Artscience | The Laboratory at Harvard/Creativity in the Post-Google Generation

Artscience | The Laboratory at Harvard

• Concept
  • The Lab
  • Summer 2012
  • Artscience
• Courses
  • Engineering Sciences 20: How to Create Things & Have Them Matter
  • Team Design Studio
  • Engineering Sciences: Design for Desirability
  • Engineering Sciences 21: The Innovators’ Practice
• Opportunities
• Content
  • Current
  • Past
  • Ideas
  • Press
• Contact
  • People
  • Contact Information
• Idea Translation Lab Summer Experience
  • Idea Translation Lab Summer 2012 – Singapore
  • Idea Translation Lab in Cape Town

Artscience

Labs are places of experience. We enter to explore. Each minute in a functioning lab is like a page of a smart novel that loses meaning without reference to what came before and is about to follow.
Art, like science, is such an experience, and, yet, we encounter art and science in our museums more frequently as outcome, as product – dug up, carved down, highly edited – that follows a mysterious process of creative thought and engagement.
Process, of course, is hard to define, to classify or to curate. Occasionally, processes of exploration, discovery and innovation matter more than any result these processes ever produce.
What is this creative process? Idea development in culture, industry, education and society can be conceived as a kind of experimentation, where the catalyst for change, for movement – for innovation – is a fusion of those creative processes we conventionally think of as art and as science. This fused process, what Professor Edwards calls ‘artscience,’ is the basis of Le Laboratoire, new kind of culture center we have opened in central Paris and the inspiration for The Laboratory at Harvard.

Artscience Experiments

Works of art and design resulting from a confrontation with science, or at least with technology, fill art and science museums today. The works of art and design that result from experiments at a culture lab possess a narrower definition.
At The Laboratory, we look for novel ideas of art and design that cannot be properly formulated without a sustained encounter with a pioneering edge of science. We then help broker encounters between artists and scientists that permit concrete idea formulation. Once ideas are formulated, we invest in development of the experimental projects that result. In this way, artscience, the process of creative thought that synthesizes esthetic and analytical methods, becomes a catalyst for innovation and the basis for partnership.

Artscience

Creativity in the Post-Google Generation

David Edwards

About This Book

• About the Authors
• Reviews

“ArtScience champions the virtues of interdisciplinary work. Using captivating anecdotes of how both disciplines can enhance each other Edwards offers one of the strongest and most original contributions to the literature on creativity. ”—William S. Hammack, Commentator for National Public Radio’s Marketplace, and Professor, Department of Chemical & Biomolecular Engineering, University of Illinois at Urbana Champaign
“The tenor of this convivial, onrushing book makes one think that what the best workers in both fields have in common is what this book consistently offers: a great and moving intellectual generosity.”—Jay Cantor
“Edwards’ book is something of a manifesto for artscience, and for the need to cultivate more porous cultural, corporate and educational institutions...Arguing passionately for the need for new collaborations between scientists, artists, industry and the social sector, Artscience: Creativity in the Post-Google Generation is ultimately a collection of enticing tales from the trenches for would-be practitioners.”—Michael John Gorman, Irish Times
“[Artscience] is less a technical tool than a motivational one: an exhortation for interdisciplinary intellectuals...Edwards infects us with his subjects’ creativity. When the final chapter turns from vignettes to his utopian Laboratoire, we’re rooting for it to succeed.”—Alice W. Flaherty, Nature
“Edwards attempts in this truly inspiring work to shed light on the perceived dichotomy between the arts and sciences and why it needs to be challenged. He looks closely at the idea of translating concepts or ideas through pure sciences and the arts as they occur in all sectors of life. Essentially, he shows how scientific ideas flourish in the artistic community and how art can inspire science. Edwards takes interdisciplinary thinking to another level, going a long way in demonstrating a kind of symbiosis that can--and for many, does--exist between the arts and sciences. He relates stories of ‘artscience’ innovation in France, Germany, and the United States; discusses his recent founding of Le Laboratoire, an artscience cultural center in Paris; and explains the theory behind his idea of the "laboratory."”—Michael McArthur, Library Journal
“There are scientists, and there are artists. Now, there are art scientists. In his new book, Artscience: Creativity in the Post-Google Generation, David Edwards explains how this group of thinkers melds the two disciplines in innovative ways to make lasting and important breakthroughs for the betterment of humanity, culture, academia, and industry.”—V. L. Hendrickson, New York Sun
“In his concise book, Edwards, a professor of biomedical engineering at Harvard, shares the stories of people who have found ways to cross this barrier [between art and science]--artscientists, he calls them--and elegantly communicates the catalytic effect of their interdisciplinary leaps.”—Daniella Maestretti, Utne Reader

• Table of Contents

1. Catalyst
2. Process
3. Idea Translation in Cultural Institutions
4. Idea Translation in Academia
5. Idea Translation for Humanitarian Causes
6. Idea Translation in Industry
7. The Idea of the Lab

• Acknowledgments

• Google Search Inside:

Scientists are famous for believing in the proven and peer-accepted, the very ground that pioneering artists often subvert; they recognize correct and incorrect where artists see only true and false. And yet in some individuals, crossover learning provides a remarkable kind of catalyst to innovation that sparks the passion, curiosity, and freedom to pursue--and to realize--challenging ideas in culture, industry, society, and research. This book is an attempt to show how innovation in the "post-Google generation" is often catalyzed by those who cross a conventional line so firmly drawn between the arts and the sciences.

David Edwards describes how contemporary creators achieve breakthroughs in the arts and sciences by developing their ideas in an intermediate zone of human creativity where neither art nor science is easily defined. These creators may innovate in culture, as in the development of new forms of music composition (through use of chaos theory), or, perhaps, through pioneering scientific investigation in the basement of the Louvre. They may innovate in research institutions, society, or industry, too. Sometimes they experiment in multiple environments, carrying a single idea to social, industrial, and cultural fruition by learning to view traditional art-science barriers as a zone of creativity that Edwards calls artscience. Through analysis of original stories of artscience innovation in France, Germany, and the United States, he argues for the development of a new cultural and educational environment, particularly relevant to today’s need to innovate in increasingly complex ways, in which artists and scientists team up with cultural, industrial, social, and educational partners.

《唐代政教史》《隋唐兩京坊里譜》《反經》

劉伯驥《唐代政教史》台北:中華  1954 1974修正



《隋唐兩京坊里譜》述評
王 靜

《隋唐兩京坊里譜》(楊鴻年著，上海古籍出版社，1999年9月，528頁，29.2圓)

