Ezekiel Emanuel on the Practice of Medicine, Policy, and Life (Ep. 67)

Just think about what the big challenge is for medicine today.

想想当今医学面临的最大挑战是什么。

The big challenge is the fact that 86 cents of every dollar goes for people with chronic illness.

最大的挑战是，每 1 美元中有 86 美分用于慢性病患者。

That’s an illness they’re going to have every day for the rest of their lives, or every day for the foreseeable future.

这是他们余生每天都会患上的一种疾病，或者在可预见的未来每天都会患上这种疾病。

The main thing is to get them to change their behaviors related to that.

最重要的是让他们改变与此相关的行为。

That is not about intelligence.

这与智力无关。

That is about relating to them, and emotional intelligence, and getting them and persuading them to change their behavior.

这是关于与他们建立联系，以及情商，并让他们并说服他们改变他们的行为。

And we talk a lot about empathy, and empathy is one component of emotional intelligence, but only one component of it.

我们经常谈论同理心，同理心是情商的组成部分，但只是情商的组成部分之一。

But there are some games that you can play in collaborative — looking at collaboration .

但有些游戏可以通过协作来玩—— 看看协作。

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We recognize a lot: you need chronic care coordinators, you need mental health specialists, you need dieticians, you need pharmacists.

我们认识到很多：您需要慢性护理协调员，您需要心理健康专家，您需要营养师，您需要药剂师。

All of them have to be components of a team, and the doctor is typically the captain of the team but not the only member of the team.

他们所有人都必须是团队的组成部分，医生通常是团队的队长，但不是团队的唯一成员。

I do think we tend to overrate the importance of a doctor and underrate the importance of a system around the doctor.

我确实认为我们倾向于高估医生的重要性，而低估围绕医生的系统的重要性。

Not everyone has encountered a community healthcare worker, but they tend to be people who want to do good, are good listeners to other people, good problem solvers for other people.

不是每个人都遇到过社区医护人员，但他们往往是想做好事的人，是别人的好倾听者，是别人的好问题解决者。

I do think that’s a group, when I’ve met them, tend to be really high in EQ.

我确实认为，当我遇到他们时，他们的情商往往很高。

The fact is, there’s no shortage at all.

事实是，根本不缺。

If you calculate out — and we did this crazy calculation; as someone said, “No higher math required, just lots of division.”

如果你算出 — ，我们做了这个疯狂的计算；正如有人所说，“不需要更高的数学，只需要大量的除法。”

If you look at the number of office visits that we have, you look at the number of primary care doctors we have, you actually are quite generous — half an hour a visit, not 12 visits a day — you could easily accommodate all the primary care visits we have, and also all the primary care visits we need, with the current existing doctors.

如果你看看我们的就诊次数，你看看我们有多少初级保健医生，你们其实很慷慨 —— 一次半小时就诊，而不是一天12次 —— 你可以很容易地容纳我们所有的初级保健就诊，以及我们需要的所有初级保健就诊，用现有的医生。

It’s really about how we allocate their time, and it’s also about not using the office as much.

这实际上是关于我们如何分配他们的时间，也是关于不要过多地使用办公室。

There are lots of things we’ve brought patients in for that we don’t have to bring them in for to actually give them adequate care.

我们带病人来的原因有很多，但我们不必带他们来真正为他们提供足够的护理。

You can do over the phone.

您可以通过电话进行。

You can do text.

你可以做文字。

You could have someone else, a nurse practitioner, even a medical assistant, the front office desk person can do it.

你可以找其他人，一个执业护士，甚至一个医疗助理，前台人员都可以做。

If you look at the number of office visits that we have, you look at the number of primary care doctors we have, you actually are quite generous — half an hour a visit, not 12 visits a day — you could easily accommodate all the primary care visits we have, and also all the primary care visits we need, with the current existing doctors.

如果你看看我们的就诊次数，你看看我们有多少初级保健医生，你们其实很慷慨 —— 一次半小时就诊，而不是一天12次 —— 你可以很容易地容纳我们所有的初级保健就诊，以及我们需要的所有初级保健就诊，用现有的医生。

It’s really about how we allocate their time, and it’s also about not using the office as much.

这实际上是关于我们如何分配他们的时间，也是关于不要过多地使用办公室。

There are lots of things we’ve brought patients in for that we don’t have to bring them in for to actually give them adequate care.

我们带病人来的原因有很多，但我们不必带他们来真正为他们提供足够的护理。

You can do over the phone.

您可以通过电话进行。

You can do text.

你可以做文字。

You could have someone else, a nurse practitioner, even a medical assistant, the front office desk person can do it.

你可以找其他人，一个执业护士，甚至一个医疗助理，前台人员都可以做。

I think getting that — the highfalutin language of task shifting — under our belt, we’re not going to need more doctors.

我认为，如果我们掌握了这一点——“任务转移的华而不实的语言”——我们就不再需要更多的医生了。

And I fear that once you train a doctor, it’s basically a million dollars or more, depending on what kind of doctor you have, of billings that you have to do to care and feed for them.

我担心，一旦你培训了一名医生，根据你拥有的医生类型，你必须支付一百万美元或更多的费用来照顾和喂养他们。

That’s a lot of money.

那是很多钱。

If you look at places that actually do a great job, they do a very good job with fewer doctors and more of other people who do respond in a timely manner to emails.

如果你看看那些实际上做得很好的地方，你会发现他们做得很好，医生更少，而其他及时回复电子邮件的人更多。

Most of those questions can readily be answered without doctor’s knowledge.

大多数问题都可以在医生不知情的情况下轻松回答。

And again, if you go around the country and you look at places that are really performing well — super high quality, low cost — they almost all give concierge medicine to the sick people, not just to the people who can afford it.

再说一次，如果你走遍全国，你会发现那些确实表现良好的地方——“超高质量、低成本”——他们几乎都向病人提供特约药物，而不仅仅是向有能力的人提供。

I think that’s actually much more relevant to what we want.

我认为这实际上与我们想要的更相关。

And yeah, the rich will always buy out, and we need to recognize that.

是的，富人总是会买断，我们需要认识到这一点。

One or two or three percent of the population can afford concierge medicine, but 97 percent of us, first of all, can’t afford it, and for many of us, it’s just not the highest priority in our life.

百分之一、百分之二、百分之三的人口可以负担得起特约医疗，但首先，我们 97% 的人买不起，而且对于我们许多人来说，这并不是我们生活中的首要任务。

So we won’t pay that extra money to get those docs.

因此，我们不会支付额外的费用来获取这些文档。

On medical school

在医学院

That dates from 1910.

这要追溯到 1910 年。

We haven’t really updated it much, except in this one way: we’ve cut down the preclinical time because — less of it — and it changes so fast, by the time you learn it in medical school, get out as a doctor, it’s out of date, A; and B, it’s more or less irrelevant to managing most patients.

我们并没有真正对其进行太多更新，除了这样一种方式：我们缩短了临床前时间，因为 — 减少了 — 而且它变化得太快了，当你在医学院学习它并成为一名医生时，它已经过时了，A; B，这与管理大多数患者或多或少无关。

Learning what kind of virus HIV is or herpes virus is — is it a lentivirus?

了解艾滋病毒或疱疹病毒是什么病毒—— 它是慢病毒吗？

Is it some coronavirus?

是某种冠状病毒吗？

Really irrelevant to medical practice.

确实与医疗实践无关。

Totally irrelevant.

完全无关。

Why we teach it, I have no idea.

为什么我们要教它，我不知道。

Similarly, the Krebs cycle, I learned it — I counted — six times; never used it once in practice.

同样，克雷布斯循环，我学了 — 我数了 — 六次；从未在实践中使用过它。

What are we doing?

我们在做什么？

So, just think about the future.

所以，还是想想未来吧。

In the future, all these preclinical courses are going to be online.

