Common

On the first glance, it seems unbelievable that while the appropriate choice of action is all too obvious to most of us, common sense is such a rare occurrence that so many people just pick the most silly way to go.

Oh, you are wrong on that.

Let's go back one step and consider. Common sense is in fact a very capability that everyone of us have - that's why it's called common. The only problem is we could use it for only two purposes:

1. To see the solution of others' problem.
   
2. To see the solution of our problem in retrospect.

Alas, it is just that most of us cannot use this extraordinary talent to solve our problem at hand.

And we call them genius for the few who could do so.

I think I should be less cynical.

Remedy

You may ask, "Why don't we include the area next to the front door of the hospital, or to perform necessary emergency care when someone has a cardiac arrest ?"

On that you are wrong. It would be an endless argument to define how far from the door we should include, who to determine the cardiac arrest, and so forth.

For those who are familiar with the theory of administration or ethics, you would notice we are falling into the trap of a slippery slope. If we take care of a distance within 10 meters, why not 20 or 50 ? If we resuscitate someone with a cardiac arrest, do we need to take care of someone with a low blood pressure (which an ordinary receptionist may mistake as cardiac arrest) ? Then, we would next be forced to ask the poor receptionist to handle someone who simply has dizziness.

You open the Pandora box.

I believe that was in fact the reason in the mind of that poor hospital chief when he at first stood firm in front of the media.

PS. When I discussed the story with KM, I commented that the only effective means to prevent such an accident - while having receptionist of the current standard of intelligence - was to move the Information Desk next to the Emergency Department. That would solve one type of silly mishaps - unfortunately only amongst a billion possible types.

Detail

In fact, a sensible (yet a wanting character) administrator should not put up operation instructions that assume the front line staff could exercise common sense - they invariably fail.

But, if we could not put up Exercise your common sense as an operation guideline, it would also be impossible to improve the condition by having more staff training or better equipment - as claimed by some of our senior officials.

The reason is simple: no training or equipment could handle all possible scenarios that happen in the real world. (Albert Einstein was wrong: God does throw dice with the universe. Everything, by the law of quantum physics, happens in a chaotic and unpredictable manner; accidents, however improbable, would occur - usually on the most inconvenient day.)

Alas, now you come to realize why the guideline says "It is not within the hospital area" and "Dial 999". These are things with a clear boundary and could be done by anyone with a motor cortex.

PS. The problem is, while a responsible administrator should never use Exercise your common sense as part of the operation instruction, its application should always be encouraged in real life practice. Many extra-terrestrials have gone so far to forbid the use of this very capability and penalize those who try to be sensible.

That's the real tragedy.

Guideline

Don't get me wrong. I am all for putting up operation guideline for front line staff. After all, we must assume there exists, and in fact it is overwhelmingly common to have, people who could not think with more than two synapses and must have something to follow.

Once we come to understand this, it becomes difficult to conceive a solution to the current problem.

For obvious reasons we cannot simply put up Guideline #1: Exercise your common sense (although that should really be the first sentence of every written instruction, while the second one should be: If you have difficulty to apply Guideline #1, continue to read.).

Then, what should we put up ?

****************************

A side track story of my own suddenly flashes back. When I was a 4th year medical student and attached to a peripheral hospital for my elective period, the consultant physician there took me around on the first day and said, "The first thing you must learn in clinical medicine is to tell if a patient is 頹." (This very Chinese word proves difficult to have an appropriate English translation - it encompasses the meanings of being critically ill, need aggressive treatment, requires invasive investigation, presence of atypical features, giving you a feeling of uneasiness, or a combination of the above.)

"But, what is the criteria of 頹?" I was naive enough to ask.

"Oh, exercise your common sense." And off he went.

Years later I realize he was paying me a compliment and assuming I have that extraordinary capability.

Sense

Many of us were mystified to hear the story of the man who died of a heart attack outside a hospital.

My friend KM outlined a story of a similar kind in his blog (http://drkmchow.blogspot.com/2008/12/ugly.html); he was certainly right in saying that it was a tragic story because of headless adherence to a guideline.

On a second thought, however, the remedy may be tricky.

Of course it is dead simple if the staff could exercise common sense. Nonetheless, as a previous professor of medicine over the other side of the harbour said, "Common sense is not common." To go one step further, if a particular staff is in possession of such an extraordinary talent of having common sense, he should be promoted to a more important position than staying as a receptionist.

Therefore, don't yell at people who blindly follow guideline. You wouldn't shout to an automatic ticket machine because it doesn't comprehen your logical argument, would you ?

You should kick its ass.

Plan

Passed by a book store; Vivian asked if I needed to buy some for my bedtime reading.

"Oh, no. My schedule is rather full. I mean there are enough books for me in the coming year." I considered for while and said.

Well, here are my plan (presumably in that order):

1. Bonkura (糊塗蟲) by Miyabe Miyuki (宮部美幸).
2. The Science of Sherlock Holmes by E. J. Wagner.
3. Freakonomics by Steven D. Levitt and Stephen J. Dubner.
4. 分類尺牘大全.
5. Yes Minister and Yes Prime Minister (re-visit).
6. Food Politics by Marion Nestle.
   
7. The Penguin Writer's Manual by Martin H. Manser and Stephen Curtis.
8. The Wealth of Nations by Adam Smith, book II and III (re-visit).

As commented by WC, a life-long friend of mine, I'm a head-to-toe pragmatist; there should never be a book bought but left un-read on my shelf.

Country

Briefly watched Love Actually again on TV - I had the whole movie some years ago when it's on the theater.

The whole of my memory with this comedy was the short speech of the Prime Minister, made during the US President came to visit 10 Downing Street and harassed Hugh Grant's secretary:

I love that word "relationship". Covers all manner of sins, doesn't it? I fear that this has become a bad relationship. A relationship based on the President taking exactly what he wants and casually ignoring all those things that really matter to, erm... Britain. We may be a small country but we're a great one, too. The country of Shakespeare, Churchill, the Beatles, Sean Connery, Harry Potter. David Beckham's right foot. David Beckham's left foot, come to that. And a friend who bullies us is no longer a friend. And since bullies only respond to strength, from now onward, I will be prepared to be much stronger. And the President should be prepared for that.

Yes, we may be a small country, but we're a great one, too. A people - be they small or large - who could appreciate the meaning of this little declaration would have hope.

Merry Christmas.

Value

You may wonder what the difference is between points #1 and #2 of the indications that I mentioned yesterday.

I would try to explain with the analogy of Andre Kostolany:

The intrinsic value of a company is the master, and the price of the share is the dog - the latter wanders around the former. Although the dog may sometimes be naughty and runs far ahead - or much behind - the master, in the long run, it is the man who leads the way.

Now, when we analyse and buy a stock, here are our assumptions:

• For type 1 value investors, he could tell where the master is at the moment.
• For type 2 value investors, he could tell where the master is going in the future.
• For speculators, (he believes) he could tell where the dog is going.

(The last scenario is certainly impossible, unless you are beast of a kind yourself.)

To me, it is definitely more easy to tell where someone is than to guess where he is going - although the latter task is not altogether impossible. My personal prejudice is, however, not to tell both at the same time. By the Principle of Uncertainty in quantum mechanics, no one could have an accurate judgement simultaneously on both the position and velocity of any particle (although I'm not sure if the analogy is right).

Reply

A few days ago, my friend Warren put up a question to me on a particular stock. Here is (part of) my reply.

***********************

Dear Warren,

Sorry I didn't make myself clear. To me there are three reasons to buy a certain stock:

1. The issue is trading at much lower a price than its intrinsic value. (This is the traditional method of Graham and Templeton.)
   
2. The company is trading at a fair value and is expected to prosper. In other words, the future value would be much higher. (This is by and large the method of Buffett and Lynch.)
   
3. The company is stagnant and is trading at a fair value, but it provides a certain amount of secure return in the form of regular dividend. (That's why many of us keep a certain proportion of our portfolio in bonds, REIT, or stocks of public utilities.)
   

The more important thing is: An investor should always be clear the original reason of buying a certain stock, because that inevitably hinges on when to sell. In the same order of the above mentioned indications, the reason to sell is:

1. When the price rises to its intrinsic value.
2. When the company ceases, or would foreseeably cease, to prosper. (Or, in the words of Peter Lynch, the story no longer holds.)
3. When the dividend rate becomes unacceptably low.

Sincerely,

CC

Dictionary

Extracted from the 2009 edition of the Practical Hong Kong Dictionary (香港常用語詞典):

深化 - The thing that an administrator claims doing when he sees a policy is going to a dead end and tries to back off.

花紅 - The method that investment banks use to keep their balance sheet zero after obtaining urgent loan from the government.

老人癡呆 - The ability to buy a TV channel with HK$100M and sell it 6 years later at four times higher a price. No wonder those who had an inferior performance in the same business lose all their nerves.

辭職 - The expert panel of Chinese language usage, led by certain Professor Ho (presumably the gold standard), formally approve the term could be used in both active and passive voice.

才子 - A small selected group of educated people who were badly insulted recently. Cao Zhi (曹植), Li Shangyin (李商隱), and Liu Yong (柳永) jointly declare their affairs had a higher spiritual level (not to say their remarkable contribution to the Chinese literature).

