Thermodynamics

The very misconception is: every man should be equal. No, we just need a fair social system (for competition).

In fact, by the law of physics, no system would ever result in every man being equal. Thermodynamic principles state that at any one time, some particles would have very high momentum energy while others have little.

That's why a glass of water gradually evaporates - some H2O molecules gain sufficient energy at a particular time and free themselves to thin air.

The very fact is, in a fair system, every particle has the equal chance of gaining energy at any moment. No particular droplet would stick to the bottom because its parents come from that layer.

To make an equal (not fair) system is, in other words, trying to heat up and boil the whole glass all at once.

That certainly results in an explosion - and still not every droplet reaches the boiling point at the same time.

PS. The only situation that every particle has the equal energy is when they have no energy - at the absolute zero temperature.

Equal

Even many of my friends could not agree to the happening that some expensive treatment could only be given (alas, affordable) to those more affluent patients.

"All men are equal." What a noble declaration.

Oh, that would mean all men should also have the same food - nutrition is important for any disease. Why should this rich man have bird's nest and wagyu while I have to be a "social vegetarian" ?

"No, food is not a life-saving measure; the drug is." You may argue.

That's a romantic idea. More people die everyday because of famine than the lack of any particular medicine. After all, how many drugs are 100% fool-proof life-saving and therefore absolutely necessary ? Less than a handful. (I can only name 50% dextrose for hypoglycemia, vitamin B12 for megaloblastic anemia, and possibly thiamine for Wernicke's encephalopathy.)

And for many of the new pharmacological gadgets, we talk about the relative risk reduction. Is that anything qualitatively different from your bird's nest ?

"There's a quantitative difference ! This monoclonal antibody reduce your risk of death by 10%; the bird's nest is at best 0.0001%."

Then who is going to judge what cut off should be used to define a necessary treatment ? Mollusks from Pluto ?

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

If you come to agree with the suggestion that all men should have the same food, then we are forced to the conclusion that we should also have the same house (a similar topic has been seriously discussed in our legislative council), clothes, travel vehicle, and income.

And we should all have the same value - assigned by the government.

That's The Road to Serfdom.

Benefit

It seems trendy - as least amongst creatures on Pluto - that clinical judgement should consider the benefit of the society as a whole.

Yes. Medical policy should have such a consideration. For example, although drug A for disease X is effective, the drug should not be freely provided for in government hospitals because of the prohibitory price - the society could make use of that sum of money to achieve a greater benefit to more people. (Communists and Marxists would disagree. We shall leave that discussion to a later day.)

But no, not for clinical decisions of treating individual patient. We do not give you drug A because of the cross-the-board policy, not because as an individual you are poor / black / have no use to us / from the Opposition Party.

Otherwise we move from being a god of our patients, which is what we are trained to be, to the grand god of the society - with the impossible assumption that we know what is good for the society.

That opens the Pandora Box.

PS. Medical policy with social consideration needs to be made by vertebrates - not mollusks on Pluto. That's why there's never such a policy in our city. You don't know what is mollusk ? Make a phonemic translation to Cantonese, and have a meeting with them !

Individual

One strong proponent of the "preemptive donor support" program in Pluto argues that since those later-to-be potential donors have irreversible brain insult, there is a ground to act aggressively to facilitate organ donation - for the benefit of the society as a whole - even though there may be a slight price to pay by jeopardizing a slice of benefit of that dying person.

I beg to disagree.

Otherwise we end up agreeing that clinical judgement for individual patient should be based on the overall benefit to the society, and the use of the body of any terminally ill patient for our own purpose. Well, we are the society !

And since it is our judgement to decide what is irreversible damage and terminally ill, it is entirely up to us - or worse, those migrated to Pluto or farther - to say whom we should save or sacrifice for the benefit of the others.

(You may realize it also means that we can say as we like to whoever of our rivals that they have an incurable disease - which would kill them in 200 years if not earlier - and we can take their organs for the benefit of the others. Don't laugh. This dark joke did happen several times in the human version of George Orwell's Animal Farm.)

PS. In my experience of communicating with extra-terrestrials, "for the benefit of the society as a whole" is often a sugar-coated synonym of damaging individual's benefit for the sake of a hidden agenda. After all, society is a collection of individuals.

Interest

You may argue since those patients are inevitably dying, it doesn't matter to have some extra treatment to maintain their organ perfusion.

