Spinoza

I knew Spinoza a few months after I was introduced to Kafka. (In this journey of philosophy the only significant other was Arthur Schopenhauer.)

Similar to Kafka, Spinoza did not live on philosophy; he lived for it. I love to imagine him polishing magnifying lens in the morning (which he earned his bread and butter) and working on his Ethics in the afternoon. He had many admirers but probably more antagonists, largely because he politely but stubbornly insisted on his view of god (or actually the church).

To summarize Spinoza's theory by the word "pantheism" is probably the worst example of jargon. God would not lift something from the earth against gravity - god is (alas, manifests as) gravity. Yes, I am sure Spinoza has hit on the bottom of the truth. It was an era before something called "logic" was developed, when big topics were explored, albeit with foggy language. Nowadays, workers on philosophy have clear thinking and precise language - but what's the good if excellent tools are used for trivia ?

Well, people are proud of having expensive Hi-Fi - even for Twins. I would prefer Mozart's sonata, maybe with a low tech cassette player.

Kafka

I was first introduced to Kafka by WK - my roommate - in the second year of my medical school, and was soon infatuated with his legendary life and mythical stories. Who else can write those fantastic novels but do not have to make a living from it ? In addition to anatomy and pharmacology, that year gave endless memory on Metamorphosis, The Trial, many of his short stories and ingenious comments. (Here is the best one: In the middle of an ever-growing crowd of people, we become more and more lonely.)

For some unknown reason, I did not have a chance to read The Castle until I started preparing for my membership exam. In retrospect that was fortunate because this piece was probably too difficult for a teenager. I read it cover-to-cover twice, and (believe I) am able to comprehend the meaning - until the two helpers of K appear. (Alas, that means 10% of it.) I always plan to read it yet another time.

That's life. One always fancies things which he could not understand and admires people whom he could only worship from a distance. When all secrets are revealed and idols put under close scrutiny, Eva and Adam cannot stay in Eden.

Five persons

Discuss with CB about job interview. I suggest to ask: What (non-medical) books have you read recently ?

Another similar question commonly asked in the old days is: Name five persons - who can be dead or mythical - do you want to dine with ?

My standard answer to this question is:
1. Franz Kafka (novelist)
2. Benedictus Spinoza (philosopher)
3. Jerome Kassirer (physician)
4. Stephen Hawking (scientist)
5. Chen Gongbo 陳公博 (politician)

Japanese comics

A few young friends comment that Death Note is a brilliant piece and has much meaning in depth. I fully agree with the first but have some reluctance to the second.

To me, the most impressive story in Japanese comics was the Galaxy Express 999 (銀河鐵路999) by Leiji Matsumoto (松本零士). A boy seeks to have a machinery (immortal) body, meets the representative from a platent far away, and boards the train to get an eternal life free. When he reaches the destiny, he comes to realize that in exchange for the machinery body, he has to use all his life to fight for the owner of that planet.

I cannot understand why Vatican did not protest.

Confidence

Visit KT's family in Yuen Long with Vivian on the Boxing Day. His wife and Vivian are good friends.

During lunch, in the middle of a casual debate on trivial matters, KT suddenly said, "They are good. But it doesn't necessarily mean that we should follow."

I clapped and laughed; could not agree more. There was a full air of confidence and not many people can appreciate. This is the caliber of people worthwhile for a gold medal.

PS. KT was the gold medalist of my medical school, four years before I graduated.

Environment protection

Always find Al Gore getting the Nobel prize amazing. If there is any award Gore deserves, it should be kind of "best marketing strategy" - on climate and environment protection of course.

By no means I think protecting the environment is a bad thing. It is just that what really protects the environment skips the eyes of most. Take the upcoming ordinance from our home city - charging for plastic bag in serial stores - as the example. If we ban all plastic bags and, as they say, "BYOB" (bring your own bag), where would the raw material - petroleum remnant - goes ? Should we wash our own bag after use ? And if yes, do we not consider the disposal of soap and water ? If no, are we risking for another epidemic of, say, cholera ?

Perhaps the old wisdom of economics applies here: any strategy we propose to tackle a problem in life would result in many (alas, many) unforeseen complications - often leaving the original problem untouched. When I was young I used to believe that the only effective measure to protect the environment is birth control. Now I realize that even this drastic measure has severe cerebellar lesion and past-pointed the target.

Textbook

"We should write our own textbook for local students," the man from Pluto so declared.

I am not aware of the possibility that we are practising a very different kind of medicine from the rest of the (western) world. Disease pattern may be slightly different here, but that should be adequately dealt with by a few tutorials and seminar hand-outs.

The same thing happens for treatment guideline - for all clinical conditions, you name it. The Hospital Authority has its guideline. The Society, of whatever specialty, has its own - often written by the same group of people as the HA one but somehow the recommendations are slightly different. (If the subject touches on more than one specialty, each society involved would of course have its own commandments.) The Cluster put up another one. The department put up yet another ... good lord.