未来，所有这些临床前课程都将在线进行。

You’re going to have great teachers who are teaching online.

您将拥有在线教学的优秀老师。

Well, what’s a medical school doing, other than showing you videos?

那么，除了给你看视频之外，医学院还做什么呢？

And we already know, today, a third of students show up to class.

我们已经知道，今天有三分之一的学生来上课。

Two-thirds of them look at the videos of their class already.

三分之二的人已经看过他们班级的视频。

So I think increasingly we’re going to go to, you’ll do the preclinical work before you get to med school, and then med school’s really the clinical work.

所以我认为我们越来越多地会去，在进入医学院之前你会做临床前工作，然后医学院才是真正的临床工作。

And then, by the way, in med school, spending your time in a hospital is not the future.

顺便说一句，在医学院，呆在医院里并不是未来。

The future of American medicine is out of the hospital.

美国医学的未来不在医院。

So we need more rotations, more experiences for students out of the hospital.

因此，我们需要为出院的学生提供更多的轮换和更多的经历。

No med school has made that big shift, and those are the shifts that are going to have to happen over the next 15 or so years.

没有哪所医学院做出过如此大的转变，而这些转变将在未来 15 年左右的时间里发生。

One of the problems, I think, of American medical training is the premed requirements.

我认为，美国医学培训的问题之一是医学预科课程的要求。

They are ridiculous, absolutely ridiculous.

他们很可笑，绝对可笑。

I’m in the literature saying they’re ridiculous.

我在文献中说它们很荒谬。

Organic chemistry: irrelevant.

有机化学：无关。

One of the things you might say that’s gone wrong with electronic health records is that they were designed by people who didn’t understand the clinical interaction.

您可能会说电子健康记录的问题之一是它们是由不了解临床交互的人设计的。

And I think one of the things that totally frustrates current doctors is, “These things were written, and damn it, they don’t integrate well into my clinical experience, into seeing a patient in the office.

我认为让现在的医生完全沮丧的一件事是，“这些东西是写下来的，该死的，它们没有很好地融入我的临床经验，融入在办公室看病人。

I’m on the screen too much.

我在屏幕上的时间太多了。

I’m not interacting eye-to-eye with patients.” And I think that’s a result of people who really didn’t understand the clinical world .

我不会与患者进行面对面的交流。”我认为这是人们真正不了解临床世界的结果。

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There’s a lot of other life that you need to really understand to understand American medicine and to understand your patients and provide optimal care.

为了了解美国医学、了解患者并提供最佳护理，您还需要真正了解许多其他生活。

I also would say to medical students coming up, I do think that this is probably the most exciting time in American medicine in a century, since really about 1910, 1920.

我还要对即将到来的医学生说，我确实认为这可能是自 1910 年、1920 年以来美国医学一个世纪以来最激动人心的时刻。

And it causes a lot of anxiety for people, so I want to be sympathetic to that.

它给人们带来了很多焦虑，所以我对此表示同情。

You know, change is — we all talk about change in America.

你知道，改变是——我们都在谈论美国的改变。

We’re all for change, except we don’t like change.

我们都支持改变，但我们不喜欢改变。

We’re all conservative.

我们都很保守。

We would prefer no change.

我们宁愿不改变。

But I do think, if you can go with the change, this is a super exciting time when lots of things are changing, and you can have a real positive impact in shaping the future, probably for at least half a century.

但我确实认为，如果你能顺应变化，这是一个超级激动人心的时刻，很多事情都在发生变化，你可以对塑造未来产生真正的积极影响，可能至少持续半个世纪。

We’re going to put in place the structure, over the next decade, that’s going to be in place for the next half century of American delivery.

我们将在未来十年内建立一个适合美国未来半个世纪交付的结构。

On improvements in medicine

关于医学的进步

I’ll just give you one example, but it’s characteristic.

我只举一个例子，但它是有特点的。

When I started out in practice, learning, in 1990, I became an Oncology Fellow at the Dana-Farber Cancer Institute.

1990 年，当我开始实践和学习时，我成为丹娜法伯癌症研究所的肿瘤学研究员。

CML, chronic myelogenous leukemia.

CML，慢性粒细胞白血病。

A disease of older people, around 60 years old.

一种多发于60岁左右老年人的疾病。

It was a chronic disease .

这是一种慢性疾病。

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smoldered along, as we said, and then blasted off, transformed into acute leukemia.

正如我们所说，闷烧，然后爆炸，转变为急性白血病。

And within six months, people died, regardless of what you did.

六个月之内，无论你做了什么，人们都会死亡。

You threw a lot of chemotherapy at them, and they died.

你对他们进行了大量的化疗，他们就死了。

Now, actually, a colleague of mine from the Dana-Farber developed a drug called Gleevec.

现在，实际上，我的一位来自丹娜—法伯癌症研究所的同事开发了一种名为格列卫的药物。

Basically made it a chronic illness.

基本上使它成为一种慢性疾病。

People don’t die of CML anymore.

人们不再死于 CML。

They die of some other condition.

他们死于其他疾病。

It is really a miracle cure, and it’s a very easy drug to take.

这确实是一种神奇的疗法，而且是一种非常容易服用的药物。

It’s very expensive, or was very expensive when it was on patent.

它非常昂贵，或者说在获得专利时非常昂贵。

Novartis jacked up the price tremendously, but that is one example.

诺华公司大幅抬高了价格，但这只是一个例子。

We now have immunotherapies that are making dramatic changes, curing kids with incurable ALL , or curing people with B-cell lymphomas.

我们现在的免疫疗法正在发生巨大的变化，可以治愈患有无法治愈的 ALL 的儿童，或者治愈患有 B 细胞淋巴瘤的人。

In the next year or so, they’re going to be treating people with myeloma with it and probably curing them.

在接下来的一年左右，他们将用它来治疗骨髓瘤患者，并可能治愈他们。

So, there’s been a lot, a lot of changes in the chemotherapy world.

所以，化疗世界发生了很多很多的变化。

So, I would say that actually what you want to look at is the relationship between .

所以，我想说，实际上你想看的是之间的关系。

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you want to look at five-year mortalities and the percent of people who have five-year mortality.

您想要查看五年死亡率以及五年死亡率的人口百分比。

But you also need to measure that by not having too much early diagnosis.

但您还需要通过不要进行太多早期诊断来衡量这一点。

So, one of the things we’ve noted is that we can diagnose a lot of cancers that would never have been a problem for people.

因此，我们注意到的一件事是，我们可以诊断出许多对人们来说永远不会成为问题的癌症。

Almost all of us have cancer cells floating around in our body.

几乎我们所有人的体内都漂浮着癌细胞。

Our immune system takes care of it.

我们的免疫系统会照顾它。

We have done a remarkable job in many things in early diagnosis.

我们在早期诊断的许多方面都做了出色的工作。

So, you need to look at the impact on mortality overall and the five-year mortality ranking, the percent of people who have a five-year mortality, controlled for stage of disease.

因此，您需要了解对总体死亡率的影响以及五年死亡率排名、五年死亡率的人口百分比（按疾病阶段进行控制）。

That’s a hard metric to come by for a non-oncologist to see.

对于非肿瘤学家来说，这是一个很难看到的指标。

We’ve done, for example, a remarkably good job of early diagnosis of breast cancer.

例如，我们在乳腺癌的早期诊断方面做得非常好。

Five-year survival of breast cancer in the United States is the highest in the world.

美国的乳腺癌五年生存率是世界上最高的。

But a lot of that, probably, is due to early diagnosis of small cancers that wouldn’t have made any difference to the woman anyway.

但其中很大一部分可能是由于早期诊断出小癌症，无论如何，这些癌症对女性来说不会产生任何影响。

We have actually not had that big an impact on larger cancers, and so what you see is, the overall mortality from breast cancer hasn’t really changed.

