All-round

Met Y in the diploma course on Sunday. Our conversation fell on to the schooling of children - his son is studying in an international school, about to choose an university.

"The new IB system is very demanding," Y sighed, "You cannot just focus on book work and must also be creative, good at presentation, and many others. Only all-rounded candidates could get into those competitive faculties."

I consider that a bad sign. Yes, it is tempting to have a candidate good at every aspect, but the obsession is too much if you have such a demand for each and every of your recruitment. A football coach who follows this rule would easily dismiss Zidane (little use for defence) and Maradona (too short for headbutts). As Adam Smith clearly pointed out, civilization roots from the division of labour. We do not need every person to be good at everything; we need a variety of people good at different things. Remind you: the most all-rounded football team - at least in 1970's and 80's - was the Netherlands, but this orange army never won a World Cup.

It is phenomenal: Netherlands lost the champion in 1974 to Gerd Muller - the German player who did nothing but the final kick of a goal.

Responsible

There is again a TV program on Sunday talking about the problem of MOI (Media of Instruction, 母語教學).

Vivian remarks, "This is no doubt the worst legacy of our previous CE." I node with agreement. She goes on, "And anyone who was asked to promote the policy would certainly put an end to his political career - look at our previous VC. I cannot imagine a professor of surgery did not see the problem right at the beginning."

"No difference there," I say coldly, "He works out all the details."

"But he is not the one who began the disaster !" Vivian is standing on the side of surgeon, of course.

"Do you think Hideki Tojo (東條英機) could blame all his doings to Emperor Showa (裕仁天皇) ?"

PS. Vivian certainly thinks I am a bit harsh. Nonetheless, take aside our patriotic feeling, I am sure the Japanese prime minister wholeheartedly believed what he did was good for his country. It is no doubt a worse crime to know something being harmful (to children !) and carry on - with an aim to climb up the hierarchy of the political ladder.

Bach

Listen to an old CD in my office - just pick by random. It is Bach's Brandenburg Concertos.

It sounds familiar, and I suddenly realise it was a gift from F.

I still see F every now and then, but certainly our paths are getting away from each other. The concerto, as F told me, was her favorite background music during study, and this box of glaring object was given to me at the height of my preparation for the membership examination. Alas, it has been 15 years ago.

I learn a lot from F. If not for her recommendation, I would not have read The Dream of The Red Chamber (紅樓夢) of Cao Xueqin (曹雪芹), or Tierra (人間昆蟲記) of Osamu Tezuka (手塚冶蟲). And whenever I think of her, my memory inevitably falls back to a poem of Li Shangyin (李商隱): 夜雨寄北.

Hour

The problem of starting work early or late brings us to another issue: how long should we allow junior doctors to work ?

"One should not work to too long an hour - otherwise you're prone to error, and it is not humane to say the least."

But, let's take a look at the other side of the coin. If one works for 80 hours per week and takes 7 years to gain sufficient exposure to be a specialist, how long does the training require if he only works 60 hours a week ?

The answer is not a simple mathematical one. You have to consider the fragmentation of work and loss of opportunity to observe the same patient for a sufficiently long period of time - all too important to make doctors mature.

"We can make up the defect by having better rotation and coverage." Some extra-terrestrials suggest.

My friend, a chunk of prime steak is never the same as an equal weight of minced hamburger meat. Don't just think of McDonald all the time, although our famous chain store has certainly got its business running on Pluto.

Early

There is a tendency that our residents do the morning round at early hours. For obvious reasons that's not very much welcome by nurses (and probably patients). Some of our residents, on the other hand, are not too happy either when the department puts it on paper that morning round before 7 AM is not allowed.

How early is early ? People like me certainly remember when our previous professor of surgery was working in the States, he did his round at 6 AM if not earlier - and he was thoroughly proud of it. For trainees or house officers eager to have more experience, getting up early is a valid strategy.

On the other hand, I do remember a vivid story of Ronald Reagan - when he first became the governor of California. One day, when he was about to off work at 4:45 PM, he met one of his subordinates - who was hurrying to a meeting.

"I need to stay late. The meeting is very important, and we have lots of urgent matters to take care of." The official explained, with a hue of dissatisfaction to his boss.

