Impact

One of the official purposes of my trip to Istanbul was to attend the editorial board meeting of a journal.

For those who are not familiar with business of this kind, it is the only time in a year when all the ones actively participating in an international publication sit around, review the operation, and have a while of brainstorming on how to make the thing better.

By “better”, nowadays people inevitably mean a higher impact factor.

The one who invented this gigget was a real genius. The principle of calculation is simple: You count the number of times people cite the paper from a journal, and adjust for the number of full paper published by the journal.

As a simple and sometimes naïve nephrologist, I found the discussion highly entertaining – if not educational.

Market

We visited the spice market in Istanbul; it is also called the Egyptian market for historical reasons.

Vivian tried very hard to encourage me to buy some local spices and try in some dishes later during my cookery experiments. Of course I waved off the idea - it is not easy to find enough volunteers to risk their lives.

Gourmets and those with some knowledge on the history of cookery would have heard of the original purpose of spices: to cover the unpleasant smell and taste of those slightly outdated ingredients, and possibly to reduce the chance of food poisoning.

The situation is rather similar to writing up for medical journals: If you have good data from a well conducted trial, you don't need much analysis - if you have a fresh catch of delicious fish, the best "cooking" is to slice it and serve it raw as sashimi. Only if the available piece of meat is old and tough (maybe half rotten), you need to wrap it with flour, deep fry, and season it with salt and garlic and pepper and curry and everything ...

... and only if the study design is shaky and data point to no where you need a lot of statistics.

PS. It is therefore somewhat disappointing to find many pseudo-gourmets in medical research keep demanding for more seasoning of research result. Yes, a bit of spice does make the dish taste better, but too much of it makes us too hot for a cool judgement.

Palaces

There are two major palaces in Istanbul: the Topkapi Sarayi (old palace) and the Dolmabahce Sarayi (new palace).

Vivian and I visited both of them, and were thoroughly impressed by the size as well as the enormous collection of antiques. A room well furnished with fur and comfort chairs was not for formal meeting with ambassadors; it was only the waiting room - for the translators ! The grandiose bedroom that we were shown was not for the Sultan (emperor), but merely his chief maid.

"The chief maid is always a significant person." Vivian pointed out rightly.

PS. On a second thought the bedroom of the maid should look more pretentious than the king's own one - in order to fool any assassinator !

Geography

Istanbul is divided into three parts: the old city (where most of the historical buildings are), the Northern part (where most of the hotels are, also the commercial and administrative center), and the Asian part (largely for local residents, and also where the major port is).

The traffic here is always horrific; most of vehicles must be made of soft plastic so that they could squeeze through those small village roads and between each other. When we navigated around the city, our local guide loved to point to the sea around and said, "This is the Golden Horn." "This goes to the Black Sea." And there are the Bosphorus, the Aegean Sea, the Meditarranean Sea. Quite an endless list of geographic term.

"How could we teach Euterpe to learn all these places in the future?" Vivian asked.

I gave a light-hearted answer, "Teach her playing Diplomacy."

PS. The only person whom I know playing this famous board game during childhood was Henry Kissinger - and, in addition to geography, an important thing that you could learn is stabbing the others' back !

Istanbul

Attended the ISPD meeting in Istanbul.

I arrived a day before the meeting actually started and joined a local tour. We visited common sight-seeing places like the Hippodrome, Hagia Sophia, Blue Mosque, and so forth. “This is three thousands year-old.” “And this is here since 600 A.D.” The list seemed endless.

I said to myself, “Oh, 600 A.D. is around the time when the Tang Empire was under the reign of Li Shimin (李世民). Where is his palace now ?”

No, there’s not a trace of it – all destroyed during the change of dynasty.

Right, Turks (突厥) were often regarded as barbarians by ancient Chinese, but at least they did preserve most of the things they inherited from the history – not only of their own, but also of the Byzantine Roman that they conquered.

As the traditional Chinese saying: 禮失求諸野.

Property

Had a brief chat with JW. He was thinking of buying a new apartment for his parents and he asked for my opinion - from a financial point of view.

