Present

Some of my friends knew I actually bought two books as presents for the Christmas Quiz. During lunch before the grand round, SN asked, "Have you ever read those books ?"

"Of course. How else could I recommend them to the others ?" I replied firmly.

For those from the next generation, I would recommend the followings:

• The Elements of Style by Strunk & White (English writing)
• Sophie's World by Jostein Gaarder (philosophy)
• How to Make Friends and Influence People by Dale Carnegie (psychology)
  
• A Short History of Nearly Everything by Bill Bryson (natural science)
• The Wealth of Nations by Adam Smith (economics)
• The Intelligent Investor by Benjamin Graham (investment)
• Murder of Roger Ackroyd by Agatha Christie (detective story)
• Freezing Point (冰點) by Miura Ayako (三浦綾子) (fiction)
• Cobra by Buichi Terasawa (寺沢武一) (comics)
• 司馬遷 《史記》 (history)

Happy new year.

Idea

After the Christmas Quiz grand round, I told Vivian the questions I put up.

She pointed out coldly, "Fifteen pairs of hands ? Alas, the idea of your mentor's distinction viva really gets you."

As always, my wife was right. In fact, I told the story here not too long ago (see http://ccszeto.blogspot.com/2009/11/contd.html).

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And I have a deja vu feeling of a scene in The ABC Murders, when Hercule Poirot described his "dream crime" to Arthur Hastings:

"Supposing that four people sit down to play bridge and one, the odd man out, sits in a chair by the fire. At the end of the evening the man by the fire is found dead. One of the four, while he is dummy, has gone over and killed him, and, intent on the play of the hand, the other three have not noticed. Ah, there would be a crime for you! Which of the four was it?"

Alas, it didn't take long before Poirot met exactly this case in Cards on the Table.

PS. According to the chronology of Agatha Christie, both stories happened in 1936. The usual Poirot would actually try to find out who was eavesdropping when he was telling his idea to Hastings (who spent all his time with Poirot during the ABC incident and was back Argentina immediately afterwards - he had no opportunity of telling anybody else).

Shift

Contrary to her usual self, my friend TW appeared hot and upset with my blog recently (see her comments during Christmas).

In my opinion, however, the annoying bit of the policy was not the resulting delay or cost to human life (by consuming everybody's time) - but the blind of shifting the responsibility.

You see, the policy of checking allergy record was put up by extra-terrestrials and executed by creatures on Neptune, but it is the duty of those who work on the Earth to decide (sugar-coated in the term "discretion on individual basis") if a particular patient needs the injection urgently. The impression to any onlooker is, therefore, all delay is the result of wrong judgement by Homo sapiens and has nothing to do with mollusks living on other planets.

And, you see, that's the general principle: Professionalism and responsibility is the two side of the same coin, which should always go together with the right to make decisions. I am always against those s0-called professionals who claim the right to decide but do away with the whole of their responsibility (often by shifting just a tiny bit of the right to the others).

Contrary to my usual self, I am serious.

Legacy

My friend VW recently expressed his concern of global warming (see http://vwswong.blogspot.com/2009/12/warm.html).

His worry was quite simple. In short, although it is unlikely that the sea level could have a meaningful rise during our life time, it seems mostly likely that the level would rise by at least 5.6 meters in the next 1000 years.

I could not agree more. As a parent, I am always concerned with what type of world I leave for Euterpe and her children.

However, at the same time, another story in ancient China comes through my mind:

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文承閒問其父嬰曰：「子之子為何？」曰：「為孫。」「孫之孫為何？」曰：「為玄孫。」「玄孫之孫為何？」曰：「不能知也。」文曰：「... 今君 ... 厚積餘藏，欲以遺所不知何人，而 忘公家之事日損，文竊怪之。」
〔史記卷七十五孟嘗君列傳〕

按：文，孟嘗君田文也。

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Is there any difference between monetary wealth and a metaphysical legacy ?

Cost

You may think my argument yesterday was irrelevant because human life should not be quantified by the dollar sign.