PS. Yu Dafu (郁達夫) ? Our apology; we've put him on the waiting.

閥閱

On a second thought, the admission system of many kindergartens and primary schools gives me a deja vu feeling of the ancient China.

You know what, in the Han (漢) dynasty, families of the upper social class used to put up two stone columns at the side of the gate door of their house. The one on the right side of the gate described the merits and achievements of the family and was called "閥"; that on the left gave details of specific government titles that members of this family held in the past, it was called "閱".

The catch is: the government selected its officials largely by the information on these two columns rather than the capability of the candidate living inside the house.

Well, this discriminating system was maintained until the Tang (唐) dynasty, when the empire used the Imperial Examination (科舉) for the selection of government official. Although the examination system was heavily criticized by many authorities, I tend to agree with Ch'ien Mu (錢穆): It was by and large a fair system; young people from the lower social class had a more-or-less equal chance of gaining entrance to the central government. In other words, it creates hope for the poor people.

That's all we need to keep the society in harmony.

PS. To be fair, part of the problem was that paper remained expensive in late Han dynasty and printing was not invented until the Tang era. Books were all handwritten and therefore unbelievably expensive - so that only the rich people could afford to have education.

Class

Dined with some university classmates. Many of us have become parents and naturally we had an active discussion on the application of kindergarten and primary school.

YC, a neurosurgeon, talking about his experience in applying a famous local school, sighed, "They consider nothing but the social status of the parents. You know what, one of our consultants had his son straight-in. The associate consultant of the other department had his daughter on waiting list. And I, a humble senior medical officer, my daughter was not even on the waiting !"

(For those unfamiliar with our system, senior medical officer is the same grade as associate consultant; you get the former title if you were promoted before early 2000s. Obviously the latter sounds better - that's what we call title inflation.)

Although I should be secretly rather happy with this system, by no means I'm at ease in such a society. If the chance of receiving (good) education depends on your family background rather than ability, what hope could we hold for our society in the future ?

PS. The major presumption of the above discussion, of course, is that those discriminating schools do provide good education. I would leave it to your judgement.

Election

Lunch with LS and FP; our discussion somehow touched on the recent election of certain society chairman north to the Shenzhen river.

"You know, although there are no less than 10,000 members of the society, there are no more than 20 who could vote for the chairman." I said.

"True." FP considered for while, "but general election would hardly solve the problem. It may actually make things worse."

I must admit there is much truth in it. And all of a sudden I realize it is never a problem of small circle election - as long as the one being elected could fulfill the dedicated task.

Of course fans of general election would argue that a truly democratic system could make sure an inappropriate ruler has a (bloodless civilized) mechanism to step down. Nonetheless I suspect a small (talented) circle could bring down any potential dictator equally well.

Alas, am I having a deja vu feeling of proposing the senate system of the Roman empire ?

Story

While we considered what to present in the medical grand round, the inevitable conclusion was to ask one trainee of ours to present the case history, and the other to review the literature.

After the division of labor was fixed, KM reminded me to take a careful look on the slides for the case presentation, which I hastily agreed. Alas, by no means we thought VK - our trainee who was responsible for the first part - was less competent. It was just that we were both convinced it was actually more trying to present a coherent and comprehensive history than to give a (brief) talk on the book knowledge of a certain subject. The latter is simple: you pick a good review article or two, perform certain copy-and-paste function, and the rest is done. In a neuroanatomy sense, it takes the Wernicke's and the Broca's areas and some connection bundles - but you can do away with the rest of your cerebral cortex.

But presenting a case history is different. You've got to give out the information bit by bit while trying to make the next happening a logical sequel of the previous step. If it happens to be a diagnostic problem, important clues would be put in an obvious place with an innocuous manner, so that when the climax comes the answer seems surprising but also inevitable.

Oh, I read too many detective fictions, I know.

But, look, the best narrator of detective story is Sir Arthur Conan Doyle - who obviously cultivated his superb skill of telling a story in the medical school.

Dinner

After Vivian's boss left, we had our family gathering three days later for the Winter Festival - in a local Peking restaurant.

(No, it was not the Spring Deer. We went to the one a block next to it.)

The main dish of this event was a beggar's chicken. We deliberately avoided all expensive stuffs. I'm sure many of the audience of this blog are the same as me and are tired of the menu of a traditional Chinese banquet, with sucking pig followed by hot dish followed by shark fin followed by abalone followed by steamed fish followed by chicken followed by rice and noodles ...

(Oh, the menu seems endless; it just put an end to your coronary artery with tons of cholesterol.)

Alas, don't have the impression that traditional Chinese people were all that affluent and they had the same list to go through in a wedding ceremony a hundred years ago. If you take a look on a banquet menu 60 or 70 years ago, you would be impressed to find the dishes were less elaborated but in fact environment friendly. (One classic example is to use crab meat for the noodles because that's what left after using the claws for the hot dish.) It is, in fact, all those restaurant owners who make this kind of lengthy and costly menu seemingly indispensable.

This is, alas, a kind of product bundling (綑綁銷售) to increase the profit margin.

Banquet

Vivian's boss in Tokyo had a brief trip to Hong Kong - we held a small reception dinner for him in a famous Cantonese restaurant.

I must say our Japanese friend seemed not all that impressed with the food. As an expert in mind-reading, I could see several problems with a traditional Chinese banquet:

• The food is too salty (even for someone coming from Tokyo) !
• The menu is too long - our friend was probably full by the middle of it.
• The soup is always shark fin in a kind of suspicious viscid liquid.
• Everything, be it deep-fried or steamed, is covered with a layer of shiny oil.
  
• Why are Chinese so obsessive with (abalone and) sea cucumber ? (Once chopped into pieces, it looks perfectly the same as the vomitus in The Alien or The Exorcist !)

No wonder why so few local restaurants won a star in the Michelin Guide. There are thousands of excellent Chinese dishes with all sorts of ingredients - but they're just not the kind of thing that we feel precious and would show to our guests.

Risk

I do not wish to elaborate on the potential risk of having a doctor with (active) psychiatric disease. It was, however, argued - by certain extra terrestrials, of course - that it would be safe if these problem graduates do not take care of real patients.

They mean radiologists or pathologists or microbiologists.

Hold on. Are you really at ease to have a radiologist who keeps having funny visual hallucination, or a pathologist who locks himself (with all the specimens and slides that need urgent comment) in his office for several days ?

(Oh, there are already some existing ones at the moment - probably because of a different cerebral pathology. That's another story.)

In that case these graduates should not even become involved in all aspects of clinical care. Then, what's left ?

Maybe health administrators in the headquarters.

Oh, maybe many did already.

PS. You may well complaint I have discrimination. But, while putting up this fully justified accusation, I would politely ask you and your family to be cared by a schizophrenic doctor next time when you have to see one.

May god bless you.

Survive

I always wonder what would happen if she didn't jump.

In fact I do not have to imagine. There was no short of examples that our students turned psychotic or depressed and continued with the study (or, on a few occasions, doctors developed mental problems and kept on the practice).

You may consider that good news. It is no doubt better than losing the life. Nonetheless, the disease and its treatment both adversely affect the concentration as well as mental sharpness. (Let's face it. This is a disease - it won't go away simply because her parents paid more attention or her friends talked to her more. And, despite of the advances in psychopharmacology, drugs that treat a brain problem would affect the neurons.)

The inevitable result was those survivors always struggled in the medical school. Some even sat on the rooftop of the student hostel or put a knife around his neck and said, "Let me pass the final or I would kill myself."

And our man from Pluto did put up green lights obediently.

I shouldn't say any more.

News

Read the blogs of several students on the morning. Surprised to find many of them put down "RIP" - I learned why that's the case later the day.

I read through the blogs of her classmates; no one seems really know her well.

I checked with the list of students in the faculty mentorship program; hers was not there either.

Her name was actually removed from the student list of our curriculum web site on the same morning. Alas, I'm not aware of the fact that administrative people could be that efficient.

On one hand it gives evidence that she was withdrawn and isolated. On the other she seems to leave without a trace.

悄悄的我走了，正如我悄悄的來; 我揮一揮衣袖，不帶走一片雲彩。

Or, maybe this one is better: 背燈獨共餘香語，不覺猶歌起夜來。

Study

Reading New Asia Life before I went to bed: There is an article on the life of Ch'ien Mu (錢穆), recalled by his wife.

As a studious academic, this founder of our university spent much of his time reading and writing. A favourite story of his, re-told by Mrs. Chien is this:

After Ouyang Xiu (歐陽修) retired at the age of 64, he continued his daily study until late evening. His wife tried to tease him, "Why are you so hard working ? Are you worried that you would be punished by your teacher tomorrow ?"

Ouyang made a seminal answer, "I'm not worried about my teacher of course, but I'm afraid that people in the future would regard me as having a big name but actually knowing very little."

*******************

While working in the university, Ch'ien used to be engaged in all sorts of administrative matters in the day time, and could only focused on his serious study after work or during weekends. Life of an academic seems not to have changed since then.