"I think both of us should go home early rather," the later-to-be president was unmoved, "If I have to work for 16 hours a day to be a state governor, how could I take up a higher post in the future ?"

PS. CH Tung ? Who ?

Salary

EW points out that the people in our canteen are grossly underpaid - hence explaining the poor quality of the food.

Of course both phenomena are true, but I suspect their relationship is slightly more complicated.

Why are the workers in our canteen poorly paid ? That's because their boss needs to squeeze down the budget when bidding for the contract - and money is the only factor that our hospital board, who themselves do not lunch here, consider.

No, it is (by and large) not a problem of relative monopoly in the hospital setting. If front line staff are allowed to choose the canteen (i.e. decide the contract), the quality would be more acceptable - otherwise the owner would lose the contract next time. The price would go up a bit - to cover a higher salary and also better quality of the food. That higher salary is needed for better employees - or, more likely, incentive for the same ones to work better.

Now, you see: the low salary bit cannot be done away by a simple government policy. If we put up a law to enforce a minimal pay, there would be fewer staff (i.e. more unemployment, and the canteen would become more dirty) and the quality of food would further deteriorate - if it is at all possible.

Confidence

Once I think of the cosmopolitan Chang'an (長安) in the Tang era, I suddenly realize it was actually the first time China faced the Eight-Nation Alliance (八國聯軍) - of civilization.

It was the time of blooming of Buddhism in China. Muslim was playing a crucial part in the nation's alliance. Turks and Arabians were friends in business but antagonists in military consideration (sounds familiar, eh). Japan, Korea and Vietnam regularly sent students and government officials to learn various aspects of civilization - from the system of words to design of the capital. Nearly 2% of the population of Chang'an were foreign citizens - and another 2% travellers. (England ? It was still the time of Heptarchy and Christianisation, and another 300 years before the appearance of King William I and the land became unified.)

And, did Tang's people boycott Arabian stores or set fire on Buddhist temples ? Of course not. Chinese at that time were confident with their own culture. A people could only be receptive if they have no inferiority complex.

驛站

On a second thought, Fang Xuanling (房玄齡) must have spent much of his time waiting the horse to be fed.

Oh, this is not (only) because most of the government structure and ordinance of the Tang Empire were planned by Fang. One of his most remarkable achievement - and also of the Empire - was the establishment of an ordered system of road and horse station (驛站): travellers and, more importantly, messengers of military news did not have to stay and wait for their tired horse - they simply changed to another one in the station. There were nearly 1500 stations of this kind in the Empire, and it took just a week or so for one to send urgent military news from Baghdad to Chang'an (長安) - at that time the biggest and the most cosmopolitan city in the world.

(Of course this system showed signs of collapse from the middle of the Tang dynasty - partly explaining why Tang's influence on the mid-Asia diminished. It is a hard task to set up those stations, but 10 times more difficult to maintain them for hundreds of years.)

PS. As I told Vivian some time ago, the transport system of the Tang Empire would be an excellent PhD topic for a person like me.

Time

JW is amazed how I could find time to write my blog.

That's not too much of a problem. Some of my blogs are written while Euterpe - my daughter - is enjoying her milk before bed; others are done over weekends (usually Sunday mornings).

Of course my efficiency could not be compared to Fang Xuanling (房玄齡), the famous prime minister of Li Shimin (李世民). Being a hardworking official, Fang was well known to be able to finish writing a government document while - on his way to work - waiting for his horse to be fed (駐馬立成). In modern words, he could draft an ordinance for the House of Common while filling the tank of his BMW in the petrol station - or, as a poor humble academic, prepare a grant proposal while waiting for bus to work.

PS. I am sure if he were born in the modern world, our great prime minister would become the most productive - in terms of research output - professor of medicine. Oh, politics would not be his choice: he could meet no Emperor Taizong (唐太宗), and, more importantly, his paper could be understood !

Canteen

You may wonder how could our canteen survive in a commercial society. (Well, I'm not too sure it could survive. I hope not.)

The answer is simple: The contract was decided by and signed with the hospital board - whose members never have their lunch here.

