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仅做 整合 / 美化 处理
I don't come to you today as an expert.
今天我并非以一个 专家的身份来这里演讲，
I come to you as someone who has been really interested
我是为了那些一直非常想要
in how I get better at what I do
在自己的领域成为行家的人
and how we all do.
而来。
I think it's not just how good you are now,
我想，重要的不是现在你有多优秀，
I think it's how good you're going to be that really matters.
而是未来你将多精彩。
I was visiting this birth center in the north of India.
我曾经到访印度北边的 这个生育中心。
I was watching the birth attendants,
我看着这些产护人员，
and I realized I was witnessing in them an extreme form of this very struggle,
发现她们正在与复杂的局面
which is how people improve in the face of complexity --
进行艰苦的斗争——
or don't.
当然，也许是我多虑了。
The women here are delivering in a region
但在当地生育中心
where the typical birth center has a one-in-20 death rate for the babies,
出生的婴儿，死亡率高达5%，
and the moms are dying at a rate ten times higher than they do elsewhere.
孕妇的死亡率也是其他地区的十倍。
Now, we've known the critical practices
现在，我们已经知道降低几十年来
that stop the big killers in birth for decades,
新生儿死亡率居高不下的关键举措，
and the thing about it is that even in this place --
以及造成这一现象的原因——
in this place especially,
像这种地方，
the simplest things are not simple.
稀松小事也可以举步维艰。
We know for example you should wash hands and put on clean gloves,
众所周知，产护人员应该 洗手后戴上干净的手套，
but here,
然而在这里，
the tap is in another room,
手术室没有水龙头
and they don't have clean gloves.
产护人员也没有干净的手套。
To reuse their gloves,
为了重复利用手套
they wash them in this basin of dilute bleach,
她们用稀释的漂白水清洗手套，
but you can see there's still blood on the gloves from the last delivery.
但手套上仍有之前使用留下的血迹。
Ten percent of babies are born with difficulty breathing everywhere.
世界上10%的孩子出生时就 伴有呼吸困难的症状。
We know what to do.
人们知道如何解决这一问题。
You dry the baby with a clean cloth to stimulate them to breathe.
用干净的毛巾轻抚婴儿 以刺激他们呼吸。
If they don't start to breathe,
如果没有作用，
you suction out their airways.
应疏通他们的呼吸道。
And if that doesn't work, you give them breaths with the baby mask.
如果效果仍然不明显， 应该给他们戴上婴儿（氧气）面罩。
But these are skills that they've learned mostly from textbooks,
这些是学校教授的方法，
and that baby mask is broken.
然而在这儿，婴儿面罩 根本无法使用。
In this one disturbing image for me
这一幕给我留下了深刻的印象，
is a picture that brings home just how dire the situation is.
不断提醒着我，情况实在太糟糕了。
This is a baby 10 minutes after birth,
这是一个刚出生10分钟的婴儿，
and he's alive,
他还活着，
but only just.
但是仅仅活着。
No clean cloth,
不仅没有干净的绵毯，
has not been dried,
也没有干燥的毛巾，
not warming skin to skin,
它感受不到任何温暖，
an unsterile clamp across the cord.
只有一个未经消毒的夹子夹着脐带。
He's an infection waiting to happen,
他即将被感染，
and he's losing his temperature by the minute.
正面临着体温下降的危险。
Successful child delivery requires a successful team of people.
每一个婴儿的顺利出生， 背后都少不了一个出色的团队。
A whole team has to be skilled and coordinated;
由技艺高超且配合默契的 成员组成的团队，
the nurses who do the deliveries in a place like this,
产护人员在团队的相互配合下工作，
the doctor who backs them up,
有医生的支持，
the supply clerk who's responsible for 22 critical drugs and supplies
供应员会在床边和仓库里
being in stock and at the bedside,
准备充足的药品和所需的用具，
the medical officer in charge,
医疗主管负责
responsible for the quality of the whole facility.
医疗设备的质量。
The thing is they are all experienced professionals.
他们都是熟练的专业人士。
I didn't meet anybody who hadn't been part of thousands of deliveries.
每个人都参与过上千次的接生。
But against the complexities that they face,
但当他们面对这种复杂的局面时，
they seem to be at their limits.
却变得束手无策。
They were not getting better anymore.
他们已经尽力做到最好了。
It's how good you're going to be that really matters.
但关键在于，未来 他们能否改变这一现状。
It presses on a fundamental question.
由此延伸出一个基本的问题。
How do professionals get better at what they do?
行家是怎么做到精益求精的？
How do they get great?
他们怎么变得杰出？
And there are two views about this.
