Three

The soap opera of the three brothers has come to the end - at least for the time being.

I must say #0016 is a highly regarded stock by value investigators such as JW. My reservation is the very worry that family business never lasts long. Although intelligence quotient has a substantial component of heritability, children of true genius are usually not as gifted.

I believe this is what we call the regression-to-mean phenomenon in statistics.

By the way, there is an old Chinese saying: 生子當如孫仲謀. This is probably because Sun Ce (孫策), his very able brother, died early.

PS. In this opera, it is real fun to see the famous barrister tries his very best to argue for the elder brother - with an astronomical charge - and, in the next minute, represents his own political party and fights for the "rights" of minority groups. I am not sure whether the billionaire has bipolar disorder, but his lawyer certainly has schizophrenia.

Observe

Having three elective students attached at the moment; two are second-year and another third-year.

They give up part of their summer holiday and come here, presumably to have some extra exposure to clinical medicine and see how it is practiced (badly) in real life.

I always believe they can hardly learn very much from a busy clinician. In contrast, JC is always a fans of attachment of this kind. "You don't have to teach them anything. They can just observe."

Yes, I still remember the story The Last Weapon in the Japanese comics Cobra by Buichi Terasawa (寺沢武一). When it first appeared, the last weapon was nothing but a stone with nondescript appearance - except there's an eye on it. The very point is, whenever it encounters another weapon, it would learn the function of - and evolve to become even better than - what it sees. Therefore, it would eventually become the best weapon on earth.

The sobering truth is, although many stones have eyes, images are projected to the retina and there's no cerebral cortex to integrate.

"You see, but you do not observe," says Sherlock Holmes.

尺牘

Find an amazing book on the shelf of my father-in-law: 分類尺牘大全. It was published in 1967 - the year that I was born.

"尺牘" is the traditional term of letter writing. For those of a younger generation, it was a compulsory subject when people of my age were in the primary school. We were taught how to properly address the others and what format we should use. It is, in short, a sign that people in the old days were more serious when they communicate.

And because everything is handwritten and the function copy-and-paste has not been invented, we must appreciate what is important and learn how to summarize.

PS. The book is - alas, the letters are - written in traditional Chinese (文言文), and in the eyes of a modern physician, all the business letters become very poetic.

Better

"A is better than B, therefore it should be A."

You may think my example of logic yesterday was child's play. Yes, of course - but many of us are easily taken in by such a simple blind.

I learnt some years ago a useful trick to sell something - from simple logo for a conference to billion-dollar-worth business proposal - is to provide an unacceptable alternative.

"Sir, we have designed two slogans for the advertisement of your product: one is so-so, and the other is hopeless. Please make a choice ... You think so-so is better ? So are we. OK, that's fixed."

Do you find this story somewhat familiar ? The one that you heard recently is this:

"Sir, we have designed six proposals for the funding of your ... Please make a choice ... "

I wish I could imitate of RK - our previous reader in neurology - and say, "I choose to make a choice later."

Doing

The story of Jet Li demonstrates a common mistake in judgement, which - in the generic language of logic - runs as follows:

"A can do this task better than B, therefore A should do it."

This is wrong. The consideration should go like this:

"If A and B can both achieve a minimal standard of accomplishing the task, and if A could use that amount of time to make a yet bigger contribution (to the organization or society as a whole), then B should do the task - even though A could do it much better."

Unfortunately, many well-intentioned A would rush to take up the task from B's hand.

And most extra-terrestrials have difficulty to follow any logical statement with more than one verb - that's how many of the hospital or department or division policies come along.

Help

I learn from To Kit (陶傑) in Apple Daily that Jet Li (李連杰) is staying in SiChuan and physically helping the victims. According to To, Li is going to stay there for a whole year - risking to lose movie contract that amounts millions of dollars.

I have no doubt the decision is noble, but it could hardly be regarded as wise. Why doesn't Li simply donate the whole year of income ?

Yes, the latter way is less theatrical - but I am sure popularity is not on the agenda of our movie star. Although the used-to-be monk may be a living Hercules and could help a lot in the construction site, he could easily use the time to earn enough money and pay for (no less than) one hundred workers to do the deed - not to say purchasing machines stronger than any legendary hero.

Risotto

Dine with Vivian at Nicholini.