(Of course our extra-terrestrial friends may actually be very generous already. They could easily have chosen a canteen that serves only cold dishes and green salad. After all, we are donkeys and horses.)

For similar reasons, if the children of our Secretary of Education do not study in a local school, and our Secretary of Health do not have his own high blood pressure treated in the government clinic, how could you rely on systems they designed ?

Alas, don't be too critical. Once remembering Yakov Stalin was driven to commit suicide by his father, I find our senior government officials really humane and naive.

Rice

Had a lunch time meeting and enjoyed a box of impressive rice from our canteen. The grains were so much alive that you could take them as seeds and use for farming.

I remember very well the story of a food critics going to a local restaurant. Before any elaborated dish is ordered, he asks for a bowel of plain rice.

"Rice is the most basic thing."

You may say rice is usually prepared by subordinates rather than the main chef. Nonetheless it is exactly this kind of minor thing that we could tell how well the chef train - and supervise - the juniors, and how serious the whole team is when it comes to the details.

Alas, the difficult bit is not to be successful in a complicated dish on a remarkable day, but to be unrelentingly consistent in doing a simple basic thing everyday - and do it well.

PS. Of course that's not my most memorable experience with this canteen. On one occasion half of the rice on a dish was raw, while the other half had the texture close to puree. (And I was sure both came from the same rice pan !) This is certainly against the law of physics and, other than a legendary Korean chef, I have never heard of anyone who could do it: the chef was Dae Jang-geum (大長今).

Buddha

Having a book on the life and basic theory of Buddha as my bedtime reading.

It is amazing to know how the theory of Buddhism evolved with time, especially the division of mahayana (大乘) from hinayana (小乘), and various schools of buddhism. Buddha, it means "the awakened one". What Siddhārtha Gautama (釋迦牟尼) did was finding the way that we should lead a living. Most of the discussion on metaphysics (alas, most of the texts on Buddhism !) were elaborations by Gautama's followers, or the followers of followers. Remind you: Paper did not appear in India until more than 500 years after the death of Gautama.

"There is no scorn more profound ... than that of the men who make for the men who explain."

PS. It was a favorite question in my secondary school: How many gods are there ? My answer is: If everyone believes in unitarianism (一神論), and there are N people in the world, then there are N gods - because everyone has a different one in their mind.

省

Had a chat with AC before leaving for home. She was just off call and told me an all-to-common scenario:

An old woman was treated by another department for a specific condition. Soon, a complication of the treatment developed. The woman was ill but not that critical - ICU refused to take her. Naturally (to that specialty), AC was asked to take the lady over for "better" care.

Most of my friends know very well that my standard response to request of this kind is to write down "This is a complication of your treatment." and off I go. Obviously AC had much hesitancy to respond that way - she did believe that she could do the patient good by taking her over.

I have no doubt that is true, but there is a risk our good would be badly abused by our "friends" in other departments. (No, there is no risk. We certainly would be abused.)

********

On my way home, I became less confident with myself. Is it my primary objective to help individual patient, or to maintain inter-disciplinary justice ?

I may try and support my ground by arguing that if "justice" of this kind is corrupted, more patients would suffer in the long run. And, as Francis Bacon said, "If we do not maintain justice, justice will not maintain us."

But, I know just to well that "more patients" are make up of many individual patients. If we do not aim the best for each and every of them, how could we achieve anything to them as a whole ?

PS. "Justice" is an alarming word. When something is "done for justice", it is almost always coming from the tongue (and hands !) of Satan.

長假

By some coincidence, I watch the Japanese TV series Long Vocation in a Sunday afternoon. This is the second time I watch this classic – and it was over 10 years ago.

That was the time shortly before I set off to Britol for training. I was in the middle of my career and everything seemed coming to a dead end. There wasn’t even a plan where I was going to work at after I came back.

It was all because of Tomoko Yamaguchi (山口智子). “When the time is not favorable, just step back and take it as a long vacation.” With this, I left. (And I was lucky enough to enjoy in Bristol the most peaceful year in my life.)