I fully agree. Life is the time that we spend in this world - let's measure it in terms of time and do a cost effective analysis:

• As stated yesterday, the average delay is 6 hours.
• During this period, a patient needs to stay in the ward and wait. This is the duration of life that is consumed. (Let's take aside the humanistic cost of suffering. I also try my best and used the word consumed rather than wasted.)
• We admit 60 patients each day, and 40% of them need antibiotics. In other words, 6 days of human life is consumed for each effective day of the policy.
• Let's assume the average life expectancy of a patient admitted to our hospital and required antibiotic treatment is 15 years. (Given the age and prevalence of multiple diseases, this is probably a slightly optimistic number.)
• The inevitable conclusion is: The policy would only achieve zero balance on its cost to human life if it could avoid one death in every two-and-a-half years.

I shall leave it to your own judgement whether the policy could save life that often.

PS. Our case is, in fact, the classical scenario of hidden social cost. No one dies of the policy that seemingly saves lives, but everyone pays part of his time.

And time - in aggregate - is life.

Bed

You may think my major concern on delaying antibiotic treatment is the potential threat to some critical patients. That's not (entirely) correct.

In fact, our friends outside the solar system would say clinicians could always ask for urgent dispensing of a drug when they really feel necessary. (Of course I could not imagine what would happen if we say 80% of our patients are urgent and have a necessity.)

But, let's assume they are sincere and that few critical patients were safe, there remains the problem of indirect cost that may skip your eyes.

Let's consider the following estimation:

• The average increase in time lag for antibiotic is around 6 hours.
• The time lag would be translated into an equivalent prolongation of hospital stay. (Let's assume there's no detrimental effect of the lag.)
• Let's assume we admit 60 patients each day, and 40% of them need antibiotics. (Both are highly conservative estimations.)
• The prolong in hospital stay would become 6 extra patients staying in ward (60 times 40% times 0.25 day).
• Assuming daily hospital stay costs HK$3000, the extra cost is $18,000 per day.

Sophisticated administrators would argue that hospital beds are fixed cost and would not disappear even if that 6 patients were not staying. Yes, that's true if we have plenty of empty beds. On the other hand, if the hospital is always full, six extra patients for this particular reason inevitably means that the same number of other patients in need would not receive the care.

There's something more than the dollar sign.

Amenity

One hot topic that keeps coming up in our professional casual chat (the term is self conflicting, I know) is the ban on ward stock of all antibiotics, with the resultant delay in availability of antibiotic for patients admitted through the emergency department.

To be fair, the ban is not without a reason; there had been quite a number of mishaps in the ward because antibiotic was given to someone with a known history of allergy. The solution adopted was to make sure all dispensing must go through the pharmacy, who would check on the history of allergy - and do away with the drug stocking in ward.

Inevitably, the price to pay is there would be some delay in given the drug (using the jargon of our cardiologist, the "door-to-injection time") - even for the vast majority of the patients without a history of allergy.

I shall not give my opinion here. Nonetheless, I am impressed with the comment of Charles, the cynical friend of Coemgenus, when the two discussed the traffic jam indirectly caused by blocking the road for the investigation of a traffic accident:

"Considerations of safety may have a higher priority than amenity but can never override it absolutely as the latter is what enriches life. I would ask the police whether the benefit to them in investigation, whether it be to satisfy those affected, to prepare for intended prosecution, or merely to cover their backs, always justifies the extent of the disruption to the lives of others that it causes."

Go read The Unknown Motorist in Clinical Medicine 2009; 9: 635-636.

Party

Attended the Christmas celebration held by Euterpe's kindergarten.

Oh, readers who are parents yourselves would know very well that celebration of this kind is nothing but an opportunity for each and every child to appear on the stage and have some performance. I must say I had very little expectation of the program (which was essentially all dancing and singing of kindergarten children), but was obliged to go and support my daughter, who took a small part in the dancing - what else do you expect from a kid of two-and-a-half ?

But I was (happily) wrong. The afternoon proved exceptionally entertaining. Not only was that the joy of a father seeing his daughter who had the first public performance in her life, but there was much fun for watching many (slightly naughty) kids on the stage - every piece of slip and mistake became an unintentional climax and invited big claps.

The program was planned to complete at 3:30 PM. By 3:28 PM, (although the whole afternoon was run by kids and there were so many climaxes) all the performances finished and the chancellor went up to the stage and thanked everyone. Each piece surprise was actually well planned and prepared.

Some of our friends in the business sector should really study (this) kindergarten again. (See http://ccszeto.blogspot.com/2009/12/powerpoint.html)

Merry Christmas.