Anniversary

First, let me tell you a slightly boring story:

Willard Huntington Wright, born 1888, was a famous art critic and journalist in America. In 1923, he felt sick because of overwork (and possibly cocaine abuse, like Sherlock Holmes) and, for over two years, was ordered by his physician to be confined to bed. In frustration and boredom, he began collecting and studying thousands of volumes of crime and detective fictions. He came to the conclusion that if other people could earn their living by writing stories of this kind, he could certainly do it better.

He was right. Since detective fiction was considered a "second class" literature in those days, he disguised himself in the alias S.S. van Dine. His first fiction, The Benson Murder Case, turned out to be a great success. Many of his subsequent stories remained best sellers. Philo Vance, the great detective that Wright created, soon became a landmark character in the history of crime fiction.

*********************

One year ago, after reading hundreds of blogs of all kinds, an university academic thought he could write better things.

That's how this blog came along.

Like Wright (disguised as van Dine and Vance) who loved to show off his knowledge in art and literature, I have an irresistible tendency of a similar kind.

Please bear with me.

Language

JW rightly pointed out that my seemingly brief answer to the kindergarten's questionnaire may not be well accepted.

I forget who taught me this very fact: Language could express your thought, conceal your thought, and often replace your thought.

After all, lengthy description is trendy. (Look at our discharge summary and consultation letters.) It gives the audience an impression that there is much substance in your answer (by the definition of physics, air is a substance - so is faeces) and, in case there's anything wrong, it could be well hidden in the jungle of words.

(It is probably of the latter reason that hand writings of doctors are so difficult to read - you can never prove they have given a wrong drug or mistaken the dosage.)

And, seriously, my friend, if (the headmaster and teachers of) a school could not appreciate a clear and brief answer, I would have much reservation to let my girl study there. Let's leave the place for the children of senior officials who live outside the solar system.

PS. I made an (almost) equally brief written response to the question "Why do you want to study medicine ?" in the application form when I applied for university some 25 years ago, and was fortunate enough to have it well received by a professor at that time.

He was the King of the round table.

Contact

Before we could actually meet the kindergarten teacher to have the interview, there was a questionnaire for us to fill in. Naturally Vivian left the task for me.

In addition to some usual stuff, one question goes like this:

"How do you think the school and the parents should contact with each other and exchange their opinion on teaching and child development ?"

I peeped around for what answer people nearby put down. Oh, there was no lack of suggestion. Most wrote three or four lines with a Times New Roman font 8 - one composed a half A4 page synopsis.

(Oh, they must be senior government officials.)

I considered a while and decided it was not a time to show off my (limited) English grammar.

And therefore I wrote:

Talk directly.

PS. When I was learning Chinese calligraphy in secondary school, there was an important principle:

筆劃少處力量要足以當多,瘦處力量要足以當肥.

Interview

Went for (yet another !) kindergarten interview on a Saturday afternoon.

It was somewhere in Kowloon Tong. Our scheduled time was 4:45 PM; (after preparatory work of nearly the whole afternoon) we arrived at 4:15 PM. To our surprise, there were no less than 80 people lining up outside the gate - waiting to be interviewed.

Don't get me wrong. The kindergarten was open - just that the whole of its garden and classrooms and corridors and every gap between the furniture were fully filled with anxious parents and suspicious-looking children. I had a gut feeling that this kind of place is not meant to be squeeze in by vertebrates.

"Should we back off ?" I asked myself.

Before I could figure out an answer, a familiar voice drew my attention, "Hi Szeto ! Nice to see you here !"

I took some time to recognize it came from the middle of the line. She was LC - my university classmate who I did not meet for at least 10 years.

"And you come for the interview as well ? What's the time for you ?" She knew just too well I have expressive dysphasia, and tried to ask a simple question.

"4:45 PM; and you ?"

"I'm 4:30 PM. You should be on the other line." She pointed to another queue.

I suddenly realized it didn't look good to quit in front of an old friend.

With that, I joined the line and waited to meet my fate.

Disturbance

Went to the Academy on a Thursday afternoon: It was the written paper of the college examination and I was the invigilator.

Most of the things were actually taken care of by some brilliant secretaries. The two invigilators were merely responsible for checking and signing on relevant documents. The papers took three hours in the early evening (so that it was concurrent with the candidates in London). During this period we switched off our mobile phone and silenced our pager. There was no Internet connection in the hall. And we have to sit there.

In other words, we had a few hours of undisturbed time.

For those practising clinicians and parents, you could appreciate how rare this happening could be.

PS. You may wonder what I did during that three hours. Sometimes you don't need any. Have you heard of the dialog between inspector Japp and Hercule Poirot in the Plymouth Express ?

"I've done some good work. And you ?"
"Me, I have arranged my ideas."

Light

You may think the story of Ivan's brother illuminating - but let's be careful where the light leads us to.

Consider the followings:

1. Was happiness the result of poverty ?
2. Was greed and other dark characters of human beings caused by affluence ?

Now you see, what the story does is inducing us to have the impression that lack of money would give you satisfaction, and getting rich is a sin. It was Leo Tolstoy who wrote the story and soon afterwards Russia turned a communist country.

And all of a sudden you realize the light is merely ignis fatuus.

Alas, how about the amount of teaching for our students ?

Ivan

While considering the effect of excessive teaching and loss of self initiative, I came over a note posted in the Facebook.

It is a short story from Ivan the Fool of Leo Tolstoy. Here is an amateurish translation:

The brother of Ivan used to be a poor farmer and led a peaceful life. The old devil, with a wicked intention, sent one of his juniors to disturb the man's life.

The little Satan turned the farm into stone-hard. The old farmer put up much effort to work with it - without any unhappiness.

The old devil sent another young one, who took away the bread and water from the farmer.

But the latter was unmoved - in fact, he was quite happy if the bread was taken by some others more in need of food.

A third representative from hell, and a really bright one, was sent. He became a friend of this farmer, told him the change in weather and every trick in business. The farmer became immensely rick in a few years and, alas, he lost all of his good characters: He counted on every penny, shouted at his servants, and did all dirty things to crave for more money.

The devil was right: The more you have, the more you ask for.

Education

You may think the story of Templeton weird.

Not at all. I have a similar first-hand experience.

Most of the early graduates of my medical school would recall for several years our internal medicine teaching did not include hematology. Well, we had some fragmented idea from our pathologists, pediatricians, and oncologists - but there's just no one dealing with blood diseases in adult.

We realized this at the beginning of the final year. There were 10 of us in a group, and I forget who made a (later proved to be) brilliant suggestion: We choose three (or four, I cannot recollect) group mates to study one major topic each and do a seminar presentation every (I believed) Thursday afternoon. (My topic was approach to bleeding diathesis.)

That was still the time before Bill Gates invented PowerPoint, and we had to use either overhead transparencies or white board / sign-pen for presentation.

And that story reminds me: our students could (should ?) settle many problems themselves. No baby would ever use the toilet if you keep them on a napkin.

PS. Of course (part of) the problem now is our baby doctors are wandering in 5-star hotels build of precious stones; management consultants would never take the risk of soiling the floor by removing the napkin from a baby !

Teach

Vivian is back from Tokyo and I went to the airport to meet her. On the way I was reading "Investing the Templeton Way" - it was my birthday present from my sister.

The book is so so, but a story of this pioneer of global investment is remarkable:

When the later-to-be great investor was in his high school days, he was convinced that Yale was the best university. Given his excellent grades and all that, there should be no problem to get entrance. To his amazement, however, he found that the admitting examination of Yale included a paper of 4th grade mathematics - a subject not taught in his own high school.

The determined student made his first move - he went to see his headmaster and seek for advice.

"We need at least 8 students for a class."

In no time Templeton persuaded eight friends of his to fulfill the quota and take that class.

"And we have no suitable teacher."

The fans of Yale was not easily moved, "I shall teach that class !"

To the credit of the headmaster, he put up green light.

And the rest is history.

Learn

You may think my grumble yesterday irrelevant. Let me give you a story that KM told me just recently.

Well, our great teacher was involved in a crash course organized by certain super-physicians. Before he did the teaching, he - like tens of the other teachers - received a standard textbook (written by creatures of some other genus) some weeks ago and was asked to go through the details carefully.

My friend duly complied.

And, as Winston Churchill said, it was the end of the beginning.

A few days before the actual teaching, he got a slightly threatening email from one of those lovely creatures, reminding him that although my friend might not absolutely agree with everything of the book - which of course was the case because some details do not conform to the ordinary practice of genuine physicians who treat Homo sapiens - he must and must only follow what's written on the book and should never inject any personal opinion - in order not to confuse our students.

I think they should actually teach by tape recorder or DVD ...

... or, if it happens that our students are literate, just leave them with the book !

PS. Some of our non-primate friends are so eager to share their knowledge but, as Hercule Poirot said: they could never learn new things.

Eager

My department is calling for nomination of an award "The most eager to learn", to be given to a basic physician trainee during the Christmas party.

The criteria, as stated in the invitation, are:

1. attends most grand rounds
2. learning attitute
3. share knowledge with colleagues
4. eager to teach interns

I must say I have difficulty to understand the relevance of the last two points. People who love to share (or show off) their knowledge or teaching (alas, cheating somehow re-arranged) may not be keen to learn new things.