此書為楊鴻年先生的另一著述《唐代宮廷建築考》（陝西人民出版社，1992年3月）的姊妹篇，本書不敘兩京宮城、皇城建置，但對隋唐長安、洛陽兩京外郭城的坊裡的史料進行敘述、增補和考證。
本書雖然是仍以徐松《唐兩京城坊考》（以下簡稱《城坊考》）為基礎進行增補校訂，但卻有自己的特色。作者把《長安志》、《城坊考》對兩京外郭城的建置沿革、變遷等等記述重新整理編排，一改以往先西京後東都，從街東到街西的形式，而是以筆劃順序來排列兩京各坊，在體例上有所發明。同時，作者以按語的形式對有關的研究成果進行總結，並以平岡武夫《長安與洛陽》第一圖《長安城圖》、徐松《長安城圖》、足立喜六《長安城圖》、福山敏男《長安城圖》及《咸寧（長安）縣志·長安坊裡圖》作參照，對相關問題進行了研究論證，提出了自己的觀點。該書內容可分為四部分：一、坊裡目錄；二、是各坊具體的內容記載；三、附錄缺名坊資料；四、隋唐兩京各種建築所在坊里索引。以下依次評介各部分的內容和特點：
第一部分坊裡目錄，按筆劃順序排列長安及洛陽的坊裡，對於想了解兩京的每一坊具體內容的研究者來說，該目錄便於查找。
　　第二部分是本書的主體部分。作者在每一坊下，先是分別述錄《長安志》、《城坊考》對每一建置的記載，說明《城坊考》對於《長安志》取捨及其原因，這使讀者對《長安志》和《城坊考》的記載一目了然。在此之後，作者以按語形式結合今人的研究，進行比較論證，同時給出自己的觀點，對於不能究其實的地方，作者並存諸說，以存疑的方式列出以待考證，其態度是認真、嚴謹的。本書並不是僅對別人的研究進行彙編，對於一些有爭議的問題也作以考證研究，在這一部分既有前人研究總結，又有自己的論證和增訂。首先，作者對《長安志》與《城坊考》及《唐兩京城坊考校補記》（以下簡稱《校補記》）的訛誤有所訂正。一方面是對所記有所混淆的坊裡的考證：《長安志》因不記洛陽而使兩京的個別坊名在記載上有舛誤，徐鬆在《城坊考》中又審之不詳而踵其錯誤：《城坊考》在西京長興坊的張嘉貞宅下稱“無思順坊”的記載是複述《長安志》的，楊先生指出此說系《長安志》不記洛陽之故致誤，而《城坊考》雖兼述兩京，卻因疏略仍襲這一訛誤。而實際上，思順坊乃是洛陽一坊，並以史料證明張嘉貞在東都思順坊有宅（202頁）。又如徐松把正平坊作為輔興坊的別名，閻文儒先生在《兩京城坊考補》（河南人民出版社，1992年6月，601頁）裡也持此說，但作者經過排比史料，論證正平為東都洛陽的一坊，長安並無這一坊名（68—69頁），這一論證結果與辛德勇的考證（《隋唐兩京叢考》，三秦出版社，1991年10月，37頁）是相同的。另一方面是對各坊裡的記載進行考訂糾誤。如作者指出《校補記》中關於宣平坊裴遵慶宅的記載，系誤解《國史補》的“遵慶罷相知選，朝廷優其年德，令就第注官，自宣平坊榜引士子，以及東市兩街”所致，裴遵慶的宅第在昇平坊，《城坊考》原來的記載是正確的（179頁）。這一考證辨誤，《中原文物》1994年第3期所刊裴遵慶神道碑可以確證。其次，作者在前人已利用過的唐代史籍、筆記小說等傳世的史料當中細心搜檢，又輯出一些前人疏漏之材料對徐鬆的《城坊考》的內容有所增補，於每一坊下將有關的史料記載一一列出，同時，也注意運用新材料來進行增補。如《城坊考》於崇義坊條下載：《通鑑》，甘露之變，右神策軍獲左金吾衛大將軍韓約於崇義坊，斬之。作者又於《冊府元龜》卷九五三中蒐集到類似的記述，並且增補了《舊唐書·五行志》中與該坊有關的一條記載（264頁）。又如，新昌坊白居易宅下，作者又於《全唐文》中輯得一條加以補充（354頁）。像這樣的史料的匯總補充書中尚有很多，在此不再一一列舉。這裡要強調的一點是在該書中，作者還利用了1983年5月西安史蹟文物展覽會隋唐史展室所展《隋唐名人所居坊名表》，比定出一些坊現在所在的地理位置，象崇義坊、通義坊、安邑坊等等，這是以前諸多增補中所未見的。此外，作者在利用出土墓誌進行增補時，比較注意京兆中城內的里與郊區的里的區別。作者據《全唐文》卷二二七張說《元城府左果毅贈郎將葛公碑》“〔夫人〕薨於京兆三真裡”補三真裡（1頁。關於三真里為修真裡之誤的論證，見朱玉麒《〈唐兩京城坊考〉增補小議》，《書品》2000年第6期），《全唐文》卷六八○《大唐故賢妃京兆韋氏墓誌銘序》所補上好裡（9頁）都涉及到這方面的問題，同時又說明並不一定就是長安城之內的坊。筆者較贊同這種態度，因唐京兆府直接管轄的有二十三縣，京師長安包括長安、萬年（天寶七年改萬年為咸寧，乾元二年，復曰萬年）兩縣，縣下又轄城外的鄉，加之隋唐長安的“坊”與“裡”又混用，京兆某里或有可能是別的縣的里，或是有可能是長安、萬年兩縣在郊區的“鄉”下所設的“裡”而不是長安城內的坊裡，所以在京兆某裡的這種情況下，增補長安城裡坊名還是應審慎對待的好。否則，這樣也會人為地增加長安城內的坊里之數，使之與歷史事實不符，給研究帶來困擾。最後，本書除了對傳世文獻史料收集詳實是令人佩服的，而且更為可貴的是作者對所引史籍、墓誌、碑刻和詩文俱給予了明確的出處，這為研究者進一步的利用和理解資料提供了便利，這也是本書的另一價值所在。
但我們在肯定本部分的成果的同時，也應看到其存在不足之處。
一、此書完成於1987年，對已發表的研究成果也有所遺漏，最典型的例子就是有關朱雀街西自北向南之第一坊和第二坊為善和坊和通化坊兩坊的問題，關於這一問題，向來眾說紛紜，但黃永年先生在1985年《中國古都研究》第一輯上所發表的《述類編長安志》中，從此書的編纂特點和版本校勘的角度已作過考定，後又經辛德勇先生（前引書，26—27頁）、趙力光先生（《唐長安城善和通化兩坊考》，《文博》1993年第5期）進一步的論證，並且，日本森鹿三和松田壽男合編的《亞洲歷史地圖唐長安圖》也據福山敏男同樣的結論補上了善和與通化兩坊。但本書所附圖卻仍依《城坊考》，並且在論證過程未引黃先生的論證，對該問題仍未作定論，不免使人遺憾。二、有的論證並不是很詳細清楚，關於“安善坊”的問題，作者同意《城坊考》及平岡武夫《長安與洛陽》的“安善”系“崇業”舊名之說，而對城東另有“安善”一坊名，一城之內二坊重名的現象未作出解釋（264頁）。三、書中有審之不詳與疏漏之處，如晉昌坊中，作者就《全唐文》卷二二四梁未賓《大唐故朝議郎行澤王府主簿上柱國樑府君並夫人唐氏墓誌銘序》中“夫人晉昌唐氏”的記載補以唐氏宅。理由是唐世習慣以坊名冠於官稱姓氏之上，推測若無他解，則晉昌坊應有唐氏宅（325頁）。唐朝的確有以坊名來稱呼或指稱居住在坊裡的有影響的人物或是具有某種特色的家族，象靖恭楊家指楊汝士等兄弟、修行楊家指楊收兄弟、親仁後裔指郭子儀之後代​​，李安邑指居住於安邑坊的李德裕、劉光德指劉崇望。在姓氏前加以坊名的記載見《唐代墓誌彙編》殘志三一“故今之勗人者，舉曰修行鄭氏，……。修行其第之裡名也。”因在姓氏前加以坊名，易與郡望相混淆，所以在後加以補充說明。而此處的晉昌唐氏，無此說明，且瓜州晉昌郡唐氏為此地大姓，所以這應是瓜州晉昌而非長安之晉昌坊。又如作者雖注意到了有光天觀和先天觀的區別，但卻認為《唐會要》務本坊“光天觀”系“先天觀”之誤，應糾正，這一論斷是失考的（288—289頁）。關於“先天觀”應為“光天觀”，閻文儒（《兩京城坊考補》）、辛德勇（《隋唐兩京叢考》）、李健超（《增訂唐兩京城坊考》）諸位先生均有論證，此不贅述。此外，《唐會要》卷五○載平康坊中有華封觀，所記建觀始末完全同於《長安志》，《城坊考》對該坊中的萬安觀的記載，因此，作者認為萬安觀又名華封觀（62—63頁），但作者卻又疏漏了在興寧坊下也有華封觀，為高力士舍宅所立（435頁），這因《長安志》、《城坊考》把太平公主、姚元崇宅、郭虔瓘宅所記於平康、興寧兩坊中所致，因此，這一問題尚待考訂，而不能遽斷定華封觀就是萬安觀別名。四、書中有宅第重出的現象，如懷遠坊下，戴夫人宅與戴氏宅所用材料相同，本是一宅，但作者卻分為兩宅作以記載，未知何故（454頁）。五、筆者覺得作者有些增補之處還是值得商榷的。在新昌坊下作者根據《太平廣記》卷四八六載天寶九年夏六月，韋崟與其從妹婿鄭六會飲於新昌里推測新昌坊或有旗亭、酒樓之類（ 356頁），我認為理由並不是很充分，也有可能是會飲於其宅第。另作者據《太平廣記》卷八四《義寧坊狂人》：“元和初，上都義寧坊有婦人瘋狂，……常止宿於永穆牆下。”疑此“永穆”或是義寧坊中一牆名，或是永穆坊之牆（54頁）。但閻文儒先生在興寧坊條下曾補一“永穆觀”，筆者認為或許此系該觀之牆。
本書的第三部分，主要是收集《全唐文》、《千唐志齋藏志》、《八瓊室金石補正》以及《芒洛塚墓遺文》所錄碑文中坊名缺一字者，作者不妄加填補，別列出，以供參考。
第四部分，為兩京外郭城中寺、祠、衙署、宅第等等具體建築的索引，憑藉此，我們很快可以查到其在兩京中具體的坊裡，這也是本書較之於他書的一突出特點。
目前，根據考古發掘和大量出土墓誌，對唐代兩京建置增補考證的成果很多,這些成果是更深層次地研究兩京的政治、經濟、文化的基礎，為都市史研究的進一步展開提供了條件。但與此同時，我們也必須看到現在據新出土的史料和墓誌進行增補的時候，仍存在著一些問題應引起我們的注意：
在眾多的增補中，往往忽視遺漏敦煌吐魯番文書中有關兩京的記載亦可對兩京的地理、歷史有所增補。陳國燦先生在《從吐魯番出土的“質庫帳”看唐代的質庫制度》（《敦煌吐魯番文書初探》，武漢大學出版社，1983年10月，316—343頁）一文中，已經根據阿斯塔那206號墓中出土的唐代質庫帳歷補長安新昌坊民宅數處，池田溫和妹尾達彥兩位先生也將此運用到自己的研究中去，但在諸增補的著作中，卻未見利用。除此之外，根據敦煌寫本《敕河西節度兵部尚書張公德政之碑》中“宣陽賜宅，廩實九年之儲；錫壤千畦，地守義川之分”，可豐富兩京城坊考中對宣陽坊中張議潮宅的記載，並可知其有莊等等居住環境和方式。同時，該碑文中關於張議潭“春秋七十四，壽終於京永嘉坊之私第”的記載（碑文見榮新江《歸義軍史研究》附錄），我們於永嘉坊下又可增補“張議潭宅”一條。除此之外，就是在已發表的出土墓誌中，仍有疏漏，據此我們還可以對兩京的坊裡宅第加以增補。
在此還要補充說明的是，在據墓誌進行增補時，我認為結合兩京已有的記載和墓誌的內容，加以分析鑑別後再做增補是必要的。墓誌中某人卒於某坊裡，未必就可以據此補以此人之宅，要考慮婦女長期居母家而卒於母家，兄弟同居一坊，幾代同居一宅的情況，否則，只憑某一墓誌就增補一坊一宅，往往會使宅第重出，這將影響在此基礎上的進一步研究。
對兩京的增補考訂，隨著新墓誌材料的出土、整理和發表，取得了很大的發展，這為以後我們進行兩京的諸層面的研究奠定了良好的基礎，從這個意義上來說，楊鴻年先生的《隋唐兩京坊裡譜》對我們今後深層次地研究兩京具有重要價值。