Balance

To our fans of environment protection, don't be too excited with my weird idea of improving the efficiency of photosynthesis - even if it were materialized, it merely alleviate the problem of food supply, but has very little to do with the prevention of global warming.

In fact, even if you have no knowledge on ecology and atmospheric structure, it is not difficult to understand the determining factors of our globe's surface temperature. Here is a simple balance sheet:

• Input of solar energy (in the form of radiation, i.e. sunshine).
• Output of solar energy reflected from earth back to the universe. (This is the bit dampened by greenhouse gas of the atmosphere. Note also that if there is absolutely no greenhouse effect, the surface temperature of the earth would be only 5 degree Celcius.)
• Input of energy from fossil fuel and nuclear reaction.

Note that photosynthesis is not in the equation, nor is wind or hydro-electric gadgets that environment protection fans are so fond of. All of these derive the energy from sunlight and would eventually dissipate as heat - the eternal last final ultimate inevitable rubbish bin of all energy by the rule of thermodynamics.

The implication ? I shall leave it to your own discretion.

Hope

You may think we are coming to a dead end.

But, unlike my usual self, I am less pessimistic on this matter.

To be specific, although the efficiency of photosynthesis seems abysmal, it also implies that an improvement to 10% would mean a doubling of food production.

In fact, a few simple figures could shed light on further areas on improvement:

• The efficiency for conversion of photosynthetically active radiation (wavelengths from 400 to 700 nm) to chemical energy or biomass is 25%.
• Only 45% of the actual sunlight is photosynthetically active.
• Plant absorbs only 25 to 50% of the incoming sunlight for photosynthesis. (The other is dissipated by reflection and respiration requirements of the plant itself.)
  

You see what we are getting at ? On the first glance, item 1 seems an attractive target. However, it is indeed quite fixed because evolution in the past millions of years have ensured the efficiency of chlorophyll and the molecular machinery.

Item 2 appears to be fixed - you cannot change the spectrum of sunlight, but we can modified the structure (and therefore absorption spectrum) of chlorophyll.

Of course, it seems more easy to make the plant reflect less light.

But, the first thing we have to accept is: We are talking about genetically modified food.

Effect

Take aside the obvious complication of acid rain, pumping sulfur dioxide onto the atmosphere - with an aim to reduce solar radiation on earth - would be a courageous (according to the definition of Humphrey Appleby) strategy.

The reasoning is simple: Despite the extensive use of fossil fuel, almost all human food comes from solar energy - directly or indirectly. Wheat and vegetables do photosynthesis; livestock and fish feed on grass and algae and so forth.

The sobering truth is, in terms of energy conversion, photosynthesis is terribly inefficient (only 3 to 6%). Reduction in solar radiation, therefore, would inevitably result in a corresponding drop in food production.

Alas, it means that the world is cooler and food is more scarce. Thank you very much.

The story of volcano Krakatoa told us that much.

PS. The next inevitable environment problem of a cooler world with less food is the increase in utilization of fossil fuel (or nuclear energy, if our fans of environment protection prefer), which increases the amount of carbon dioxide release and cancels out the effect of sulfur dioxide.

SuperFreak

While I was pondering on the superb wisdom that I learn from Freakonomics, our famous local magazine put its brother - SuperFreakonomics - under the limelight.

One of the major focus of the book was the debate on global warming. In short, Steven Levitt put much emphasis on Nathan Myhrvhold's idea of pumping sulfur into the upper atmosphere. The idea comes from the observation following the 1991 eruption of Mount Pinatubo in the Philippines, which discharged more than 20 million tons of sulfur dioxide into the atmosphere - acting like a layer of sunscreen and reducing the amount of solar radiation, with resultant cooling off the earth by an average of one degree Farenheit.

Ingenious it seems, I am worried.

Seasoned readers of this blog may notice I put up The Scream of Edvard Munch as my profile picture.

Do you notice the colour of the sky ? Although Munch was portraying the Norwegian scene, the sky was red as a result of the 1883 eruption of volcano Krakatoa from Indonesia. With that event, temperature of the globe dropped by 2 degrees, all rain became acidic (it was sulfur dioxide !), and agricultural production fell for some years, followed by several political repercussion.

I need to scream.

Name

Another topic that Stephen Levitt spent quite some pages was the change in the parents' choice of name for their boys and girls.

I shall not go through his idea here. Suffice to say the choice of name for our children does reflect our value and wish on them - I realized this as soon as I entered the secondary school and was exposed to a wealth of different names.