No, you're wrong there. There is more than a fine line of difference between end-of-life palliative care and all those intravenous fluid and inotropes to sustain the blood pressure. (It may be fun to see your pulse go mad with dopamine or noradrenaline infusion - at least fun for your rivals.)

True, very often we do advise our patients and relatives to surrender and forget about further treatment - but that's for the benefit of the patient (for example, to avoid unnecessary suffering as a result of aggressive surgery). Palliative or symptomatic care is never the item to be withheld for any living Homo sapiens.

To go one step further, it is therefore not appropriate to start those "organ maintenance" procedures in someone with irreversible brain damage and the GCS falls to 5 - even if the family volunteered to have organ donation (which did happen more than once). Our primary objective is to act according to the interest of that patient - who is still alive - and not the family. You won't stick a needle into your patient's leg in order to please the family, will you ?

PS. Our supreme objective may be to act for our own benefit and prevent our names from appearing in the court or, even worse, the media. Well, in that case one should explain and explore in full detail - to all parties concerned - about the potential risk of every remotely possible and impossible complications, as well as the complications of those complications, with an inevitable though not totally unwelcome nor undesirable conclusion that we should do nothing.

Donation

A group in Pluto decided recently to set off and explore measures to promote organ donation. Noble as it sounds, I find the preliminary suggestions innovative.

For example, the guideline says that specific procedures to preserve the organ perfusion will be started when the Glasgow Coma Scale of a patient (with obvious irreversible brain insult) falls to 5 or below.

The obvious question is who would make the treatment order.

For sure not the transplant team. Otherwise it means their taking over the care of all dying patients - and for the team's own agenda.

"Could he be the patient's original doctor in-charge ?" Those extra-terrestrials suggest.

In that case is this doctor acting according to the benefit of the patient (who is still alive by law), or that of those potential recipients ?

PS. The composition of this extra-terrestrial committee is in itself remarkable - all being permanent citizens of this most distant planetary (i.e. those who are involved in receiving the organs) and none from other parts of the solar system (alas, those who take care of potential donors, such as intensivists and neurosurgeons). Oh, is that some careful planning by certain Humphrey Appleby ?

Suspicion

This is the "death note" of the man who burnt charcoal in his car and kill himself some days ago - it was all on the local papers.

(My salute goes to our local journalist.) Nonetheless I find the notes suspicious.

The numbers do not add up: 6905 + 1355 + 1390 + 877 = 10527, not 431.

Of course. It should go like this: 6905 + 13550 + 13900 + 8774 = 43129.

(Certainly all numbers have 2 or 3 zeros missing - only that amount of money would kill a man like him, but we can imagine the author omit some zeros for simplicity.)

The question is: who cut that slice of paper on the right side of the notes, and why ?

Apparently that missing piece was not found in the car. Was the note brought from elsewhere, or was that piece being taken away ... by who ?

PS. I read too much Conan Doyle, I know.

Senior

As KM says, the Appleby's Law goes like this: If you are incompetent you have to be honest, and if you are crooked you have to be clever.

In our circle there is yet another modification of the law: If you are incompetent you have to be senior, and if you are junior you have to be clever - to win any argument.

You sense the truth in it, eh ?

The very phenomenon that hides between the lines is: clever ones do not always become senior (while less clever ones being eliminated); it is equally common the other way round.

As the old saying: The cream rises to the top - so does the scum.

Cheer up, man. Therefore we have a chance !

Mature

I am not sure it is all good thing for our new graduates to learn all those dirty tricks to handle unrealistic tasks. Do we want a doctor to be honest but simple and naive, or scrupulous in achieving everything - with a wicked smile ?

Well, it doesn't matter whether (I think) it is good or not. That's an inevitable path that we all got through years ago.

And when we (and they) grow up, we give impossible missions to the new comers - expecting them to accomplish by whatever tactics that they could make use of.

That's how our world becomes the Asura realm.

PS. My friend KM discussed a similar thing several days ago in his blog; you may like to see his view (which I am sure is a more proper one) - http://drkmchow.blogspot.com/2008/07/disclosure.html

Training

One of our new house officers commented that the most difficult part of her job was to liaise for an urgent radiological investigation.

This is no doubt the case. My initial reaction was, however, that represents part of the training. It needs quite a bit of medical knowledge and linguistic skill to appreciate why an investigation was ordered and present the story in a coherent (and hopefully persuasive) manner.

You may argue, "but not all of the tests were requested because of completely logical and scientific reasons !"

Certainly. That's life. Everyone who takes a salary would have the experience of being asked to take up some unrealistic tasks - why should doctors be spared ?