PS. Contrary to what you imagine, I brought with me just a few books to Britian. Here are all of them:

1. Rose & Black's Clinical Problems in Nephrology
2. Clinical Dialysis (by Allen Nissenson)
3. Janeway’s Immunobiology
4. 史記(白話版)

Fire

Fire is such a symbolic item that it is always a bad idea to run around with it.

Fire spreads. Ever since Prometheus brought it to human, fire was taken as the symbol of glory and hope – that’s why it is risky. When someone is holding a torch, you can’t really tell it comes from Olympus or some mimic of the stature outside New York.

And it cannot be done away that easily. As the old Chinese sayings: Be there a stone, there is always a source of fire. (石在,火種不絕.)

PS. Ancient Chinese had the wisdom and put fire under the symbol Li (離, see below), with a dash line inside two solid ones. Yes, many of our pursuit and enthusiasm have hot and vigorous coating, albeit the content is nothing but ash.

Lesson

Why should he be jailed for 18 years ? Most people of his kind would be sentenced to death.

Because the worst bit of his doing has not been revealed (or charged).

Of course not all of his doings are revealed. Otherwise more people will come to the light.

Without this layer of consideration, how could THH step down without a second word ?

Or, if not for that THH, why could the man come to the light after all ?

Lesson learnt.

PS. As Alan Greenspan once said: If you think you know what I’m saying, you’ve definitely misunderstood me.

Food

Don't be mistaken. I am all for a healthy diet – but for a different reason.

The argument is simple: the productivity of an area of land that is needed for your dinner of 12-oz sirloin steak can keep the same you fed for a whole week with rice, vegetables and to-fu. High school ecology teaches us that energy conversion from the sun to grass, and then cow always means more wastage than from sun to rice or potato.

(And when a big country has remarkable economic growth and many of the people become meat-lovers, it inevitably uses more farmable land - despite of its successful policy on birth control.)

Of course it is a real dilemma whether we should try and feed as many people on earth as possible - by eating more vegetables and less meat - or to keep a variety of diet (after all, cookery is an important part of human civilization) and aim to have fewer people.

Smoking

I have all my respect to senior government officials – oh, of America and many other developed countries. (China is of course on the list. Alas, not those ex-colonial ones. Don’t be silly.) One exemplary incident – after our discussion on diet – is their attitude on cigarette smoking.

Why does it take half a century (or longer ?) to recognize the harm of tobacco ? The evidence has been overwhelming to start with.

But, what could be more effective to make sure your citizens die at a desirable age – that is, without taking pension for too long ? (I suspect if there is a soluble and tasteless substitute, some governments would add it to the drinking water.)

And there's more. Philip Morris and companies of this kind are great tax payers – and the tax of course comes from the profit, alas, customers. Now you see: when you buy cigarettes, you are actually paying extra tax to the government, and you slowly kill yourself – usually around the age of retirement – by a series of small fires.

Lifespan

You may think my grumble yesterday was silly. Although all people must die, cancer screening of that kind could certainly prolong our life span.

For a similar reason, there is a continuous effort to promote healthy diet – both in Hong Kong and many other (affluent) countries. Why, most of the modern diseases root from too rich a diet. Diabetes, high blood pressure, high cholesterol, heart disease, colon cancer … you name it. We can live longer and prevent major diseases – thereby reducing the burden on the health care system.

This argument is no doubt delusion of the worst kind. Any one who lives longer – however healthy he appears to be – would of course put burden on the system. For the society as a whole, increasing the life span from 70 to 80 adds nothing to the productivity. If anything, the overall productivity decreases because some extra (human and environmental) resources are drained to take care of the old people.

Oh, no, I am not against old people. (I am one very soon, if not now already.) From an individual point of view, it is fantastic to have another 10 years to live – provided that the quality of life is reasonable. What I am getting at is: when it comes to health care, a responsible government should not promote programs that prolong life span in general, and there is an obvious conflict of interest between individuals and the government.

Do you still believe in any health financing system advocated by the officials ?

Prevention

There is an interesting report on our morning paper promoting whole body MRI screening for occult cancer. The same study appears formally in the Hong Kong Medical Journal at the same time.

This is of course an admirable marketing strategy – which we can discuss later. As a lover of philosophy, I am more concerned about the very question: how are these participants going to die ?