But that's for our Chinese name only. At least amongst my generation, English name of a person is usually his (or her) own choice.

In other words, at least amongst people of my generation, the English name reflect what he or she wish to be, or what kind of person they are.

For example:

• A difficult person usually has a long and complicated name.
• Aggressive and fame-seeking people tend to have a name starting with "A".
• More humble people would choose to have their name beginning with "B". (Ironically, they are often aggressive subconsciously, because they are more aware of the difference between A and B.)
• Other subconsciously aggressive people would choose a name beginning with "Z", for obvious reasons.
• People who choose to have a simple name (for example, John or Peter) tend to be friendly and easy going.

I shall not elaborate further.

Dealers

One excellent story that Stephen Levitt told was the balance sheet of a drug-dealing gang.

The idea was simple: Although selling crack cocaine does make quite a bit of money, the leader of the gang always gets the lion's share of the profit - so much so that the actual salary of ordinary dealers (so-called foot soldiers) is rather abysmal. (In Levitt's own description, they've got to live with their mothers.)

Then why do so many young people want to become drug dealers ?

The answer is obviously the (hallucinatory) bright future of becoming the leader of a gang.

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I could not stop smiling while reading this chapter - a similar story is regularly happening in our circle.

I mean, our house officers. (By the way, they are drug dealers !)

You know what, as soon as we were in the final year of the medical school, we realized that the salary of a houseman was actually lower than those working in McDonalds. Nonetheless, calculated as always, our class still very much looked forward for the job.

As I told my classmate, "The paid is hell, but there is hardly any other job in the world that one would sure be promoted in a year - with the salary more than doubled."

The sobering truth is: fewer young people now wish to become a drug dealer because their leaders have much less glory nowadays - the profit has dropped a lot, and the risk of being arrested is higher than ever.

And the same is happening to our fresh graduates ?

Freakonomics

I was quite sure I could finish with Freakonomics this year (see my blog on 11 December) because I brought it with me to Chiang Mai - and it was such an enjoyable reading that I went through, from cover to cover, during the flight.

The book was a layman's summary of a few somewhat unrelated papers by Stephen Levitt, a Chicago economist.

I shall not elaborate the content here - you should really experience yourself. Although many of us have the impression that research in economy is related to tax, stock market, GDP, and other similar big topics, I agree with Levitt it is really the small bits on micro-economics that most of us find interesting.

Alas, even Adam Smith (began in the field of philosophy and) was flourished by his wealth of data in micro-economics before he could put up an overall picture in the Wealth of the Nations.

And, for an amateurish lover of wisdom like myself, there is no necessity what so ever to have an overall picture - I'm overjoyed to appreciate another piece (actually several pieces) of ingenuity.

Talk

The Thank You Dinner finished early, and HQ – a friend of mine from the mainland – invited me for a beer.

We found ourselves sitting in a seafood restaurant of the local bazaar, and were joined by BL (a senior physician from Sweden) and PH (a nephrologist from Belgium) - both good friends of HQ.

After a glass of beer or two, the two Europeans began to share their view on the history of the world - I was too happy to be a humble audience. The discussion began from the construction of the Grand Canal of China (京杭大運河), then the genetic mix-up between Mongols and Han people in the Yuan dynasty, followed by the invasion of Europe by Genghis Khan (成吉思汗), next to the invasion of England by Roman and Viking, and concluded with the development of the English language in the past millennium.

When we walked back to the hotel after a heated discussion, I said to PH, "Gosh, you are the only one I know who could tell the history of medieval England to the accuracy of year. Knowing that you are actually a Belgian, it is really an admirable achievement."

"Not at all," my new friend replied, "I lived in England for three years as a student."

I nodded, but said to myself, "Many of us lived in our country for half a century but still know close to nothing about our own history."

孔明燈

Recently attended a conference in Thailand.

I shall not elaborate the detail of the conference, which may not be entirely interesting, here. As usual, all speakers were invited to a Thank You Dinner. On the schedule, it was nothing remarkable: we were led by local tourist guides to see some temples, followed by a short boat trip on the river, and finally a BBQ buffet.

But there was surprise after the food: We were invited to go back to the river side, and were met with a few young men, who gave us tens of (what appeared as) gigantic paper bags.