"But our objective is to treat the patient !"

No, you are wrong there. Treating the patient is merely one of the objectives - and often not the one top of the list. We also treat the relatives, colleagues, and seniors - in an ascending order of difficulty.

And very soon house officers would mature and learn the non-scientific ways to handle illogical requests: fraud, bribery, intimidation, and what not.

浮雲

It was exceedingly impressive to hear what our CE said: 視民望如浮雲.

As Philo Vance said (in The Benson Murder Case), I was so impressed that I lost my nerve.

In fact, I am about to expect my Indonesian maid - who does understand quite a bit of Cantonese - says, "I just don't care what you comment about my work."

Maybe she is true. After all it is just a job, and my maid expects to complete the term in a year or two. She has her own family and friends. I'm sure the biggest wish of Uny (that's how we call her) is to embrace her 2-year-old son and sing songs to soothe him to sleep. Unless she makes a complete mess so that I am forced to find another one, otherwise why should she care ?

Well, no one (south to the Shenzhen River) could fire Mr. Tsang.

PS. He told you that much when he applied for the job: he is a politician, not public servant.

Complaint

GC receives a complaint from the medical students - I find it unbelievable.

The story goes like this: The introverted hematologist was scheduled by some governor of the universe to have a seminar for the final year students earlier this week. As we expect from all dinosaurs of administration, it took quite some time for a nerve signal to be transmitted from the tail to the anus, and our professor was again scheduled (alas, by that anus, I suppose) to do a tutorial for the third-year students at the same time - apparently right at the next room.

Alas, you can tell what would happen next. The more senior students were attended to - and those new comers went straight to the faculty office and fired.

The tutorial was scheduled to another time, of course. I met our autistic friend in the corridor some days later, and he was still thoroughly disappointed. If I were him, I would certainly remind the delinquent children that I would ensure they have a fair treatment in the examination.

By the way, there are two ways we treat our students in examination: fair or nice.

PS. To be exact, it takes around 3 seconds for a reflex arc between the tail and the anus of a Titanosaur to work - sufficient for Liu Xiang (劉翔) to make a 25-meter escape, with hurdles on the way.

Suitable

Don't be taken aback by my blog yesterday if you have an interest in laboratory study but do not do well with cookery. The latter merely signify a suitable personality to do the hand-on bench work, but not actual planning of the experiment - which needs a different domain of intelligence.

The sobering truth is many people fail to realize the difference in requirement and believe that we should promote the one who has the best hand-on performance to the position of planning, or the clinician who could care their patient best to become an administrator.

"In any organization, every worker would be promoted to a position that he could not handle."

Things are actually worse. Once promoted to that higher position, these used-to-be excellent workers often lose the capability that they are proud of.

PS. Many VIPs also have the romantic idea that the administrating consultant is also the best clinician - including stuffs like setting up a drip. Well, I fully agree extra-terrestrials should be cared by their own species.

Girardet

Those who visited my Facebook profile frequently would note that I have been reading a book called Girardet for quite some time.

Seriously I am not reading the book - just flip it through every now and then. Fredy Girardet is one of the three (generally regarded as) best chefs in late twentieth century, and the book is a nice summary of his recipe.

Oh, no. I do not have time to try those experiments as yet. But I will - enjoying the cuisine may satisfy your palate, but trying them out by yourself is a different kind of great fun.

I always regard cookery a kind of laboratory study: you plan ahead what to do, collect the ingredients, mix them in proper sequence, and (the good deal of the time being) wait. You know what, I often ask junior doctors who claim an interest in laboratory study whether they enjoy cookery - it seems an excellent screening test on personality.

Air

Industry in China is facing problems - I see it from the air quality.

You know what. Most of the evenings I go home by taxi via the Kwun Tong Bypass, where I could see the other side of the harbour. Contrary to the expectation of many tourists, the scene could hardly be called impressive - at least in the recent few years. There is always fog and smog; the neon lights from the Hong Kong island seem dim and dingy - the previous colony looks like London more than ever.

But there is a change. Recently I could enjoy the beauty of our famous harbour view once again. The sky is often clear, and I could appreciate much details of the advertisement boards across the sea. I search in the web site of the Environment Protection Department, and learn that the Air Pollution Index of the second quarter of this year (i.e. after all workers coming back from the New Year holiday, and all factories are in full gear) was the second of the best since 2000.

Of course it could be natural variation.

And we got a lot of rain lately.

