Mohohan

Just finish reading Mohohan (模倣犯) of Miyabe Miyuki (宮部美幸).

It takes quite a while to go through this 1300-page classic of modern detective fiction. As Miyuki herself says, you do not have to guess who the murderer is until the very last page - it is plain obvious from the middle. Well, you may have a glimpse of some social problems that the younger generation of Japanese is facing at this moment, and it remains enjoyable to read every details of all doings and thinkings of everyone involved.

The careful audience would ask: who was the Mohohan ? The two murderers were certainly not - as one of them insisted towards the end of the story, the crime was entirely a drama of his own invention. On that, I would say Miyuki herself is the one who imitates. As a fans of Hercule Poirot, one would find the plot very much similar to that in The Curtain, and Agatha Christie was certainly a cut higher in elaborating the plot and, with due respect to Miyuki, telling a story.

PS. And Miyuki is not the only Mohohan. Yoichi Takato (高遠遙一) in the Kindaichi Case Files (金田一少年之事件簿) is another clumsy one - Seimaru Amagi (天樹征丸) could have done better.

Purpose

K asks why writing a handbook or protocol or guideline could boost up one's ego.

What a question ! On the contrary, if we follow the logic of Sigmund Freud or Arthur Schopenhauer, we should ask: Could there be any other reason for writing up those things besides ballooning up the ego ?

Let's take away the consideration of metaphysics and psychology. In general, there are a few reasons for our friends on Pluto to write a handbook or guideline:

1. I (or the board or council) exist.
2. (Since we get funding to improve the service,) we have done some work.
3. We are independent and we think independently. Therefore we will not blindly follow the existing guideline across the Atlantic (or the Victoria harbour).
4. (To their juniors) we have told you what to do; we will not bare any responsibility for your mistake.

And, as the traditional teaching in Zuo Zhuan (左傳), there are three ways of being immortal: 太上有立德，其次有立功，其次有立言.

For sure the first two are beyond the reach of most of us. That's why many creatures on Pluto go for the last - and mistake it as the second.

PS. You may find my argument familiar. Yes, I wrote a similar thing on this blog some months ago. That's a traditional wisdom: It doesn't matter everything has been said - nobody was listening.

Misconception

The very misconception is: by winning the gold medal by a man who could run fast and over the hurdles, we become a stronger people and a great country.

The scenario is all too familiar. Many fans of the Chinese martial arts in the Qing Empire tried to prove their daggers were better than the bullet; an equal number of the Red Guards (紅衛兵) in the Cultural Revolution attempted to show abacus could do the arithmetic faster than a calculator.

On a few occasions they were successful - in fulfilling their inferiority complex but grandiose ego paradox.

But, let's take aside our patriotic feeling and passion for traditional Chinese culture. There are millions of people who could use the bullet or calculator - and they are ordinary people who had a reasonable training. Our genius in flying dagger or abacus are one-in-a-million and their achievement take years of hardship.

And although Liu Xiang (劉翔) may actually run faster than Dayron Robles, it doesn't necessarily mean that you are any faster or stronger than a man from Cuba, or Jamaica, or London.

If our people is straight and have confidence in ourselves, why bother so much about the one who quited the game and lost "your" gold medal ?

王楠

Watched the Women's Table Tennis final. I was thoroughly impressed by Wang Nan (王楠).

(My friend KM had a vivid account on why we thought the performance of our silver medal winner was seminal. Go and read http://drkmchow.blogspot.com/2008/08/table-manner.html)

Yes, our media put just too much emphasis on how many gold medal our country won from the Game. That's beyond the point - sports should be promoted for better health of the people, and got to be something for the player to enjoy. What's the good to win a gold medal by stressing your spine too much at your childhood so that you have to walk with a crutch at your 30's ?

And what could we hope a people could achieve if they put all their enthusiasm on a man who could won a gold medal by running fast and over the hurdles - but not all those important problems of the nation ?

All of a sudden I imagine an excellent motto for the next Olympic game in London:

Let's enjoy the game.

PS. There is no better metropolis than the one on River Thames to hold the game in 2012. English people are well known for their passion for fair play, and Karl Marx began the origin of communism in this very city.

Confusion

Although the extra-terrestrials tried very hard to avoid duplication in our curriculum, paradoxically they put up many integrated teaching sessions - so that the same topic is covered by "experts from different areas" in the same morning or afternoon.

