情況和所面臨的問題。

this overload of health information

而那些以抽象的數字存在的信息對我們來說就根本沒用了，

that we're inundated with.

雖然這種我們本來就不懂的健康信息

But it actually hits home.

總是像洪水一樣向我們撲來，

It's not just hitting us in our heads; it's hitting us in our hearts.

但是這些信息的確反映的是根源。

There's an emotional connection to information

這些信息不僅在思維上影響我們，也在心理上給我們警示。

because it's from us.

這就是所謂的在情緒上和客觀信息達到了相通，

That information then needs to be connected to choices,

也正是因為這些信息來源於我們自己。

needs to be connected to a range of options,

接著這些信息需要和選擇聯繫起來，

directions that we might go to --

需要和各種各樣的選項聯繫起來，

trade-offs, benefits.

並且引導我們的行動——

Finally, we need to be presented with a clear point of action.

也許要權衡各種利益。

We need to connect the information

最後，我們需要看到一個清晰的行動方向。

always with the action,

一直伴隨我們的應該是把信息

and then that action feeds back

和行動聯繫起來，

into different information,

接著行動再反饋成

and it creates, of course, a feedback loop.

不同的信息，

Now this is a very well-observed and well-established notion

當然，這樣最終就形成了一個反饋環。

for behavior change.

這樣就形成了一套便於觀察和建立的方法，

But the problem is that things -- in the upper-right corner there --

專門用於行為改變。

personalized data, it's been pretty hard to come by.

但問題是，圖中右上角的

It's a difficult and expensive commodity,

個人數據總是難以獲得的。

until now.

到目前為止，個人數據還是一種非常難以取得

So I'm going to give you an example, a very simple example of how this works.

並且昂貴的商品。

So we've all seen these. These are the "your speed limit" signs.

那麽我就來展示一個非常簡單的例子，說明一下這項工作是如何進行的。

You've seen them all around,

我們都看過這個圖，限速標誌。

especially these days as radars are cheaper.

這是大家在任何地方都能看到的，

And here's how they work in the feedback loop.

特別是在雷達越來越便宜的今天。

So you start with the personalized data

下面我們可以看一下在反饋環中如何實現這項任務。

where the speed limit on the road that you are at that point

一開始你的個人數據是這樣的，

is 25,

當你到這個限速牌的時候你的車速是32，

and, of course, you're going faster than that.

而限速牌上的標識是25，

We always are. We're always going above the speed limit.

顯然，你超速了。

The choice in this case is pretty simple.

我們總是超速。

We either keep going fast, or we slow down.

在這個例子中選擇是非常簡單的。

We should probably slow down,

我們要麽繼續超速，要麼減速。

and that point of action is probably now.

我們可能應該減速，

We should take our foot off the pedal right now,

那麽就馬上行動。

and generally we do. These things are shown to be pretty effective

我們應該立刻把腳從油門上鬆開。

in terms of getting people to slow down.

我們通常就是這麼做的，從讓人們減速這件事來看，

They reduce speeds by about five to 10 percent.

這幅圖顯示的閉環方案非常有用。

They last for about five miles,

這個方法使人們減速了百分之五到百分之十。

in which case we put our foot back on the pedal.

並且保持大約五英哩，

But it works, and it even has some health repercussions.

然後才把腳踩回油門上。

Your blood pressure might drop a little bit.

但這的確起作用了，甚至還帶來了一些健康的效應。

Maybe there's fewer accidents, so there's public health benefits.

血壓可能也降低了一些吧。

But by and large, this is a feedback loop

可能也減少了事故，因此的確給公眾健康帶來了益處。

that's so nifty and too rare.

但是大體上，這是一個很漂亮也很罕見的

Because in health care, most health care,

反饋環。

the data is very removed from the action.

因為在醫療保健中，或者說大多數醫保中，

It's very difficult to line things up so neatly.

數據是和行動分開來的。

But we have an opportunity.

這就很難把各項事物分得如此清晰。

So I want to talk about, I want to shift now to think about

但是我們是有這樣的機會的。

how we deliver health information in this country,

那麽接下來我就要轉而談談

how we actually get information.

在這個國家我們是如何傳達這些健康信息的，

This is a pharmaceutical ad.

以及我們如何能得到這些信息。

Actually, it's a spoof. It's not a real pharmaceutical ad.

我們來看一個藥的廣告。

Nobody's had the brilliant idea

其實這是個欺詐廣告，而非真的藥品廣告。

of calling their drug Havidol quite yet.

到目前為止還沒有什麼好辦法

But it looks completely right.

能做到Havidol真的宣稱能做到的那樣。（Havidol號稱是目前唯一一種能治療由於社會關注度缺乏而造成的焦慮症的藥）

So it's exactly the way we get

但是這廣告看起來好極了。

health information and pharmaceutical information,

這也正是得到

and it just sounds perfect.

我們的健康信息和藥物信息的方法，

And then we turn the page of the magazine,

而這看上去的確很好。

and we see this --

接著我們翻到雜誌的這一頁，

now this is the page the FDA requires pharmaceutical companies

我们可以看到這樣的情況。

to put into their ads, or to follow their ads,

沒錯，這就是食品及藥物管理局要求製藥公司

and to me, this is one of the most cynical exercises in medicine.

放在廣告裡或者寫在廣告後面的說明。

Because we know.

在我看來，這是對醫藥體系的一種諷刺。

Who among us would actually say that people read this?

因為我們都知道這些。

And who among us would actually say

而在座的各位誰會去真的閱讀這些說明呢？

that people who do try to read this

或者在座的各位有誰

actually get anything out of it?

試圖去讀這些說明

This is a bankrupt effort

並且從中獲益呢?

at communicating health information.

這些信息在獲得醫療信息上

There is no good faith in this.

簡直就是徒勞。

So this is a different approach.

所以根本沒人信這玩意。

This is an approach that has been developed

接下來是另一種不同的辦法。

by a couple researchers at Dartmouth Medical School,

是達特茅斯醫學院的一些專家們

Lisa Schwartz and Steven Woloshin.