One of them put up a fire under a bag, which soon became swollen because of the hot air and flied up to the sky. Suddenly I realized what they were doing, “Oh, god. They’re setting up Kongming lanterns (孔明燈) !”

We were immediately encouraged to do one after seeing. Although the “game” is not new to me, it remained slightly challenging – to prevent the fire from actually burning the paper, which happened for my first try – and it was real fun to see the paper toy grew up in my own hands, seemed to loss its weight, and freed itself up into the thin air. In now time, we saw dozens of glowing stars on the winter sky of Chiang Mai.

PS. On a second thought, did Zhuge Liang (諸葛亮) make this gadget in order to confuse the astronomers of Sima Yi (司馬懿) ?

天譴

Before I left for Thailand, my attention was caught by the judge's comment to someone who was found guilty on a local drama: 必遭天譴.

As Philo Vance's criticism on Markham (the District Attorney of New York County, in The Benson Murder Case), "I can understand a lay person making such a comment. But to say this as a professional, it is a bad sign."

And that's exactly the point - our court is supposed to practice justice, and I consider our legal professionals not doing their job right if a man (oh, a woman in this case) has done something evil but his punishment is left to some supernatural power.

To go one step further, even if the guilty person could escape from loopholes in our legal system - be it the law per se, or the litigation procedure (which is far more common) - the duty of our court is to point out the loophole and arrange its fix up. In layman's term, there's not point to cry over spoiled milk.

Copenhagen

The big thing on earth (the planet we live, I mean) at this moment is no doubt the Copenhagen Climate Conference.

I shall not elaborate my view on environment protection here. Nonetheless, the Conference does provide great substance for us to ponder - on democracy.

Oh, yes, you see the right word: democracy.

Just a few simple questions:

• Are climate change and environment protection important issues ?
• Do they affect every human beings ?
• If there is any policy, should everyone contribute to make it successful ?
  
• Does everyone have a say when the policy is being prepared ?

If you answer yes to all these questions, would you come to the inevitable conclusion that any policy on global environment protection should be decided by the most democratic procedure: referendum of the globe ?

Alas, that's probably the rare occasion where you would find China is all for democracy while the States and Europeans would protest vigorously with reasons all familiar to us.

That would be fun.

Missing

While reviewing my reading list this year, I realize there are quite a number of good books that I never have the opportunity to read (from cover to cover).

This is, again, an incomplete list:

• A Tale of Two Cities by Charles Dickens
• Alice's Adventure in the Wonderland by Lewis Carroll
• The Joke by Milan Kundera
• 1984 by George Orwell
• The Valley of Fear (of Sherlock Holmes) by Sir Arthur Conan Doyle
• The Travels of Marco Polo
  
• Genesis of the Bible
  
• From Fish to Philosopher by Homer Smith
  
• 黃宗羲 《明夷待訪錄》
• 吳敬梓 《儒林外史》

PS. For those who are not familiar with examination terminology, "never have the opportunity to" is the synonym of "forget" or "do not know".

Reading

It's coming to the end of a year, probably a good idea to look back and consider what book I planned to read but didn't.

Seasoned readers of this blog may recollect I made such a plan at the beginning of the year (go read http://ccszeto.blogspot.com/2008/12/plan.html). When I go through it again, many of them were done - except Food Politics and Freakonomics - the latter of which I planned to read in the coming weeks.

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My friends KM and BK were recently amazed to find me keeping a few non-medical books in my office. I must say these volumes are there largely for reference.

Here is my (incomplete) list:

• On Writing Well by William K. Zinsser
• Troublesome Words by Bill Bryson
• How to Say It at Work by Jack Griffin
  
• Fowler's Modern English Usage
  
• Contemporary Debates in Applied Ethics by Andrew Cohen and Christopher Wellman
  
• The Science of Sherlock Holmes by E. J. Wagner

PS. Strunk & White is not there; I keep it at home for careful study.

Nightingale

While recovering from my late-evening hypoglycemia, a few great speakers in the history came to my mind.

And I could not stop thinking of Florence Nightingale - the great lady who is commonly regarded as the mother of modern nursing.

Another talent of Nightingale that may skip your eyes is her remarkable presentation skill.

In fact, the great nurse was also a pioneer in the graphical presentation of information and statistical illustrations; she was renowned for her ability to use visual impact to convey important message - so as to influence various policies on public health. A particular form of pie chart which she developed, now known as the polar area diagram, is also called the Nightingale rose diagram.