Look, this is a game of zero return (零和遊戲). By reducing the mortality of cancer – if this kind of screening really could – there would be more deaths from atherosclerotic diseases, infection, degenerative diseases, or something that we never dream of.

For sure, seeing an increase in mortality of that very something, we put more resource there. Mankind has become the First Emperor (秦始皇) and medical researchers Xu Fu (徐福). We set off to find the immortal medicine – knowing perfectly well that nothing of that kind exists. (A few Xu Fu of us certainly have the wit and try sending occasional good news to the Emperor – so as to prove they worth their salt, or worth more salt.)

And, unlike our famous predecessor, we have no fairy island ahead of us to settle.

PS. Rather than publishing in HKMJ, I find this article more suitable for journals of a much higher impact factor. For example, the Journal of Biological Chemistry would be a perfect choice – according to their regulation, any paper published in JBC with page charge should state that it is an advertisement.

清明

My mother is preparing for the Ching Ming festival. As usual she makes an impressive volume of paper work - money for the underworld (溪錢), paper folded into gold bullion, and so forth.

I always consider all those Chinese rituals in funeral full of science. You know what, papers folded into gold bullion are easier to burn - because of the amount of air inside. Money of the underworld are in fact specially designed: the hot air from an incinerator (or any fire) would suck up a pile of "money" (that is properly put) next to it and burn them piece by piece.

After all, if you go to the funeral of your "good friend" and could not stop laughing, what else is better to bring up your (crocodile) tears than those fume and smoke ?

PS. My mother keeps all her paper crafts in a plastic bag - on which is a picture of the famous Japanese comics: The Fullmetal Alchemist (鋼の錬金術師). It is her sense of humour, I am sure.

Obituary

A few years ago there was an occasion when CB was back from a holiday, he asked in the round a light-hearted question, "Who has died recently ?" After working together for more than 15 years, I knew perfectly well that he meant (our dialysis) patient.

I decided to be naughty and said,"Francis Crick died." (I learnt that from the Lancet that morning.)

CB appeared confused for a moment. I made the second hit," And George Thorn died too."

(Of course CB rushed to the computer and wrote an urgent referral for me - to see the psychiatrist. That's another story.)

*******

With this small comedy, if any one of you asks me today that very same question, I would reply, "William Ganong died."

Rest in peace, amen.

Degree

Visited my hairdresser early in the morning of a public holiday. On the radio there was an official from the nursing council - explaining why graduates from some nursing courses were not recognized and not allowed to register.

After half an hour of torture (ironically, by the man who was famous for his lack of university degree), this guest of the program admitted - unwillingly - that there is a plan to accept only those nursing courses that give a bachelor degree.

My immediate reaction was we do not need university graduates to feed or change napkins for our patients.

On a second thought, I was wrong - our nursing colleagues have secretly upgraded themselves over the years. Those messy jobs are now delegated to "health care assistants" (alas, hospital amah in sugar coating). Nurses are now responsible for doing dressing, dispensing drugs, checking blood products - and documenting records. Oh, I'd better say no more.

PS. The most difficult thing to train a nurse, I am sure, is how to read doctors' handwriting.

Recycle

Until very recently I threw away most of the (non-medical) books after reading.

You may think that's a waste. To me, books are for reading. After that very purpose is served, what could be better than have those slim sheets of cellulose fibers recycled ?

Yes, we should make the best use of the time when together - and, when it is over, put it in the memory and be ready for a new chapter of our life. If we just flip through a book, keep it on the shelf and hope that we shall later have the mood to read it seriously - and that day never happens - what's the difference from those sons and daughters of that father (or mother), who keep yelling to make sure their dying parent could take a few more breathes, but wasn't dare to pay a visit when the old man was much alive ?

Book

BM - another young colleague of mine - asks whether I have the collection of every edition of Harrison.

That's really an idea. (Oh, I am pretending to be Baldrick of the Black Adder. For sure you have not watched this comedy - thanks god.) But, when it comes to books, I am a head-to-toe pragmatist. Books are kept for reading or later reference, and never a third purpose. I put previous versions of major textbooks in wards so that I - and other people - can get a handy reference. (Yes, I keep the old editions of RJ Epstein and Ryder - that's because they are better written than new ones and cannot be replaced.)