In fact, more often than not they are the ones who shut themselves in an ivory castle.

$1000

What would happen with the consumption voucher (消費券) of $1000 ?

Does it help local business ? What an idea ! We all know people would pay with the voucher and save up the money.

For those who are not familiar with the history of Europe, there was a time when South America was newly discovered and gradually conquered by the Spanish people. There was no short of good silver mines in Peru and areas around. In fact, when Francisco Pizarro first defeated the Inca Emperor and took over the place, he was amazed to find local children have lots of silver toys and decorations. When tons of silvers were shipped back to his home country, however, the Spanish king did not grow richer. In fact, the whole Europe saw drastic inflation and a marked fall in the price of silver - a simple result of excessive supply.

Consumption voucher and other kinds of money in effect follow the same rule.

PS. For myself, I would try to support local economy and buy a new chair for myself in the office. The one that I'm sitting on is 13-year old and I inherited it from my predecessor.

Controversy

Appreciating a poster announcing the grand round of our sister department.

"Current controversies in the management of toe diseases."

To be given by Professor J, head of the division of scalp problem.

And therefore I know where the controversies are - it's all written on the poster.

Thank goodness this is not the memorial lecture of the King of the round table. I'm not sure how His Highness feels when he sees his knights fight with each other.

****************

Talking about the scalp, although I may not like the King very much, it is His Highness who taught me the meaning of a scalp doctor when I was the assistant intern of his team - and the intern who took the leave has become the chairman now !

Fail

RT, one of our medical officers, failed in the recent MRCP examination - we are all worried.

No, we have very little doubt she would pass next time. After all, who hasn't failure of one kind or another in their life ? I always quote the example of LSF, one of our consultant and previous division head, passed the membership on the sixth attempt. So what ? (I suspect he is secretly quite proud of it.) He moved on in his career like rocket, and turned into a well-known hawk by the time he became the examiner !

(Our previous professor of child psychiatry told me this is called Dracula syndrome.)

But we are concerned when our little girl would leave the dark room she builds for herself, , when she would stand up a cheerful doctor again, and when she would stopped looking back the long dreadful night ...

when the dawn is one minute ahead.

PS. You know what: I failed English examination twice when I was in high school. That's not a reason to stop writing - that's the one to write more !

Kurukawa

Read a small book during the weekend. It was [讀書術] written by Yasumasa Kurukawa (黑川康正).

I read it at least a handful of times before. It is, in fact, one of the few books that I deliberately thumb through again every few years. Well, you may find the title somewhat explicit. It is written by a Japanese expert in public examination, and there is no commandment of life or other great topics in philosophy. All it has is a list of practical ways to gather and organize information for a profession.

But I consider that one of the most important capabilities to master.

PS. A poetic subject of our current medical students is Life Long Learning Skill, which largely focuses on gathering information from Internet and interpretation of medical literature. In reality the most important aspect of this subject, in its literal sense at least, is how to handle information overload.

Thermos

Just finished with the licentiate examination.

The drama in itself was smooth. Nonetheless, in the middle of the morning session, a hospital amah appeared. She was pushing a trolley of thermos bottles - it was time to have some fresh hot water for the patients.

AL, our chairman's secretary, was taken aback, "Why are they so obsessive in changing the thermos bottles ?"

"That's the sign of a modern civilized society." My answer was as vague as the speech of Alan Greenspan.

You know what, before the mid 1970s, patients in a public hospital needed to give red-pocket money (利是) to hospital amahs in order to get some hot water. It was therefore a great step forward with the establishment of ICAC: thermos bottles are changed regularly and available to all patients - free of charge.

Despite all the hiccups, our society did advance a lot.

Interest

Don't get me wrong. By no means I think by progressing from stage 1 to 4 that I described yesterday one would become a better physician.

In fact, quite the opposite. (At least it is not a "linear" relationship.)

Think. A doctor would remain interested in medical practice when he sees the real world and progresses from stage 1 to 3. Once he moves further and appreciates the similarity between patients, he does research and writes papers but he losses interest in (taking care of) individual subjects.

That's the point: by then, patients become subjects.

That's why I always consider a professor of medicine who publishes widely is usually not a good clinician.

PS. Of course there are exceptions. After all there are schizophrenics within the "normal" population.

Simple

Contrary to what I said yesterday, it is not uncommon for amateurish medical practitioners to conclude things are often simple.

One favorite story told by WB, a friend and previous colleague of mine, is most illustrative. For a short while he was working with someone who "rotated" to the medical unit for certain months in order to fulfill the training of another specialty. After a week or so in medicine, the new comer made a casual remark to WB, "Internal medicine is not all that difficult - all you see are nothing but heart failure and chronic bronchitis and stroke and just a handful of conditions."

"Certainly," contrary to his usual self, my friend tried to be polite, "If you missed all other diagnoses !"

That's an extreme case of course. In fact most students are fascinated with all those rarities in medicine. I fancy there are several stages of maturation of a physician:

1. Interested in rare things.
2. Interested in picking up rare problems in common conditions.
3. Interested in the difference between patients with the same common condition.
4. Interested in the similarity between patients with the same common condition.

By stage 4, he becomes a clinician-scientist.

Complexity

One hot topic amongst extra-terrestrials recently is the plan of change in the hospital funding system.

That sounds logical: for sure one should allocate the resource according not only to the number but also the complexity of the cases.

The problem is: how do we define complexity ? I shall not elaborate on the problem on the use of computer coding for diagnosis and procedure as the yardstick. The real fundamental problem is: The proposed system awards physical activity rather than the effect. Is a patient who had a whole body MRI (or other autopsy-equivalent investigation) and needs to stay in hospital for weeks more complex than another who is sent home by the consultant the next morning after admission ?

No, the two patients may well have the same problem - just that the latter one is cared by a capable and confident physician, who spots the problem right from the beginning and starts effective treatment.

(Oh, it is somewhat like Philo Vance in The Benson Murder Case. The whole of the New York Police Department had no clue on who the murderer was despite working like chickens of no head for several weeks - but the solution was crystal clear within half an hour after the great detective arrived at the scene. An auditor outside the solar system would conclude: You just solved a simple case !)

Well, with the new system, a capable but realistic physician would not need to think - even if he could spot right at the beginning what the problem is, he would go for all expensive and useless things to prove the case is difficult. (In reality he will actually screen for all occult comorbid conditions to make the case difficult.)

As Lao Zi (老子) said: 聖人不死,大盜不止.

唏噓

The news of lemming is: the classical periodic surge in the population of this lovely species has disappeared, and recent research showed that it is related to climatic change.

In short, lemming lives happily when warmth from the ground melts a small layer of snow above it, leaving a gap between ground and snow. This space provides warmth and food (i.e. moss on stones) and protects them from predators. With a warmer temperature, snow melts and refreezes, producing a sheet of ice that exposes them to foxes and prevents lemmings from feeding on the moss.

*************************

I cannot agree more with VW - the article is an enjoyable piece of intelligence. Here is the cover email that he sent me with the paper:

"When I was a little boy, I learnt from a scientific book that lemmings were genetically programmed to migrate through a certain path. After the change of landscape in Norway, the lemmings just jumped into the water and got drowned. I cannot express my complex emotion when I read this article last week. On one hand, I have been so wrong for more than 20 years. On the other hand, I was filled with overwhelming joy for finding out the truth. It would be a blessing if I can have many such encounters in medicine in the future.

I send you this because not many others think the story is interesting. I guess my daughter would, but I need to wait a few years."

I could understand his feeling.

Lemming

Met VW after lunch. He asked, rather suddenly, "Have you heard of the recent story about lemmings ?"

My face showed plainly that I did not.

He went on, "It's in Nature last week."

I considered for a while, but could not recall what he was talking about. Later the day he showed me an article by Tim Coulson and Aurelio Malo in the November 6, 2008 issue of Nature.

***********************

The story goes like this:

Norway lemmings live through winters beneath the snow and feed mostly on moss. The myth of lemming mass suicide is long-standing and has been widely advocated - generally in sensational literature.

In fact that's not the case. Lemmings have remarkable capability of reproduction. When the lemming population becomes too big and there is a lack of food, they will migrate in large groups. Since lemmings could swim, it is not uncommon to have large migrating groups trying to cross a body of water in search of a new habitat - and they die of exhaustion.

***********************

That sounds familiar, eh ? Why do so many amateurish investors commit mass suicide in a maniac stock market ?

They've never thought of dying !

And why do so many of our graduates jump to into the ice-cold water of certain specialties ?

"The word competition is not in my dictionary."

Your dictionary has very few words in order to suite your level, I know.

Moai

The more I think of the upcoming infra-structure construction, the more I have a flash-back of the Easter Island.

The story was simple: This lovely place at the south of Pacific used to be occupied by a tribe of hard-working people. The place was fertile and, using the jargon of Adam Smith, the product of the land could sustain a considerable population - probably a few times more than the number of farmer that was needed.