(I do not intend to discuss the definition of expert today. Maybe later.)

And therefore we have the pathophysiology of certain condition taught by a chemical pathologist and then a physician an hour later, or the structure of certain part of our body explained by an anatomist and then a surgeon soon afterwards.

In the latter scenario, you may come to the conclusion that there must be two species of Homo sapiens on earth. As we know, the degree of confusion increases exponentially with the number of people to explain the condition.

That's in fact simple psychology of education. A child who is exposed to two different languages simultaneously learn both slower than another child who is taught one language at a time.

As Duan Yu (段譽) tried to learn the Meridian Swords (六脈神劍) in Demi-Gods and Semi-Devils (天龍八部), he was advised by his uncle: 先練一圖,學完再換.

Duplication

In a recent meeting, our man from Pluto told us that a few final year students complained about the change in the arrangement of ward attachment this year - they do not have a chance to follow the gastroenterologist.

Some of us reminded him that the change was based on the feedback from students last year: some of them were assigned to gastroenterologist in this hospital and again in another one. Since it is (politically) incorrect to take out the one from the peripheral hospital, we could just do away with our own one.

I suspect our students wish to have it the other way round when they made the proposal. Oh, they do not have a grip with the world.

But we shouldn't blame them. By and large, the decision roots from an obsessive idea hold by many extra-terrestrials that we should have no duplication in our curriculum. The aim was to cover as many things as possible - and that 5 years would be orchestrated in such a highly coordinated manner for every minute detail that each topic is touched on but once.

They have forgotten that we could forget.

After all, we don't read a textbook once and expect we could remember everything (or even 70%) in it, do we ?

Edition

In the very evening that I gave a chapter of Harrison's to the girl of our ward to read, I received a Facebook message from HM - one of my university classmates.

"I have checked your statistics book reference in your web site unfortunately this one is printed in 1991 and the next edition will be OK in mid-2009. Any new suggestions ?"

I replied, "Statistics has not advanced that fast; the 1991 edition is good enough for any purpose - and probably easier to read."

For a similar reason I keep a copy of the first edition of Gray's Anatomy: human structure has not evolute in any noticeable extend over the past 100 years. The same argument also applies for classics by Adam Smith (on economy), Benjamin Graham (on investment), and so forth.

No, it's more than that. The same principle may also apply to subjects that do advance quickly, such as internal medicine. It is generally better to read a well-written but slightly outdated book than the most updated publication whose existence serves nothing but the ego of the author - or worse, the administrator.

Handbook

The little girl in my ward tried and helped to do morning round for some of our cases - the duty medical officer is on leave.

I gave a weired smile after knowing she prescribed certain drug in the dose half tablet twice daily - that medicine could act for over 24 hours.

"How do you arrive at this idea ?" I asked.

"It's written in the Hospital Authority Handbook." She replied, neither haughty nor humble.

I was about to say one cannot rely on medical (hand)books written by extra-terrestrials to treat Homo sapiens - well, I swallowed that back to my throat. Of course our girl found me unbearable when I gave her copies of the relevant chapter in Harrison's and a paper from the New England.

But that's the whole reason that I'm against the idea of writing our own textbook: we could hardly make one better than those from the two sides of the Atlantic. All we achieve is, besides fulfilling whoever's ego, taking up the opportunistic cost of our students so that they would not have time to read texts by those giants.

"Think global. We've got to be international." So does our VC say.

For once I agree with an economist.

Pips

After reading my recent blogs, you may begin to believe I am going to vote for the man who sent the five orange pips.

(And not the one with an unbeatable platform - since there's no substance in the platform.)

Yes, in fact I was about to think so - until I got a letter of advertisement from him.

Oh, don't be silly. There's no orange pip in it. He has not gone that far. The letter was about his stand on the law against discrimination. All he cared was to make sure private practitioners do not need a translator for each and every patient who speaks an exotic dialect.

My god, the law does not prevent discrimination. If it does anything, it provokes argument and aggravates the discrimination against the good majority of ordinary people. Any educated vertebrate should notice the problem and voice against it - unless he has bitemporal hemianopia and could only see a small part of the picture.

As I told Vivian some weeks ago, I am about to vote for anyone who (have the courage to) stand up and say, "The law is stupid. I am all against it."

PS. Haven't you heard of The Five Orange Pips ? Go and read Sherlock Holmes !

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Author's declaration: The reference is purely based on the similarity in their names - or acronyms, but not the society that the man belongs to !