实际上，我们对较大的癌症没有产生那么大的影响，所以你看到的是，乳腺癌的总体死亡率并没有真正改变。

You need to look at overall mortality in the population.

您需要查看人口的总体死亡率。

We’ve done, for example, a remarkably good job of early diagnosis of breast cancer.

例如，我们在乳腺癌的早期诊断方面做得非常好。

Five-year survival of breast cancer in the United States is the highest in the world.

美国的乳腺癌五年生存率是世界上最高的。

But a lot of that, probably, is due to early diagnosis of small cancers that wouldn’t have made any difference to the woman anyway.

但其中很大一部分可能是由于早期诊断出小癌症，无论如何，这些癌症对女性来说不会产生任何影响。

We have actually not had that big an impact on larger cancers, and so what you see is, the overall mortality from breast cancer hasn’t really changed.

实际上，我们对较大的癌症没有产生那么大的影响，所以你看到的是，乳腺癌的总体死亡率并没有真正改变。

So, what’s gone wrong with either the medical establishment, the scientific establishment .

那么，医疗机构、科学机构出了什么问题。

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somewhere, something is failing?

某处出现故障？

So, it is a reasonable metric, but if you really want to affect life expectancy — and by the way, I’m not a big proponent of using that as a metric, for all sorts of reasons — we should invest in education, better housing, more equal incomes for people, not invest 3.5 trillion dollars in the healthcare system.

所以，这是一个合理的指标，但如果你真的想影响预期寿命 ——顺便说一句，出于各种原因，我不太赞成使用它作为指标—— 我们应该投资于教育、更好的住房、人们更平等的收入，而不是在医疗保健系统上投资 3.5 万亿美元。

The healthcare system by and large has come at the end.

医疗保健系统总体上已经走到了尽头。

People already have diabetes.

人们已经患有糖尿病。

People already have cancer.

人们已经患有癌症。

That’s not the best place, most cost-effective place to invest.

这不是最好的、最具成本效益的投资地点。

And we know that, probably, the opportunity costs of overinvesting in healthcare come at the cost of education, housing, and other things in society.

我们知道，医疗保健过度投资的机会成本可能是以教育、住房和社会其他事物为代价的。

And so, it’s not a surprise that we’re spending a lot of money and the returns are down.

因此，我们花费大量资金而回报却下降也就不足为奇了。

It’s not because Japan spends a lot of money that they have an average life expectancy of, whatever, 84 years, the highest in the industrial world.

日本并不是因为花了很多钱，他们的平均预期寿命才达到 84 岁，是工业世界中最高的。

On biomedical ethics

论生物医学伦理学

What connects your views on concrete issues of biomedical ethics and philosophy?

您对生物医学伦理学和哲学具体问题的看法有何联系？

What’s the transmission belt?

传动带是什么？

I would say that, in general, what I try to do is intuitively figure out what the right answer is to a situation, and then figure out, what are the principles that got me to that right answer?

我想说的是，一般来说，我试图做的是直观地找出某种情况的正确答案是什么，然后找出让我得到正确答案的原则是什么？

And what are we trying to do?

我们想做什么？

I would say that .

我会这么说。

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so, this is a biographical statement about the way I do it.

所以，这是关于我的做法的自传。

In general, when there’s a conventional wisdom about a problem, I usually find that wrong.

一般来说，当对某个问题存在传统看法时，我通常会发现它是错误的。

And I spent .

我花了。

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most of my career is like, “Oh, that’s the conventional wisdom.

我职业生涯的大部分时间都是这样的，“哦，这是传统智慧。

It must be wrong.

一定是错的。

Here’s the right answer, and here’s why it’s the right answer, and the conventional wisdom is wrong.”

这就是正确的答案，这就是为什么它是正确的答案，而传统的智慧是错误的。”

And typically, one of the problems, I think, with the conventional wisdom is that they overemphasize one set of values and tend to underemphasize other values that are important.

我认为，通常情况下，传统智慧的问题之一是他们过分强调一组价值观，而往往低估其他重要的价值观。

I’ll give you an example.

我给你举个例子。

For, I think, most of our discussions, we have overemphasized individual autonomy.

我认为，我们的大多数讨论都过分强调了个人自主权。

Certainly since I’ve been working in this area, since the mid-’80s, it’s autonomy, autonomy, autonomy.

当然，自从我在这个领域工作以来，从八十年代中期开始，它就是自治、自治、自治。

That disengages people in two ways.

这会以两种方式让人们脱离。

One, it removes people from their social network, whether it’s family, community, religious orientation, and I think that’s just wrong.

第一，它将人们从他们的社交网络中移除，无论是家庭、社区、宗教取向，我认为这是错误的。

Lots of emphasizing the individual has consequences for other people.

过分强调个人会对其他人产生影响。

The second thing is, it ignores the economic, political realities that some choices for individuals will have big economic or political consequences for other people that we need to take account of.

第二件事是，它忽略了经济和政治现实，即个人的某些选择将对其他人产生重大的经济或政治后果，这是我们需要考虑的。

Spending a lot of money on one person definitely means we’re not spending it on other people.

在一个人身上花很多钱肯定意味着我们不会把钱花在其他人身上。

Giving one person an organ means someone else won’t get an organ.

给一个人一个器官意味着其他人不会得到器官。

And we need to take that into account.

我们需要考虑到这一点。

So, part of what I have .

所以，这是我所拥有的一部分。

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I think a lot of what my work has been is, the values that we emphasize tend to be exaggerated and probably inadequate to describe the situation.

我认为我的很多工作都是，我们强调的价值观往往被夸大，并且可能不足以描述情况。

We typically need to put in more values.

我们通常需要输入更多的值。

So, once we have lots of values in the pot, as it were, we tend to be really bad about prioritizing them.

因此，一旦我们有很多价值，我们往往很难对它们进行优先排序。

I think I tend to be one person who says, “Here is the constellation of values, and here’s how you should prioritize them.” Not everyone agrees with me a lot of the time, but I do think I try to bring in more subtle values and widen the way we think about issues.

我想我倾向于这样说：“这是一系列价值观，这是你应该如何优先考虑它们的方式。”很多时候并不是每个人都同意我的观点，但我确实认为我试图引入更微妙的价值观并拓宽我们思考问题的方式。

Well, I don’t have enough time to get information on everything I have to do.

好吧，我没有足够的时间来获取我必须做的所有事情的信息。

I have to trust lots of institutions.

我必须信任很多机构。

I have to trust the regulatory oversight bodies that are making sure the airplanes are working.

我必须信任确保飞机正常运行的监管机构。

I can’t go out and inspect the plane every time I take off, and things like that.

我不能每次起飞时都出去检查飞机之类的。

I agree with you.

我同意你的看法。

In low-trust societies, or societies where there aren’t good institutions, relying on individuals is no substitute for relying on institutions to protect us.

在低信任度社会或没有良好机构的社会中，依靠个人并不能替代依靠机构来保护我们。

I have often said that it’s very hard for an individual to figure out the risk-benefit ratio of, say, a research experiment or any medical procedure, and that you need to rely on others with expertise.

我经常说，个人很难计算出研究实验或任何医疗程序的风险收益比，并且您需要依赖具有专业知识的其他人。

I think one of our problems at the moment is we’re way over on “Let’s give people information, and they’ll decide.” No, it doesn’t work that way.

我认为我们目前的问题之一是我们已经远远超出了“让我们向人们提供信息，他们会做出决定”的状态。不，事情不是这样的。

Information overload, lots of us have inertia, and we have a hard time.

信息超载，我们很多人都有惰性，我们过得很艰难。

I will tell you, I read financial information about my stocks or my bank account or my credit cards, and my eyes glaze over.

我会告诉你，当我阅读有关我的股票、我的银行账户或我的信用卡的财务信息时，我的眼睛变得呆滞。

I’m very bad at it.