And then the leader of the tribe got a grandiose habit to build gigantic Moai - the construction of which required much labour, chopping down woods or things alike that hurts the environment. When the forest was turned down, drought set in, and there was no material to build boats for fishing (or to fly). It was followed by famine and civil war and all possible tragedies.

Many authorities (for example, Jared Diamond) found it difficult to imagine why the leaders of the Easter Island allowed all these to happen: they should be sufficiently smart to foresee the inevitable disaster. (Even though they were not geologists and did not appreciate the relation between forest and water supply, the effect on fishing was immediately obvious.)

But we are wrong. More likely the leaders did not make such a decision - at least not deliberately. Since a (probably small) portion of the population could work as farmer and produce enough food for the whole tribe, the remaining people needed to find something to do to earn their living. In those days there was nothing called "industry" or "overseas trading".

Yes, it was a problem of unemployment.

And therefore they roared and insisted their leaders to build more Moai.

And the rest is history.

PS. You may ask why didn't those people find something fruitful to do. Well, there is an old saying: If the only tool you have is a hammer, every problem comes up needing a nail.

Construction

One favorite strategy that our government - and many others - uses to tackle the recent tsunami is to put up more projects on infrastructure construction.

That sounds great: Expanding the government expenditure would give a kick to the gasping local economy; we could also bring down the unemployment. After all, it is of the public interest to build more roads, bridges, and culture centers alike.

But hold on. If there is such a real demand on those infrastructures, government does not have to make the lead; business people would - for the sake of profit.

For me, it is of course a nice thing to build a highway and connect my hut in the suburb to the downtown. It is, however, a waste of public resource if the government uses tax-payers' money to do such a thing.

And, more than that. When those infrastructures are neither cost-effective nor necessary, wouldn't it be an unworthy thread to the environment ?

Now, you see: John Keynes is the worst enemy of the fans of environment protection.

But, alas, many of these fans just disappear at a convenient time; others turn around and put their heads in some trivial matters.

History

I was recently asked to write a chapter for a book on the history of dialysis.

Once started writing, I began to regret: It is not easy to find suitable reference from the Internet.

On a morning last week, the server of the university computer system was down. I looked at the half-finished manuscript and began to wonder what I could do. Naturally I went through the small library in my office - and a small paperback volume attracted my attention.

The title is: Peritoneal Dialysis - Summary from the Second European Meeting.

By thumbing through the pages I find a wealth of information on the development and change in our practice since the last millennium. In no time I understand how to finish with the rest of the chapter.

The trouble is: this book was given to me by the man who still had a moustache - when I first became his trainee some 15 years ago.

And it was meant to be an up-to-date review of the subject at that time !

Time flies.

How depressing.

Seizure

Another recent seizure attack of the local population is the scandal of Lehman minibond - our honourable members of the legislative council decide to set up a committee and investigate into the matter.

That's a bad sign.

I will not elaborate on the possible effect to the finanical system - that's all done by the few who voted against the proposal. It's more a worry of the delirium of the others on some fundamental principle of a government.

Yes, I agree genuine Trias Politica (三權分立) is often not feasible. Nonetheless it is usually a combination of legislature and executive powers while leaving the judicature independent - the last being the founding stone of a civilized society.

And, when a legislative council does not put its effort on improving the rule of the game but tries to become a judge outside the court, what's the difference between their members (and we !) and those barbarians who stone to death any (suspected) thief or prostitute that they arrest ?

Well, one glorious reason that was put up for this investigation outside the court was "正義得到彰顯". My goodness, one should always be skeptical when someone claims to be doing things for justice. After all, do we know what justice is ?

The Chongzhen Emperor (崇禎) quoted (almost) the same phrase when Yuan Chonghuan (袁崇煥) was cut into pieces by the epileptic Beijing citizens.

Resonance

When the limbic system of a large number of people develops in-phase electric current and becomes resonant, it ends up in a political pressure.

Therefore it is so easy to gain support and have our names removed from all the places in the recent incident.

The same is true for the recent story on melamine. Do you know what is the most common and serious medical problem resulting from its contamination in our food ?

No, not kidney stone.

Not cancer either.

It is the delay in diagnosis of many other disease (for example, by ultrasound or other X-ray) - because the effort of many radiologists, together with the available machines, are diverted to the screening program for people who drink milk from China.

Well, if there were actually many cases of those plastic stones, I agree the resource is well spent. But if the program is largely for relieving the anxiety of many mothers and the general public, it may be more cost-effective to buy some alprazolam (or any other anxiolytic agent) and add it to their drinking water ...

... oh, and the coffee and red wine of our highly respected members of the legislative council.

陰影

In response to my blog on doctor's name, EW - a friend of mine and a regular audience of this site - argued that with our limited resource, we shouldn't ask for too much.

He may be right, but one should try to make the best use of sow's ear and have a nice purse - albeit not a silk one.

**************************

But why does the limbic system of so many of us ring an alarm when our name is put down black-and-white by the others ?

I am not sure. One vivid scenario comes to my mind is (those usually naughty) kindergarten or primary school students have their names being jot down by their teacher. Alas, it is a symbol of doing something wrong - and having punishment not long later.

Sigmund Freud was right: It is a kind of psychological trauma from the experience in childhood.

PS. Psychoanalysis makes depression worse (and induces schizophrenia), I know.

Material

One obvious loophole of my discussion yesterday is: Why don't we make good use of the years in medical school to ensure the graduates to be capable of ordering sound investigations and prescribing effective treatment ?

Well, there are many practical and political difficulties (excuses). Nonetheless, on major question is: How could we ensure a student learn a particular thing ?

By putting it in the examination, of course. (Alas, that's what our educationalists call Outcome-Oriented Teaching.)

There comes the problem: How could we examine those practical aspects ?

No, don't be silly. It's not as easy as you imagine to test how a student order investigation and prescribe treatment in a real-life manner. "Which one of the following five treatment options would you choose ?" Have you ever seen a patient giving you options ?

With some grey hairs and wrinkles, we know very well whether a treatment order is reasonable or potentially lethal - but it is almost impossible to fit it in a (well-defined 10-point) marking scheme.

But we need to be fair ! We should therefore confine ourselves to reproducible scenarios and rigid marking schemes ...

... Things that could be counted, not those that count.

Wage

The major reason for a lengthy medical education is to maintain the wage of doctors.

I shall not elaborate here the major determinants of wage for any occupation - suffice to say it depends on the degree of dexterity, extend of physical (and mental) exertion, risk of fluctuation in income, and social position associated with the job.

You may say: That's the point ! Physicians need much mental (and probably physical nowadays) exertion, and we need to be very knowledgeable to achieve the task. The time of a doctor should be better spent in ordering tests, interpreting results, prescribing treatment, and performing procedures - not doing ECGs or typing discharge summaries.

Alas, don't be naive. Do you seriously think fresh graduates from medical school could order sound investigations and prescribe safe (let aside effective) treatment ? It takes some more years of training and experience. Moreover, do you think we need that many doctors if they only have to do the rosy tasks ?

And therefore we need people with five or six years of medical education to do ECG and other simple donkey job. "A long term of apprenticeship restrains (the competition in employment) more indirectly, but as effectually, by increasing the expense of education." (See Adam Smith, The Wealth of Nations, Book I, Chapter X.)

PS. In fact we are heading that direction. Over the years the wage of junior doctors come down a lot - much donkey work is delegated to nurses and paramedics; doctors are given less demanding a task but also a rapidly vanishing degree of freedom to practice independently, and specialty college replaces medical school as the barrier to minimize competition of practising medicine (which is the most effective means to keep the wage high).

But, look, with this argument, the wage is high for (senior) specialists only.

Work

While waiting for some X-ray procedures of a patient, KT - one of our medical officers - sighed, "Why do we need a doctor to do ECG and all the clerical work ? You can train an assistant to do so in two months."

I gave a light-hearted reply, "Well, what proportion of our work really need the training of five years in a medical school ?"

In fact not much. Even for those often-considered precious elements of medical practice, such as physical examination, ordering of investigations, and drug prescription, you don't really need a full 5 or 6 years of medical education. In United States and many other countries, there are physician assistants who, after 2 years of medical education, could practice as primary care provider - and with satisfactory result. The appearance of "In-Store Clinics" in some states of America further shows that we could safely cover a substantial portion of primary care practice by minimally-trained people who follow well defined practice protocols (see Bohmer R. N Engl J Med 2007 February 22).

Then, what's the point of having such an elaborated medical education ?

Lead

The same problem of choosing a topic also happens when we decide what to teach our medical students. Should we teach what they prefer, or should we decide what is important ?

You may think that's simple: Of course the faculty should decide - how could our younger generation know what is important in the future ?

But students are our customers ! (That sounds crazy, but many extra-terrestrials take it as the serious official view.) With their feedback years after years the university is slowly giving way. We put less emphasis on the teaching of basic science (i.e. anatomy and physiology), we introduce clinical skills early, and we take away many excellent - but with an arm-breaking weight, I agree - textbooks from their shelf.

"We should listen to them - they are on the spot and know what's important." Creatures living outside the solar system explain.