关于此问题有两类观点。
One is the traditional pedagogical view.
一类是传统的教学观点。
That is that you go to school,
去学校学习，
you study, you practice, you learn, you graduate,
上课，做功课，考试，毕业，
and then you go out into the world
然后走向社会，
and you make your way on your own.
独自前行。
A professional is someone who is capable of managing their own improvement.
成为一个能自我管理， 不断进步的专家。
That is the approach that virtually all professionals have learned by.
这几乎是所有专业人士学习的方法。
That's how doctors learn,
是医生学习的方法，
that's how lawyers do,
是律师学习的方法，
scientists ...
是科学家学习的方法，
musicians.
也是音乐家学习的方法.....
And the thing is, it works.
并且这个方法效果显著。
Consider for example legendary Juilliard violin instructor Dorothy DeLay.
比如朱利亚音乐学院的 传奇教师多萝西·迪蕾（Dorothy DeLay）。
She trained an amazing roster of violin virtuosos:
她培养了一大批杰出的小提琴演奏家：
Midori, Sarah Chang, Itzhak Perlman.
美岛莉， 张莎拉，伊扎克·帕尔曼等。
Each of them came to her as young talents,
他们拜入她门下时都已锋芒毕露，
and they worked with her over years.
经历数年的练习后， 最终达到了很高的水准。
What she worked on most, she said,
她说，她最大的贡献是
was inculcating in them habits of thinking and of learning
培养了他们思考和学习的习惯，
so that they could make their way in the world without her
当他们毕业后
when they were done.
可以独自走好以后的路。
Now, the contrasting view comes out of sports.
另一类观点来自运动项目。
And they say "You are never done,
教练往往说：“你们还差的远呢！”
everybody needs a coach."
每个运动员都需要一个教练。
Everyone.
是的，每一个。
The greatest in the world needs a coach.
即使是世界上最杰出的运动员。
So I tried to think about this as a surgeon.
我试着用一名外科医生的 思维来考虑这一观点。
Pay someone to come into my operating room,
请一个人来手术室，
observe me and critique me.
对我进行观察及评判。
That seems absurd.
这听起来很可笑。
Expertise means not needing to be coached.
因为专业技能意味着 不需要再被训练。
So then which view is right?
那么，哪一个观点是正确的呢？
I learned that coaching came into sports as a very American idea.
我了解到，教练模式源于美国。
In 1875,
1875年，
Harvard and Yale played one of the very first American-rules football games.
哈佛和耶鲁之间举行了 美国历史上早期的橄榄球比赛。
Yale hired a head coach;
耶鲁聘请了一位主教练。
Harvard did not.
然而哈佛没有这样做。
The results?
至于结果？
Over the next three decades,
在之后30年的比赛里，
Harvard won just four times.
哈佛只赢了四场。
Harvard hired a coach.
后来哈佛不得不也聘请教练。
(Laughter)
（笑声）
And it became the way that sports works.
之后聘请教练成了体育界的标配。
But is it necessary then?
但教练真的这么有用吗？
Does it transfer into other fields?
这一模式有没有进入其它领域？
I decided to ask, of all people,
我决定请教一下他人，
Itzhak Perlman.
伊扎克·帕尔曼。
He had trained the Dorothy DeLay way
他按照多萝西·迪蕾的方式练习，
and became arguably the greatest violinist of his generation.
成为了同时代最杰出的小提琴家。
One of the beautiful things about getting to write for "The New Yorker"
为《纽约客》写文章的 一个美妙之处在于，
is I call people up, and they return my phone calls.
我给人们打电话，他们都会回我电话。
(Laughter)
（笑声）
And Perlman returned my phone call.
伊扎克·帕尔曼回了我的电话。
So we ended up having an almost two-hour conversation
围绕着他如何取得如此成就，
about how he got to where he got in his career.
我们进行了两个小时的长谈。
And I asked him, I said, "Why don't violinists have coaches?"
我问他：为什么小提琴家没有教练？
And he said, "I don't know,
他回道：我不知道别人有没有，
but I always had a coach."
但是我一直都有。”
"You always had a coach?"
“你有教练？”
"Oh yeah, my wife, Toby."
“对，就是我的爱人托比。”
They had graduated together from Juilliard,
他们一起从朱丽亚音乐学院毕业，
and she had given up her job as a concert violinist
为了当他的教练，
to be his coach,
她放弃了担任乐团小提琴手的工作，
sitting in the audience,
在观众席中
observing him and giving him feedback.
对他进行观察，并给予反馈。
"Itzhak, in that middle section,
“伊扎克，中间那部分
you know you sounded a little bit mechanical.