Hubris

On a second thought, it is actually more common for straight upright unselfish people to become corrupted when they have the power, rather than a secretly ambitious tyrant keeps a nice face for 30 years with all the struggles before reaching the top of the political hierarchy.

The former has a name in medical jargon: the Hubris syndrome.

"Most political leaders become mentally or physically incapable of sound judgment and lose their grip on reality." Lord David Owen, the former UK Labour Foreign Secretary, said. He is the one who invented the name of this condition.

(Oh, we know. They emigrate to Pluto.)

Hubris syndrome is inextricably linked with power. Indeed power is a prerequisite, and when power passes the syndrome will normally remit. The disease is more likely to manifest itself the longer the person exercises power and the greater the power they exercise.

Hubris is not the name of any person; the meaning comes from ancient Greece. A hubristic act is one in which a powerful figure, puffs up with overweening pride and self-confidence, treats others with insolence and contempt, and the one seems to derive pleasure from using his power to treat the others in this way.

Difference

I might be wrong yesterday.

It was equally possible that the Chen's couple and Wang were genuinely unselfish politicians in those days - and the heroes became corrupted only after they rose to a high position. Who can tell ?

Well, if there is no objective means to distinguish an ambitious tyrant under incubation from a great democracy fighter that (are prone to) have mutation later, they are all but one type of people.

"But their minds are different !" You may argue.

You may be right, but no body could tell what's in their mind. (In fact I always want to have someone who could tell what's in my mind - I don't seem to know.) We could only judge people by what they do - not by guessing what possible electric current goes between their neuron, nor what vibration wave comes out from their vocal cord.

And we always remember the most critical voice on the radio would convert to a die-hard royalist once he became the backbencher.

放言

The latest and worst example of choosing a political leader is no doubt Chen Shui-bian (陳水扁).

If Chen died in 1974 as a young lawyer (soon after he graduated with distinction), or if Wu Shu-Chen, his wife, were killed in 1985 by that truck (after Chen lost the election for county magistrate), the couple would always be remembered as heroes of Taiwan.

I begin to think of the poem <放言> of Bai Juyi (白居易):

周公恐懼流言日，
王莽謙恭未篡時。
向使當初身便死，
一生真偽复誰知？

And if Wang Jingwei (汪精衛) were actually executed after his failed assassination of Zaifeng (醇親王載灃), and leaving a poem like this:

慷慨歌燕市,從容作楚囚,
引刀成一快,不負少年頭.

I would fall for the later-to-be traitor if I were a woman in that era.

Leader

In addition to mutual trust fund and academics, we make the same mistake in choosing political leader.

"He has led us through the difficult days and kicked away the tyrant - who else could be a better president ?" And we have Vladimir Lenin for Russia, Lech Wałęsa for Poland, Nelson Mandela for South Africa, and Sun Yat-Sen for our own self.

Oh, many of them are highly respected people; they fought wholeheartedly for the freedom and benefit of their own people - but they were simply not the best one to rule the country when there was peace. It just demonstrates their inadequacies and leaves them bad names.

That's why I have all my respect to English people. When the empire was under the thread of the Nazi Germany, they put up Winston Churchill as the prime minister, but soon after Adolf Hitler shot himself, the Anglo Saxon did not have to think twice but said to the depressed politician:

你好,請你下來.

Fund

You may consider the trick I mentioned yesterday child's play. Nonetheless, many of us fall into this kind of trap.

For example, we often put our money on mutual trust fund according to its past performance. "Look, this fund rose by 80% in the past year. It's going to be a great investment."

My friend, all funds have their own market to focus on. The huge amount of earning happened because the market that this particular fund invested shot up - isn't it a sign of bubble and correction should come soon ?

Well, I have a specific distaste towards mutual trust fund after listening to the argument of Tony Measor. Ten years ago, to receive sufficient management fee for hiring one full time fund manager, a trust fund needs to manage around 400 million dollars - which only accounts for less than 10% of all funds on the market, and this full time person may not be far from a fresh university graduate - otherwise the salary would be much higher. For the rest of the funds, they could only employ part time and not too experienced people to take care of your money.

Therefore, unless the market is not within my own reach, otherwise why shouldn't we do our own investment ?

PS. Creatures on Pluto also love to employ people who had track record of publishing an impressive paper (note: usually singular, not plural). Alas, I could not remember anyone who got the Nobel prize twice - except Madame Marie Curie.