On that they are wrong. Students are not on the spot - practising doctors are. Go and ask any medical student what good is learning anatomy. None what-so-ever - until you become a surgeon or radiologist.

By then you would certainly become Franz Kafka (in The Trial) and say, "Since it is there and it's so important, why don't you tell me earlier ?"

Topic

"Didn't we have the same topic in this conference last year ? Why do we have it again ?" Our man from Pluto asked - in the middle of the conference organizing committee.

A few of us hurried to explain, "Em... Two drug companies wish to sponsor the symposium, and that's the topic that they specify."

Of course that's the case. There are new products in that area and our "business partners" are just too eager to push for the sales. After all, many participants of the meeting are sponsored by those companies.

A die-hard follower of market economy would not consider that a problem: Areas of new advances naturally attract more audience - that's exactly the purpose of having this kind of scientific conference. However, you may have a skeptical view and witness a professional meeting degrading to a extravagant pharmaceutical fair.

The problem is: Should be aim to provide a forum for our business partners to educate the audience, with the obvious benefit of revenue generation, or should we lead the way and choose topics that we believe important ? (Provided that we know the way. Do we ?)

"We should strike a balance between the two ..." You may say.

Alas, it's so much easier to be said than done.

By the way, BALANCE stands for By And Large A Naive Cockeyed Eunuch.

Will

I must say I am thoroughly happy because I need not to have an opinion. That's a privilege of those living in Eden.

The argument put up by my friend was completely sound and logical. In fact, I could foresee if the series of communication was let known to some Patient Right Association, the hospital would be forced to resume the practice - and being asked why this policy was not effected earlier.

Nonetheless it is not always easy to act according to what logical arguments lead us to. As Arthur Schopenhauer pointed out, humans were motivated only by their own basic desires (Wille zum Leben, or "will-to-life"). More often than not we determine in no time the conclusion by our limbic system (which has a much higher speed of computation for evolutionary reasons), and for the rest of the time that we spend on so-called "thinking", we try to put up reasons and logic for what's been decided.

In other words, most of us use logic like a drunk uses a lamp post - for support, not illumination.

Name

With the new admission system, it was somehow decided that the names of the in-charge medical officer and physician would be put black-and-white on a card next to the bed of the patient. Furthermore, all patients would receive - upon admission - a piece of paper with the names of those responsible doctors.

That created a major hiccup - so much so our man from Chaozhou hurried to take it away the next day after the policy took effect.

Is that appropriate ? I received this email the next day:

"To me, disclosing the name of doctor / physician is never an issue. Why should we hide from them? I remember very well when the name chop system was introduced in our hospital; this chop simply reminds me to write in a decent and responsible manner (under the name chop of XXX). Can't really see any down side of it."

My reply was all too slippery:

"I'm not sure whether I need an opinion. It seems a conflict between ethical and political considerations, or an argument between the neocortex and the limbic system."

Tsukiji

After a night of complete bed rest we were more refreshed, and we found the streets more easy to recognize.

(Well, our IQ probably doubled once our blood was diverted from muscle back to the brain.)

We set off to the place where Vivian is going to work - the National Cancer Center of Tokyo, which is some 20-minute walk from where my wife lives. Although we knew beforehand the Center is a luxurious building complex, Vivian and I remained stunned when the extravagant palace of oncology appeared - it seemed the diamond on the crown of the Ginza (銀座) area.

As a distinct contrast, on the opposite side of the road we saw the Tsukiji market (築地市場).

And, almost drowned in a crowd of tourists and local housewives, we suddenly realized why Shintaro Ishihara (石原慎太郎) proposed to move the market to somewhere else.

PS. Vivian and I took some time to navigate through the market to search for daily needs. Thinking of her new working place, my wife commented, "Japanese are so fond of salt and nitrosamine - that's why they have so many (cases of) cancer and high blood pressure."

I considered for a while, "That may be true, but after all they have the longest life expectancy."

Destination

After struggling for nearly a whole hour, my wife decided to take a taxi.

The anti-climax was: the taxi driver didn't know the way either.

But he was certainly a traditional Japanese gentleman and was all too helpful. He drove us to somewhere (he believed) near our destination - which was probably a mile away - and stopped in front of a police station.

He went out and asked.

Another anti-climax: the police didn't know either. (The driver told me when he was back on the taxi.)

But our new friend seemed to have more confidence. He drove for another 200-m and dropped us - he pointed at a small road and told us that it should be somewhere inside.

We hesitated for a moment. Thank goodness we met another gentleman who spoke perfect English, and he gave us the same instruction.

It was, alas, already three hours after we left the Shinkansen (新幹線) station (enough for us to go back to Osaka). We put up the last drop of our courage (and strength) and went into that small road.

Around a corner there was a modern-looking building. At the door of which we found the (representative of the) housing agent.

He shouted aloud Ri Ha Min (my wife's name in Japanese translation) when he saw us.

Despite of the funny pronunciation, it was no doubt the most enjoyable circumstance when my wife hear someone yelling out her name.

PS. Some time later I found out why we went astray: We read the map up-side-down (or actually north-side-south).

And an old saying came to my mind: If the world appears all crooked, maybe you are just tilting your own neck.

Move

We left Takatsuki (高槻) on a Friday morning after saying sayonara to Professor O, Vivian's boss in Osaka.

The train service of Japan is superb. We took JR and arrived at Kyoto in 20 minutes. There was Shinkansen (新幹線) train to Tokyo nearly every 10 minutes; in two-and-a-half hours Vivian and I found ourselves in the most busy city on earth.

My wife reserved an apartment at Hatchobori (八丁堀), which is one station by JR from the Tokyo terminal. We got there all right (despite quite a bit of effort with all our luggage). The problem was: Where should we be going ?

I had a Google map of that area - printed before I came here. We checked again with the map in the train station. In no time local Japanese observed a foreign couple pushing and pulling tons of belongings on the streets of this metropolitan.

But the roads did not appear the same as what's on the map - and so were the buildings. Many of you may know Google map has a satellite view and I had a bird's eye idea on the place before we set off.

We walked further and found the streets even more unfamiliar. Vivian asked a couple of people, but none seemed to have heard of the place that we were heading ...

嵐山

I went to Japan largely to help my wife to move to Tokyo. Before we leave Osaka, Vivian had a half-day off; we decided to pay a visit to Arashiyama (嵐山).

This was not the first time we came to this lovely town outside Kyoto, and we knew a bit the whereabouts. For that reason we deliberately avoided those well-known sight-seeing spots. After getting off the Hankyu Train (阪急電鉄) and passing the Cross Moon Bridge (渡月橋), we had a long walk to admire the red leaves.

After half an hour or so, we stopped at the Cool Temple (清凉寺) - Vivian was too excited to tell the story about the place with the same name in our own country, with a playful description in the all-time classic of Jin Yong (金庸) - The Deer and The Cauldron (鹿鼎記).

We found another small place nearby: the Garden of Two Buddhas (二尊院). There was, at the time, a small exhibition of some antiques, and we naturally took the advantage. Amongst all artistic work of Buddhism displayed, a piece of calligraphy caught my attention - it was not Japanese kanji (漢字), but genuine Chinese.

Vivian tried and read it, but was soon at a lost: like all traditional Chinese writings, there was no punctuation.

But I could understand it all right. The last sentence was all that attracted me. It said: 能言不能行,國之師也。

What a humorous twist of the traditional teaching by Xun Zi (荀子).

PS. The original saying was:
口能言之，身能行之，國寶也。
口不能言，身能行之，國器也。
口能言之，身不能行，國用也。
口言善，身行惡，國妖也。

Neck

You may consider my blog two days ago somewhat ill informed: neither the Grand Council of Qing Empire nor the Standing Committee of PRC are the head administrating body of the country.

Yes, maybe you're right - but they are the ones who make the most important decisions.

They are not rubber stamp; they are the stamp pads.

And they are not the head, but the neck of the kingdom.

What is neck ? My friend MF had a vivid explanation: Neck is the structure that controls the head and determines whether it turns left or right.

By the way, MF is an eminent neurologist - who certainly has a more insightful view on the structure of the higher part of a body than infra-diaphragmatic physicians like myself.

After all, if you want to control any body, you grasp his neck, not the head.

Book

About to set off to Japan and visit Vivian.

As usual, I bring a book with me for the trip. In the past, I usually took a volume of Agatha Christie for that purpose: It is easy to read and almost always enjoyable.

But the thing is slightly different this time. In the coming few days, I would probably spend most of the time on travel and waiting. It seems an excellent opportunity to read something serious.

I decide to take the Wealth of Nations by Adam Smith.

Yes, I read it some time ago. In fact, I read it twice - once a modern Chinese translation, and once the English original. With the tsunami and increasing government control, this bible on free market seems untimely.

But, what could be better than visiting someone you admire when he is down and neglected by the public ?

PS. We know very well the book is called "國富論" in Chinese. The first Chinese translation, however, was by Yan Fu (嚴復), with a title "原富". The poetic nomenclature obviously roots from the all-time classic of political sociology by Huang Zongxi (黃宗羲): 明夷待訪錄.

Committee

Most of my friends know just too well I am always skeptical with any meeting that needs more than a handful of people.