我很不擅长。

I’m not protecting myself.

我没有保护自己。

I need someone else to protect me.

我需要别人来保护我。

On fixing institutional review boards

关于修复机构审查委员会

One of the problems is, you go to an IRB, their almost entire focus is on, “What’s in the informed consent document?” That’s wrong.

问题之一是，当你去IRB时，他们几乎全部关注的焦点都是“知情同意文件中有什么内容？”那是错误的。

I’ve written extensively about, there’s an orderly process for thinking about the ethics of research, and informed consent is at the bottom of the process.

我已经写过很多文章，思考研究伦理有一个有序的过程，而知情同意是该过程的基础。

There are many things you need to consider, and I think the number-one thing that needs to be considered is really risk-benefit ratio of research protocol.

你需要考虑很多事情，我认为需要考虑的第一件事是研究方案的风险收益比。

It’s the hardest thing for individuals to understand who aren’t experts, and it’s really where the focus should be.

对于非专家来说，这是最难理解的事情，而这确实是重点应该放在的地方。

If you put the focus on risks and benefits, some things that IRBs often object to might turn out not to be really that problematic.

如果你把重点放在风险和收益上，IRB 经常反对的一些事情可能并不是真正的问题。

And some things that IRBs don’t object to enough, they turn out to be really problematic.

有些事情IRB并没有足够反对，但事实证明它们确实是有问题的。

And so, I think more emphasis on risk-benefit ratio and less emphasis on informed consent, and certainly no responsibility for the IRB in terms of confidentiality.

因此，我认为更多地强调风险收益比，而不那么强调知情同意，而且 IRB 在保密方面当然不承担任何责任。

That’s someone else’s .

那是别人的。

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some other arrangement.

其他一些安排。

I think that’s very important.

我认为这非常重要。

Also, we shouldn’t have IRBs at each institution.

此外，我们不应该在每个机构都有 IRB。

I think the whole notion of IRB, institutional review board, is a mistake.

我认为 IRB（机构审查委员会）的整个概念是一个错误。

If there’s a protocol that’s being run at hundreds of institutions, which is quite common, we should not have each institution reviewing it.

如果有一个协议在数百家机构中运行（这很常见），我们不应该让每个机构都对其进行审查。

It’s the same risk-benefit ratio; it’s the same group of people.

风险收益比相同；这是同一群人。

One body can interview it, and that’s much more efficient.

一个机构就可以采访它，这样效率要高得多。

Efficiency is also important because delaying protocols by a year wastes a lot of money, time, and for no benefit.

效率也很重要，因为将方案推迟一年会浪费大量金钱、时间，而且没有任何好处。

On the right to try

在右边尝试一下

We all need to rely on the fact that the medicines we take are proven safe and proven effective, and we have to have institutional structures to oversee that.

我们都需要依赖这样一个事实：我们服用的药物已被证明是安全且有效的，并且我们必须有制度结构来监督这一点。

Some individuals may be able to do it.

有些人也许能够做到。

But we have a society of 325 million people, and we have these institutional structures to oversee what we’re taking is safe and effective for all of us, not just for the lone individual who’s got a lot of money who says, “I want to do it.

但我们有一个拥有 3.25 亿人口的社会，我们有这些制度结构来监督我们所采取的措施对我们所有人来说都是安全有效的，而不仅仅是对那些有很多钱的孤独的人来说，“我想做这件事。

Damn you all.”

你们都该死。”

You want to do it, damn us all?

你想这么做吗，该死的我们大家？

You’ve got enough money.

你有足够的钱。

Go to Tahiti.

去塔希提岛吧

It’s really not the institutional structure we want.

这确实不是我们想要的制度结构。

And we know that because thalidomide .

我们知道这一点是因为沙利度胺。

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。

unfortunately, I think the FDA has swung to approving drugs that have risks and either low or, in some cases, they’ve even approved drugs with no benefits.

不幸的是，我认为 FDA 已经转向批准风险较低的药物，或者在某些情况下，他们甚至批准了没有任何益处的药物。

I think that’s a mistake.

我认为这是一个错误。

We have to get better approval.

我们必须获得更好的认可。

We have created a process of compassionate use where, if a drug’s been proven relatively safe — not completely safe; relatively safe — patients can solicit to get it without, I think, before it’s been finally approved.

我们创建了一个富有同情心的使用流程，如果某种药物被证明相对安全，则不完全安全；相对安全——我认为，在最终获得批准之前，患者可以请求获得它。

I don’t actually .

我实际上不知道。

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。

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。

I’m not a big fan of that.

我不太喜欢这个。

And we have seen in the case of nutritional supplements that thank — and this is sarcastic — to the Utah delegation, where a lot of nutritional supplements are made, that they removed FDA oversight.

我们在营养补充剂的案例中看到，感谢犹他州代表团，他们取消了 FDA 的监管，因为该州生产了大量营养补充剂。

There’s been a lot of deaths on nutritional supplements when they don’t regulate them.

如果营养补充剂不加以监管，就会导致很多人死亡。

I don’t think that’s a good thing.

我认为这不是一件好事。

On genetic engineering

关于基因工程

And I don’t think this is a way .

我不认为这是一种方法。

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。

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。

I do think this is a very good place to draw a line.

我确实认为这是一个划清界限的好地方。

I don’t think we’ve had a very good educated national discussion about what it would mean to enhance children or not enhance children.

我认为我们还没有就增强儿童或不增强儿童意味着什么进行过一次受过良好教育的全国性讨论。

I think we have to have that kind of discussion before we go forward.

我认为在我们继续前进之前我们必须进行这样的讨论。

I’m no big fan of it, in part because I don’t think we’re wise enough to figure out what’s good, and we are very likely to overemphasize the wrong thing.

我不太喜欢它，部分原因是我认为我们没有足够的智慧来找出什么是好的，而且我们很可能过分强调错误的事情。

As I said, we tend to overemphasize certain values and ignore other values.

正如我所说，我们倾向于过分强调某些价值观而忽视其他价值观。

We do this individually, and we do this collectively.

我们单独做这件事，我们集体做这件事。

So, I’m not a big fan.

所以，我不是它的忠实粉丝。

I remember going to Africa for the first time and happened to be in a country where the national exams — they had national exams — were done.

我记得第一次去非洲，碰巧是在一个进行国家考试的国家——他们有国家考试。

The whole first six pages of the paper were the people who did really well on national exams.

论文的前六页都是在全国考试中取得真正好成绩的人。

Go and try to figure out in some American town where they’re going to list, on page one, the top 10 kids in all the local high schools.

去尝试找出美国的某个小镇，他们将在第一页列出当地所有高中排名前 10 的孩子。

We don’t do that.

我们不这样做。

We do Friday Night Lights and football games instead.

我们改为举办周五之夜灯光秀和足球比赛。

That’s what we emphasize.

这就是我们强调的。

Is that what we really want with genetic engineering?

这是我们真正想要的基因工程吗？

You’re going to be better football players?

你会成为更好的足球运动员吗？

Seems to me we tend to make a lot of mistakes.

在我看来，我们往往会犯很多错误。

We’re not necessarily the wisest judge.

我们不一定是最明智的法官。

I’ll give you another good example.

我再给你举一个很好的例子。

Just go to any airport.

去任何机场都可以。

Go any place where people collect with kids, and watch.

去任何人们带着孩子聚集的地方，观看。

The American Academy of Pediatrics.

美国儿科学会。

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there’s almost no one who thinks a lot of screen time, especially for young kids, is a good thing.

几乎没有人认为大量的屏幕时间，尤其是对于年幼的孩子来说，是一件好事。

What do you see throughout these places?

你在这些地方看到了什么？

Lots of screen time for young kids.

小孩子有很多屏幕时间。

Why?

为什么？

It’s easy for parents, right?