原載《唐研究》第六卷，2000年

《反經》由唐人趙蕤著。

目錄 1 內容 2 思想 3 評價 4 參考文獻 5 參考

內容

該書共有六十三卷，上自「君德」、「臣行」、「王霸」，下至「是非」、「通變」、「相術」，旁及「出軍」、「練士」、「教戰」，博採諸子百家，結合歷代史實，針對近世弊政而發，具文學、史料、鏡鑒三重價值。原名《長短經》，有是非、得失、長短、優劣的意思。紀曉嵐編撰的《四庫全書·〈長短經〉提要》說：「此書辨析事勢，其言蓋出於縱橫家，故以『長短』為名。」

思想

該書雜糅儒家、道家、兵家、法家、雜家、陰陽家等諸家思想，論述霸王之術和官場秘訣，深刻而犀利。該書歷史事件從上古黃帝時期到唐朝前期，總結了中國歷代歷代的政治權謀得失。^[1]

評價

唐朝人稱：「趙蕤術數，李白文章」。^[1]
清高宗乾隆帝^[1]：

「

題《長短經》 郪縣創為救弊論，愛憎毆業匠和函。 向時雖類縱橫說，憂來原歸理道談。 宋刊棄自教忠堂，通變稱經曰短長。 比及亂時思治亂，不如平日慎行王。

」

毛澤東：《資治通鑒》是權謀，是陽謀，《長短經》是陰謀，是詭謀。^[1]

參考文獻

1. ^ ^{1.0 1.1 1.2 1.3} 趙蕤. 《反經》. 內蒙古: 內蒙古人民出版社. 2009:  導讀. ISBN 9787204036936 （簡體中文）.

維基文庫中相關的原始文獻：

反經

參考

維基文庫中相關的原始文獻：

長短經

• 儒門經濟長短經（繁體：天策府繁體兵書）

陶百川《困勉強狷八十年》 中国人権 《人權呼應》/《為人權法治呼號》

陶百川《困勉強狷八十年》台北: 三民書局 1984
1984年1月7日台北的季園: 此宴可待成追憶只是當時已茫然 : 陶百川應沈君山先生之邀與黨內外人士餐敘: 謝長廷、江春男、康寧祥、田弘茂、方素敏、陶百川、陳履安、周清玉、城仲模、沈君山、關中、張忠棟

 《論語》:

 困而知之
或勉強而行之
強哉矯
狷者有所不為


陶百川《困勉強狷八十年 自序》台北: 三民書局 1984 

 356-63頁的  "寧鳴而死，寧鳴而生"翻譯
 范仲淹《靈鳥賦》
 這在9年前胡適就發表過 他沒翻譯成白話文
 (自由中國 第12卷 七期 : 1954/9/3 日作 ；9/1 是范文正公生日)

-----
書名

	為人權法治呼號
作者	陶百川
出版者	文星1964/ 傳記文學出版社1970 /三民書局經售, 1973

「中国は人権状況改善を」　オバマ大統領、陳氏軟禁巡り

関連トピックス
バラク・オバマ

米国のオバマ大統領は４月３０日の会見で、中国の人権活動家、陳光誠氏が軟禁されていた自宅から脱出したことに関連し、「人権状況の改善は米中関係の強化や中国のさらなる繁栄につながる」と述べ、中国に人権問題への取り組みを求めた。
日米首脳会談後の共同記者会見で、質問に答えた。陳氏が北京の米国大使館の保護下にあることや米国への亡命の可能性については「この件について話すつもりはない」と述べるにとどめた。

我還沒讀過共33冊的《陶百川全集》(台北三民)

 不過現在二手書可能都可以找到諸如《中國勞動法之理論與實際》、《比較監察制度》、《監察制度新發展》、《臺灣要更好》、《臺灣怎樣能更好》、《人權呼應》、《東亞豪賭》、《陶百川叮嚀文存》等。

 

 《人權呼應》台北:遠景 1978  這是他剛"退休"之後的結集 同年初 杭立武等人成立人權協會
 可能是陶百川全集(5)《為人權呼號》台北：三民出版社1992

有趣的是《人權呼應》改為《為人權呼號》實際上原呼應的是世界人權宣言三十周年

维基百科，自由的百科全书

跳转到： 导航, 搜索

陶百川（1903年1月19日－2002年8月9日  HC案: 生日有1912  1911），浙江省紹興縣人，歷任中國國民黨上海市黨部執行委員、"干社"副幹事長、中國文化建設協會上海市分會幹事長、海《民國日報》編輯、《晨報》總主筆、香港《國民日報》社長、重慶《中央日報》總社社長、國民參政會參政員、制憲國民大會代表、上海大東書局總經理、監察院第一屆監察委員。

事略^[1]

• 大清光緒廿九年（1903年），即民前9年1月19日生於浙江省紹興縣。
• 民國15年（1926年）畢業於上海法科大學(法學士)，南方大學(文學士)
• 民國23年（1934年）赴美國哈佛大學進修
• 上海市臨時參議會參議員、淞滬警備司令部軍法處長
• 民國37年（1948年）上海市選出之第一屆監察委員
• 民國66年（1977年）獲聘為總統府國策顧問
• 民國79年（1990年）國家統一委員會委員。「國家統一綱領」的大部分內容是參照他起草的「國家統一初級綱領」寫成的。
• 民國89年（2000年）因健康因素請辭總統府國策顧問，並獲頒一等卿雲勳章。

著有《陶百川全集》　增《陶百川全集》共33冊，內容收錄陶百川先生在政治、外交、經濟、教育及法治方面的學術見解；從威權體制到民主開放的過程中，對於時事的觀感與看法；以 及擔任監委期間，不畏威權，挺身為人權法治秉筆直書、仗義直言的篇章。從中我們看見了傳統知識份子的仁心與義行，也看見了一個崇高清穆的人格典範。陶百川 先生被譽為「臺灣的良心」，可謂恰如其份、實至名歸。

參考文獻

1. ^ 「陶百川傳」《浙江省新聞志》,浙江省新聞志編纂委員會編,浙江人民出版社,2007.05，第904頁

Philip Roth

人物

菲利普·羅斯要說的話都說完了

CHARLES McGRATH 報道 2012年11月26日

這些日子以來，在菲利普·羅斯(Philip Roth) 上西區家裡的電腦上一直貼着一張即時貼，上面寫着：“與寫作的戰鬥結束了。”羅斯先生到明年3月就80歲了，自從1959年開始寫作以來，總共出了31本 書，是美國文學界最為長盛不衰的作家之一。這張字條是為了提醒他自己，他已經從寫小說這項事業中退休了。“每天早上我都看着這張便條，”他在不久前的一天 說道，“它給了我很多力量。”

對於朋友們來說，“羅斯不再寫作”這個念頭就和“羅斯不再呼吸”沒什麼兩樣。有時候他生活中好像只有寫作。每次他獨自呆在自己康涅狄格州的房子里， 一寫就是好幾個星期，每天早上到附近的工作室報到，在那裡站着寫作，經常是晚上又回去接着寫。在大多數小說家都已放慢腳步的年紀，他重又煥發出活力，寫出 了幾部可以躋身他最佳作品的小說：《薩巴斯劇院》(Sabbath’s Theater)、《美國牧歌》(American Pastoral)、《人性的污穢》(The Human Stain)和《反美陰謀》(The Plot Against America)。他70多歲時寫的書短了些，但仍保持幾乎是每年推出一本的速度。