听起来没有灵气。
What can you differently next time?"
下次你会进行不同的处理吗？”
It was crucial to everything he became, he said.
这对他如今取得的成就 至关重要，他说。
Turns out there are numerous problems in making it on your own.
当你独自一人时，会面对很多问题。
You don't recognize the issues that are standing in your way
你意识不到自身的问题，
or if you do,
即使你意识到了，
you don't necessarily know how to fix them.
也可能不知道怎么改正。
And the result is that somewhere along the way,
一路走来，你所面临的就是
you stop improving.
自己的能力开始停滞不前了。
And I thought about that,
这使我陷入沉思，
and I realized that was exactly what had happened to me as a surgeon.
意识到这正是出现在我身上的问题。
I'd entered practice in 2003,
我从03年开始从医，
and for the first several years,
在最初的若干年中，
it was just this steady, upward improvement in my learning curve.
我的学习曲线在稳步改善。
I watched my complication rates drop from one year to the next.
术后并发症逐年下降。
And after about five years,
之后五年，
they leveled out.
这一数字不再变化了。
And a few more years after that,
再往后几年，
I realized I wasn't getting any better anymore.
我基本上是在原地踏步。
And I thought: "Is this as good as I'm going to get?"
我不禁暗想：“难道 我的能力已经达到顶峰了吗？”
So I thought a little more and I said ...
再次忖度后，自言自语地说，
"OK,
“好吧，
I'll try a coach."
我要需要一个教练。”
So I asked a former professor of mine who had retired,
于是我邀请了教过我的 已退休教授，
his name is Bob Osteen,
鲍勃 · 欧斯丁，
and he agreed to come to my operating room
他答应了我的请求，
and observe me.
到手术室来观察我。
The case --
那次手术——
I remember that first case.
我清晰地记得，
It went beautifully.
手术堪称完美。
I didn't think there would be anything much he'd have to say
手术结束后，
when we were done.
我以为他没什么好说的。
Instead, he had a whole page dense with notes.
结果，他写了满满一页的笔记。
(Laughter)
（笑声）
"Just small things," he said.
“都是些小问题，”他说。
(Laughter)
（笑声）
But it's the small things that matter.
但是细节决定成败。
"Did you notice that the light had swung out of the wound
“在手术中，你注意到 光源没有很好地
during the case?
对着伤口了吗？
You spent about half an hour
这半个小时的手术
just operating off the light from reflected surfaces."
都是在光照不足的情况下进行的。”
"Another thing I noticed," he said,
“另一件事是，”他说，
"Your elbow goes up in the air every once in a while.
你会不时地抬起你的手肘。
That means you're not in full control.
这说明你有些地方不受控制。
A surgeon's elbows should be down at their sides resting comfortably.
手术时手肘应该自然的下垂。
So that means if you feel your elbow going in the air,
以后你感觉手肘抬起时，
you should get a different instrument, or just move your feet."
应该换一个更称手的器械， 或者调整一下站姿。”
It was a whole other level of awareness.
这席话让我醍醐灌顶。
And I had to think,
我不得不思考，
you know, there was something fundamentally profound about this.
这背后一定有着更深的意义。
He was describing what great coaches do,
他不愧为一个出色的教练，
and what they do is they are your external eyes and ears,
因为出色的教练就是 充当你的第三只眼睛和耳朵，
providing a more accurate picture of your reality.
为你的状态提供一个更真实的描述。
They're recognizing the fundamentals.
他们更注重细节。
They're breaking your actions down
他们会细致地剖析你的行为，
and then helping you build them back up again.
并帮你建立正确的习惯。
After two months of coaching,
经历两个月的训练后，
I felt myself getting better again.
我犹如脱胎换骨。
And after a year,
一年之后，
I saw my complications drop down even further.
我发现术后的并发症 进一步减少了。
It was painful.
这一过程是非常煎熬的。
I didn't like being observed,
我不喜欢被监督，
and at times I didn't want to have to work on things.
有时候也厌倦工作。
I also felt there were periods where I would get worse before I got better.
在达到最佳状态之前， 我也经历过低谷。
But it made me realize
但这使我意识到
that the coaches were onto something profoundly important.
教练扮演着极其重要的角色。
In my other work,
除了本职工作，
I lead a health systems innovation center called Ariadne Labs,
我还领导着一个叫阿里阿德涅实验室 （Ariadne Labs）的医疗系统创新中心，
where we work on problems in the delivery of health care,
致力于提供医疗保健服务，
including global childbirth.