这对父母来说很容易，对吗？

It’s a terrible way to raise our kids, and some parents doing it voluntarily affects all of us.

这是一种可怕的抚养孩子的方式，一些父母自愿这样做会影响我们所有人。

We’ve got behavior problems in class.

我们在课堂上有行为问题。

We have different ways of learning that probably aren’t good.

我们有不同的学习方式，但这些方式可能并不好。

Imagination is curtailed that way.

想象力就这样被限制了。

And yet, it’s voluntary choice.

然而，这是自愿选择。

It’s not very well thought out.

这不是经过深思熟虑的。

People do it because it’s easy rather than thoughtful.

人们这样做是因为它很容易，而不是经过深思熟虑。

So, your voluntary choice that has, I guess, since I’m talking to an economist, lots of externalities for the rest of us that we tend to downplay doesn’t seem to me to be a wise choice.

因此，我想，因为我正在与一位经济学家交谈，所以，你的自愿选择对我们其他人来说有很多我们倾向于淡化的外部性，在我看来这并不是一个明智的选择。

So, I’m probably sticking by that 1984 article.

所以，我可能会坚持 1984 年那篇文章。

That’s pretty good, right?

这很好，对吧？

Thirty-five years, same view?

三十五年，同样的看法？

On the other hand, I do think we get a .

另一方面，我确实认为我们得到了。

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And I am a person who tries to do something pretty radically new every year.

我是一个每年都尝试做一些全新事情的人。

About four years ago — more than that; five years ago — I made this pledge that every year, I’d try to do something really out of the box for myself.

大约四年前————比这还要多；五年前 —— 我许下承诺，每年我都会尝试为自己做一些真正突破常规的事情。

So, I was a chef.

所以，我是一名厨师。

I’ve made chocolates.

我做了巧克力。

I’ve taken up not terribly long distance, but very serious bicycle riding.

我骑自行车的距离虽然不是很远，但非常认真。

Nonetheless, I do think our brains .

尽管如此，我确实认为我们的大脑。

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and again, this is a general comment.

再说一遍，这是一般性评论。

There are some outliers.

有一些异常值。

There’s natural selection among our neurons.

我们的神经元之间存在自然选择。

The parts we use over and over again get very well done.

我们反复使用的零件都做得很好。

The parts we don’t use tend to die off, and it’s very hard to keep that plasticity over time and to do new things and to be new and curious.

我们不使用的部分往往会消失，随着时间的推移，很难保持这种可塑性，很难做新的事情，变得新鲜和好奇。

If you look at the number of people who are creative after 75, who do new things after 75, and really new things, it’s very small.

如果你看看 75 岁以后有创造力的人、75 岁以后做新事物、真正新事物的人的数量，你会发现这个数字非常小。

I think that there’s a neurological reason for that.

我认为这是有神经学原因的。

It’s not just the physical body.

这不仅仅是肉体。

It’s also the brain and the ability to think new things, be creative, and not just be ho-hum.

它还包括大脑和思考新事物的能力，具有创造力，而不仅仅是乏味。

Even — I’m in the midst of doing a lot of reading about Benjamin Franklin, probably the most creative person born in the North American continent in the 450 years we’ve been around.

甚至 —— 我正在阅读大量有关本杰明·富兰克林的文章，他可能是我们生活 450 年来北美大陆出生的最具创造力的人。

Constantly new, and yet if you look past 75, slows down.

不断更新，但如果你过了 75 岁，就会放慢脚步。

Yes, he does do his autobiography in his 80s and stuff, but even he recognizes that the mental abilities, the ability to focus in on science and make new discoveries, went way down.

是的，他确实在 80 多岁时写了自传之类的东西，但即使是他也承认，他的心智能力、专注于科学和做出新发现的能力已经大幅下降。

It’s very hard for us.

这对我们来说非常困难。

So, I think, yes, we could do new things, have new experiences.

所以，我认为，是的，我们可以做新的事情，获得​​新的体验。

But would we be new and creative?

但我们会是新的、有创造力的吗？

I doubt it.

我对此表示怀疑。

So, say I’m 75.

所以，假设我75岁了。

I’ve decided I agree with you, but the NBA Finals aren’t over yet.

我决定同意你的观点，但 NBA 总决赛还没有结束。

I want to see game seven.

我想看第七场比赛。

I want the Mueller report to come out.

我希望穆勒报告能够出来。

Isn’t there always something?

不是总有什么吗？

And then, it’s kind of intransitivity of indifference.

然后，这是一种冷漠的不及物性。

Every day there’s something, and you just keep on hanging on, even if one accepts your arguments in the abstract.

每天都会有一些事情，即使有人抽象地接受你的论点，你也只能坚持下去。

Can you talk me out of that?

你能劝我别这样吗？

We all know, from any cosmic standpoint — even not a cosmic standpoint, just a 2,000-foot standpoint — most of those things are not irrelevant.

我们都知道，从任何宇宙的角度来看——即使不是宇宙的角度，只是 2000 英尺的高度——大多数事情都不是无关紧要的。

It’s really cool to know.

知道这真的很酷。

You often ask — and this happens to me all the time.

你经常会问“——”，而这种情况也经常发生在我身上。

I teach undergraduates.

我教本科生。

Pretty smart undergraduates.

非常聪明的大学生。

Very smart undergraduates.

非常聪明的大学生。

MBA students, nurses, doctors, right?

MBA学生、护士、医生，对吗？

They have no understanding of history.

他们对历史一无所知。

So, whoever finishes in the NBA Finals, in five years, people have forgotten.

所以，无论谁进入NBA总决赛，五年后，人们都已经忘记了。

You ask people .

你问人们。

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I ask, Richard Nixon?

我问，理查德·尼克松？

They have the vaguest memory, Tricky Dick.

他们的记忆最模糊，狡猾的迪克。

They can’t really tell you very much.

他们真的不能告诉你很多。

Even Ronald Reagan.

甚至罗纳德·里根。

Even Bill Clinton.

甚至比尔·克林顿。

Much less, you ask them, Bill Russell.

更不用说，你问他们，比尔·拉塞尔。

No idea who Bill Russell is.

不知道比尔·拉塞尔是谁。

Oscar Robertson.

奥斯卡·罗伯逊。

No idea who Oscar Robertson is.

不知道奥斯卡·罗伯逊是谁。

These were my heroes.

这些是我的英雄。

These are phenomenal, the people who made modern basketball.

这些人都是非凡的，他们创造了现代篮球。

No idea.

不知道。

So, this idea .

所以，这个想法。

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you’re absolutely right.

你说得对。

We cone down.

我们向下倾斜。

Lower and lower, the parts .

零件越来越低。

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what will make us satisfied, and we have to step back and realize those are pretty trivial.

什么能让我们满意，我们必须退后一步，意识到这些都是微不足道的。

The NBA Finals?

NBA总决赛？

The Final Four?

四强？

Tyler, who was in the Final Four five years ago?

泰勒，五年前曾进入四强？

But, you know, if you’re at 80, there’s no more character building.

但是，你知道，如果你已经 80 岁了，就没有更多的性格塑造了。

Your character’s set.

你的角色设定。

You’re not changing your character.

你没有改变你的性格。

At 80?

80岁？

Who changes their character at 80?

谁在80岁时改变了性格？

Now, whether that’s good immortality in the sense that the body’s going to be able to work well?

现在，从身体能够正常运转的意义上来说，这是否是好的永生呢？

My brother, who is not a doctor but a Hollywood agent, had a very insightful comment to me recently.

我的兄弟不是医生，而是好莱坞经纪人，最近对我发表了非常有见地的评论。

It’s like, “You know, we’re going to be able to replace my heart, my lungs, everything.

就像，“你知道，我们将能够更换我的心脏、我的肺，以及一切。

But, damn it, that cartilage.

但是，该死的，那个软骨。

You know, my back pain.