按圖放大

Fred R. Conrad/The New York Times

羅斯先生說自己2010年就已經決定停止寫作，只是未對任何人說起。

按圖放大

年輕的菲利普（左二）與父母和哥哥桑迪在他們康涅狄格州的房子外面。

Fred R. Conrad/The New York Times

羅斯先生與奧巴馬總統，這位小說家如今正和自己的傳記作者一起工作。

按圖放大

羅斯先生的母親。

但在長達3小時的採訪過程中（他說這是自己最後一次接受採訪），羅斯先生看上去好像對自己、對這個決定感到喜悅、輕鬆和平靜，這個決定是上個月他對 法國的《Les InRocks》雜誌首次宣布的。他開着玩笑，追憶過去，聊起其他作家和寫作的事情，追溯自己的寫作生涯，他看上去很滿足，也有寥寥的遺憾。春天時他指定 布萊克·貝利(Blake Bailey)來寫他的傳記，此後貝利便開始與他密切合作。

羅斯先生說自己其實在2010年寫完小說《復仇女神》(Nemesis)幾個月後就已經做出了停止寫作的決定，那本小說是關於他的家鄉紐瓦克1944年的脊髓灰質炎(hc: 小兒痲痺)大流行事件。

“我當時還不確定這個想法是不是真實的，所以什麼也沒有說，”他說，“我想，‘等一等，可別宣布了自己退休然後又反悔。’我可不是弗蘭克·辛納塔(Frank Sinatra)。所以當時我沒對任何人說起這件事，只是想看看事情到底是不是這樣。”

在他起居室的桌子上放着一堆表親剛送來的照片，其中有他母親的婚紗照，她的頭紗一直垂落到台階上；羅斯先生小時候與父母和哥哥桑迪(Sandy)在 紐瓦克家門口拍的照片；十幾歲時的羅斯和第一個正式女友坐在沙發上拍的照片；還有羅斯在軍中服役期間穿着二等兵軍裝、戴着頭盔拍的照片。

桌上還有他新買的iPhone。“為什麼？”他說，“因為我自由了。每天早上我都讀一章《iPhone傻瓜指南》(iPhone for Dummies)，現在已經是專家了。兩個月來我沒讀什麼東西，光是把這玩意兒拿出來玩。”

然後他又糾正自己：“我白天不閱讀，到晚上才閱讀，每天讀兩個小時。我剛看完路易斯·厄德里奇(Louise Erdrich)精彩的小說《圓屋》。但主要還是讀20世紀的歷史與傳記。我曾生活在20世紀，在那個時代里上學和工作，那是我的時代。”

羅斯先生說，就他所知，唯一一個仍有很強創作能力卻急流勇退的作家是E·M·福士特(E. M. Forster)，他在40多歲時停止了寫作。但福士特先生擱筆主要是因為他最感興趣的是同性之愛，他覺得關於這個主題的書肯定無法獲得出版。而羅斯先生 停止寫作是因為覺得自己想說的話已經說完了。

“我坐在那兒思考了一兩個月，看看能不能再想出點什麼別的，後來我想‘也許已經結束了，也許已經結束了’，”他說。“我給自己來了一劑文學果汁，就 是重讀那些當年曾對我有重大意義，但已經50年沒讀過的作家們的作品。我讀了陀思妥耶夫斯基和康拉德，每個人的書我都讀了兩三本。還有屠格涅夫的兩篇最好的短篇小說：《初戀》(First Love)和《春潮》(The Torrents of Spring)。”此外他還重讀了福克納和海明威。

“然後我又決定重讀我自己的書，”羅斯先生繼續說，“我從自己最新的書讀起，對它們冷眼旁觀。我想：‘你寫得還不錯。’但當我讀到‘波特諾’那本的 時候，”——他指的是1969年出版的《波特諾的抱怨》(Portnoy’s Complaint)——“我失去了興趣，就沒再接着看自己最早的那4本書。”

“就這樣，我讀了那些偉大的作品，”他接著說，“然後又讀了我自己的書，我知道自己不會再有好點子，就算有，也會被它所奴役。”

羅斯先生現在身體非常健康，4月份他的背部動了手術，之後一直有規律地進行鍛煉。但他說：“我知道自己不能再像以前那樣寫作。我不再有那種忍耐挫敗 的毅力。寫作是一種挫敗——是每天都要面對的挫敗，更別提羞辱的感覺。就像棒球一樣，你總是輸掉2/3的比賽。”他繼續說：“我再也不能面對寫了5頁紙然 後把它們全扔掉的日子。我再也無法忍受了。”

當秋日的陽光過於耀眼，羅斯先生拉上了起居室一扇大窗的窗帘。這是他在紐約的家，不過他仍然會在康涅狄格州的家常住，不再寫作讓他可以有空娛樂。

“今年夏天我家裡客人不斷，”他說，“差不多每周末都有客人，有時候一呆就是一星期。現在有個廚師給我做飯。以前我從來不請人去那棟房子。他們一去那兒過周末，我就沒法去工作室寫作了。”

羅斯先生並沒有完全放棄寫作。他通過e-mail正在和一位前女友8歲的女兒合寫一個短篇小說；還為自己的傳記作者寫大量的筆記和備忘錄。

“我現在是在為布萊克·貝利工作，”他說，“報酬可不怎麼高。”他還說，自己以前從來沒對任何人這麼誠實過。

“布萊克減輕了我的負擔，”他說，“我不必再對自己的人生負責，也不必再去深挖它。你知道，為了寫小說，我需要把自己的人生當做一塊跳板。寫作的時 候，我腳下必須有些堅實的基礎。我可不是奇幻作家。這感覺就像站在有彈性的跳水板上，身體隨之上下起伏，然後一頭躍進小說之水。但是創作小說還是要以真實 人生為起點，這樣才能讓小說自始至終富有生命力。”
貝利先生說，羅斯先生準備的筆記已經裝滿了幾個箱子。“它們文筆雄辯，內容廣泛，”他補充說，“但是太多了，幾年工夫我都讀不完。”

羅斯先生有一件事要澄清：經常有人錯誤地引用他的話，說他曾聲稱“小說死了”。“我不相信小說會死，”他堅持道，“我是說小說讀者正在消失。這是事 實，這話我已經說了15年了。我說屏幕會殺死讀者，事實也的確如此。先是電影屏幕，然後是電視屏幕，現在又是最後一擊——電腦屏幕。”
但是，就算讀者人數減少了，偉大的小說還是會持續不斷地創作出來。“艾德·道克托羅 (Ed Doctorow)，”他開始列舉自己喜歡的作家。“堂·德里洛(Don DeLillo)，還有丹尼斯·約翰遜(Denis Johnson)，他們都非常棒。弗蘭岑(Franzen)——非常棒。厄德里奇(Erdrich)——簡直太厲害了。還有20來個非常非常不錯的年輕作家。都值得關注。”
他還說：“為什麼還需要更多讀者呢？數量不代表全部。圖書有自己的意義。”
此刻天色已晚。他站起身來，腳上只穿着長襪。他走到房間另一頭，打開了幾盞燈。

本文最初發表於2012年11月18日。

翻譯：董楠

《美國畫時代作品評論集》

 

第一次世界大戰前後的時代氛圍，因人因地有許多不同的看法和展現。譬如說，美國文學上稱戰後為失落的一代，《美國畫時代作品評論集‧E. E. Cummings的《巨室》》(Landmarks of American writing. Edited by Hennig Cohen)朱立民等譯， 台北：新亞出版，1971，頁364-80

 

 

 

《美國畫時代作品評論集》朱立民等譯， 台北：新亞出版，1971.  
北京: 三联书店 1988  有PDF

Landmarks of American writing. Edited by Hennig Cohen

Bib ID	1000518
Format	Book
Description	New York, Basic Books [1969] xiv, 398 p. 22 cm.
Notes	"Essays ... originally prepared for the Voice of America for presentation as lectures ... through its Forum series." Includes bibliographical references.
Subjects	American literature - History and criticism.
Other authors/contributors	Cohen, Hennig, ed  |  Voice of America (Organization)

The Checklist Manifesto: How to Get Things Right

此書中國有翻譯本: 清單革命


The Checklist Manifesto: How to Get Things Right [Hardcover] 2009
Atul Gawande (Author)

Amazon's December Book of the Month summary describes the author's mission of revolutionizing the "to-do list...without programmatic steps or tables to help reshuffle daily tasks." One may infer from this recap that this is a how-to-self-improvement book for making one more productive, more efficient and less stressed - this couldn't be farther from the core message of this book.