Somehow JW has a romantic idea that I am a wise man. It has certainly disappointed him this time - local banks announced an increase the interest rate of mortgage soon after I said it was a good idea to buy. To me the consideration is simple: buying property is almost always a good idea for real use, but never as an investment.

Yes, buying apartments for renting is the favorite kind of investment by many traditional Chinese tycoons and respectable investors (like Tony Measor), and many real wise men do make money by buying and selling. Nonetheless buying with mortgage - for the purpose of investment - is no different from gambling in the stock market by margin trading - except the fact that a flat is less liquid but more volatile. As the owner of a property, you have to take the risk of encountering malicious agent or tenant, and you cannot sell the stuff on any day by just a few clicks on the computer keyboard !

After all, if one has a good reason to invest in the property market, why don't we just put the money on the share of well-managed companies ?

WG

WG, my PhD student, just passed the oral defence for his thesis. I was more anxious than defending my own one.

(In my days, MD did not need an oral defence what so ever.)

But yes, it is natural to be more exited on something that we can do very little. I often have some inderal tablets with me when our membership candidates take their clinical examination, and I didn't sleep well the night before Vivian took her exit examination.

Oh, this is not a problem of me only. Some years ago, when VW - our double gold medalist and to me an impossible candidate to fail - sat for the MRCP examination, our man from Pluto rang me up late in the evening and asked, "VW may not be doing all that well. Shall we do something to improve our training ?" (It took me quite a while to sooth our boss - although I was not the least easier in my mind.)

Of course VW passed - with an excellent score. It doesn't mean, however, that our training is good. As Immanuel Kant said: Real genius does not need education.

Sunset

My friend AW says that one of the greatest happiness of life is watching sunset. I cannot agree more.

(I was too much affected by the poem of Li Shanyan [李商隱]: 若使曉珠明又定,一生長對水晶盤.)

I was fortunate enough to have a room with a good view for sunset when living in the hostel in Bristol. There were many evenings I sat by the side of the window, with a cup of coffee and admired the beauty of nature. Summer evenings in England are usually long, and I could easily have two hours sitting there with my mind wondering nowhere. A year later, on my way back Hong Kong, I was sure I used up all the quota of watching sunset in my life.

Unfortunately I was right. And I pull down the curtain to hide me from the glaring light in the west – so that I could focus on the computer monitor and meet some deadline.

Deficit

If the exportation of "a sense of security" by the America to cover for its deficits in trade is ingenious, the Victorian Britain was certainly more realistic.

You know what, in the 16th and 17th century, there was a huge deficit in English trade with China. That's easy to understand: tea, silk and china were all in great need by the Anglo-Saxons, but what did the Qing Empire want from them ?

Nothing, except silver.

(It was fortunate for all European countries because silver price fell a lot in that century because huge silver mines were discovered in Peru.)

Then, the wind changed. Opium dominated the trade, and the flow of silver went the other direction. It was a time when the Qing Empire used the silver standard for its currency, a negative silver balance inevitable resulted in bankruptcy of the government, and the rest, alas, has become history.

PS. Silver balance and supply used to be a hot topic for lovers of economy and history. Interested readers may like to read the original report in Adam Smith's The Wealth of Nations.

Safety

One principle of economy that Tim Harford spends some time to elaborate is that a country must be exporting something while importing from other places - otherwise the value of the currency of that country would fall and cannot be used to buy anything.

Honestly I have the same puzzle for some time - for America.

It is not news. For many years America had persistent deficits in its trade with other countries, notably Japan and China. It doesn't mean that the States is not having any industry and export, but the amount was much less compared to what it bought overseas. (At the same time, the Federal Government's expenditure has almost always been greater than its income - the so called financial deficits.) How could that happen ?

"That's easy," a financial analyst educated me, "The US government issues lots of bonds."
"But who would like to buy those bonds ?"
"Stupid ! Of course they are the Japanese, Chinese ... Arabians, and many others."

Quite true. But why do these countries buy the bonds from a country with huge spending but little income ? Any banker with a sound mind would not issue a credit card to a shopping maniac - not to say an unemployed one.

No, the States was exporting something. Our subconscious mind knows that very well - it is the sense of security. If I were a merchant, or even a government, who has just sold some goods to the New World, I would prefer to pocket my money in Treasury Bonds rather than changing it back to Yen or RMB - it just feels safer in an insecure world with so many things unpredictable.