你知道，我的背痛。

Can’t you doctors cure back pain and the common cold?

你们医生不能治疗背痛和普通感冒吗？

You can’t do any of this simple stuff.”

这些简单的事情你都做不到。”

And so, living a long time with a lot of back pain?

那么，长期生活在背痛中吗？

That just doesn’t seem like a great life.

这看起来并不是美好的生活。

On things under- and overrated

关于被低估和高估的事情

Now, Sam Adams gets a lot of attention, and Sam Adams was a rabble-rouser, but Joseph Warren was a guy who organized it all, who made it coherent, who had an objective.

现在，萨姆·亚当斯受到了很多关注，萨姆·亚当斯是一个煽动者，但约瑟夫·沃伦是一个组织这一切的人，他使一切变得连贯，他有一个目标。

He was president or head of almost every one of those committees that they established.

他是他们设立的几乎每一个委员会的主席或负责人。

The Committee of Correspondence, this and that.

通讯委员会，这个那个。

And he, unfortunately, was prematurely .

不幸的是，他还为时过早。

.

。

.

。

he should not have done this.

他不应该这样做。

He ran to the Battle of Bunker Hill when it was in process —

当邦克山之战正在进行时，他跑到了现场——

And everyone, for the first hundred years after he died, everyone knew about him.

每个人，在他死后的前一百年里，每个人都知道他。

Warrenton, West Virginia, or something?

沃伦顿，西弗吉尼亚州，还是其他地方？

Lots of towns are named after him.

许多城镇都以他的名字命名。

Boston, 20, 30 years ago, you used to be taught about him all the time.

波士顿，20、30年前，你一直被教导关于他。

Way underrated.

被低估了。

He needs a great biography.

他需要一本精彩的传记。

That’s my retirement.

这就是我的退休生活。

The infrastructure .

基础设施。

.

。

.

。

I mean, just the life of people.

我的意思是，只是人们的生活。

They’re very warm, but I’ve been to many other parts of Africa that I would rate way over it.

他们非常温暖，但我去过非洲的许多其他地方，我对这些地方的评价远远超过它。

Places that are not necessarily highly recognized .

不一定是高度认可的地方。

.

。

.

。

Mali I found one of the most amazing places.

马里 我发现了最神奇的地方之一。

People are incredibly warm.

人们非常热情。

Mud mosques that you can see.

随处可见的泥巴清真寺。

The Dogon villages that are just truly amazing.

多贡村庄确实令人惊叹。

Lots of cultural resonance that you just don’t find in Madagascar.

许多在马达加斯加找不到的文化共鸣。

We were not very rich when we grew up.

我们长大后并不十分富有。

He was a struggling, newly immigrated doctor to the United States, but my father saved all sorts of money.

他是一位刚移民到美国、处境艰难的医生，但我父亲却存了各种各样的钱。

We had holey pants.

我们有破洞的裤子。

We used to go to school in holey pants before holey pants were fashionable.

在破洞裤流行之前，我们常常穿着破洞裤去上学。

But he would save money for international travel in the ’60s.

但他会在 60 年代为国际旅行存钱。

Most of our rich friends, they went to Florida.

我们大多数富有的朋友都去了佛罗里达。

But we would go on very cheap trips to Europe, very cheap trips to Israel, because he always thought going and experiencing other cultures increases your empathy, increases your understanding of the complexity of the world, different cultures.

但我们会去欧洲、以色列进行非常便宜的旅行，因为他一直认为去体验其他文化会增加你的同理心，增加你对世界复杂性和不同文化的理解。

It’s very important to do.

这非常重要。

Not important to go to the heavily touristed Paris, London, but I think other places, like Alesund, is definitely well worth it.

去游客密集的巴黎、伦敦并不重要，但我认为其他地方，比如奥勒松，绝对值得一去。

He kept me running.

他让我继续奔跑。

He was a great kid.

他是一个很棒的孩子。

He’s now actually a health law professor at Loyola.

他现在实际上是洛约拉大学的健康法教授。

It’s always good to have a Spencer Waller in your life.

生活中有一个斯宾塞·沃勒总是件好事。

We knew what was right and what was wrong.

我们知道什么是对的，什么是错的。

We knew that we had to defend what was right and what was wrong.

我们知道我们必须捍卫什么是正确的，什么是错误的。

And we had a lot of restrictions on what we could do and could not do.

我们对能做什么和不能做什么有很多限制。

But we were also given a lot of responsibility, and allowed to explore, and allowed to make mistakes.

但我们也被赋予了很多责任，允许探索，允许犯错误。

So, I wouldn’t have called our raising free range, actually.

所以，实际上我不会把我们的饲养称为自由放养。

Maybe I’m misunderstanding your notion.

也许我误解了你的想法。

So, I’ll just give you an indication of what we did for my kids, which is, “Your room, your castle.

所以，我只想告诉你我们为我的孩子们做了什么，那就是，“你的房间，你的城堡。

You want it piggy?

你想要小猪吗？

You can have it piggy.

你可以把它当成小猪。

That’s fine by me.

对我来说没问题。

I’m not .

我不是。

.

。

.

。

Common space?

公共空间？

You have to keep it clean because it’s common with everyone else, and you’re living with other people.”

你必须保持干净，因为这对其他人来说很常见，而且你和其他人住在一起。”

I don’t consider that free range.

我不认为自由放养。

I consider that, “Here are the limits, and you have freedom within these limits.”

我认为，“这是限制，在这些限制内你有自由。”

So, there are two problems here.

所以，这里有两个问题。

What’s the right amount to spend on drugs?

购买药物的正确金额是多少？

And that extra year of life when you’re 80, going to 81, is that really that valuable to you?

当你80岁时，多活一年，到81岁时，这对你来说真的那么有价值吗？

You know, if I got that extra year, if I had — instead of 10 years in my 30s, if I had 11 years in my 30s, that’s a different story.

你知道，如果我有额外的一年，如果我在 30 多岁时有 10 年，而不是 10 年，如果我在 30 多岁有 11 年，那就是一个不同的故事了。

I think you have to put it in context.

我认为你必须把它放在上下文中。

Part of my thinking is, you have to put it in context into someone’s entire life, and how much money they have in their entire life.

我的部分想法是，你必须将其与某人的一生以及他们一生拥有多少钱联系起来。

The average person, American with a BA, average male with a BA — women make less — but the average male with a BA, their entire lifetime earning’s about $2.2 million.

普通美国人，拥有文学学士学位，普通男性拥有文学学士学位——女性赚得更少——但是普通男性拥有文学学士学位，他们一生的收入约为 220 万美元。

Now, $3,000 a year for 70 years is about $200,000, so it’s 10 percent of all their lifetime earnings for an extra year.

现在，70 年每年 3,000 美元大约相当于 200,000 美元，所以这是他们额外一年的终生收入的 10%。

That just doesn’t seem to me to be a good ratio.

在我看来，这并不是一个好的比例。

So it’s one extra year.

所以又多了一年。

That’s 1 over 80; that’s 1.2 percent of a life for 10 percent of your dollars?

80 分之一； 10%的钱换来1.2%的生命？

That’s not a good ratio.

这不是一个好的比例。

There are many other things you could spend it on.

您还可以把它花在很多其他事情上。

Right now, if hospitals create local monopolies, where local can be pretty big, they can take a lot of money from private insurers, who have to negotiate with them and have to keep them in their network if they’ve got a local monopoly.

现在，如果医院建立了地方垄断，地方可能相当大，他们可以从私人保险公司那里拿走很多钱，如果他们拥有地方垄断，私人保险公司就必须与他们谈判，并且必须将他们保留在他们的网络中。

And that drives up the cost for all of us.

这增加了我们所有人的成本。

So capping that, how much they can charge, if we cannot get effective antitrust, is really important.