The author's key message is that the volume and complexity of knowledge today has exceeded any single individual's ability to manage it consistently without error despite material advances in technology, boatloads of more training and super-specialization of functions and responsibilities. Yet, despite demonstrating that checklists produce results, there is resistance to their use because of the (1) Master of Universe mentality (Rock Star; Fighter Pilot; Hero), (2) our jobs are too complex to reduce to a checklist, (3) checklists are too rigid and don't force us to look up and see and think ahead of what's in front of us. Yet, in a complex environment, he states that experts are up against 2 difficulties - the fallibility of human memory when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events and secondly, people can lull themselves into skipping steps even when they remember them - after all certain steps don't always matter...until one day they do. Gawande makes a persuasive case in his book as to why you should develop and implement a process checklist for critical processes/decisions.

* Whether you are from the medical field or not, you will benefit from the inspiring thinking and insights.

* This book is game changing - a call-to-action for generating better results despite the pull to run with intuition or gut instinct. If you are implementing via intuition rather than a systematic process, this book's message will force you to pause in your tracks to seek a more disciplined approach.

* The author uses a wide range of industries to make his case using an engaging blend of anecdotes, storytelling and research - from healthcare to aviation (US Airways 1549 landing in Hudson River) - - to high-end award winning restaurants - - to building massive office skyscrapers and shopping centers - -to setting up a Van Halen rock concert - - to FEMA's response to Hurricane Katrina in New Orleans - - to money managers making investment selections.

* Can be read in 1-2 sittings. Page Turner. Fully engaging and riveting until the last page is turned.

* Author's determination, authenticity, inspired thinking, modesty and willingness to disclose personal mistakes makes this an inspirational book. Both brilliantly written and a pleasure to read.

My favorite excerpts:

"Despite showing (hospital) staff members of the benefits of using the checklist, 20% resisted stating that it was not easy to use, it took too long and felt it had not improved the safety of care. Yet, when asked an additional question - would you want the checklist to be used if you were having an operation - a full 93% said yes."

"In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person's abilities, individual autonomy hardly seems the ideal we should aim for. ..what is needed, however is discipline...discipline is hard - harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can't even keep from snacking between meals. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at."

"We don't study routine failures...when we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It's time to try something else. Try a checklist."

"We're obsessed in medicine with having great components, the best drugs, the best devices, the best specialists - but pay little attention to how to make them fit together well""

"It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us - those we aspire to be - handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating."


----

Excerpt

‘The Checklist Manifesto’

By ATUL GAWANDE

Published: December 23, 2009

Chapter 1: The Problem of Extreme Complexity

Related

The Sunday Book Review on ‘The Checklist Manifesto’ (January 24, 2010)

Robin Marantz Henig’s Review of ‘The Checklist Manifesto’ (December 24, 2009)

Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three- year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in after her. But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.
Rescue personnel arrived eight minutes later and took the first recordings of the girl's condition. She was unresponsive. She had no blood pressure or pulse or sign of breathing. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.
But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crew straddling her on the gurney, pumping her chest. A surgical team got her onto a heart- lung bypass machine as rapidly as it could. The surgeon had to cut down through the skin of the child's right groin and sew one of the desk- size machine's silicone rubber tubes into her femoral artery to take the blood out of her, then another into her femoral vein to send the blood back. A perfusionist turned the pump on, and as he adjusted the oxygen and temperature and flow through the system, the clear tubing turned maroon with her blood. Only then did they stop the girl's chest compressions.
Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half. By the two- hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.
After six hours, the girl's core reached 98.6 degrees, normal body temperature. The team tried to shift her from the bypass machine to a mechanical ventilator, but the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the breathing tube to reach her blood. So they switched her instead to an artificial- lung system known as ECMO — extracorporeal membrane oxygenation. To do this, the surgeons had to open her chest down the middle with a power saw and sew the lines to and from the portable ECMO unit directly into her aorta and her beating heart.
The ECMO machine now took over. The surgeons removed the heart- lung bypass machine tubing. They repaired the vessels and closed her groin incision. The surgical team moved the girl into intensive care, with her chest still open and covered with sterile plastic foil. Through the day and night, the intensive care unit team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. By the next day, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.
Over the next two days, all the girl's organs recovered — her liver, her kidneys, her intestines, everything except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team escalated the care one step further. It drilled a hole into the girl's skull, threaded a probe into the brain to monitor the pressure, and kept that pressure tightly controlled through constant adjustments in her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.
First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely. Physical and neurological examinations were normal. She was like any little girl again.
What makes this recovery astounding isn't just the idea that someone could be brought back after two hours in a state that would once have been considered death. It's also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated. Rescuing a drowning victim is nothing like it looks on television shows, where a few chest compressions and some mouth- to- mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life. To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart- pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the exposed fluid in her brain; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.
For every drowned and pulseless child rescued, there are scores more who don't make it — and not just because their bodies are too far gone. Machines break down; a team can't get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don't get written up in the Annals of Thoracic Surgery, but they are the norm, though people may not realize it.
I think we have been fooled about what we can expect from medicine—fooled, one could say, by penicillin. Alexander Fleming's 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. Penicillin, after all, seemed to be effective against an astonishing variety of previously untreatable infectious diseases. So why not a similar cure- all for the different kinds of cancer? And why not something equally simple to melt away skin burns or to reverse cardiovascular disease and strokes?
Medicine didn't turn out this way, though. After a century of incredible discovery, most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors once treated with penicillin: not all bacterial strains were susceptible and those that were soon developed resistance. Infections today require highly individualized treatment, sometimes with multiple therapies, based on a given strain's pattern of anti biotic susceptibility, the condition of the patient, and which organ systems are affected. The model of medicine in the modern age seems less and less like penicillin and more and more like what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity — and a test of whether such complexity can, in fact, be humanly mastered.
The ninth edition of the World Health Organization's international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury — more than thirteen thousand different ways, in other words, that the body can fail. And, for nearly all of them, science has given us things we can do to help. If we cannot cure the disease, then we can usually reduce the harm and misery it causes. But for each condition the steps are different and they are almost never simple. Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right.
There is a community clinic in Boston's Kenmore Square affiliated with my hospital. The word clinic makes the place sound tiny, but it's nothing of the sort. Founded in 1969, and now called Harvard Vanguard, it aimed to provide people with the full range of outpatient medical services they might need over the course of their lives. It has since tried to stick with that plan, but doing so hasn't been easy. To keep up with the explosive growth in medical capabilities, the clinic has had to build more than twenty facilities and employ some six hundred doctors and a thousand other health professionals covering fifty- nine specialties, many of which did not exist when the clinic first opened. Walking the fifty steps from the fifth- floor elevator to the general surgery department, I pass offices for general internal medicine, endocrinology, genetics, hand surgery, laboratory testing, nephrology, ophthalmology, orthopedics, radiology scheduling, and urology — and that's just one hallway.
To handle the complexity, we've split up the tasks among various specialties. But even divvied up, the work can become overwhelming. In the course of one day on general surgery call at the hospital, for instance, the labor floor asked me to see a twenty-five- year- old woman with mounting right lower abdominal pain, fever, and nausea, which raised concern about appendicitis, but she was pregnant, so getting a CT scan to rule out the possibility posed a risk to the fetus. A gynecological oncologist paged me to the operating room about a woman with an ovarian mass that upon removal appeared to be a metastasis from pancreatic cancer; my colleague wanted me to examine her pancreas and decide whether to biopsy it. A physician at a nearby hospital phoned me to transfer a patient in intensive care with a large cancer that had grown to obstruct her kidneys and bowel and produce bleeding that they were having trouble controlling. Our internal medicine service called me to see a sixty- one- year- old man with emphysema so severe he had been refused hip surgery because of insufficient lung reserves; now he had a severe colon infection — an acute diverticulitis — that had worsened despite three days of antibiotics, and surgery seemed his only option. Another service asked for help with a fifty- two- year- old man with diabetes, coronary artery disease, high blood pressure, chronic kidney failure, severe obesity, a stroke, and now a strangulating groin hernia. And an internist called about a young, otherwise healthy woman with a possible rectal abscess to be lanced.
Confronted with cases of such variety and intricacy — in one day, I'd had six patients with six completely different primary medical problems and a total of twenty- six different additional diagnoses — it's tempting to believe that no one else's job could be as complex as mine. But extreme complexity is the rule for almost everyone. I asked the people in Harvard Vanguard's medical records department if they would query the electronic system for how many different kinds of patient problems the average doctor there sees annually. The answer that came back flabbergasted me. Over the course of a year of office practice — which, by definition, excludes the patients seen in the hospital — physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures — from vaccinations to setting fractures.
Even considering just the office work, the statistics still didn't catch all the diseases and conditions. One of the most common diagnoses, it turned out, was "Other." On a hectic day, when you're running two hours behind and the people in the waiting room are getting irate, you may not take the time to record the precise diagnostic codes in the database. But, even when you do have the time, you commonly find that the particular diseases your patients have do not actually exist in the computer system.
The software used in most American electronic records has not managed to include all the diseases that have been discovered and distinguished from one another in recent years. I once saw a patient with a ganglioneuroblastoma (a rare type of tumor of the adrenal gland) and another with a nightmarish genetic condition called Li- Fraumeni syndrome, which causes inheritors to develop cancers in organs all over their bodies. Neither disease had yet made it into the pull- down menus. All I could record was, in so many words, "Other." Scientists continue to report important new genetic findings, subtypes of cancer, and other diagnoses — not to mention treatments — almost weekly. The complexity is increasing so fast that even the computers cannot keep up.
But it's not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution — the practical matter of what knowledge requires clinicians to do. The hospital is where you see just how formidable the task can be. A prime example is the place the girl who nearly drowned spent most of her recovery — the intensive care unit.
It's an opaque term, intensive care. Specialists in the field prefer to call what they do critical care, but that still doesn't exactly clarify matters. The nonmedical term life support gets us closer. The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst aorta, a ruptured colon, a massive heart attack, rampaging infection. These maladies were once uniformly fatal. Now survival is commonplace, and a substantial part of the credit goes to the abilities intensive care units have developed to take artificial control of failing bodies. Typically, this requires a panoply of technology — a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don't work. If you are unconscious and can't eat, silicone tubing can be surgically inserted into your stomach or intestines for formula feeding. If your intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into your bloodstream.
On any given day in the United States alone, some ninety thousand people are admitted to intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: care for premature infants; for victims of trauma, strokes, and heart attacks; for patients who have had surgery on their brains, hearts, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, ICUs barely existed. Now, to take a recent random day in my hospital, 155 of our almost 700 patients are in intensive care. The average stay of an ICU patient is four days, and the survival rate is 86 percent. Going into an ICU, being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.
Fifteen years ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty- four- hour stretches. They found that the average patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions — but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot. You have to stretch and exercise patients' flaccid limbs daily to avoid contractures; you have to give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and the care of open wounds, and the difficulties only accumulate.
The story of one of my patients makes the point. Anthony DeFilippo was a forty- eight- year- old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones. The surgeon was finally able to stop the bleeding but DeFilippo's liver was severely damaged, and over the next few days he became too sick for the hospital's facilities. I accepted him for transfer in order to stabilize him and figure out what to do. When he arrived in our ICU, at 1:30 a.m. on a Sunday, his ragged black hair was plastered to his sweaty forehead, his body was shaking, and his heart was racing at 114 beats a minute. He was delirious from fever, shock, and low oxygen levels.
"I need to get out!" he cried. "I need to get out!" He clawed at his gown, his oxygen mask, the dressings covering his abdominal wound.
"Tony, it's all right," a nurse said to him. "We're going to help you. You're in a hospital."
He shoved her out of the way — he was a big man — and tried to swing his legs out of the bed. We turned up his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually tired out and let us draw blood and give him antibiotics.
The laboratory results came back showing liver failure and a steeply elevated white blood cell count, indicating infection. It soon became evident from his empty urine bag that his kidneys had failed, too. In the next few hours, his blood pressure fell, his breathing worsened, and he drifted from agitation to near unconsciousness. Each of his organ systems, including his brain, was shutting down.
I called his sister, his next of kin, and told her the situation. "Do everything you can," she said.
So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident "lined him up." She inserted a thin two- inch- long needle and catheter through his upturned right wrist and into his radial artery, then sewed the line to his skin with a silk suture. Next, she put in a central line — a twelve- inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to — inside his vena cava at the entrance to his heart — she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.
We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of 100 percent oxygen every minute. We dialed the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt, as well. He was, we liked to imagine, a simple machine in our hands.
But he wasn't, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway 18wheeler hurtling down a mountain. Keeping that patient's blood pressure normal required gallons of intravenous fluid and a pharmacy shelf of drugs. He was on near- maximal ventilator support. His temperature climbed to 104 degrees. Less than 5 percent of patients with DeFilippo's degree of organ failure make it home. A single misstep could easily erase those slender chances.
For ten days, though, we made progress. DeFilippo's chief problem had been liver damage from his prior operation: the main duct from his liver was severed and was leaking bile, which is caustic — it digests the fat in one's diet and was essentially eating him alive from the inside. He had become too sick to survive an operation to repair the leak. So once we had stabilized him, we tried a temporary solution — we had radiologists place a plastic drain, using CT guidance, through his abdominal wall and into the severed duct in order to draw out the leaking bile. They found so much that they had to place three drains — one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His need for oxygen and fluids diminished, and his blood pressure returned to normal. He was beginning to mend. Then, on the eleventh day, just as we were getting ready to take him off the ventilator, he again developed high, spiking fevers, his blood pressure sank, and his blood- oxygen levels plummeted again. His skin became clammy. He got shaking chills.
We couldn't understand what had happened. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source. Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded and went back into rhythm. It took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty- eight hours later, the results returned. All the lines were infected. The infection had probably started in one line, which perhaps was contaminated during insertion, and spread through DeFilippo's bloodstream to the others. Then they all began spilling bacteria into him, producing the fevers and steep decline.
This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection. After ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.
It was another week before DeFilippo recovered sufficiently from his infections to come off the ventilator and two months before he left the hospital. Weak and debilitated, he lost his limousine business and his home, and he had to move in with his sister. The tube draining bile still dangled from his abdomen; when he was stronger, I was going to have to do surgery to reconstruct the main bile duct from his liver. But he survived. Most people in his situation do not.
Here, then, is the fundamental puzzle of modern medical care: you have a desperately sick patient and in order to have a chance of saving him you have to get the knowledge right and then you have to make sure that the 178 daily tasks that follow are done correctly — despite some monitor's alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help "get this lady's chest open." There is complexity upon complexity. And even specialization has begun to seem inadequate. So what do you do?
The medical profession's answer has been to go from specialization to superspecialization. I told DeFilippo's ICU story, for instance, as if I were the one tending to him hour by hour. That, however, was actually an intensivist (as intensive care specialists like to be called). As a general surgeon, I like to think I can handle most clinical situations. But, as the intricacies involved in intensive care have grown, responsibility has increasingly shifted to super-specialists. In the past decade, training programs focusing on critical care have opened in most major American and Eu ro pe an cities, and half of American ICUs now rely on superspecialists.
Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one- year medical degree to practice medicine. By the century's end, all doctors had to have a college degree, a four- year medical degree, and an additional three to seven years of residency training in an individual field of practice — pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology, or critical care. A young doctor is not so young nowadays; you typically don't start in in de pen dent practice until your midthirties.
We live in the era of the superspecialist — of clinicians who have taken the time to practice, practice, practice at one narrow thing until they can do it better than anyone else. They have two advantages over ordinary specialists: greater knowledge of the details that matter and a learned ability to handle the complexities of the particular job. There are degrees of complexity, though, and medicine and other fields like it have grown so far beyond the usual kind that avoiding daily mistakes is proving impossible even for our most superspecialized.
There is perhaps no field that has taken specialization further than surgery. Think of the operating room as a particularly aggressive intensive care unit. We have anesthesiologists just to handle pain control and patient stability, and even they have divided into subcategories. There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists, and many others. Likewise, we no longer have just "operating room nurses." They too are often subspecialized for specific kinds of cases.
Then of course there are the surgeons. Surgeons are so absurdly ultraspecialized that when we joke about right ear surgeons and left ear surgeons, we have to check to be sure they don't exist. I am trained as a general surgeon but, except in the most rural places, there is no such thing. You really can't do everything anymore. I decided to center my practice on surgical oncology — cancer surgery — but even this proved too broad. So, although I have done all I can to hang on to a broad span of general surgical skills, especially for emergencies, I've developed a particular expertise in removing cancers of endocrine glands.
The result of the recent de cades of ever- refined specialization has been a spectacular improvement in surgical capability and success. Where deaths were once a double- digit risk of even small operations, and prolonged recovery and disability was the norm, day surgery has become commonplace.
Yet given how much surgery is now done — Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually — the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year — more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.
Medicine, with its dazzling successes but also frequent failures, therefore poses a significant challenge: What do you do when expertise is not enough? What do you do when even the super-specialists fail? We've begun to see an answer, but it has come from an unexpected source — one that has nothing to do with medicine at all.
Excerpted from The Checklist Manifesto by Atul Gawande. Copyright © 2009 by Atul Gawande. Published in 2010 by Henry Holt and Company, LLC. All rights reserved. This work is protected under copyright laws and reproduction is strictly prohibited. Permission to reproduce the material in any manner or medium must be secured from the Publisher.