And it is for the same reason the States is losing its edge and its dollar is declining like hell. The European Union is breaking the monopoly of that very product. One of the greatest worry on insecurity - Soviet Union - has vanished. More so, America may now be the place least safe in the world !

Harford

Having Tim Harford's The Undercover Economist as my bedtime reading lately.

The book is, no doubt, well written and opens the eyes of many. (Of course it cannot be compared to classics like The Wealth of Nation by Adam Smith. But that's beyond the point.) The chapter on insider's information and health insurance is particularly illuminating.

Harford is obviously a head-to-toe supporter of open market, free trade, and taxation for externalities (alas, pollution and so forth). Even for those without much knowledge on economy, however, it is not difficult to see many loopholes in his argument. For example, it is of course the right strategy for a country to focus on a business that has an edge and give up those less competitive industries. Nonetheless, blue collars cannot change their skill over night (we know that just too well) - not to say jobs that require sophisticated training.

And, even the best industry of a country may not outshine your competitor and earn a living.

Hypothesis

You may think movement of earth crust is beyond our comprehension.

Not to the least. The recent happening in Si Chuan (四川) is an unfortunate example - and this is not an isolated event.

You know what, the Himalayas are the result of continental collision between the Indo-Australian and Euro-Asia Plates of the earth crust. The boundary of these two pieces continues to force against each other, disturbing our pandas while the Mount Everest shoots up. The same movement probably explains the tsunami near Indonesia some years ago.

(Oh, I learn all these from "十萬個為什麼".)

Now we are getting to the heart of the problem: When the world's highest mountain gets even higher, some land must be falling. Where would it fall ? For sure those at the margin of the (Indo-Australian) Plate.

Were we talking about the submerging south Pacific islands yesterday ?

Kiribati

The president of Kiribati, a small country that makes up of many small islands in southern Pacific, made a horrifying prediction in the UN's World Environment Day: his country would be submerged within this country.

The speech was, no doubt, an excellent marketing strategy of the UN.

But, before jumping up and say we should do this and that, let's sit quiet for a while and consider the followings:

1. Is the sea level rising ?
2. If yes, what causes the rise ?

I am no geologist and could answer neither. Nonetheless, the sea level was apparently significantly higher than today over the past 500 million years, and long term changes in sea level are the result of changes in the oceanic crust. (Interested ones may like to read a recent paper by R. Dietmar Muller in the 7 March 2008 issue of Science.)

PS. Oh, I don't mean we can do what we want - but we should not have the grandiose idea human beings are all that important.

Ache

Have stomach ache again - this is usually a sign of stress.

An old story flashes up in my mind: Towards the end of the Three Kingdoms period, Zhuge Liang (諸葛亮) planned to have another campaign against Wei (魏). Sima Yi (司馬懿) - at that moment the "Secretary of Defence" of the opponent empire - was not at all worried. He made a comment about the Prime Minister of Shu Han (蜀漢):

食少事繁,豈能久哉?

Thank god, I am not a fans of Zhuge Liang. Fan Li (范蠡) is my cup of tea.

巨塔

Please believe me. By no means I was implying the Academy and Colleges are at the moment abusing their power - but there could be a risk, to say the least.

College councils are, in general, respectable professionals.

But there lacks a mechanism to monitor. It is possible that the academy may, some time later, be dominated by senior private practitioners who are more interested in their own business than what the society as a whole needs. It is also not a far-fetched idea to have in the future a college hijacked by a dictator, who could point finger to his opponents and limit their practice (or promotion).

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

Author's declaration: The above deductions are purely imaginary and it does not imply wrongdoings of these kinds did actually happen. 此地無銀 ? My Chinese is very limited. What does it mean ?

Shift

What would happen if we allow only specialists but not medical school graduates to practice independently ?

An important, although possibly unintentional, consequence is that medical schools would have a declining say on the profession - because they give only intermediate products. Yes, you're right: their position is to be taken over by the Academy and Colleges. After all, they are the ones to control who could practice.

You think that doesn't matter, does it ?