I come to realize that guidelines are not there to guide your practice. It serves, however, a few nondescript purposes:

1. We (the board or council) exist.
2. (Since we get funding to improve the service,) we have done some work.
3. We are independent and we think independently. Therefore we will not blindly follow the existing guideline across the Atlantic (or the Victoria harbour).
4. (To their juniors) we have told you what to do; we will not bare any responsibility for your mistake.

Paul McCartney

Had some apparent compliments for my notes on Paul McCartney and Mozart.

I had no intention to imply that McCartney is on any aspect inferior than Mozart. They are just different. McCartney is meant for simple pieces suitable for the palate of most; Mozart is admired by many but understood by a few - with an everlasting impact. McCartney's songs are not - as yet - considered as classical music.

PS. What do you think Leslie Cheung (張國榮) would feel - given his depressive and introverted personality - if you call him Mozart ?

Death Note

Finished with the TV version of Death Note. An excellent piece.

There are of course many hiccups in the detail. By the end of the story, Light had obviously no direct possession of any Note - that's why his father Soichiro (夜神總一郎) could see the date of death over Light's head and believed that Light was not Kira. In the last scene, however, Teru Mikami (魅上照) could tell who Kira was by just a look - a serious flaw.

The final plot was also disappointing: Light himself could predict that his opponent - if as good as the original L - would see through the trap and spot that the Note was a fake. (Light was right. N was a bit thick and did not see the trap; the success was largely luck.) What Light should have done was to ask Teru Mikami to secretly keep a few pages of the real Note - saving all the trouble to ask Kitomi Takada (高田清美) to do the actual killing - and let N go ahead and steal the real Note. On the day of combat, Teru Mikami could then write on those secretly kept pages, just like what Light himself loved to do.

Well, as Philo Vance used to say: "and nothing flawless, my dear fellow, is natural or genuine."

Ability

Feedback after anatomy examination from a medical student:

"Dr. X taught us that the inferior tip of scapula is over T8. The answer of this MCQ is, however, T7. I look up in Moore ... and it is T7. How can Dr. X taught us such a wrong thing !"

My usual half-hearted motto is you cannot trust anything a man says. As a man I obviously know very well that you cannot trust anything a woman says either.

But this story brings my memory back to another incident some years ago, when a few colleagues of my department - including myself - were invited to share our experience with a group of new medical students. My talk followed the one by PS - a young lady endocrinologist.

I began my speech, "Don't think that I am very senior. Although I look aged, I am actually the junior of Dr. PS ..."

The students were all in a roar. After I finished with my talk and went back to the seat, JS asked - somewhat incredulously, "Are you really younger than PS ?"

"Of course not," I could not stop laughing. JS had his eye almost propped out. "But they are university students and should judge for themselves right and wrong. How can they believe everything told by the others - however senior and serious that person is ?"

Difference

Dined with some students last evening. One of them asked, "What's the difference between Davidson and Harrison ? I think they are both medical textbooks."

I made some unrelated comments, but I should have said, "Davidson, however good, is Paul McCartney. Harrison is Mozart."

Retirement

Chat with LS and WH during lunch. Naturally our discussion comes to the soon expected retirement of CS and JW.

I said - quoting the news from AL - "JW will be extended and do for another year or two."
"Of course. What else can she do ?" WH remarked rather drily.

I consider that a bit sad - from the point of view of her life. JW is no short of money. Yes, she is thoroughly respectable and it is always a good idea to have someone experienced amongst us. One may argue if you are really enthusiastic and enjoy your work, why shouldn't you put all your effort on it ? It is just that if a person - and someone really intelligent - can do and enjoy only one thing, it would be real boring and not having the best use of his ability.

The Parthenon is not supported by one pillar - no great building is.

Computer problem

My computer in out-patient clinic hanged three times this afternoon. This is too much.

The clinic nurse called the "help-desk" in Neptune, and the eternal answer was to re-boot the computer again. Well, those who live in Neptune may be lovely and timid creatures, but they hardly know what's happening on earth.

I used to be puzzled for this very phenomenon: why don't they ask someone on earth to take charge of the hospital information system ? With time, I come to realize that anyone who is recruited into the team to work with this system emigrates to Neptune spontaneously over night. The fact that someone is responsible for designing and maintaining this system means that this person needs to attend all those board meetings and so forth, and therefore there leaves no time for him to actually use the system.

The same argument holds true for any hospital administration. Whatever their background, those who manage the hospital obviously have no time to take care of the patients - which is what a hospital is supposed to do.

OK, the only difference is administrators emigrate to Pluto, not Neptune.

To hell they go.

Election

Being a minority group, I am all against general election (unless I become the majority, of course).