美國醫療界危機之(七本)書評 Medicine Becomes a Science: 1840-1999

Title	Medicine Becomes a Science: 1840-1999 History of medicine
Author	Kate Kelly
Publisher	Facts On File, Incorporated, 2010

 acts On File, Incorporated, 2010 - 168 pages

Spanning 160 years, this volume offers information about medical knowledge, describing the historic events, scientific principles, and technical breakthroughs that have led to rapid advancement in combating disease. It also features a chronology, a glossary, and an array of historical and other sources for further research.

 

 

 

 

 中譯 醫學成為一門科學  上海科學技術文獻  2012    簡單精彩!

書名, 從體液論到醫學科學(From humors to medical science)作者, John Duffy. : 青岛出版社，2000 從體液論到醫學科學:美国医学的演進歷程

2007年初對於七本探討美國醫療界危機之書評

Knowledge Review

---

Does Health Care Have a Future?
by Joe Flower and David Knott

Eight books about the health-care system diagnose its problems and offer solutions.

Photograph by Opto

It is no secret that health care in the U.S. is in crisis. Americans share a sense of impending catastrophe, and for good reason. Health care in the United States consumes some $2 trillion per year — 16 percent of the GDP, and four times the expenditure for national defense. Yet U.S. health care’s performance is ranked 15th globally by the World Health Organization; American life expectancy ranks 22nd in the world, and infant mortality ranks 39th. The U.S. spends more on health-care insurance than any other nation, yet 46 million Americans do without — a number that increases every year. The out-of-pocket costs of those who have insurance have nearly tripled in the last six years, as health-care premiums continue to rise at nearly three times the general inflation rate. Unpaid and unpayable health-care bills account for the majority of all personal bankruptcies in the country.

This can’t go on. We cannot continue to have rising costs, uneven quality, and shrinking access to care. The appalling realities of the chaos we call health care (don’t bother calling it a system) have spawned a cottage industry of pundits, consultants, critics, and professional headscratchers. And this industry has spawned an ever-growing library of books hawking solutions, ranging roughly from the “manna from heaven” vision to the “let them eat Vioxx” point of view. But has anyone come up with a real solution?

To know a real answer when we see it, we must define the question clearly. On the basis of our research, our experience, and a broad review of the literature, we believe that a true health-care solution would meet eight criteria.

1. Consistent High Quality. A large and growing body of evidence suggests that health care in the United States could be far more effective than it is now. One data point to consider: In December 2004, the not-for-profit Institute for Healthcare Improvement, based in Cambridge, Mass., launched the “100,000 Lives Campaign”; its goal was to save those lives in U.S. hospitals through improved care. By June 2006 it had already exceeded that goal by 20 percent. That this campaign succeeded so quickly is impressive, but the very swiftness of that achievement also shows how pervasive care of uneven quality is, and how little attention it has received until recently.

2. Lower Cost. In many cases, this point follows from the first. Higher-quality care is often inherently less expensive; providers improve their quality by honing their organizational processes to become more efficient and effective, to avoid error, and to do things right the first time. We’ve seen this happen in branches of the health industry that compete directly for the consumer dollar, such as plastic surgery and laser vision correction, where a proliferation of products and providers over the past 15 years has been accompanied by provably higher quality and dropping prices. Such examples make it clear that health care could not only slow its inflation rate but actually drop its costs substantially.

3. Available to All. For ethical, political, systemic, and business reasons, health care must be universal: available to everyone. There are many ways to enable this — for example, by extending Medicare universally, establishing government-funded medical savings accounts and catastrophic health plans for the working uninsured, creating combinations of tax credits and vouchers, or some other approach. And universal coverage need not mean a single-payer system or more government control.

4. Single Model. For many of the same reasons, it will not work to have one system for the well-off while everyone else gets what health-care futurist Ian Morrison calls “the Department of Motor Vehicles with stethoscopes.” The market can be segmented, as most markets are, but one way or another, every provider in the system must compete to offer the best product at the best price.

5. Shaped by Market Forces. The experiences of the past 30 years make it clear that the market has the sustained systemic power to bring consumers more for less. We’ve already seen this phenomenon in other industries, as well as in the portions of health care that compete directly for the consumer dollar. (See number 2.)

6. Practical. Politically, economically, and systemically, the solution must arise from present realities. We cannot take seriously any proposal that wipes out the existing health plans, for example, for the simple reason that health plans alone represent 5 percent of the U.S. economy.

7. Progressive. The solution must recognize that dramatic change cannot happen all at once. It has to be possible for any sector of health care, or even individual organizations, to move toward the new way of operating and be rewarded for it.

8. Self-Reinforcing. As any one part of the system moves toward the new reality, that movement must allow and encourage other parts of the system to move forward as well.

Taken together, these make for a very tall order. But if a proposed solution does not satisfy all of these criteria, it is either incomplete or impossible. The experience of reading through the reform literature, however, is an exercise in frustration. Author after author describes a piece of the problem and solution perfectly, each feeling a different part of the proverbial elephant, but no one author has addressed the whole problem.

Achieving Universal CareFew books do a better job of describing the ills afflicting the U.S. health-care system than Donald L. Barlett and James B. Steele’s Critical Condition: How Health Care in America Became Big Business and Bad Medicine. This book is both true and infuriating. It shows vividly why almost everyone is deeply outraged about health care, and how a complex, dysfunctional system can look like a conspiracy to outsiders.

Most importantly, this book focuses on the problem of universal care. The Pulitzer Prize–winning investigative team documents the plight of the tens of millions of uninsured or underinsured Americans who can’t easily get access to treatment, and the horrors of a system that forces doctors and nurses to cut corners with patients in order to save money while companies notch ever-higher profits.

If you wish to put shape and detail to your outrage, read the work of Barlett and Steele. But their prescription for reform, a single-payer system, suffers from the problems common to all such arguments: Eliminating the entire health insurance industry with a stroke of a legislative pen is politically and economically impractical. And although such schemes eliminate the huge cost of private insurance, they do nothing to drive down the root costs of medical care or to improve its quality.

Alternatively, to compare a variety of proposed payment mechanisms that would cover all Americans in the name of universal care, you could look into a number of recent titles, including Uninsured in America: Life and Death in the Land of Opportunity, by Susan Starr Sered and Rushika Fernandopulle; the Institute of Medicine’s Insuring America’s Health: Principles and Recommendations; Charles R. Morris’s Apart at the Seams: The Collapse of Private Pension and Health Care Protections; and Jill S. Quadagno’s One Nation, Uninsured: Why the U.S. Has No National Health Insurance. Each of these books argues compellingly for its own set of schemes, including among them total government control and direct payment, mandated employer insurance, government-subsidized insurance for the near-poor, vouchers, and tax credits. Some propose funding such an expansion by ending the tax deductibility of health insurance.

Unfortunately, none of the books engages the full scope of the problem. Although any number of these schemes might effectively give all Americans access to the existing health-care system, none addresses the fundamental systemic drivers that have caused health-care costs to increase while those of other industries have moderated or dropped. And none addresses the demonstrated unevenness of current medical care. If health care continues to eat up more and more of the national economy, no scheme to cover every American can work. However you slice and dice the economy, there simply will never be enough resources to pay for a perpetually expanding health-care system. Anyone who wants to argue a social agenda for insuring all citizens must show how we can change the current system to make health care less expensive and more effective, so that we can afford universal coverage.

We get closer to the nub with a pair of books about how society can fund health-care coverage: Arnold S. Kling’s slim Crisis of Abundance: Rethinking How We Pay for Health Care, and a massive tome edited by Regina E. Herzlinger, Consumer-Driven Healthcare: Implications for Providers, Payers, and Policymakers. Kling’s book advocates greater government involvement in the care of the very sick, the chronically ill, and the very poor — those who really need it. His principal argument is that governments waste their tax dollars with a number of policies: by paying for the care of all people over 65, including those who are not poor or sick; by making health insurance tax deductible for everyone, whether they need it or not; and by stinting on services for the very poor and uninsured, who end up spending more than they would otherwise need to because they tend to wait to seek care until the last minute, when their condition has become acute. Kling offers a number of specific insurance mechanisms for shifting tax-supported health care to those who really need it, and away from those who need it less, such as healthy, childless adults. Yet none of his solutions are self-generating or self-sustaining. All require major legislation and central direction. And oddly, considering the libertarian bent of the publisher, the Cato Institute, he does not focus on the capacity of competition to shape the health-care market.

By contrast, Regina Herzlinger, a professor at Harvard Business School, does focus on competition. Consumer-Driven Healthcare examines the power of the new “consumer-directed health plans” (CDHPs), which combine high-deductible catastrophic insurance with health savings accounts to remold health care around consumers’ needs and desires. CDHPs, she argues, will open health care to new levels and types of competition, bringing us savings and higher quality — the usual products of market competition. You can gather the core of her argument in the first section of the book, a cogent and knowledgeable 202 pages written by Herzlinger herself, leaving aside the subsequent hundreds of pages by 92 other authors. She gets the key points right: What is missing in health care is true competition, driven by information and the power of the consumer to choose. For the first time, CDHPs allow for that possibility. If even a significant fraction of health-care consumers begin operating like true retail buyers, then the market as a whole will begin to act like a true retail market.