包括全球生育。
As part of it,
同世界卫生组织合作，
we had worked with the World Health Organization
我们共同设计出了 一个安全可行的生育检查表，
to devise a safe childbirth checklist.
这也是该项目的内容之一。
It lays out the fundamentals.
这张表列出了基本要求，
It breaks down the fundamentals --
并细化了这些要求——
the critical actions a team needs to go through
强调了一个团队 必须遵守的行为规范，
when a woman comes in in labor,
比如一个孕妇进入产房时，
when she's ready to push,
她准备用力时，
when the baby is out,
婴儿出来之后，
and then when the mom and baby are ready to go home.
母亲跟孩子准备回家时， 他们应该分别采取怎样的行动。
And we knew
我们知道
that just handing out a checklist wasn't going to change very much,
仅仅制定出检查表， 效果并不会有太大的改观，
and even just teaching it in the classroom wasn't necessarily going to be enough
甚至在学校里着重强调这些内容，
to get people to make the changes that you needed to bring it alive.
也不一定能有多少效果。
And I thought on my experience and said,
于是，我又想到了自己的经历，
"What if we tried coaching?
“我们尝试一下教练模式如何？
What if we tried coaching at a massive scale?"
在大规模范围内进行试验怎么样？”
We found some incredible partners,
我们找了一些出色的合作伙伴，
including the government of India,
比如印度政府，
and we ran a trial there in 120 birth centers.
并在印度最大的邦，北方邦的 120个生育中心
In Uttar Pradesh, in India's largest state.
进行了试验。
Half of the centers basically we just observed,
我们观察了半数的生育中心，
but the other half got visits from coaches.
但另一半即使没有被监督， 也有教练进行指点。
We trained an army of doctors and nurses like this one
我们训练了一组 医疗人员充当教练队伍，
who learned to observe the care and also the managers
学着观察护理过程还有管理人员，
and then help them build on their strengths
然后帮助他们发挥长处，
and address their weaknesses.
弥补不足的地方。
One of the skills for example they had to work on with people --
比如，他们要学着与他人打交道——
turned out to be fundamentally important --
为日后能进行高效的交流
was communication.
打下坚定的基础。
Getting the nurses to practice speaking up when the baby mask is broken
当婴儿面罩坏掉，手套没有库存，
or the gloves are not in stock
或者有人没有洗手，
or someone's not washing their hands.
护士们应学着去指出这些问题。
And then getting others, including the managers,
而其他人，包括管理人员，
to practice listening.
应该学会倾听。
This small army of coaches ended up coaching 400 nurses
这支教练队伍已经 培训了400个产护人员
and other birth attendants,
和一些助理，
and 100 physicians and managers.
还有100个医生和管理人员。
We tracked the results across 160,000 births.
我们追踪了16万个出生案例。
The results ...
至于结果——
in the control group you had --
在对照组，
and these are the ones who did not get coaching --
也就是没有接受培训的结果——
they delivered on only one-third of 18 basic practices
我们要考察的18个基本要求中，
that we were measuring.
他们只做到了1/3。
And most important was over the course of the years of study,
最重要的是，经过数年的跟踪，
we saw no improvement over time.
对照组的表现没有任何改善。
The other folks got four months of coaching
而实验组的人经过4个月的训练，
and then it tapered off over eight months,
死亡率连续八个月都有所下降，
and we saw them increase
我们看到了他们的进步，
to greater than two-thirds of the practices being delivered.
成功分娩的婴儿数量 比以前足足多了2/3。
It works.
教练模式起作用了。
We could see the improvement in quality,
我们发现很多生育中心
and you could see it happen across a whole range of centers
都发生了质的改善，
that suggested that coaching could be a whole line of way
这意味着整个过程有教练的参与，
that we bring value to what we do.
可以为我们的工作带来更多价值。
You can imagine the whole job category that could reach out in the world
想象一下，如果世界上 所有的工作都有教练的加入，
and that millions of people could fulfill.
无数的人就可以从中获益。
We were clearly at the beginning of it, though,
尽管在起初，我们成效显著，
because there was still a distance to go.
但我们还有很长的路要走。
You have to put all of the checklist together
我们需要整合所有的检查表，
to achieve the substantial reductions in mortality.
以在降低死亡率方面 实现实质性的进展。
But we began seeing the first places that were getting there,
最早实施这一项目的地方 已取得了一些进展，
and this center was one of them
这个生育中心就是其中之一，
because coaching helped them learn to execute on the fundamentals.
因为教练模式帮助他们 学会了解决根本问题。
And you could see it here.
你们可以看到这一过程。
This is a 23-year-old woman
这个23岁的产妇
who had come in by ambulance,
是被救护车送来的，
in labor with her third child.