Well, it does make a difference. Medical schools are funded by the government, albeit indirectly, and is under the monitoring of UGC and the Bureau of Education. The College is largely independent financially and the council is responsible for themselves. (Oh, maybe for the members, I hope.)

But doesn't that sounds good ? Government control is always a bad thing.

Friends, things could be worse. As the old Chinese saying: 絕對的權力等於絕對的腐化.

Independent

I am serious: medical graduates in the future would not be allowed to practice independently.

You see, the whole world is moving towards that direction. In the old days, an MBBS or MBChB would give you permission to do intubation, perform endoscopy, repair hernia, and deliver a baby by your own. I must say most graduates in those days were fully capable of doing all these. A favorite story that I tell my students is that a now professor in chemical pathology - also a classmate of mine - used to repair perforated peptic ulcer by himself when he was a surgical house officer !

No, not in the future. You need a specialist in general surgery to supervise. (This is not all bad a policy. Quality of care could be ensured. After all, the complexity of procedure has increased over the years - for example, you need to repair the same perforation laparoscopically nowadays.)

Yes, this is not new. We have already moved a long way. Many areas of medical practice are now restricted to specialists: eye, ENT, gynecology, and so forth. Surgery and internal medicine are doing so by having sub-specialities - leaving very little for general surgery and medicine (mostly the part that is suitable for protocol-driven practice or, alas, for trainees). The only remaining subject that is not well specialised - at least in Hong Kong - is general practice, but I am sure we will eventually follow the footsteps of the States, Britian, and Australia.

Do you see the implications here ?

Graduates

You may think to understand all those principles and be that flexible is just asking to much for our students.

You're right. But don't get me wrong. I was talking about specialists.

For the others, there are shortcuts: A substantial portion of routine clinical practice could be standardized by protocols and checklists. (Alas, in the language of Pluto, the practice is "protocol-driven".)

(My friend JW knows all these just too well. When he was a trainee, he began to prepare a few standard management orders for emergency admissions of several common clinical problems - so that he could sleep slightly longer during night-calls.)

As for medical students, it would be good enough if they could take a history, perform a reasonable physical assessment (I deliberately avoid the term "physical examination" for a reason that many of you know just too well), have some understanding on common conditions, could faithfully follow established protocols, and able to practice under supervision. (They are, in other words, expected to be neither creative nor even flexible.)

Oh, this paragraph is not my invention. Many of you who had experience in communicating with extra-terrestrials should have read similar things - and it has been put into action over the years. Do you spot the catch ?

Right, what it means is medical graduates are not expected to practice independently.

Information

Then, what should test our candidates ?

For sure it is their understanding of important principles, and, preferably, how they adapt to actual needs and constraints - which is a good indicator on how well they understand the principle. After all, this is the capability we expect for specialists. They are no primary school students and should not earn their salt by their short-term memory (which inevitably would decline with age) and being able to recite textbooks.

As TS Eliot said:

What's the wisdom we lost in knowledge ?
What's the knowledge we lost in information ?

Well, Eliot is too much for many with tunnel vision (a sign of papilloedema as a result of too much stuff in their head), I know.

PS. In our case of brain-stem death, for example, it would be more appropriate to ask what the candidate would do if the patient has a skull or neck fracture so that some of the cranial nerve test could not be performed, or what to do if one of the tests does turn out to be reactive !

Risk

The diagnostic criteria of brain stem death is so important (and complicated) that we should not rely on the memory of any doctor.

In other words, we should prepare standard protocol and checklist to ensure all criteria are checked - and checked properly. Every time when there is such a patient, we put that sheet in the case record and follow the procedure line-by-line, and we put a tick on each of the criteria once checked. Yes, in fact this kind of checklist is widely in active use.

This is a simple principle of risk management.

You may say, "But there's no harm to be able to remember the criteria !"

No, there is harm. Think: there would be no risk if you do not remember the criteria - just follow the checklist. Risk would only set in when someone believe they remember the criteria and act accordingly - without referring to the paper.

(To my surprise, I was surrounded by a sea of HA consultants in Aberdeen - many of them being die-hard fans of risk management in ordinary days - but nobody brought this up in the discussion.)