And our CE would like to claim some credit.

Nonetheless it remains worrying.

PS. I have paranoid personality disorder, I know.

盈喜

Quite a few of the banks announced excellent profit to be expected in their coming mid-term report.

Good news as it appears to be, two questions come to my mind:

1. Why is it announced ?
2. Is it true ?

By "why", I mean "why now". That's easy: because of the game.

It is the second question that troubles me. Where is the profit coming from ? With a shrinking loan market (the deposit reserve ratio has been drastically raised in the past one year), limited contribution from service charge, and an (appears to be) ever-falling stock market, how did they make the money ?

Yes, we are talking about the earning some months ago, when the climate was not as bad.

But that's the worrying bit. Why publicising the good news when one expect it would not sustain (or worse, it is not there) ? Does it mean the political drive does not only facilitate the announcement ?

Leftovers

I must admit I have a passion of making use of leftovers.

Some years ago I paid a visit to Toronto. In one evening I dined alone in a Japanese restaurant. After several days of bread and cheese, I ordered the neck of king mackerel (鯖魚), fried in saute (塩焼き). The dish was superb, and I enjoyed quite a while by dissecting the gigantic opercle and related structures with my chopsticks.

To my surprise, the owner of the restaurant appeared towards the end of my dinner, and greeted me in great enthusiasm.

"This is the most delicious part of the fish - but hardly any one here would order it !" So I was told.

"And, looking at the bones on the table, you do appreciate it." The owner added.

PS. Fortunately the lighting of that restaurant was not good, for my face was slightly red. I ordered the fish largely because it was nearly the cheapest thing on the menu !

Soup

The logical choice of soup after sashimi would certainly be miso shiru (味噌汁).

Don't look down upon this simple brownish liquid. It has quite a bit of science.

Miso shiru has three major ingredients: miso (味噌/麵豉), konbu (昆布), and katsuobushi (鰹節).

Miso is made of soy bean, and represents a great source of vegetable protein, sodium, and various vitamins (including B12).

Konbu is a rich natural source of glutamic acid. Yes, with sodium, it becomes monosodium glutamate - that's why it adds flavour to the soup. (Ancient Japanese had the wit to call this excellent but poorly defined taste umami [旨味]. Alas, this is what we now know as 鮮味.)

Katsuobushi also stimulates our taste buds - by its rich content of inosinic acid. It is, in other words, a purine derivative, and the building block of nucleotides.

And, with all these three, we have an almost ideal oral nutritional supplement - in a solution !

PS. An excellent property of miso shiru is that you can add whatever kind of ingredient to it. To show their support to environment protection, our G8 leaders should use the bones and leftovers of those fishes used for sashimi to make the base of the soup. It adds to the flavour, and it was the way how many poor ancient Japanese could get some animal protein.

Sashimi

I read with great admiration the dinner menu of the recent G8 summit at Hokkaido.

No doubt it brings much criticism. There are 18 courses in this feast, including caviar, goose liver, and six or seven kinds of wine. How could you have all these (publicly) after discussing the problem of food and poverty in developing world just an hour ago ?

The first idea comes to my mind is: Maybe sashimi is a better choice. Dishes of this kind appear humble but could be luxurious and have elegant presentation. After all, pieces of raw fish get along well with the idea of environment protection - you don't need any fuel and produce extra greenhouse gas to make such a dish.

(A rumour says that sashimi was first developed in ancient Japan because of the limited supply of wood as domestic fuel, and people were forced to cook their rice but eat the fish raw.)

Of course not all sashimi is environment friendly. Blue fin tuna, for example, is now close to extinction - and the problem could not be solved by fish-farming. It is not only because the captive fish tastes inferior to wild ones (according to our great gourmet Chua Lam [蔡瀾]), but that all those captive fishes actually come from small wild ones that are netted and transported to the farms. No one could raise adult blue fin tuna from spawn as yet.

Voice

I talk to Vivian every evening by the Microsoft Messenger video call and voice mail.

You know what, now my laptop computer is connected to the board-band, a camera and a microphone - so much so I can hardly use it for other purpose. In a sense it has become the bridge between Hong Kong and Osaka.

It is our Wish Door (任意門) of Doraemon.

PS. One morning, when I look at the computer, I suddenly have a deja vu feeling of seeing Alphonse Elric - the younger brother of Fullmetal Alchemist (鋼の錬金術師), and the famous character by Hiromu Arakawa (荒川弘), with no flesh-and-blood body, but the soul is trapped in a large suit of armor.