Redefining Competition
But Michael E. Porter and Elizabeth Olmsted Teisberg carry the argument a crucial step further in Redefining Health Care: Creating Value-Based Competition on Results. Porter and Teisberg — he is a professor at Harvard Business School and she at the Darden School of Business at the University of Virginia — ask the key question: Why has competition failed to work the same wonders in health care that it has in so many other industries? Their answer: because competition has taken place at the wrong level and over the wrong goals. Further exacerbating the problem is the complete absence of feedback loops (information channels that help a system govern itself). Very little in health care has a real price or a real, measurable result. This book comes closest of all to getting at the core problem of the U.S. health-care system and, for that reason, is the single indispensable work in the current field.

Competition in health care has consisted, in the main, of health plans’ and providers’ attempts to push cost and risk off themselves and onto each other or onto employers — and now, in some cases with CDHPs, onto the consumer. To the extent that providers have competed against one another, it has been as massive institutions that claim to do everything well. The first key insight of Porter and Teisberg is that, as health-care consumers, we are not looking to embrace an institution, but for a solution to a particular medical condition. We want the baby successfully delivered, the knee fixed, the diabetes managed. It is at this level, the level of the medical condition, that any true competition must occur.

Their second key insight is that when we turn to health care for a solution to our medical condition, we do not typically find any products designed to solve our problems. We find a vast array of specialists, technologies, devices, drugs, and therapies. Unlike other service industries, health care does not usually offer discrete, comprehensive “packages,” such as a “birthing program” that carries the mother and child from the earliest prenatal care through the birth, dealing with any complications, until mother and child are comfortably home. Or a “knee service” that includes diagnosis, an array of offerings ranked by severity and type of problem, treatment, rehabilitation, physical therapy, and follow-up condition management, all in one package. Or a comprehensive “diabetes product” to help people manage the disease, including a dedicated insurance (or prepay) program.

The third key insight proceeds directly from the other two: When we turn to health care with our medical condition, there is no value proposition even if we are paying part of the cost through our CDHPs. That’s why the lack of real prices and measurable results matters so much in health care. If you are considering buying a Toyota Prius, you know the value proposition: It costs about $24,000, it gets about 50 miles per gallon, and it carries Toyota’s reputation for quality. If you are getting knee surgery because you want increased range of motion and decreased pain and swelling, you don’t know the true price of the whole experience, whether your surgeon and the rest of the team are better or worse than average, or whether you can rely on getting what you (and your employer or insurer) are paying for.

You can’t know, your referring physician can’t know, even the surgeon can’t know, because the actual quality is never measured in any standard way. In those parts of health care in which actual results are measured, the data is typically either kept secret or not broken out in a way that would help the consumer make a choice (such as by institution, team, or individual practitioner). As a consumer or referring physician, your most appropriate question is not, “Which is the most impressive institution?” or even, “Which institution or surgical practice has the best overall reputation for quality?” Your question is, “By measurable, risk-adjusted results and published prices, who can do the best job on this knee for the lowest price?”

Porter and Teisberg offer a vision in which health care is organized mainly around products tailored to particular medical conditions. These products are delivered by medically integrated practice units made up of teams that work together on the same medical condition over long periods of time, continually learning from their experience with the condition and from each other. These teams are comprehensive and seamless. A diabetes management team might include an endocrinologist, a behavioral therapist, a nurse educator, a dietitian, an exercise physiologist, a podiatrist, a dentist, and even a computer technician to help patients set up their home health monitoring devices. These products are clearly delineated, with real prices and a single bill, and the teams compete directly against other teams that work on the same medical condition, on the basis of value: measurable results at a published price.

In this vision, transparency drives quality. Health plans steer patients toward the providers who offer the best results for the least money. Referring physicians refuse to recommend any specialist or package with quality scores in the lower quintiles, for fear of being sued for malpractice themselves.

When health-care providers compete at the level of the medical condition, on real prices and real results, the feedback loops will become extremely compelling. Offering the highest possible quality at the lowest possible price will no longer be voluntary. Health plans will also be forced to compete on the basis of real results and genuine customer service at the lowest price, rather than their current modus operandi — which can include denying coverage and shifting cost and risk to employers, consumers, and providers.

Porter and Teisberg argue strongly that such a model would actually work better under a universal, single-tier payment system. “Universal coverage provides a payment mechanism that covers everyone but does not guarantee good-quality care,” they write. “Changing the structure of health care delivery is fundamental to improving care for the poor. Value-based competition on results will be necessary to ensure that excellent care is received by all patients.” Reducing the cost of care through competition makes it possible to treat those who cannot afford it. A single-tier system eliminates the perverse incentives to shave coverage and quality for those in the lower tier.

Delivering Value
Put together any of the schemes for introducing universal coverage with Regina Herzlinger’s vision of consumer-driven health care and Porter and Teisberg’s vision of value-based competition on results, and you get a system that meets all eight of the criteria above.

The most compelling part of this “health-care delivery value chain” model is that it is possible: It can arise from current realities, piecemeal, in a self-reinforcing fashion. In fact, it already is doing so. New structures for public reporting of medical results are popping up on federal, state, and regional levels. Weak, voluntary, and secret reporting systems are being superseded by mandatory public systems tied to reimbursement, such as the U.S. Health and Human Services Department’s “Hospital Compare” initiative. In many of these initiatives, process measures (such as use of thrombolytics in heart attack patients) are starting to give way to results measures (such as risk-adjusted mortality rates for patients undergoing bypass grafts).

In a number of regions, new tiered payment models use co-payments and other means to encourage patients to use the providers with the lowest cost and highest quality scores. Such models also reward more efficient systems, those that beat their risk-adjusted cost targets, with higher reimbursements, and punish less efficient providers with lower reimbursements. New insurance companies like HealthMarkets of North Richland Hills, Tex., provide customers with cost and quality scores by procedure, physician, and facility for all providers in their area; other companies, such as Boston-based Best Doctors, offer the information independent of insurance products. A number of major providers, such as Intermountain Healthcare of Salt Lake City, the Cleveland Clinic, the Boston Spine Group, M.D. Anderson Cancer Center of Houston, the Texas Back Institute, the Texas Heart Institute, and Wisconsin’s ThedaCare, have moved increasingly toward organizing their care into the kinds of medically integrated practice units that Porter and Teisberg describe.

Each of these pieces — transparency, integrated products, and true measurement — is coming into play in the health-care marketplace, and as they do, those who use them are being rewarded. The result is likely to leave health care looking dramatically different in as little as five years. As Porter and Teisberg express it: “If competition on results drove the pursuit of health care value for patients, the gains would be enormous. Huge gains are possible by reducing the variations in the value of care across geography and providers, reinforcing and rewarding excellent providers, and encouraging physician and consumer choices based on information and results. It is within the nation’s capability to increase health-care quality and lower cost dramatically, even using today’s technologies and methods. The enormous savings that could be achieved would help pay for improved care for every American, especially those who lack access in the current system.”

A health-care system arising from true value-based competition is not inevitable. To reach that goal, we need a wholesale reorganization of health care. And although it does not require government to pass any mind-numbingly vast scheme that changes everything all at once (as the U.S. Congress is sometimes tempted to do), it does require legislators and regulators (including state and local officials in the U.S.) to understand the goal well enough to get out of its way — by changing the numerous laws and regulations that impede transparency and consumer choice. And this plan requires both providers and payers to see and seize the opportunities it affords. Based on Booz Allen Hamilton’s experience with clients, we believe this will require nothing less than a fundamental transformation of health care from a wholesale to a retail industry. (See “The Retail Health-Care Solution,” by David Knott, Gary Ahlquist, and Rick Edmunds, s+b, Spring 2007.)

Yet the version of reform presented by Porter and Teisberg remains the most hopeful of all possibilities. Much depends on how far providers allow transparency to go, and that may depend on how emphatically consumers demand it. Once it becomes common for health-care providers to post actual prices and actual results in standardized ways that produce comparable data, it is hard to see how consumers, insurance companies, and referring physicians would ever choose low quality at high prices, as they do today. Real transparency will mean real competition, and real competition, in every other industry, has benefited the consumer. One does not have to be an oblivious optimist to imagine health care 10 to 15 years from now being available to all and offering substantially higher quality at significantly lower cost than it does today. This is the magic, and even the inevitable result, of competing on value.

Reprint No. 07110

Author Profiles:

---

Joe Flower (bbear@well.com) writes on management and medical issues, and has long been a contributing editor and columnist at the industry publications Healthcare Forum Journal, Hospitals and Health Networks Online, and Physician Executive.

---

David Knott (knott_david@bah.com) is a senior vice president with Booz Allen Hamilton based in New York City. He works with health services clients on corporate and business unit strategies and transformation programs.