Tactics

Many happenings of Sir Humphrey Appleby were never known to the world. Here is one:

On one occasion, a friend of our Chief Cabinet Secretary went for a backbencher, and asked the latter to help. Although civil servants should be politically neutral, Sir Humphrey gave a useful tips to his friend, "Look, there is huge pressure from the public for policy X, and the government will inevitably approval it - in order to gain some popularity. It does no harm for you to send letters to all voters in your district, saying that policy X is important and therefore you will do everything to fight for it ...

... And, when the policy is approved, you could claim that you are responsible for this success !"

Sounds good, eh ? Our ex-colonial politician applies this trick a few times before.

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Vivian was not at all happy with my blog Labour; she thought I was going to support a non-clinical candidate. She reminded me that she received a letter, which fought for free cancer drugs, a few months back - from a microbiologist.

忌日

Visited the graveyard of my father on Sunday - it is exactly 20 years after he RIP.

My memory of him has faded. He worked for the Royal Navy and did not spend much time in the family. Ironically all I could remember of him is a family man: He prepared delicious and complicated dishes (when he was at home), and quite a few of the furniture in our home were his own handicrafts.

And he was a shrewd critic of Chinese history, with a strong distaste for dictatorship and communism.

As a naval officer, he travelled a lot - from Singapore to Cyprus, and from Norway to Falkland Islands. (Yes, he was in the front line of the battle in 1982, and we still keep the precious medal he earned from the war.) Those were the difficult days when we counted on every penny, but he promised to bring my mum to visit the Harold's one day.

Alas, that's the rare occasion where he could not fulfill a promise.

Maybe I should take it up.

PS. I could still remember hearing the radio broadcasting the 1980's classic <人在旅途灑淚時> during the funeral - hope he could lead a happy life and make the full use of his talent in the other world.

Change

TW has got the wit to recognize what we face in the change of attitude of medical practitioner is unavoidable but would also inevitably lead to disaster - as she says in a slip-of-the-tongue manner: 與時並盡.

Yes, it is the old Latin proverb: Tempora mutantur, nos et mutamur in illis. (In English, it is: The times are changing, and we are changing with time.) But not every change is good. The principle of genetics predicts that over 99% of all new mutations (alas, changes) are detrimental.

There is, of course, 1% of them advantageous - the important bit to keep the evolution going. Nonetheless it doesn't mean we keep all mutations in the genome. For the majority of them, we should have the courage and discard once we see they lead to birth defects.

Some days ago, when K commented on another blog of mine, she asked (rather seriously): And the solution ? I have no idea. As a passenger, and being on the death seat, I know the brake is not working alright and the driver is half asleep. I cannot drive, but I could shout to keep the man next to me awake - hopefully he would then slow down the car and fix up the defect in the system.

PS. This analogy is not an invention of mine. Socrates told an almost identical story (on ox-cart) over 2000 years ago. Our great philosopher died of that "ox", I know.

Link

Visited the shopping mall near my hospital on a Saturday morning - I need some refill of milk and instant coffee.

I have not been here for quite some weeks. To my surprise, many shops were closed, "To Let", or under construction for the new tenant.

The mall is, of course, run by the Link.

This is no news. Many shopping malls under this government sponsored enterprises (GSEs) see the same fate. Small local shops are forced out of the competition because the rent rises like rocket. Chain stores and big names are introduced - that's the deliberate policy.

I have a small fortune of The Link REIT. As a stock holder I should not be too concerned with the rent, but I do. Yes, you could say even business establishments have a social responsibility, not to say a GSE. Oh, my ethics standard is very low. Nonetheless it doesn't feel good to see the mall (that I have a hand on) half empty - even though you have doubled the income from the other.

Games

Much to my surprise, fans of environment protection often lie low for the Olympic Games.

Of course it is grand and attractive to hold the event every 4 years in a different city, but building a new set of stadium and Olympic village each time is another story.

Think: How often would Beijing people go to the Nest Stadium after 2008 ?

And it is not merely the construction of the white elephants. You need the maintenance. To make it appear to be better used, officials would no doubt give it for events that could be held in a much smaller place - yet aggravating the wastage.

Well, we shouldn't be too critical. It is just too common to believe building a theatre with gigantic atrium would promote cultural activity, or filling your shelf with dozens of books from the Fair means better knowledge, or underlining and highlighting every sentence of the textbook guarantees a pass in the medical examination.