PS. You may argue most of the candidates would refer to the protocol in real life practice (probably true), and they are able to recite the list by a short term memory - an indicator that they have seriously prepared for the examination. Friends, we are looking for mature medical specialists here; there is no point to test irrelevant ability such as short-term memory. After all this "domain" has been tested in their university days already - during the study of anatomy.

Exit

With all my thoughts on creativity, I went to Aberdeen and observed the exit examination of the College. (The rain was torrential !)

For those who are not familiar with this exercise, it is an oral examination by three pairs of examiners. The questions are fixed by the College, and all examiners receive a set of model answer.

On the whole the questions seemed appropriate, but one of them caught my attention - it is about brain-stem death. One (major) part of it asked for the detailed criteria for confirming the diagnosis.

To my surprise, many candidates could recite the whole page, which consists of nearly 15 items. I must say, despite working in a transplant center for 15 years, I could never name all the points without looking at a reference. No doubt many of the trainees specifically read up the subject before they came.

Of course it is nice to be able to remember all the criteria. However, if I were in charge of the Hospital Authority, I would NOT allow any doctor to put it in their head.

Why ? I'll tell you tomorrow.

Creative

One alarming "domain" of the "expected outcome" that our friend from Pluto mentioned was creativity.

It is of course a romantic idea of the general public that doctors need to be creative. Yes, for a few clinical researchers, that capability is important. (But, even for them, it is not a essential character. Many academics make a big name by simply doing "me-too" studies.)

For the vast majority of practitioners, however, all they need is a good working knowledge of their own field, and a careful practice that conforms to the contemporary guidelines and protocols. Creativity, in contrast, is not desirable. What would you think, say, if your surgeon tells you that he will try to be creative when opening up your abdomen ?

Yes, this is a painful fact. For most of the new doctors, the society should prefer humble and reliable workers rather than (self-regarded-as) genius who keep questioning and challenging existing practice. As Hercule Poirot - while pretending to be the great detective from Baker Street - once told Arthur Hastings: I don't want you to become a second-class Sherlock Holmes; you'd better be a first-class Dr Watson.

Outcome

In our department board meeting a few days ago, a representative from Pluto presented the courageous project (according to the definition of Sir Humphrey Appleby in Yes Prime Minister) of our faculty to put up learning objectives and outcomes for our students.

This is the first time I realize the language of Pluto - although nothing of which I could understand - also consists of 26 alphabets.

Oh, I did comprehend a little. For example, one of the expected outcome of back pain for a (I think) year 3 student is to be able to locate where the pain is - by history taking. (Well, Euterpe - my 15-month-old daughter - is learning the word "where" at the moment.)

No doubt I am thoroughly impressed by their meticulous attention to details - and to cover every aspect of medicine needs gigantic effort. Well, it probably serves one purpose: the hard copy of this "objective" may be thick enough to bridge Pluto and the Earth - so that those extra-terrestrials could come back and take a look on what's actually happening.

PS. For those who wish to have a glimpse on great work of this kind (which summarizes what should happen when and where), I would recommend the classical work of Shào Kāngjié (邵康節) in Chinese mythology: 皇極經世書.

成蹊

My congratulations to JW, who won the VC Exemplary Teaching Award 2007.

And I am amazed to find that he named me as one of the mentors from whom he shaped his teaching method. It sounds like Warren Buffet thanks Benjamin Graham for the teaching on how to make money in stock market.

The good news is our Buffet of medicine is still active in clinical practice and teaching. Every morning when I observe him being surrounded by a crowd of medical students, I could believe our graduates would not be all that bad.

PS. Yes, as you recognize, that's not only teaching - but mentorship. But it is for this very reason, I have much reservation on the faculty mentorship program, which assigns each group of students to an elderly with nondescript facial appearance and obscure personality. We need role models - and a few high flying ones would do.

TW

Had a chat with TW over the phone in the Saturday afternoon.

It is always warm to talk to your friend - especially if you have not seen each other for some time, and more so if your friend is a cut higher in the brain and often gives you illumination.

And TW is no doubt the most intelligent person whom I ever make acquaintance with.