My wife had a five-dishes course. I ordered crab cake with salad as starter, and frog legs in risotto as the entree. (The waiter was of course slightly surprised to find the lady had a better appetite.)

The risotto was excellent: smooth (but still chewy), creamy, and full of the flavour of cheese and asparagus. In fact, there was nothing special in the ingredient - and the dish was purely a test of patience of the chef. I know just too well after trying to make risotto myself: it is essentially a continual hour of adding the broth bit by bit to the rice.

For that reason, it is not an entirely good idea to have risotto in a Italian restaurant. Because of the time consideration (well, you won't wait for an hour for your risotto; will you ?) many restaurants have the pot of rice half-done and put aside. When a customer make an order, it is put back on the stove and finished with.

PS. Although there are many similarities, paella is a somewhat careless simplification of risotto - the whole volume of broth is added all at once and the pan left to boil until the whole thing is done. Well, that's why the Collosseium and Pantheon are in Roma - although I also prefer paella when I have to do it myself !

Account

There is a flooding of donation accounts.

The Hospital Authority itself has two. There is one for the Society of Nephrology, yet another for the Kidney Foundation. I ask myself: why don’t we save all redundancy in administration and have just a few of them ?

(No, not one. Charity is a big business and we need competition; monopoly inevitably means inefficiency.)

But I am wrong. We want the beneficiaries to know we are the ones helping them – how could we hide our names inside Red Cross or MSF ? As individuals, we use our own names on the cheque. Yes, many humble and practical people make anonymous donation. But when it comes to an organization, things become slightly more tricky. Nine of the ten board members may have no problem to give the money, but the remaining one suggests, “Why don’t we set up our own account and put our names on it ? It is for the good (alas, publicity) of our society ?” How could the others disagree ?

And when your sister organization set up an account with her name, how could you lie low ?

PS. There is an important doctrine in statistics: one poorly conducted study would mess up the whole meta-analysis. Or, in traditional Chinese sayings: 一粒老鼠屎，整壞一鍋湯。(I know it is not a very good analogy, but there seems some truth in it.)

GN

After JVO retired, the second chairman of my department was GN: a gentle and quiet man from New Zealand - in the eyes of a third-year medical student.

Those were the days when medical sub-specialties were less well defined, and GN certain sat on the border of many: he was an endocrinologist, cardiologist, nephrologist ... and what not.

That was also the time when the chairman was in charge of both clinical service and university affairs, and every morning GN went up the (post-call) ward and had a chat with the sisters - usually before medical officers started their morning round. (As the old proverb says, I know, because I was there.)

And he was the first to recognize we need some handy reference for the on-call doctor, and bought a set of Oxford Textbook of Medicine and British National Formulary for each ward - rather than calling another meeting to put up our own guidelines.

PS. AW told me a story of GN when we dined in Kuala Lumpur: When the university planned to send some of our medical students to the hospital that AW is working at, our second chairman was responsible for the liaison, and he quickly recognized - and offered - what the others needed to get them going (alas, house officers and the title of honorary lecturer).

"He knew what's going on." AW said. I took that as a compliment - and a sincere one, too.

JVO

I am taken aback to know many of our graduates have not heard of JVO - our founding chairman.

Of course knowledge of this kind has nothing to do with their ability to take care of the sick people. Nonetheless it doesn't feel good if a native Chinese have not heard of Sun Yat Sen (孫中山), or an American does not know of George Washington. (By the way, for new immigrants to the new world, you probably would not get your citizenship.) History is in itself no doubt an interesting subject. With time, I also come to realize that those who are interested in other people and their doings usually prosper - and make their own names a must-know in the years to come.

And JVO is the all time idol for people with a distaste for hypergammaglobulinemia and granuloma. During his leadership for 5 years, there was no need to hold a single department meeting; every problem could be solved by talking face-to-face within his office or along the corridor. Things would happen as said, and therefore there was no need of documentation in black-and-white.

Yes, maybe the world has changed. At least none of us is as able as that Just Very Old man.

Premier

I have all my respect to our Premier - and the Secretary General of course - who made a relentless effort and travel around to materialize much of the work.

Nonetheless I am not all easy. There was a vivid incident in the early Han Dynasty, when the emperor asked Zhou Bo (周勃) - one of the prime ministers - the market price of crops and the number of court cases each year in the kingdom. Being a life-long soldier and probably illiterate, Zhou knew the answer of neither, and his face became all red.