Thunder

To be fair, it was not all poor planning so that the Ming Empire used up all suitable woods for the new palace. In their original plan, there was some allowance - sufficient wood would remain after the Forbidden City was completed, and the country could continue her exploration of the world.

The real bad luck came when the Ancestral Temple (太廟) - one of the major buildings in this gigantic complex - was completely demolished in a fire soon after the opening ceremony. (Apparently it was secondary to a thunderstorm, exactly 100 days following the opening ceremony.) That accident left the empire no choice but to use the reserve material and build the Temple again.

The rest, alas, has become history.

PS. Lightning rod (避雷針) was invented in 1750 - nearly a hundred years later, ironically for the protection of European churches.

Wood

It remains uncertain why the Ming Emperor stopped the construction of new ships after the apparently successful voyages of Zheng He (鄭和) - it seemed unlikely that the young dictator had sufficient foresight to predict communication with foreign countries would shake his reign.

There are several hypothesis. The one that I favour boils down to the fact that the capital of the empire moved from Nanjing (應天) to Beijing (順天) around the same time - with the inevitable happening that a new palace was needed.

Yes, it was the Forbidden City (紫禁城); and you also need all other buildings related to it, such as the Temple of Heaven (天壇), the Ancestral Temple (太廟), and so forth.

You know what: this new palace was made of wood. Specifically, most of it was Phoebe zhennan (楠木) - huge trees from the southern part of China, which took a thousand years to grow, and with the trunks that were resistant to insects and fungus. The process of transportation of those woods - from the forest of Guangxi (廣西) to Beijing - took almost a year.

The very fact was: this gigantic project possibly exhausted all suitable wood in the country, leaving very little for ship-building. No, it is not a problem of manpower. Workers could easily turn their job to make more ships once the palace was done - but it took some hundreds of years before the supply of wood was back.

Those were the years of Renaissance and great scientific advances.

PS. Once you learn how they named their new capital, you can say for sure that the Ming people would not prosper: they didn't try to make appropriate response, but would simply accept what came about.

Dictator

On a second thought, dictatorship and restriction of information available for the general public end up in a vicious cycle.

For those who are familiar with the Chinese history would remember the incident that Qin's First Emperor (秦始皇) burnt all books and buried a whole lot of scholars (alas, the opposition party). That's just one side of the story.

You know what. The worst dictatorship in the Imperial China was probably not the Qin, but Ming Dynasty - a time when information and new idea were under extraordinary scrutiny: No new ship were made after Zheng He (鄭和) completed his voyage, commercial activity via ports was much restricted, and students were not allowed to discuss or develop material not taught by their teacher - which was known as "師承".

With these, the voice of opposition was put to silence (almost) forever - which sustained a kind of one-man show in politics for some hundreds of years.

Hayek

Contrary to my initial worry, The Road to Serfdom turns out to be an excellent reading.

True, the English is a bit bumpy - typical of writings by German-speaking authors. Nonetheless, Hayek put up a horrifying but absolutely logical argument, showing us a road of no return once we decide to intervene on a small part of our economy or social policy:

1. Intervention of a small part of the economy system eventually lead to total control (or, "planning") of the whole economy,
2. which would then inevitably include control of the government and political system,
3. which will give birth to a dictator (and the worst come to the top of the society),
4. who will shut down voices of opposition, restrict information, and take off personal freedom.

Well, you may not agree with the whole of his idea, but history tells us that there is at least some truth in it. After all, it is always an enjoyable intellectual exercise to follow a (long and) logical argument to arrive at somewhere that you have not thought of.

Information

The improvement in the technology of communication also means a change in the political system of many countries. Specifically, it becomes more difficult to run a government by dictatorship.

During my recent trips to Istanbul and Osaka, I read FA Hayek's The Road to Serfdom. One important principle that the Austrian economist put up is that maintenance of dictatorship requires restriction (alas, control) of information to the general public.

The idea is not new - the Book of Genesis told us that much. When Adam and Eva ate the apple of wisdom (information ?), they opened their eyes and had to leave Eden - a figurative if not exemplary place where everything is under government control and every decision is from the top.

PS. Do you think any dictator could be better than god and would make a better Eden ?

Close

Ironically Vivian and I talk to each other more often after she's in Osaka - there is a short while every evening that both of us drop all things at hand and enjoy the conversation over phone. It is a precious moment to be treasured.