因此，如果我们无法获得有效的反垄断，他们可以收取多少费用，这一点非常重要。

On healthcare costs

关于医疗费用

Most big employers want to satisfy their workers.

大多数大雇主都希望让他们的员工满意。

You know, human resource departments, their number-one obligation is typically not to keep healthcare costs down but to keep kvetching down, keep down the complaints of workers.

你知道，人力资源部门的首要任务通常不是降低医疗成本，而是降低员工的抱怨。

The easiest way to do that is have a wide network of hospitals, wide network of doctors.

最简单的方法是拥有广泛的医院网络和广泛的医生网络。

That drives costs up and handcuffs the insurer in terms of their negotiating power.

这会推高成本并限制保险公司的谈判能力。

Nonetheless, I think they could do better than they are doing, and I do think, over the next few years, you’re going to see them do better.

尽管如此，我认为他们可以做得比现在更好，而且我确实认为，在接下来的几年里，你会看到他们做得更好。

One major reason is that employers have said, basically, “Enough is enough.

一个主要原因是雇主基本上说：“够了。”

Now, cost is at our limit, and we want you to be better about cost control.” I think that’s risen to number one, as opposed to just rhetorically number one.

现在，成本已达到我们的极限，我们希望你们能够更好地控制成本。”我认为这已经上升到第一，而不仅仅是口头上的第一。

I think, actually, it’s risen pretty much to number one.

我认为，实际上，它已经上升到第一名了。

First, it doesn’t serve anyone’s interests, except the plaintiffs’ lawyers.

首先，除了原告律师之外，它不符合任何人的利益。

It doesn’t serve the interests of patients.

它不符合患者的利益。

It doesn’t serve the interests of doctors.

这不符合医生的利益。

It doesn’t service interests of the healthcare system.

它不服务于医疗保健系统的利益。

And it’s too easy an excuse for doctors in the healthcare system to blame malpractice for not doing the right thing.

对于医疗保健系统中的医生来说，将不做正确的事情归咎于医疗事故太容易成为借口。

I think changing malpractice reform would be effective.

我认为改变医疗事故改革将会是有效的。

I don’t like the general conservative approach, which is limit the length of time people can file suits.

我不喜欢一般保守的做法，这种做法限制了人们提起诉讼的时间长度。

Limit the amount that people can get for noneconomic damages.

限制人们因非经济损失可以获得的赔偿金额。

Those turn out not to be good reforms.

事实证明，这些都不是好的改革。

I do think moving to things like either safe harbors, where if a doctor followed the protocols, they are presumed — that’s a rebuttable presumption — to not be guilty.

我确实认为转向安全港之类的事情，如果医生遵守了协议，他们就被推定——“这是一个可反驳的推定”——“无罪”。

Or have what they pioneered at the University of Michigan: just say you’re sorry, identify problems, offer a standard payment back for identified problems that are admitted to be problems.

或者采用他们在密歇根大学开创的做法：只需说声抱歉，找出问题，对已发现的问题（承认是问题的问题）提供标准退款。

People can still sue, but it leads to much quicker resolution and much more focus on improving the quality of the system as opposed to hiding problems.

人们仍然可以提起诉讼，但它可以更快地解决问题，并且更加注重提高系统的质量，而不是隐藏问题。

One of the things I like that they do that we could never get here is, they pay their government officials a lot of money because they want the absolute best people in government.

我喜欢他们做的一件我们永远无法做到的事情是，他们向政府官员支付很多钱，因为他们想要政府中绝对最优秀的人才。

They don’t denigrate their government the way we tend to denigrate our government and regulation.

他们不会像我们诋毁我们的政府和监管那样诋毁他们的政府。

That’s one reason we probably will never get the Singaporean system.

这就是我们可能永远不会采用新加坡系统的原因之一。

I’m not even sure it’s worth studying that carefully for how to import it here.

我什至不确定是否值得仔细研究如何将其导入这里。

And here’s my worry.

这是我的担忧。

It’s really hard to pick winners in advance, and to the extent venture capital works, it’s because your winners are really big, that they’re rapidly scalable, their marketing expenses are not too high.

提前挑选赢家确实很困难，就风险投资的作用而言，这是因为你的赢家非常大，他们可以快速扩展，他们的营销费用也不太高。

There’s not a 10-year approval process to put Facebook or Uber on the market.

Facebook 或 Uber 上市并没有经过 10 年的审批流程。

Things just happen.

事情就这样发生了。

So, here you have a biotech sector, where so often, you have a sales force; you need legal and regulatory expertise.

因此，这里有一个生物技术行业，通常有一支销售队伍；您需要法律和监管方面的专业知识。

It seems no easier to pick winners, so why be optimistic about venture capital in this space?

挑选赢家似乎并不容易，那么为什么要对这个领域的风险投资持乐观态度呢？

The medical system has long ignored those, and we have invested in small companies that we’re hoping are going to transform these areas and develop solutions that are scalable beyond them.

医疗系统长期以来忽视了这些，我们投资了小公司，希望它们能够改变这些领域并开发可扩展的解决方案。

And we also .

我们也。

.

。

.

。

I do think, once we’ve proven things — we’ve proven models can improve, bigger companies come in and want to adopt those and scale them.

我确实认为，一旦我们证明了事情 ——我们已经证明模型可以改进，更大的公司就会介入并希望采用这些模型并扩大规模。

And I do think generating these new ideas, getting really smart people to come into the space, has actually dramatically improved — ideas, again, in what had traditionally been backwaters but we’re now recognizing are critical for improving the healthcare delivery system.

我确实认为，产生这些新想法，让真正聪明的人进入这个领域，实际上已经极大地改善了传统上停滞不前的想法，但我们现在认识到这对于改善医疗保健服务系统至关重要。

Silicon Valley is a very good example.

硅谷就是一个很好的例子。

San Francisco’s got great restaurants, but Silicon Valley itself, where there’s a gazillion dollars sitting there, not great restaurants.

旧金山有很棒的餐厅，但硅谷本身却没有很棒的餐厅，那里坐拥数以亿计的美元。

I’m not an expert on the business side of food, but it is peculiar that you go to many interesting places that have a lot of people with money, and yet you get a lot of places that have bland or not very adventurous food.

我不是食品商业方面的专家，但奇怪的是，你去了很多有趣的地方，那里有很多有钱的人，但你却发现很多地方的食物平淡或不太冒险。

I like to make jams.

我喜欢做果酱。

This year, I think our goal is to try to get apricots to make jam.

今年，我想我们的目标是尝试用杏子来做果酱。

We hope it’s a good apricot season.

我们希望这是一个好的杏子季节。

And blackberries.

还有黑莓。

I have not made blackberry jam yet.

我还没有做黑莓果酱。

I have made a very good raspberry jam, and I like that a lot.

我做了一个非常好的覆盆子果酱，我非常喜欢。

But we’re going to try blackberries and apricots this year.

但今年我们要尝试黑莓和杏子。

It’s a lot of fun, by the way.

顺便说一句，这很有趣。

It’s also a good thing to do with kids.

和孩子一起做也是一件好事。

I also think that there are a series of manufacturers — I won’t name all the great ones — that consistently make phenomenal chocolate.

我还认为有一系列制造商 —— 我不会说出所有伟大的制造商 —— 始终生产出非凡的巧克力。

The guy I do my chocolate with, Shawn Askinosie, Askinosie Chocolate, I think, is fantastic consistently.

和我一起做巧克力的人 Shawn Askinosie，我认为 Askinosie Chocolate 一直都很棒。

Fruition, in the Hudson Valley, husband and wife team, make great chocolate.

硕果累累，在哈德逊河谷，夫妻团队，制作出很棒的巧克力。

Rogue out of Massachusetts, I really love his chocolates.

来自马萨诸塞州的流氓，我真的很喜欢他的巧克力。

There’s a guy named .

有一个人叫。

.