The emperor then turned the questions to Chen Ping (陳平) - the other prime minister. Chen's response was seminal: "There are responsible officials for each of these questions. As the top administrators of the empire, our task is to advise Your Majesty on important policies and make sure people at all levels of the system are doing the right job, rather than knowing - and have a hand on - every details of all aspects of the government operation."

PS. There is a fine line between emigrating to Pluto and giving a free hand to the front line people (but still know what's going on). The sobering truth is: many extra-terrestrials live outside the solar system but keep having a hand on things happening on earth.

DDx

Or could it be our Premier ?

Oh, don't be silly. He did have a fall and hurt himself while seeing to the situation in Sichuan - but that won't kill ...

... at least the fall won't. I'm not sure about the "seeing to the situation" bit.

For sure this is a perfect example of the excellent crisis management and transparency in administration of the country. (Thanks for the disastrous counter-example in Burma.) It is therefore better to leave the task to the Secretary General. Premier should not take any credit.

Otherwise it could be him.

卦

Many of the traditional (superstitious ?) Chinese - like me - are concerned with the astrological implication of the recent happenings in Sichuan.

You know what, Mao Zedong died shortly after the Tangshan earthquake (唐山地震) in 1976. For those who are not familiar with the geography of China, Tangshan is near Beijing.

What do we expect this time ?

The monk in exile is now 73.

Who would be, and how long does it take to find, the next ?

My limited knowledge on political ecology says that it is usually the more aggressive person to emerge when a figurehead dies in the middle of a movement ...

(... not to say of an assassination.)

PS. First came the typhoon in Burma, then the earthquake in Sichuan. 巽下震上,乃易經第三十二卦<雷風恆>。 象辭原文：恆；君子以立不易方。

Quality

Although our man from Pluto is secretly rather happy with the low failure rate in our final examination this year, I am less optimistic with the quality of our graduates.

After participating in this examination for 12 years, I understand the most trying task is to prepare the cases. These are the patients whom we use to test not only our students, but all those trainees about to sit for membership examination. Remind you: they are physicians-to-be and should, in theory, do much better than most of the final MB candidates. I would be very worried if they forget to mention a sternotomy scar, or the size of a spleen, or whether there are cervical lymph nodes, or haven't heard of inverted champagne bottles.

And therefore I am worried.

Or maybe I am outdated and completely wrong. When we were checking the cases and GY asked me what Kennedy's disease was, I gave him a one-minute lecture on the topic. In return he looked at me with an expression of seeing a monster rather than any sign of respect. And when the Royal College begins to cut down the requirement of acute medical training (for her membership examination), what could we expect elsewhere ?

Aim

Finished with the final examination. Quite a relief.

As usual, our man from Pluto did his very best to save every borderline student - to the extend that our external examiners might not be all too happy. Of course it is terrible to fail after 5 (or more) years of work. On the other hand I strongly believe medical schools should bear social responsibility, and have to make sure every graduate is up to the standard. If we pretend to be kind and let through a weak candidate, it would equally mean we are reckless of the danger to our patients.

After all, medical schools should not be judged by the number of graduate they produce (which unfortunately is by some of our government official), but by the quality of the doctors that come out.

PS. You may argue it is our responsibility to educate students and make sure they pass. No, they should be responsible for their own fate. Medical school provides the appropriate environment and hardware to train up a doctor - but it is entirely up the students' effort to determine how much they could get from that 5 years.

Organizer

JW and RM are busy organizing the final examination.

One eternal difficulty is to recruit sufficient number of cases - with reasonable physical signs. For this very reason, coordinating final MB is generally regarded as the most trying task for an academic staff.

But, on a second look, it reflects the problem of our examination. Why is it so difficult to recruit suitable short cases ? Alas, because patients with good physical signs are not that common in the ward and clinic. In other words, it is not a bread-and-butter part of our daily medical practice - why on earth do we put so much emphasis in it, but not areas that we expect our graduates to be more capable of ?

PS. I am not against all physical examination. Nonetheless, I see no real value for a house officer - and even a consultant respiratory physician - to be able to detect an apical lung fibrosis by percussion and auscultation. Would it not be more important to assess by the bedside how well (or poor) the asthma is being controlled ?