PS. It is impressive to learn how Japanese re-name the Martial Arts Hall, built for the 1964 Summer Olympics, to the Nippon Budokan (武道館) and use it for pop star concerts. In a sense, the white elephant was sucessfully made used of by the Carthage of the east.

Motto

The Olympic motto is Citius, Altius, Fortius, which - as we all know - means "Faster, Higher, Stronger" in English.

As a rule, I am always skeptical with Castles (of Franz Kafka) such as the International Olympic Committee, which we could only meet the messenger - or merely subordinates of the messenger - but never the Count himself.

To any onlooker, the IOC should be an organization that aims to promote sports and fair game. It is therefore surprising to learn that this ambitious establishment has officially sixteen roles and objectives, from promoting sports to prevention of doping. (If someone tells you in a job interview that he has 16 objectives in his life, you can be sure that he could achieve none of them.)

One of the objectives is: to ensure the regular celebration of the Olympic Games.

"The aim of this organization is to exist." I have a déjà vu feeling of reading Jean-Paul Sartre. Does this event actually promote health and sports to people at large ?

And the Games is no doubt one of the major reasons for doping in sports.

As Laozi (老子) said: 聖人不死, 大盜不止.

Migraine

Had a few migraine attacks recently. It seems that the problem does not disappear with age.

I had migraine since the age of 14. (My first attack was, alas, while I was reading Genesis.) It was the classic type, with aura and photophobia and all textbook symptoms. Although it only happened a few times each year, the episodes were so severe that every time I had to lock myself up and stop doing everything for a day or two. Thank god the attacks became less severe over the years, although it remains no fun to do the clinic while seeing the computer screen all disturbed by zig-zags.

Troublesome as it seems, I learn something important while living with the disease: Since the attacks always come suddenly at an inconvenient time, I have to prepare everything in advance - in case something unpredictable happens.

And it fulfills my grandiose ego to learn I share the trait with many big names in history: Vincent van Gogh, Claude Monet, Sigmund Freud, Friedrich Nietzsche - just to say a few.

Oh, and there was Cao Cao (曹操).

PS. It was fortunate for the legendary physician Hua Tuo (華佗) - I always wonder what would happen if the great dictator did accept the proposal of craniotomy.

Labour

You may consider I am completely outdated.

We should not work when there is a typhoon, the working hour should be limited, and there should be post-call day-off ... all are simple labour laws that we should follow.

Yes, those are labour laws. That's why by following the laws you become a labour, not professional.

Nonetheless, the ones who make the biggest thrust in pushing for these "benefits" gain so much popularity that they are almost taken as the Che Guevara of the local medical community.

Would it be possible that pushing for these "benefits" is merely betraying our professional stand in an attempt to achieve certain personal political agenda ? For the backbencher ?

Oh, maybe not. He may just be simple and naive.

But the harm is done. No one could tell a clever crook from a naive idealist - and I have a low opinion on either.

Typhoon

I realized it was typhoon signal number 8 only after I arrived at my office.

But I was not alone. To my surprise, I met Madam Wah - the hospital amah responsible for cleaning up many of our office - sharp at 7:45 AM. (I shall probably adjust my watch by the time this faithful woman appears, just like what Prussian people did for Immanuel Kant.)

I said good morning to her, and asked in a rather light-hearted way, "You still have to come in this weather ?"

"Of course," she replied in her characteristic accent, "or they shall deduce today's wage from my salary."

I said nothing more. Our punctual lady was actually very well off and could retire in luxury any time she wishes.

The morning passed by. I finished with some paper work and went for a round on my cases. Many of the medical officers were already at work.

But there was no house officer - who should all be living at the hostel - in most of the wards.

"Why, by the regulation they do not have to work." You may argue.

Certainly. But it is also because of their willingness to follow regulations of this kind they lose their professional stand. Today I have more respect to a reliable dust-woman than some nondescript youngsters who claim themselves medical practitioners.

Class

Another sobering truth is medical education also conforms to the Baumol's curse.

Think. To do a bedside teaching, it takes a small group of students, a teacher, some patients, and some fixed unit of time together. The supply of good teacher is limited, and it helps little if we increase the size of the group. Good teaching is, after all, a kind of handicraft, and productivity improvement is limited by the almost fixed human cost.