After all, if the whole Qing (清) Empire could be ruled by a committee of five or six (the Grand Council, 軍機處), and a country of over 1 billion people by a committee of nine (the Standing Committee of the Communist Party of China, 中央政治局常務委員會), why do you need a crowd of 50 for whatever matter at hand ?

In fact, for professional administrators, most would follow the teaching of Humphrey Appleby:

1. Do not go to a meeting without a (clear) agenda.
2. Before calling a meeting, make sure you are able to prepare the minutes before the meeting actually takes place.

Yes, your eyes are right. A desirable meeting is one that you could prepare the minutes in advance - in other words, you are sure what's going to happen.

You wouldn't watch a drama without a script, would you ? (Not to say you are someone on the stage !)

Sharing

"What's the agenda of this meeting ?" I asked Irene.

"Eh ... there's no agenda. Dr. X just want everyone sit down and share what they think." My secretary explained - with some hesitancy.

I did not go further. It's not within her control. Nonetheless my limbic system rang a bell upon the word "share". (Oh, nothing to do with the stock market. Don't be paranoid.)

I am neither a Christian attending a religious gathering nor a French existentialist discussing the (abstract) purpose of life in a salon. There seems little point to have a few dozens of people sitting around in order to so-called share their opinion by what actual is talking to themselves. Worse still, if your opinion does not conform to the unspeakable pre-determined decision of that whoever, you would receive a good lecture to explain why your opinion is not satisfactory. The torture would linger on forever, until you express a desirable opinion.

I used to be puzzled what those Red Guards from the Cultural Revolution become when they grow up. Oh, they're all around.

Or is there reincarnation of Gestapo ?

Price

While planning to go to Osaka in the middle of this week, I made some exchange for Japanese Yen.

I did it in a small shop of the shopping mall next to where I live. Well, the charge was considerable, but I was more than happy to pay that extra bit: it opens till late hours, and the attendant appears quiet and studious.

That's how small shops - without the advantage of scale - survive. After all, price is not everything. Many of us are willing to pay for convenience and service.

And that's the thing some Mr. Tsang went wrong. What's the point of (using government subsidy for) setting up an elaborated system to compare the price of every bread-and-butter need between various supermarkets and local stores ? Would that help to bring the price down ? No, don't be silly. That simply makes the price uniform - and exactly because the information on price is readily available and your competitor could easily follow - no one would have the incentive to lower the price.

(This argument is not my invention; it is something taught in the first month for any introductory course on game theory.)

Further, a policy of this kind is a subconscious advertisement that customers should focus on price and nothing else. Because large business has a higher bargaining power with the supplier, they make a better profit (or have a better chance of survival) when the price is fixed.

In other words, it encourages monopoly (or oligopoly).

Oh, maybe he's not wrong - that's what he aims for after all.

Interview

Went to the kindergarten admission interview with Euterpe.

The meeting took 15 minutes in late afternoon, but it needed quite a bit of planning and preparation. You know what, we've been busy from the morning: arranged a proper dress, had lunch, took a nap, opened the bowel, and packed up for outing. Although the kindergarten was just a 5-minute-walk from my home, I don't think I had more preparatory work for a trip to America.

The classroom was full of children and parents. (I learned later the day that there were 600 kids but 60 vacancies.) In spite of all the effort, my worry turned into reality and Euterpe didn't say a word with the teacher - she was just interested in the toys at hand.

The teacher gave me a polite smile; I returned an embarrassed one.

And off she went.

Alas, I suddenly remembered what LS told me: A professor of a medical school is nothing when compared to a kindergarten teacher.

I shouldn't worry that much, I know.

PS. Time has changed. Kindergarten was nothing important when I was a kid. In fact, I had merely 3 months of K-2 and a year of K-3 before entering primary school. Thank goodness my mother was a full time housewife and took the trouble to teach me language and arithmetic. After all, that's all you have to learn.

Slow

You may find my comment yesterday that HP-12c calculator is deliberately slow somewhat unbelievable. Nonetheless, it is ordinary psychology. We tend to put more trust on people who say things slowly - because they probably have a more thorough consideration of the problem (even though that's actually the result of a slow CPU).

This is, in fact, not the only application of slowness.

You know what, all Intel chips are made of one computing speed - the fastest one of course. All the other versions on the market are deliberately slowed down. In fact, the cost is actually higher for those slower chips. What's the point ? Well, it creates a desire on your side to buy (and pay more) for the "most advanced" version.

The same is true for Microsoft Office. We know very well there are the Professional version, Standard one, and Microsoft Work. You could easily guess now all three are made from the same base - just that some valuable parts are removed (suppressed ?) from the CD for the latter two versions. Again, it is a bait.

PS. My friend TW made a similar comment a few days ago on my blog about how quick we see cases in the out-patient clinic. She's perfectly right.

Calculator

Downloaded an electronic version of the HP-12c calculator for my computer. You know what, this pocket-size gadget is HP's all-time best-selling product, and is still in production since it was first introduced in 1981.

Well, for those who are brought up with CASIO 3600p, Americans are difficult to understand - there is not even an "=" button on the keyboard. Nonetheless it is a superb instrument to work on mortgage and bonds and compound interest payments. Although similar calculations could be achieved - and in a more speedy way - by spreadsheets (such as Excel), many practising professions in the financial sector still find this little piece of metal handy and user-friendly.

Talking about speed, the original HP-12c was actually rather slow in calculation - as compared to other newer models. Nonetheless, to be quick is not always good. In the late 1980's, the HP's market research actually found that the users (alas, thick-head financial analysts) did not trust results obtained too quickly, and so - despite rapid advances in the computer chip technology over the years - the CPU speed of HP-12c was not improved for nearly 20 years.

PS. Many general physicians have the romantic idea that nephrologist always carries a calculator for electrolyte and acid-base problems. Well, I have one in my office - it is a Texas Instrument BA-II-Plus professional financial calculator. By looking at the name you could imagine how often I use it for serious acid-base computations.

Fairness

One major reason for the down-grading of the college examination - and to a large extent examinations in (our) medical school - is the obsessive passion for fairness.

"Why do I have a long case who speaks this funny dialect while my friend had one who volunteers to regurgitate the whole history in five minutes ?" Well, let's have a few standard scenarios for history taking.

"Why do I see three short cases in 20 minutes but the other candidate sees seven ?" OK, let's fix the number of case and the time for each.

"Why does the examiner give me such a vague instruction - I don't even know which system to examine." Oh, our apology. We shall specify the system and standardize the instruction.

But, nothing would happen exactly the same twice. The same patient could behave differently. Even the mood of the examiners may change. And, after all, most patients in real life could not tell you which system do they have the problem.

At the end of the day, we change a smart test that picks up bright candidates to a dense examination for dumb doctors.

Change

Had a brief chat with MN - the chief local examiner - on the upcoming change in the format of MRCP examination.

As organizers and host centers, our attention were of course directed to the difficulty in recruiting English-speaking patients with suitable physical signs. As an experienced on-looker, it seems a pity to see how a respectable examination disintegrated rapidly in less than 20 years.

The new move of the college is to put more emphasis on an integrated skill of history taking and physical examination for endocrine and rheumatology cases. I asked MN, "How about fundi cases, which usually do not have much history in it ?"

The senior consultant said with some hesitancy, "They would probably no longer appear in the examination."

He may be right. Many of our younger generation doctors do not know how to use an ophthalmoscope, and fundi examination is often left to specialist.

Well, you may say my feeling is merely deja vu of those Song (宋) and Qing (清) emperors, who saw their kingdoms melt away after giving out piece by piece to some barbarians.

PS. Towards the end of the day, the chief external examiner asked if I had passed my MRCP. I took that as a compliment on my lack of grey hair. Nonetheless, I must say the glory of passing this trying examination dimmed down a lot since the system changed at the turn of the millennium.

Fantasia

Just a random collection of some weird thoughts:

1. Dinosaurs got extincted because their size became so big that nerve signals from their tail never reaches the brain.
2. Neither the university nor hospital authority would arrange professional examination (i.e. final MB and licentiate examination) in the future - because there is a complaint from the Patients' Right Association that doctors should use their time to treat patients rather than organizing examination.
3. Don't worry. There would not be a shortage of doctor. Since 80% of the medical practice involves common sense rather than any specific knowledge, the medical council concluded that 80% of the medical curriculum is not necessary. In other words, you need just one year of medical education.
   
4. Mr. Tsang takes away the fruit money from our senior citizens so that the latter could not throw banana or other vegetables to the CE in the future.
5. Yung Chi Kin (榮智健) would be awarded the Gold Bauhinia Star Medal (金紫荆星章) next July - for successfully diverting all public attention and possibly colourful languages away from Mr. Tsang.
   

Overhead

What's the difference between boosting the economy by paying the bread-and-butter needs of our senior citizen and building a grandiose theatre ?

The overhead.

By this poetic term I mean the amount that is spend on areas that are not for the support of local economy. It includes:

1. Imported material, such as (for Hong Kong) iron and other raw material for the flesh and blood of a white elephant.
2. Administrative charge, manifesting as the profit of those intermediate agency (say, the building contractors).