Do you seriously believe election means a fair system ? Look at the NBA: Yao Ming got the highest vote for two years - not by any extraordinary performance, but by the extraordinary group of immigrants. What do you think would happen if these people could elect the leader in their home country ?

Take another example from our home city. Does Mrs Chan mean democracy ? Well, nearly half of it - no demo, just crazy. Yes, Mrs Yip is all against democracy. (It is a pity that she doesn't come out and declare her view openly.) Nonetheless, the enemy of someone against democracy does not mean that this enemy is democracy. A people that fail to appreciate this simple logic should - and could - hardly be gifted with a civilized political system.

What one is doing

On the cross, Jesus said, "Forgive them, because they don't know what they are doing."

I soon realize that it is in fact a great compliment to say someone knows what he is doing. Take our famous weekly magazine as an example, medical incident is - once again - under the spotlight. The conclusion they are driving at is simple: public hospital provides substandard care. Their recommendation also seems simple enough: the government should put in more money for the health of the poor.

Even if the government follows, the problem is not solved - it gets deeper. Trust on public doctor is damaged. But what the hell is wrong if these lousy doctors cannot be trusted ?

The answer is not difficult for those who think with more than one synapse. It is plain fact that patients and relatives are more critical to health care professions now than - say - 20 years ago. Decisions are challenged and minor slips become major headings on newspaper. Capable doctors have the choice to leave this hostile environment and set up their own business; the scum, not the cream of the cream, rises to the top - and remains. Who is going to suffer ?

How about that more money ? It cannot keep good doctors in the system - the monetary gain from private practice is way different. So, the system can only reward the scum.

Working hour

Amazed to hear the hospital north to us allows house officers to be off-duty during daytime before call, had protected time to sleep at night during call, and have post-call off. I hope those who set up this policy - or their family - would agree to be taken care by doctors trained up with this system.

People from Pluto say we should limit the working hour of our staff to 65 hours per week - I used to think we can only talk about working hour to canteen cashiers or security guards.

Physical examination

Some grumbles of the man from Pluto:

"The physical sign stated on the summary is not right. There is now ascites."
"You cannot rely on signs from trainees ... and young fellows."

For us practising on earth we know that physical signs change with time, and two equally able physicians often have some discrepancy in their physical findings on the same patient. (That is why the Royal College asks for two examiners to sign on the "agreement on physical signs".)

That's a minor point. The important thing is: why on earth we need this kind of examination ? I must say I am absolutely happy to have a physician who cannot detect any heart murmur or ballotable kidneys or apical lung fibrosis. Yes, it is nice to be able to do so, but lack of that skill is not really a fatal sin to bar someone from practising medicine. Not only can we compensate for the deficiency by imaging, technological advances have actually replaced the need of doing a substantial bulk of physical examination in real life clinical medicine. Yes, we have (some of) ECG and chest X-ray in MB and MRCP examination, but they play a really minor part in these examinations as compared to their value in actual practice.

There are of course clinical skills that are of vital importance and need to be mastered - fundi (say, for papilloedema), meningism, GCS, diabetic foot, or even thyroid status. Strange enough the very first item on this incomplete list - alas, fundi - is exactly the one that our man from Pluto believes not important and was deliberately removed from MB examination.

An equally important but even more brutally neglected area of "professional competance" - according to our educationalists' jargon - is the ability to take care of patients with common chronic medical problems in an out-patient setting. For example, how to handle a diabetic patient who comes back for a routine follow up - without any specific complaint. I said brutally neglected because this kind of skill is not only absent in the examination, it is actually not (properly) taught in the current medical curriculum - most of the emphasis goes to acute and emergency medicine. Students do not have to attend out-patient sessions nowadays, and when they graduate and practice medicine, they just find themselves in an utterly unfamiliar battlefield. Yes it is important if my doctor can revive me from a diabetic coma, but I would prefer him to take good care of me so that I do not have a coma at all.

(Note. This is a copy from my notes on Facebook some time ago.)

Up to date

My resident loves to say "I have checked with Up-to-Date and we should do this and that."

Well, literature can only be as good as the person who uses it. If you ask a wrong question or - more commonly - put your emphasis on irrelevant things, no clinical trial or textbook could help. Unfortunately, laboratory and radiological investigations are now performed in such a shotgun approach that there are often more red herrings than genuine problems. It really needs wisdom rather than book knowledge to decide that a slightly abnormal investigation result is irrelevant and should be put aside (at least for the time being).

Translational research

JC is always proud of her "translational research".

To many of them, translational research means participating in multi center study on a new drug - usually one with many others of the same class already on the market.

In a cynical mind, this is outsourcing of business duty from pharmaceutical companies. There is of course nothing wrong with this kind of work - unless you consider it as the only form of science.

Third Chimpanzee

Finish with the Third Chimpanzee by Jared Diamond. Quite a good piece. In fact, it seems a waste of time to read Gun Germ and Steel and Collapse; the idea is somewhat repeating.