她即将迎来第三个孩子。
She broke her water in the triage area,
她的羊水在分流区破裂，
so they brought her directly to the labor and delivery room,
因此医护人员直接 给她安排了产房接生，
and then they ran through their checks.
并且着手检查。
I put the time stamp on here
我为这些照片加了时间标记，
so you could see how quickly all of this happens
大家可以看到， 这一切都发生得如此迅速，
and how much more complicated that makes things.
大大增加了整个过程的复杂程度。
Within four minutes,
在四分钟以内，
they had taken the blood pressure, measured her pulse
她们测量了产妇的血压，脉搏，
and also measured the heart rate of the baby.
还有婴儿的心率。
That meant that the blood pressure cuff and the fetal Doppler monitor,
这意味着血压袖带和 胎儿多普勒监视器都在现场，
they were all there, and the nurse knew how to use them.
并且产护人员知道怎么操作。
The team was skilled and coordinated.
团队技术娴熟，配合默契。
The mom was doing great,
这位妈妈状态良好，
the baby's heart rate was 143, which is normal.
婴儿的心率是143，属正常范围。
Eight minutes later, the intensity of the contractions picked up,
八分钟后，子宫收缩的 强度开始增加，
so the nurse washed her hands,
产护人员将手清洗后，
put on clean gloves,
带上干净的手套给她做检查，
examined her and found that her cervix was fully dilated.
发现她的子宫颈完全张开。
The baby was ready to come.
婴儿即将出生。
She then went straight over to do her next set of checks.
产护人员立即进行剩余的检查项目。
All of the equipment, she worked her way through
她对各项逐一进行检查，
and made sure she had everything she needed at the bedside.
确保需要的所有设备都已就绪。
The baby mask was there, the sterile towel,
婴儿面罩，无菌毛巾
the sterile equipment that you needed.
和需要的无菌设备，全部就位。
And then three minutes later, one push and that baby was out.
三分钟后，产妇开始用力， 婴儿出来了。
(Applause)
（掌声）
I was watching this delivery,
当时我正在注视着产房，
and suddenly I realized that the mood in that room had changed.
突然发现产房里的气氛变了。
The nurse was looking at the community health worker
产护人员正看着护送产妇进来的
who had come in with the woman
社区保健人员，
because that baby did not seem to be alive.
因为那个婴儿似乎状态不妙。
She was blue and floppy and not breathing.
她全身发紫，皮肤松弛 并且没有呼吸。
She would be one of that one-in-20.
她似乎就是被死神选中的那一个。
But the nurse kept going with her checkpoints.
但是产护人员按部就班地 行动了起来。
She dried that baby with a clean towel.
她用一个干净的毛巾擦拭婴儿。
And after a minute, when that didn't stimulate that baby,
但一分钟后，婴儿还是毫无反应，
she ran to get the baby mask
她立刻跑去拿婴儿面罩，
and the other one went to get the suction.
另一个产护人员拿来了吸管。
She didn't have a mechanical suction because you could count on electricity,
因为没有可靠的电力供应， 她没有用电动吸管，而是用口用吸管
so she used a mouth suction,
清理小女孩的呼吸道，
and within 20 seconds,
在20秒内，
she was clearing out that little girl's airways.
异物被一点点吸了出来。
And she got back a green, thick liquid,
在一分钟内，
and within a minute of being able to do that
她不间断地重复着，
and suctioning out over and over,
最终吸出了粘稠的异物，
that baby started to breathe.
婴儿开始了呼吸。
(Applause)
（掌声）
Another minute and that baby was crying.
孩子的哭声紧随而至。
And five minutes after that,
5分钟后，
she was pink and warming on her mother's chest,
她的肤色变得正常， 被母亲抱在了怀里，
and that mother reached out to grab that nurse's hand,
那位母亲激动地 握住的产护人员的手，
and they could all breathe.
那一刻，大家都松了一口气。
I saw a team transformed because of coaching.
我目睹了一个在教练模式下 发生华丽转变的团队。
And I saw at least one life saved because of it.
目睹了无数生命因此获救。
We followed up with that mother a few months later.
数月之后，我们拜访了那个母亲。
Mom and baby were doing great.
母女健康平安。
The baby's name is Anshika.
女婴名叫安西卡，
It means "beautiful."
意为“美丽”。
And she is what's possible
她的存活证明了，
when we really understand
当我们真正明白
how people get better at what they do.
如何更出色地做好本职工作时， 一切皆有可能。
Thank you.
谢谢。
(Applause)
（掌声）