You may argue the profit of a company represents a plus for the economy. That's true - but that "economy" falls to the pocket of a different group of people...

... the group that could murmur at the side of our (retiring) government officials, so that the latter choose to buy fruits for some white elephants rather than elderly people.

PS. Right, money gives only fruit and flesh and blood to an elephant - not the soul of it.

Allowance

I was puzzled for a while why our Mr. Tsang proposed to introduce the Mean Test for applicants of the Old Age Allowance - he could have many better ways to ask for colourful languages if not vegetables.

Is it because we are expecting so many senior citizens that we should limit our expenditure on them ?

No, don't be silly. Old people would not vanish into thin air and their basic need won't go away just because our government turns a blind eye to them. If we don't support them by tax, we've got to pay for their living in one way or another. After all, if our life span is 80 and we retire at 60, it is a mathematical certainty that we have one senior citizen for every four of us. You can do nothing about it - unless certain Mr. Tsang or one of his delegates is courageous enough to put some poison into our drinking water.

Well, on a first glance it is incredible for a keen follower of John Keynes to take such a step. You know what, giving Old Age Allowance is a highly effective way to boost the local economy: they would spend most of the sum to support (mostly small) business.

At least it seems better than building a cultural center.

Then, why ?

Expenditure

On our way back from Macau, I noted the ferry passed a big chunk of land before we arrived at the TST pier - it was the (later-to-be) West Kowloon Cultural Center.

"You can't promote the cultural standard of a society by simply building a grandiose theatre." I said to myself, "After all, there may not be a sufficient number of art performers - not to say audience."

But I was completely mistaken. The Cultural Center was not built to promote cultural activity but economic ones. No, it's not the center, but the construction per se which was the point. With the recent tsunami, our government is more eager than ever to keep the rate of unemployment down (especially amongst the group with low technology). It is also the classical Keynesian teaching that increasing government expenditure - in construction, for example - would give a kick on to the local economy in the period of depression.

For once I seem to understand what our Mr. Tsang means. It is probably also because of that British economist, our CE goes seriously for the legislation of minimal wage. As pointed out by John Kaynes, in order to boost employment, wages had to go down. However, that would reduce consumer demand, which would in turn reduce business sales revenues and expected profits. Investment in new plants and equipment would decline. In short, instead of raising business expectations, wage cuts could make the matter worse.

It all sounds incredibly simple, so much so I (almost) have a hallucination that our government could solve all problems of the society by following every line of John Kaynes' teaching.

Alas, do you know why did Zhao Kuo (趙括) die ?

Speed

Went to Macau with LS - we were both invited to give a brief talk in a scientific conference there.

We chatted on almost everything and somehow our discussion fell on to the out-patient clinic:

"Some residents are just too slow. If we have 80 cases and 5 doctors, and you see just five or six cases in a clinic, how could we survive ?" She sighed.

"But could you ask them to speed up ?" I suggested.

She asked back, "Can I ask you to slow down in your clinic ?"

"No way. That would cost my life. But I could speed up no problem !" I must admit, on average, I spend 7 to 8 minutes for each out-patient, and I could do it in 5 minutes if necessary, but it would be an intolerable torture if I have to face the same patient for more than 15 minutes.

"Exactly !" The rheumatologist explained, "You are the quick type and you could speed up further. They are the slow type and could go only slower ..."

Alas, I see her point. It is in fact the Newton's First Law.

And it reminds me of the teaching by the King of the Round Table: A quick surgeon may not be a good surgeon, but a slow surgeon must be a lousy one.

Letters

Wrote a lengthy letter for certain bureaucratic problem. This is not my cup of tea, but, as people often say, part of my salary pays for it.

Many of my friends know that I have dyslexia and could not stand any letter with more than three lines. Nonetheless this disability reminds me to keep most of my letters short and comprehensible to any recipient with a similar medical condition - which means the majority of our general population.

After all, why do you need three pages for a trivial matter if a president of the United States (alas, that's Richard Nixon) wrote his resignation letter in just one line:

"I hereby resign the office of President of the United States."

It also reminds me of our sister department in the era of the Knights of the Round Table. In one incident, the King wrote the following letter to fire one of his professors:

"Because of well known reasons, Professor X will leave the XX University with immediate effect."

And his Highness had sufficient foresight to provide a Chinese translation of the letter for his faculty staff:

"基於人所共知的理由,X教授已離開X大學."

What else do you have to say ?

PS. The latter letter was shown to me by the man who still had his moustache, when I was his trainee - as an example of how to write simple letters.

LKS

TW asks whether we should invite LKS to be our Financial Secretary - that's an idea (hopefully not in the sense of Baldrick in The Black Adder).

In that case we may expect our government buying all the Lehman minibonds at hell low a price and sell them (back to the current owners !) some years later - when the price is three or five times higher.

Based on the past record, our new Financial Secretary would also approval building new hospitals in every district - provided that the government pays only for the chairs and tables.

And our senior citizens will have their Old Age Allowance (生果金) increased to HK$1000 - but paid in supermarket coupons. (Well, that's at least better than the current proposal of some Mr. Tsang, whose scheme would certainly bring him many sunny days with a clear sky - because there's no more that kind of cloud [浮雲].)

PS. The most famous Chinese businessman who turned Financial Secretary was Soong Tse-ven (宋子文). For those who are not familiar with the history of our country, Soong was once considered the richest man on earth - after he became the Financial Secretary of the formerly Republic of China (not People's Republic). Would you consider that good news ?

Munger

If not because of his age, Charles Munger would be a better choice of the next United States Treasury Secretary than Warren Buffett.

For those who are not familiar with the financial news, Munger is the Vice President of Berkshire Hathaway, and is the business partner of the famous investor for decades. Contrary to Buffett, who devotes his time almost exclusively to business, Munger is not involved in the day-to-day operations of Berkshire for many years.

The more important character of this right-hand man of Buffett is that he is a generalist - investment is only one of a broad range of his interests. He would certainly have a bird's view on the financial country of America (and probably of the world).

One famous piece of his work is Elementary, Worldly Wisdom, which is a speech he gave in the University of South California in 1994. It is no doubt an ideal syllabus of general education.

PS. Before writing this blog, I had the romantic idea that Munger is much younger than Buffett. It just came as a surprise when I looked up the Wikipedia and realized that the former is actually 84-year-old.

As Martin Ruth said: You will find it very good practice always to verify your reference, sir.

Secretary

On the point of giving the public hope in the middle of a financial crisis, Barack Obama is certainly more creative than any of our local officials:

"(If I am elected to be the president,) I would ask Warren Buffett to be the Treasury Secretary of the United States."

It creates a hallucination that the US government could be run like Berkshire Hathaway.

In that case you should expect the government grows with time, but, as a stockholder (or stakeholder), you would hardly receive any dividend.

PS. John McCain made the same suggestion for the next Treasury Secretary a few days later. It reminds me of the sayings that the first man who compared woman to flower was a genius; the rest of us using the same tactics are nothing but Mohohan.

Tactics

Another recent example of how our officials chose inappropriate words was this:

"The SAR government would exhaust the last penny in order to maintain the stability of the financial system of Hong Kong."

No, there's nothing wrong in its literal sense, but it's just against the principle of public speaking (or advertisement). The above declaration, despite of its noble intention, just create an impression that our government is about to, or has a real risk in, spending the last penny.

That's not what (or how) you want to be reassured with in the middle of a crisis.

For those who are not familiar with standard tactics for this problem, here they are:

1. Appear to be confident and know more than the others.
2. Emphasize you have more than one way to deal with the problem (without specifying what these methods are).
3. Point out a simple practical way for the public that could help protecting them.

For the last point, it doesn't matter if the way you advise has no genuine value - no one could (nor would anyone have the courage to) disprove it. One excellent demonstration by our own officials was the advice to clean the floor and furniture with 1% hypochlorite solution during the SARS epidemic. It does not work - the thing was transmitted by droplets, not fomites. Nonetheless it worked well in terms of soothing the public and prevent further panic.

As Franz Kafka said: The lie is made for world order.

團結

With the tsunami our senior officials have been running like chickens with no head.

One said, "Hong Kong citizens must come together and do not lose our unity in order to tackle the worst financial crisis in our history." (Come together for what ? Jewish people did so in the Nazi concentration camp - it just made them easier to be exterminated.)

The other said, "Hong Kong has a small and open economic system; we are prone to hiccups of financial tyrants overseas." (Translation to modern layman English: It all depends on the others; we could do nothing about it.)

And the third commented, "What's going on is just a prodrome - the worst is yet to come." (Do you mean the Hang Seng Index is going to touch the floor, and we're heading level B18 ?)

But, on a second thought, I shouldn't really be too harsh to them. At least they are honest. What they are trying to tell us are:

1. The stock market will continue to fall,
2. and we can do nothing about it.
3. You guys should stay where you are and meet your fate.

I'm sure if anyone says a similar thing north to the Shenzhen river, he will be at once arrested for spreading rumour - with a possibly malicious intention to disturb the order of our financial system. (By the time the case comes up to the court, of course, they will instead be found guilty for leaking national secret. That's another story.)