。

.

。

why am I blanking on it?

为什么我对此一片空白？

Dick, he’s from Eureka, California; Dick Taylor.

迪克，他来自加利福尼亚州尤里卡；迪克·泰勒.

Great chocolates.

很棒的巧克力。

Most of these are very small manufacturers, and what they do is, they source their own beans or make sure that their beans are really good.

其中大多数都是非常小的制造商，他们所做的是，他们采购自己的咖啡豆或确保他们的咖啡豆真的很好。

So, my next chocolate, which I’m going to make in May, we’re sourcing out of Ecuador.

所以，我将在五月份制作下一款巧克力，我们将从厄瓜多尔采购。

We’re getting only criollo beans.

我们只得到克里奥罗豆。

And it should be a phenomenally good chocolate.

它应该是一种非常好的巧克力。

And then it’s all in the roasting, like coffee.

然后一切都在烘焙中，就像咖啡一样。

Lighter roasts rather than darker roasts.

较浅的烘焙而不是较深的烘焙。

If someone advertises dark roast coffee, you know they’ve burnt it to hell, and it’s probably not great.

如果有人宣传深度烘焙咖啡，你就知道他们已经把它烧得很烂了，而且可能不太好。

The new, I think, recognition is a lot more volatile organics are critical for great taste, and that’s the same thing in chocolate.

我认为，新的认识是挥发性有机物对于美味至关重要，巧克力也是如此。

So, when I made my chocolate, we roasted for about 7 minutes and 40 seconds.

所以，当我制作巧克力时，我们烤了大约 7 分 40 秒。

And that really allowed a very bold start and a very long tail, which is what I try to get in my chocolates.

这确实让我们有了一个非常大胆的开始和一个非常长的尾巴，这就是我试图在巧克力中得到的东西。

You know, I talk to my brothers three, four times a week.

你知道，我每周和我的兄弟们聊三四次。

Talked to my younger brother yesterday.

昨天和弟弟聊天。

I talked to my middle brother, Rahm, the day before.

前一天我和我的二弟拉姆谈过。

We trade back book recommendations.

我们交换书籍推荐。

We spend some vacations together; we’re planning a big vacation to Antarctica.

我们一起度过一些假期；我们正计划去南极洲度过一个愉快的假期。

So, yeah, having brothers is probably the smartest choice they made.

所以，是的，拥有兄弟可能是他们做出的最明智的选择。

But it also .

但它也。

.

。

.

。

look, what did it do?

看看，它做了什么？

My parents were very good about raising us and having us know what was right and defend what was right, even if the majority of people were against us.

我的父母非常善于抚养我们，让我们知道什么是正确的，并捍卫什么是正确的，即使大多数人反对我们。

And so, we would be made fun of because we took ballet lessons, but we defended that, and we defended ourselves.

因此，我们会因为上芭蕾舞课而被嘲笑，但我们捍卫这一点，我们捍卫自己。

And I think that idea, that you didn’t have to go with the flow .

我认为这个想法是，你不必随波逐流。

.

。

.

。

if there’s anything that characterizes my brothers and myself, it’s we don’t go with conventional wisdom.

如果说我和我的兄弟们有什么特点的话，那就是我们不遵循传统智慧。

We make our own judgment, and we defend that.

我们做出自己的判断，并为此辩护。

I think my father was very much that.

我认为我的父亲就是这样。

He’s not a guy who does big policy issues.

他不是一个处理重大政策问题的人。

He did good .

他做得很好。

.

。

.

。

a family that had the fourth child who came to him was free.

一个有第四个孩子的家庭是免费的。

Every kid after three was free because he knew it was a burden to charge them.

三岁以后的每个孩子都可以自由活动，因为他知道向他们收费是一种负担。

He did good on a local level.

他在地方层面做得​​很好。

My mom tended to be more of a community organizer and interested in public policy.

我妈妈更像是一名社区组织者，对公共政策感兴趣。

And I think that’s rubbed off, certainly, on me.

我认为这当然对我产生了影响。

Part of the job in this world is to make it better, and the easiest way to make it better for more people is through public policy.

这个世界的部分工作就是让世界变得更好，而让更多人过得更好的最简单方法就是通过公共政策。

My mom tended to be more of a community organizer and interested in public policy.

我妈妈更像是一名社区组织者，对公共政策感兴趣。

And I think that’s rubbed off, certainly, on me.

我认为这当然对我产生了影响。

Part of the job in this world is to make it better, and the easiest way to make it better for more people is through public policy.

这个世界的一部分工作就是让世界变得更好，而让更多人变得更好的最简单方法就是通过公共政策。

But I tend, on a personal level, to have an ascetic element.

但就我个人而言，我倾向于具有禁欲主义的元素。

I don’t have fancy clothes.

我没有漂亮的衣服。

I don’t have a lot of fancy furniture and stuff.

我没有很多精美的家具和东西。

But I do splurge on experiences because I think having good experiences and interesting experiences are what create a rich life.

但我确实在经历上挥霍，因为我认为拥有美好的经历和有趣的经历才能创造丰富的生活。

They’re more memorable.

他们更令人难忘。

I like the experience of eating food.

我喜欢吃食物的体验。

I like the experience of meeting people.

我喜欢与人见面的经历。

So that’s where I spend my money.

所以这就是我花钱的地方。

So, you will not find me with a lot of material items, but you will find me trying to get a lot of interesting experiences.

所以，你不会发现我拥有很多物质物品，但你会发现我试图获得很多有趣的经历。

I would say that there are two things that I would really like to do.

我想说有两件事是我真正想做的。

One is, we’re working with a lot of players in the healthcare system to try to transform various parts of the healthcare system to dramatically increase the quality.

一是，我们正在与医疗保健系统中的许多参与者合作，尝试改造医疗保健系统的各个部分，以大幅提高质量。

I’m super excited about that.

我对此感到非常兴奋。

We’re trying to work on getting the drug choices better so that they’re cheaper for people.

我们正在努力改进药物选择，以便对人们来说更便宜。

We’re trying to get primary care better by paying doctors differently, so that they’ll think about the total cost of care.

我们试图通过向医生支付不同的费用来改善初级保健，以便他们考虑总护理费用。

They’re also dramatically improved quality.

它们的质量也显着提高。

So, we’re launching a venture on that.

因此，我们正在为此开展一项冒险活动。

That’s a super exciting part of my academic life.

这是我学术生活中非常令人兴奋的部分。

The other thing is, I’d like to get back into government.

另一件事是，我想重返政府。

Again, one of the great things, I think, is that changing government policy has a big impact.

再说一次，我认为最伟大的事情之一是政府政策的改变会产生巨大的影响。

I think there are a number of things the government can do to actually improve the American healthcare system.

我认为政府可以采取很多措施来切实改善美国的医疗保健体系。

And one of the reasons I really focus on the American healthcare system is, if we can really bring down costs, we can have money to spend on other things, whether it’s individually, whether it’s as a society in governments, and I think there are lots of low-hanging fruit in that direction.

我真正关注美国医疗保健系统的原因之一是，如果我们真的能够降低成本，我们就可以有钱花在其他事情上，无论是个人还是政府中的社会，我认为在这个方向上有很多容易实现的目标。

Regulating drug prices is but one area.

监管药品价格只是其中之一。

As I mentioned, limiting what hospitals can charge so that they don’t get too much money out of the healthcare system’s another way.

正如我提到的，限制医院的收费，这样他们就不会从医疗保健系统中获得太多资金，这是另一种方式。

Transforming how doctors are paid also, we’ve got some good evidence, can transform how they deliver care, the quality of care, and reduce costs.

我们还获得了一些充分的证据，改变医生的薪酬方式，可以改变他们提供护理的方式、护理质量并降低成本。

And so, that’s a second thing I would love to get back into.

所以，这是我想重新讨论的第二件事。