Dictator

You may be puzzled how dictatorship began in Burma - and some other countries. There is, in fact, a general formula.

Years ago, when the Burma kingdom, made up of mostly Bamar (緬族), tried to expand, it conquered many of the small tribes around - all of which had their distinct culture and of course fought for their own land. To keep the entire kingdom in "harmony", there was no choice but to allow the army to have more power - on the now "internal" affairs. Years later, when the king was thrown out of his palace - alas, by the so-called democratic movement - military leaders naturally took charge of the country.

Oh, you may find this story familiar. Yes, it did happen more than once in human history, and tragedy always tends to repeat itself. When I first read The Animal Farm in secondary school, I did think that it was not about the Soviet Union but somewhere else !

Burma

Reading To Kit's (陶傑) Sunday commentary about the United States' policy on Burma. Despite of To's explanation, it is obvious that you can never expect the Police of the World to reach out her hands to a place with no petroleum or nuclear weapon.

I am of course all against dictators. Nonetheless Burma stands as a classical scenario against those obsessive proponents of democracy and general election. You know what: 70% of the population in this country are Bamar (緬族), while the other 30% are make up of over 150 "minor" ethnic groups. What do you expect would happen when national policies are decided by election ? Shan (撣族), Kayin (克倫族), Chinese, and many others would have very little say on the country - and their situation would be no better in a democratic system.

You may say all these grumbles of mine are far away and irrelevant. In that case let's propose some ordinances once there is general election here: (1) All people with asset over HK$10 billion should share half of their money with all of us (I can see your smile); and (2) the only crab that could escape from the wok should be pulled back and stay with all other dying ones.

Now you see: democracy - in skilled hands - would become the root of social division and means to discriminate minority groups.

Chair

Went to the other side of the harbour with TL to attend a meeting. Our chat somehow touched on the two newly promoted chair professors in our sister university - TL was obviously not too happy.

I can understand his feeling; it is not all sour grape. When we were medical students, there were only one or two chair professors of medicine on each side of the harbour. Now, we have seven; they, nearly 20. Oh, that's not because we have now many more distinguished academics than 20 years ago: universities make up new chairs for anyone who donate the money.

I suddenly realize local universities are following the footsteps of the Qing (清) Empire: When the king was tight in his purse, titles of government official were sold to generate revenue. Yes, it does solve the problem for a while - but we face an explosion of people with flowery titles, inevitably followed by declining respect. Oh, when the head has so many things, the organization develops intra-cranial hypertension, as evident by papilloedema.

That explains the constricted visual field and enlarged blind spot.

PS. The most interesting account on this happening is the all-time classic of Li Boyuan (李伯元): 官場現形記.

Subject

AW told me his daughter took mathematics as her major in the university - as a slightly old-fashioned consultant, he seemed not too happy with the choice.

I must say even from a practical point of view, doing mathematics is an excellent idea: most investment banks and insurance companies make money by complicated calculations.

More importantly, many international firm deliberately recruit trainees with an unrelated degree. You know what: when Andre Kostolany first arrived at the States, he failed to get the job in Goldman Sachs - because he was just too familiar with the operation of the stock market. University education is for us to broaden our perspective and not (merely) receive training for a particular job. Otherwise we should call the school a polytechnics.

(That's why a Pandora's box was opened when the Hong Kong Polytechnics was "upgraded" to become an university. People with skill but not bachelor degree are discriminated against, and the market value of an university graduate also deteriorates - because of the increase in supply. It is, alas, one of the classical example of social decision with a loss-loss result.)

MSG

Dined alone in the food court of the shopping mall besides the convention center before I was back home. I had a dish of simple Malaysia fried rice noodle.

It was surprisingly good - dry, ingredients well mixed, tasty, spicy but not too hot. But, in a few hours I knew why: the dish was heavily seasoned with MSG. I woke up in the middle of the night, intensely thirsty. (As a traditional Chinese brought up with salted fish and pickled fofu [腐乳], I can eat any salty dish without a drop of water, but neurons in my thirst center are no doubt using glutamine as their stimulatory transmitter.)

But I am never against MSG. To the contrary I enjoy a small bit of it in my dish. We have special receptors on our taste buds for glutamine - an evolutionary adaption to guide us for food with high protein. Soy sauce and soup are, alas, two ingenious strategies to fool our tongue and, to their credit, provide the bare minimum of protein intake for a large number of people from limited resource.