For the same argument, I am always against the idea of teaching grand rounds of 30 or 40 people. What good could it do besides fulfilling the grandiose ego of the one who leads the round ? If the material of discussion is meaningful to medical students, it would certainly be dead boring for trainees. On the other hand, the two specialists who try to have a slightly sophisticated dialog are probably Immanuel Kant and Georg Hegel of medicine to most of the students.

PS. Of course the worst scenario is the discussion of administrative matters in the round. How many of us understand the language on Pluto ?

Curse

You may not be a fans of Mozart and find no difference between a CD and live concert, but most of us would be more choosy when it comes to medical care.

What does a physician actually do in providing the "care" ? We take a history, perform a physical examination, perform tests, and spend time discussing our conclusion and plan of treatment with patients. The handicraft of medical care is all about personal concern.

Yes, we can increase our productivity by speeding up the clinic visit, working longer, or delegating part of our job to nurse practitioners and other trained persons. However, we are close to our limits because patients do not want shortcuts in their perceived care. In an attempt to further reduce the time of a clinic visit or hospital stay, it is actually very probable to cause more indiscriminate testing and referral.

What about advances in technology ? For many parts of economy and social system, that's a brilliant way to boost up productivity - but unfortunately not for medical care. In the contrary, advance in technology actually reduces productivity because our time - the limiting resource - is diverted to playing with computer records, doing cardiac catheterization, or other procedures. We have less time to take care of our patients.

That's the curse.

PS. I claim very little credit to the above discussion. Much of the argument was raised recently by Eric Neilson in his article Baumol's Curse on Medicine in the May 2008 issue of the Journal of American Society of Nephrology.

Baumol

Another of my concern about the admission system is the Baumol's curse.

William Baumol was an economist at New York University. Together with William Bowen, he wrote a book titled Performing Arts: The Economic Dilemma in 1966. His point was simple: economic productivity of a society is reduced by the persistent rising costs in the performing arts.

For example, a string quartet 200 years ago had two violinists, a cellist, and a violist playing a piece of Mozart for 30 minutes. It is of course absurd to reduce the number or quality of the musicians - the productivity would not increase that way because no one would come to hear such a thing. Technology (say, DVD and iPod) would improve the productivity very little either, because live performance is just different.

The very fact is: musicians today expect a much higher wage than their predecessors 200 years ago. As a result, the cost of live production will continue to rise to hear Mozart.

The argument sounds child's play, doesn't it ?

The point is, medical practice also fits well into this logic.

Dog

One worry of mine is the place of general medicine is vanishing.

Of course it remains arguable whether there is a need of general medicine. As Adam Smith pointed out, it would be much more effective to have a division of labour, and each doctor would do better to focus on a small area and excel.

Yes, surgeons are more advanced in their step of differentiation - and there is no difficulty to see the problem of general surgery nowadays. When the first edition of Farquharson's Textbook of Operative Surgery was published in 1954, many surgeons were capable of practising a wide spectrum of operations, and it was possible for a single author to provide comprehensive advice within a single book. In its latest (ninth) edition, ironically edited by the daughter of the original author, there are no less than 24 contributors - and none claim themselves a general surgeon.

And surgery is different. With an inherited emphasis on handicraft, division of labour has the obvious advantage. Of course a surgeon who treats a young woman with recent onset vomiting might do all exotic endoscopic examinations but miss the diagnosis of pregnancy. We laugh at them but, in the future, gastroenterologist may fail in the same way. This argument is just too familiar and I shall not go further.

What troubles me is: physicians' role is often more subtle. Many a time the practice depends on a bird's-eye view of the whole picture and application of common sense that is not common. This patient will die of cancer in three months and there is no point to talk about diabetic control. Salbutamol puff is out for the asthma of this man because he also has severe rheumatoid arthritis of his hands. And the list is endless.

With extensive sub-specialization, who is responsible for practising simple common sense and taking care of cases who are turn away by every specialist ?

Maybe the dogs.

As Geoffrey Vickers said, "Even the dogs may eat of the crumbs which fall from the rich man's table; and in these days, when the rich in knowledge eat such specialized food at such separate tables, only the dogs have a chance of a balanced diet."

Admission

On the very last day of CSC, we had a lunch time service meeting on the coming admission ward system. (Of course our retiring professor was not there - he had very little to do with service.)