There was a time when TW and I made our private study on the stock market. While I was working with Benjamin Graham's Security Analysis and Philip Fisher's Common Stock and Uncommon Profit, TW simply made her own pick by what she called "intuition" - and she was often right.

As Hercule Poirot said: Les femmes ... observe subconsciously a thousand little details, without knowing that they are doing so. Their subconscious mind adds these little things together - and they call the result intuition.

PS. Don't be mistaken. In addition to being a shrewd investigator, TW is also a double-gold-medalist of my medical school, an eminent physician, and a critical practitioner of top fashion !

Tobacco

Appreciating the press conference of the World No-Tobacco Day. I can hardly believe the function roots from the WHO.

"Over 50% of the smokers fail to quit - says a large survey."

But if the survey asks only active smokers, they should have either never tried to quit or failed to do so - otherwise they would not be active smokers.

And there comes a (private) specialist in respiratory medicine who, in front of huge commercial logos, gives us a lecture on the need of drug treatment to help quitting the tobacco. Oh, I've almost mistaken the scene as an advertisement for the election of American president.

How could the world's leading establishment of medicine allow all these to happen ? Did the organization make such a dramatic involution in the recent years ? Is it because of that remarkable secretary ? (I must admit I am thoroughly biased after the horrifying mess she made in the SARS epidemic.)

PS. KL, my previous office room-mate, always says: Give me a hypothesis, and I can show you are right (or wrong, if you prefer).

Reply

(Reprint from my facebook communication with an elective student.)

Dear James,

I am not sure what you guys could learn from here. It may feel good to sail with someone in a charted sea, but the journey would not be fruitful if you do not have a map yourself.

Take care,

Szeto

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

On a second thought, James - and many students - do have a map at hand all through the trip. The dilemma is, during the voyage, whether they should look out the window and enjoy the scene, or hide their heads under the map when the sailor is trying to control the rocking boat !

Sugar

The cake tastes sweet without much glucose and sucrose because it has lots of HFCS.

Oh, HFCS stands for high fructose corn syrup - a common sweetener we use in bakery and soft drinks, and a classical story of how (pseudo)science could pull our own legs ...

Many decades ago, people began to realize ordinary sugar - glucose and sucrose -could increase blood glucose level, and is probably no good for large scale public use. (Diabetes was a big name !) The search for a natural sweetener that would not rise blood glucose level (that much) eventually gives the answer fructose - which comes from fruits and vegetables, is equally sweet as glucose, and the final product has a long shelf life. That's how HFCS came along.

Yes, it remains controversial how much does HFCS contribute to the epidemics of obesity and insulin resistance. Nonetheless, everything sweet has a cost (alas, contains calorie if not carcinogen), and the fat you get remain the same no matter what's written on the label.

Sweet

And, how many of those who voted for this ordinance in the Legislative Council could understand those labels ?

That's the eternal problem of democracy: A policy with trivial benefit to many but tremendous cost to a few would get through - even though the overall effect is negative. We see an exaggerating case here, because the so-called benefit is quite imaginary.

Well, even if you (think you) could read all those chemistry terms, let me give you a simple blind: This piece of cake contains 100-gram carbohydrate, it has minimal glucose and sucrose, absolutely free of saccharine or aspartame. Sounds good (and tastes sweet), eh ?

I shall show you where the catch is tomorrow.

Label

From now we have to put bilingual label about the ingredient of all packed food.

You may say: Why, we ought to know what we eat; it is of course a good move to promote public health.

In that case, why do we only ask for labels on, say, packed sandwiches but accept chain-stores selling hamburgers or fried chickens without regulation ? Many of us should remember the famous story a few years ago: Many local nuns discovered to their horror that the french fries from a famous Hamburger maker are not suitable for Buddhist because the potatoes are actually fried in animal oil - and there was never a label what so ever.

No, don't get me wrong. I'm not asking for more laws here - it ruins the free market. After all, as Marcus Cicero said: the more law, the less justice.

PS. A more cost effective way to promote public health, I believe, is to ensure the expire date on all packed food to be placed on an eye-catching place - and in, say, Arial 40 font. At least it could prevent some immediate deaths from food poisoning - a not-too-rare happening after consuming bargain purchase from some supermarkets !