"We should love people and use things, but not love things and use people." (我們應愛人而御物,非愛物而御人)

PS. BM has probably never been to my office - which is well known for my extraordinary collection of space and emptiness.

Breeding

One serious obsession of the man from Pluto is the passion to have breeding outside our own department.

"They bring in new ideas and techniques," he loves to explain.
"We have to be international," so is said by the VC as well.

I am not against people outside - but it seems disheartening to employ someone simply because he is coming from elsewhere.

There was an illuminating story I learnt some years ago: A man was invited to join a new company, and seek his friend's advice. The friend asked, "Why do you want to join ?"

"Because the boss is very nice to new comers elsewhere."

"In that case you should not join," the friend pointed out coldly, "Otherwise you will become one of his own men - for whom this boss never feels precious."

PS. You know what: Although America is a well known cosmopolitan country, the law actually states that their President (and the Secretary of State) must be born in the United States.

Friend

"Oh, we are friends ..." Z suddenly says to me.

I feel cold and dizzy, probably also a sense of nausea. After years of experience in dealing with MBA, I realize any statement that needs extra emphasis must be false, and any organism of Z's kind that calls you friend must be trying to make an unpleasant proposal.

Friendship is a strange thing. Two persons become friend because of similar interest, but when the two of them get too close together, friendship will be spoiled by (the conflict of) interest.

PS. MBA stands for Master of Bureaucracy and Administration. (Alas, it has nothing to do with business - does Warren Buffet or Bill Gates ever need such a degree ?)

Harrison

Receive the new edition of Harrison’s Principle of Internal Medicine just now (I ordered it on-line some weeks ago). Many of my friends know that I have an obsession with this bible.

I first met Harrison as a first year medical student – it lied in a corner of the university bookstore as a bargain item. I knew nothing about the background of this giant, but was impressed by its huge size (though not as much as it is now), and it was sold at merely HK$10. Without a second word, I – as people usually say – put my money on it.

(There was another book which I bought at the same time – also as a bargain; it was Washington Manual. I always wonder if I could be half as sharp when it comes to choosing stock.)

There is always a worry that textbook of medicine would become a dinosaur – because of the rapid advance in clinical science, a textbook becomes outdated by the time it is published. I hold the faith that there must be pearls hiding under the sea of information that can stand time.

Nice to see you again, my friend.

Examiner

(This blog was written on 20 March 2008. I deliberately deferred the post to 2 April.)

Appreciating the examiner list of our third year medical OSCE. It is hard work to do a 4-hour clinical examination, and I find most participants young and enthusiastic. You know what, amongst the 7 chair professors within the department, the name of only one appears on the list.

Ironically we hold the department board meeting earlier today. Teaching is a big thing. "We should do this" and "we should do that". I suddenly understand why Gongsun Long (公孫龍) said a white horse is not a horse (白馬非馬) - because "I" am not one of the "we" either.

PS. I cannot recollect who told me this very fact: you do not judge people by what they say, but by what they actually do.

Advance

You may ask, "Aren't there real advances in medical treatment ?"

Yes, of course. The very fact is, however, the magnitude of improvement (or, as some extra-terrestrials who are obsessive in evidence-based medicine loved to say, the absolute risk reduction) is declining. (Well, there aren't very many common conditions that has 50% mortality in short term - except perhaps the victim of homicide secondary to psychiatric manifestation of acute hypoglycemia during a lunchtime meeting sine lunch with organisms in Pluto; I just had one earlier today.)

What's the result ? Since we need large trials to prove a small benefit, clinical studies are more and more influenced by pharmaceutical (i.e. business !) companies. As you can predict, the more the participant, the more the mishappenings - which means more controls and bureaucratic formalities.

That's the short term effect. In the long run, the cost to prove a product being superior would increase exponentially - eventually outweight any monetary return from the successful product. (Note also that with more control and bureaucracy, the chance of having a successful product - in terms of getting it on to the market - is ever decreasing.)

Would there be a point when no new drug would be developed because it is just too expensive to prove effective ?

PS. For those not familiar with Latin, "sine" means "without".