Some of my friends would know I have a completely schizophrenic view on this matter. On one hand I have long for triaging acute medical admissions according to the sub-specialty. However I am somewhat uneasy with the proposed "protocol-driven" management. (There are certainly political considerations in my amygdala, which I shall not elaborate.)

Yes, we can cover 80% of our acute admissions by six or seven diagnosis - and we could design protocol for each and every one of them. Nonetheless, not all exacerbation of chronic bronchitis (or heart failure or stroke) are the same.

And my anxiety goes further up when I come to realize that those protocols aim to discharge the patients in four days. In other words, they got to be highly intensive and focused (i.e. narrow-minded in sugar coating) - and would deliberately turn away from the possibility of difference between individuals.

It seems trying to draw a rose by a ruler.

(Oh, yes, ruler. What an appropriate term.)

The creatures on Pluto have probably consumed too many eggs in mechanical circle.

PS. As KM points out, an important aspect of medical practice is to pick up the case of theophylline overdose amongst the 100 emphysema patients that you see - it would never happen if the only thing we do is to follow a protocol.

CSC

This is the last day of CSC.

Our professor from England has been with us for nearly 25 years. As a medical student brought up in the colonial days, I am somewhat uneasy to have no one with silver hair and blue eyes around (except BT - who hardly ever appears or gives an opinion).

Of course many of us - including myself many a time - often think that the part-time endocrinologist gives too much of his opinion. Nonetheless I feel a loss.

Or, in a poetic description, Eraritjaritjaka.

The last event of the day was medical grand round, while CSC used to be a regular audience. The round today was, by coincidence, an endocrine topic - and a few of his papers were actually quoted in the talk. I saw him giving a weired smile, said goodbye to CC (one of his earliest students in Hong Kong), and left the lecture theatre almost unnoticed.

You may wish to quote: 悄悄的我走了,正如我悄悄的來,我揮一揮衣袖,不帶走一片雲彩。

But I'm thinking of: 君子 不出惡聲。

Oh, maybe the voice was made - but never heard.

PS. For those who are not familiar with the term Eraritjaritjaka, I would suggest the article of this title by Joris Nauwelaers in The Lancet on December 23, 2000, page 2169.

Standard

Ever since Vivian went to Osaka, I had to lunch alone every Saturday.

As a rule, it is rather inconvenient - to say the least - to lunch or dine outside on your own. Last week I visited a local hamburger shop, which is highly recommended by the gourmet's web site Openrice. Let's call it Season's Fast Food.

It is a small store at Hung Hum, with a hue of the 1970's, and obviously run by a family. You can find almost any kinds of thing here: rice, spaghetti, sandwich, hot dog, and what not.

But hamburger is what makes it famous.

I tried the double-cheese-burger with egg. Well, there might be better ones (say, in Triple O's) - but I was entirely satisfied. The hamburger meat was home-made and had a rich flavour of onion, the cheese was half-melt into the piece of bread, and the egg was pan-fried to an irregular shape - to me a human touch as compared to those mechanical circles you find in other chain stores.

I can see the shop thriving, but I can also sense it striving. Her market place is slowly whip out by McDonald's and other big names. It is obvious: size is an advantage.

Alas, we thought it a laughter when watching Modern Times of Charlie Chaplain a hundred years ago. I'm not sure we still find it a comedy nowadays - we may have lost that sense of humour after eating eggs all in mechanical circles.

Minimum

You may argue, "We should nonetheless ensure a minimum standard - on health care, food, living, and all basic human needs - to the disadvantaged."

Quite true.

But in that case you make a classical flaw in logical argument: transfer of proposition (命題轉移). We set off to discuss whether people should receive the same medical care - including all new expensive gadgets - irrespective to their financial ability; we end up supporting a minimal standard, with the inevitable implication that things could be different if you have the money.

The more of the problem is: what is the minimum standard of medical care ?

Say, for the treatment of acute heart attack, is it aspirin and beta blocker, or thrombolytic therapy, or high dose recombinant tPA, or direct angioplasty, or direct angioplasty with stent, or direct angioplasty with drug-eluting stent, or the further addition of monoclonal antibody against certain glycoprotein receptor ?

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"Of all of the forms of inequality, injustice in health is the most shocking and inhumane." So was it declared by Dr. Martin Luther King, Jr.

It seems a sign pointing our way to Utopia.

And, true, any difference in health care should not be the result of age, sex, or race.

But obsessive asking for equal care of every man leads us nowhere but the Utopia of absolute zero.