Aquarium

Visited the aquarium at the basement of the Kuala Lumpur Convention Center during lunch break. Of course it is smaller than the theme park in Hong Kong, but still worth a look.

I suddenly realize there is a whole lot of coral fish which are considered not edible by local people but favorites for southern Chinese: grouper, Cheilinus undulatus (蘇眉), and so forth. Of course, the more amazing bit is the consumption of parts of fish that any naive ancient fisherman could never imagine eating: shark fins, gas bladder (花膠) ... what not. It seems most possible that early Chinese immigrants - maybe in the Song or Ming dynasty - found it a waste to do away with these "dispensable" parts of their catch. The traditional practice was, not unexpectedly, to preserve by sunlight and keep them for their own consumption.

That also explains why these dried seafood are largely used in soup - the major method for Chinese to extract nutritional ingredients (mostly amino acids) from left-overs. (In comparison, abalone and sea cucumber are often cooked as a whole - they are obviously suitable for human consumption; the catch is sun-dried for preservation and transportation.)

Poirot

Paid a visit to a local bookstore by the side of the Kuala Lumpur Convention Center during the lunch break. Amongst a sea of fictions, I met this one: The Life and Time of Hercule Poirot by Anne Hart.

The book is not a fiction; it is a detailed summary of the life of this great detective by Agatha Christie. For all lovers of our Queen of Detective Fiction, or fans of this Belgian with an egg-shape head, Hart has make this character very much alive.

You may wonder why I am so fond of this arrogant old man. Well, he was the first detective I ever met in the world of crime fiction. And, both of us have the incurable obsession to keep everything clean and in order. You know what, the very thing that I do every morning before I leave the hotel for the day is to tidy up my own bed – Vivian points out that I have probably read too many detective fiction and subconsciously want to make up false clue that I have not slept through the night.

PS. I owned one copy of this book 10 years ago when I was in Bristol, which - as usual - I threw away after finished reading it. When I realized I wished to keep a copy, I was back Hong Kong; the book was out-of-print. A few years ago Vivian got me the galley proof of this work as my birthday present, but it is still nice to have the final published version - after all these years.

AW

Dined with AW in Kuala Lumpur.

It feels warm to hear how he practised "front line" medicine in the last millenium at a peripheral hospital - I was the surgical houseman in the same hospital, probably around the same time. Inserting a jugular line for someone lying on a camp bed, doing liver / bone marrow / kidney biopsy and endoscopy by the same doctor, inserting 6 chest drains on one day ... Everything seems so unbelievable for trainees nowadays.

For new comers, it is an eternal dilemma whether one should go for busy clinical job - with little chance to think - or for leisured job with plenty of time to study. Of course, that plenty of time does not necessarily result in better thinking. (As Albert Einstein suggested, it may merely be continuous rearrangement of your prejudice.)

On the other hand, if a busy job per se can give rise to a good doctor, we should appoint our ward amah as the professor of medicine !

Abuse

There is a huge light box advertisement on the prevention of child abuse in the MTR station: 暴力零容忍 - 由停止體罰開始.

This is no doubt a reflection of digitization of our society: things can either be yes or no, and all or none. To anyone who understand people not our friends are not necessarily the friends of our enemy, there is not a fine line between child abuse and corporal punishment - they are way different. After all, boars and wolves that have not seen the rough of the world would not survive on their own; they become pigs and dogs.

(Oh, maybe that's the purpose.)

You may say most of the abuse begins as corporal punishment. True, but most of the corporal punishment do not result in child abuse. Most of the traitors are well educated, but you wouldn't ban your child from going to school, would you ?

Melt

The answer to the question yesterday is simple: water would not spill out of the glass when it melts. Aristotle had done a similar experiment thousands of years ago.

Why ? Because when some water freezes to become an ice cube, its volume expands. (That's why it floats.) The volume of water displaced by a free floating iceberg is exactly the same in weight - and hence volume - when the latter melts.

And, when the temperature rise to 4-degree, water level actually falls because it is the temperature at which water shrink to the smallest volume.

Oh, haven't you heard of this ? Go and read <十萬個為什麼> !