The same thing happened when I was in Bristol. Neither before nor after that peaceful year did I have a weekly intimate chat with my mother and sister - each for half an hour. Yes, long-distance is expensive, but absolutely worthwhile. (It costed me nearly HK$4000 each month, and I am sure I became a life-time VIP of Hutchison !)

As a bonus of these costly conversations, I learn the very fact that maintanence of a close relation hinges on having some dedicated time to talk regularly to the one you feel important.

Maybe as what Zhuangzi (莊子) said: 相濡以沬.

Letter

"People often overestimate what will happen in the next two years, and underestimate what will happen in the next ten."

Since Vivian stayed in Osaka, I realize how true it is more than ever.

I still remember during the days of my primary school, we received telegrams from relatives overseas. Naturally, roaming through mobile phone amazed me so much by the time I was in Bristol for overseas training ten years ago. Why, it is really warm to talk to your friend in Hong Kong while you are walking alone in the street of Southmead or boarding a train in Paddington.

Now I can talk with Vivian via phone or Skype, chat with her by Microsoft Messenger or Facebook, and even see her face through MSN or 3G.

Li Shanyan [李商隱] used to say: 閬苑有書多附鶴，女床無樹不棲鸞。

And nowadays who has the leisure to employ the long-neck bird to send a message ?

斜陽

One of the most famous novels of Osamu Dazai was The Setting Sun (斜陽).

The story of this masterpiece may appear slightly outdated now: Kazuko (かず子), a young woman from a declining noble family and married to a novelist, had an affair with a soldier soon after the war and became pregnant - for sure a tragedy.

"When a girl reaches the stage of having her own secrets, it means that she has grown up." What a romantic declaration.

The tragedy of Kazuko started when her mother died of tuberculosis; Osamu Dazai himself followed the same course a few years after the novel was published. It was 1948 - twenty four years after Franz Kafka succumbed to this all-time killer.

Dazai

In the next morning we set off to know the whereabout and tried to buy some daily needs for Vivian. We soon entered a large local 100-yen store, which we could have almost everything in need - even some that we had not thought of.

What happened was I find myself in the stationery corner for some minutes, appreciating a large collection of plastic named-seal for all common Japanese family name.

"Don't be silly," Vivian said, "There will not be yours."

Of course, I think. But soon an idea came to my mind, and I continued the search, "I know which Japanese name - if there is the seal - would suite me."

"Eh?" Vivian was incredulous.

I said, "It is Dazai (太宰)."

"Well ... ?" my wife was at a lost.

"太宰 [Dazai] was the title of a government official in the Warring States Period of ancient China (戰國時代), with the capacity similar to 司徒 [Szeto] in the Han Dynasty," I went on to explain, "and there was the famous Japanese novelist Osamu Dazai (太宰治)."

Takatsuki

Had a short trip to Osaka - Vivian is going to have her elective training there and I went with her to help setting up some of the things.

Although the place that Vivian is going to work at is the Osaka Medical College, it is actually in a small town called Takatsuki (高槻), somewhere between Osaka and Kyoto. We arrived late in a rainy evening after a slightly confusing journey from the Kansai Airport. (Thanks to the extra-ordinary railway system in Japan. I am sure the twin brother of one of our consultants is orchestrating all these - or is our master of the universe himself secretly doing a part time job here ?)

Small town as it appears to be, we found the street full of people when we arrived, and many restaurants were still open. We bought some octopus-ball from a "sheltered hawker" nearby as night food. Drink is never a problem here - you can find a flood of automated machine selling all kinds of tea, coffee, carbonated water, and many brands of other beverages around.

The only problem is we can hardly find anyone around who speaks English. Thanks god Vivian could speak some broken Japanese (she had some private tutorials before she came) and I could communicate by writing Chinese character and reading a few Japanese ones - which I learnt before entering the University.

Tactics

If the design of impact factor is ingenius, the one who decided to apply the number as a measure of how successful a journal is was probably pocessed by the devil.

To run a journal is no different from other private company. If money is the goal of your business, you tap every possible resource to try and make one more penny. If impact factor is the ultimate aim, there are always methods to juggle with the numbers.

Here are some:

1. Ask the authors – in order to get their manuscript accepted – to quote previous articles from your journal, the more the better.

2. Publish guidelines. Think: What else could a health administrator quote ?

3. Publish papers with controversial results: People could only cite your paper before arguing with it.

4. Create a sister journal. Accept good quality (alas, high hope of being cited) manuscripts for the major journal and dump the others (that you want to maintain a friendship with the authors) to the new sister.