PS. Of course if the ice is not free floating but lying on a piece of land, there would be problem when it melts. In that sense the South Pole is more of a problem than the North.

Ice

Another horrific prediction by fans of environment protection is that as a result of global warming, icebergs in the two poles would gradually dissolve and the sea level would rise.

There is some good evidence that icebergs are melting away, but, as to the sea level, I would try and give you a secondary school chemistry test. See the following diagram:



If we provide the latent heat to melt the ice and keep the system at 0-degree, how much water would spill out of the glass?

And, if we further increase the temperature of the system to 4-degree, what would happen to the water level?

Fuel

Despite a rapid rise in the price of various agricultural products, proponents of environment protection are keen to promote "biological" fuel. They have, however, two supporting reasons whose contradiction may skip your eyes:

1. Petroleum is not reusable and will certainly be exhausted one day.
2. If we continue to use petroleum but not biological fuel (for example, ethanol from corn), there will be a continual rise in atmospheric carbon dioxide concentration - with all the greenhouse effects and so forth.

Yes, both are true. What you may not appreciate is: they will not happen together. Either the atmospheric carbon dioxide level rises to an intolerable (for human) high because of a good supply of gasoline, or we exhausted all petroleum on earth before the greenhouse gas accumulate to a toxic level.

The question is, therefore, which one would come first ?

I am quite certain it is the second. From what we know, atmospheric carbon dioxide level was probably 100 times the present concentration 4 billion years ago. What brought it down was, of course, photosynthesis. Oxygen was released and carbon was buried as fossil (alas, coal and petroleum). If we forget about the "educated estimation" of petroleum reserve on earth and consider the law of physics, there should be enough fuel behind our feet to push up the level of greenhouse gas by at least 50 times - of course that's not what we want.

PS. You may ask why should there be such a big discrepancy between the current estimation of fuel reserve. Well, that may be the result of the limitation of current technology. On the other hand, there may be perfectly legitimate business reasons which I should not elaborate.

柏楊

It is sad to see the obituary of Bo Yang (柏楊).

I read the first half of <柏楊版資治通鑑> during my preclincal years of medical school - when the latter half was not yet published. Oh, with time I know there are many inadequacies in the historical details with this supposedly biblical work, but its weight in my "mental record" remains. After all we read this series not for what had happened, but for the orderly presentation of the comments by all those giants in history study - from Sima Guang (司馬光) to Bo himself.

"God cannot alter history, but historians can." Thanks god for sending Bo to us - he told us the things that did happen (sadly, only up to the Song [宋] dynasty).

PS. It is twenty years after Bo's The Ugly Chinaman (醜陋的中國人) was published, and it remains great fun to read this masterpiece. You will be surprised to find quite some local columnists earn their salt by making good use of it - I mean keeping the idea but changing the term China to Hong Kong.

Crab

JW makes a remark that I do have guts. Well, yes, sometimes.

But he brings my memory to crabs - the gentlemen with no guts (無腸公子).

At least I realize the very fact that those who have a fierce looking and walk in the transverse direction are exactly the ones with no guts. (My salute to ancient Chinese biologists – if there were such a people exist.) For the same reason, those in deep – and hot – water and try to pull the others back to the wok have no guts.

Oh, don’t look down upon crabs. You know what: Nowadays there is no clean and genuine gentleman with no guts in our home country. The pollution is so bad that the famous Chinese mitten crab (大閘蟹) has become extinct – or they have actually mutated and their body (and brain !) is now full of poisons.

Alas, there are a few remaining: They are descendants of the fortunate ones who emigrated to Holland in the last century and became settled in the underground sewage drains.

Isn’t it a vivid demonstration of our country ?

Selection

Although one should target to admit a variety of students for a whole university, there is usually a particular type of applicant being accepted when a small department is recruiting new resident - and this very choice governs what type of department it becomes.

For this, KL and I have an eternal disagreement: If two candidates are equal in the overall assessment, should we take the one more knowledgeable, or the other who is more presentable ?

Those who know the personality of KL and me would easily predict the difference in our answer. My standard argument is: Presentation skill could be trained in a latter day, but there is much basic knowledge which could not be picked up again once you passed the stage.

PS. My logic is based on the recruitment system of government officials in the Tang dynasty – again worked out by Fang Xuanling. Of course I may well be wrong; there are many people who make no improvement in their presentation after years in the field.