Nightingale was elected as a member of the Royal Statistical Society in 1859 - she was the first female member of that society in history.

PS. Is it the reason so many of our senior nursing officers love paper work and presentations ?

Powerpoint

Went to a dinner meeting hosted by a group of extra-terrestrials. (Alas, that's included as part of my job description - or, to put it simply, my salary.)

The evening program was planned to be a simple one: There was an invited speaker from the States, who was supposed to share his experience in a brief presentation of half an hour; the dinner was after the talk.

The disaster began when the host forgot to bring a computer for the presentation.

They tried to borrow one from the venue (which was supposed to be a business center), but there was none for hire.

One of the hosts contacted a friend in office at a distance of a 10-minute walk, and it took half an hour before a small lap-top appeared - only to discover that it could not be logged on without an appropriate fingerprint.

Another audience appeared late and brought with him a computer - but it was an Apple and therefore not compatible.

The group of extra-terrestrials remained chaotic for an hour or so; I continued to wonder how Winston Churchill delivered his talks before Powerpoint was invented.

The dinner finally began by 9:40 PM. I left without saying goodbye as soon as I took the appetizer - so that I would not fell hypoglycemic on my way home. As Churchill once said, a gentleman is a man who would not be rude unless he intentionally does so.

PS. After we got married for over six years, Vivian had never heard so much colourful vocabulary from me.

Reviewer

You may laugh at my blog yesterday and think the problem of conflict of interest happens only in the circle of politics.

On that, you are wrong; we have just too much experience in academic medicine. Let me tell you a remarkable story:

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A few years ago, one of my colleagues and I were invited by a particular journal to write a commentary on a published paper - the two of us had done some similar work but the result was quite opposite. Naturally, we tried to explain the difference in result, and pointed out a few methodological problems of the others' paper.

When the journal editor showed our commentary to the original authors (for those who are not familiar with our life, it is a common practice), they protested:

"These two Hong Kong authors did not declare their conflict of interest - their group and ours work on the same area but they hold a different view."

My colleague asked how we should respond. I said, "If we work on the same area and share the same view, there is an even more vigorous conflict - we would like to suppress their paper and publish ours."

"What about if we work on a different area ?" My friend remained puzzled.

"In that case, we are not in the position to - and should not have been invited to - comment on their paper !" I laughed.

PS. I suggested to the editor that we put down a conflict of interest statement at the end of our commentary, stating that the two groups worked on the same area. The editor certainly saw the nuisance of my declaration and waved off the idea.

Conflict

For those who have no experience of being an expert witness, it is actually not easy to find someone who agrees and is agreeable.

In short, the earth is so small that everyone who have sufficient knowledge in a particular area would have something (albeit indirectly) related to the matter at hand, and people call it conflict of interest - another term that has been raped for so many times that it has become a prostitute.

A notable recent example is the barrister who failed to do business with a billionaire - and it is a conflict.

What about if there was a successful business relation ?

In fact, even if the barrister does not know the rich man at all, there remains a conflict: envy because of failure to make acquaintance.

Well, critics probably believe that there exists a human species called professional layman.

Alas, even if there were such a man, he would still have conflict of interest with that billionaire - the golden spoon that the latter was born with might have belonged to the layman if it were not for the existence of the latter.

Witness

Soon after my astronomic encounter, I was summoned to the court as an expert witness.

I shall not elaborate on the details of my appearance - it is neither appropriate nor interesting. But a small incident was really remarkable.

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To put it simply, the point of discussion was what actually happened during a critical period.

Early in the morning, a key witness - let's call him Mr. A - was asked to describe and was questioned in great detail about the sequence of event.

After an hour, another witness presented what he did. The judge suddenly interrupted, "That could not be the case. Mr. A just said that he tried the car before calling for help."

A few of the audience (including me) looked puzzled - we seemed to have heard a different story; the barrister of the (supposedly) defending side rose up, "Sir, Mr. A actually said that he called for help before he tried the car."

The judge checked with his own notes that he put down, and he insisted, "No, I did make some notes when Mr. A was giving his evidence. He tried the car first."

I turned around and looked at the seat behind me; Mr. A was humbly sitting there.

"Why don't they ask him again ?" I said to myself.

But no. The point was not what the fact was, but what was being said. The two legal professionals discussed for another minute or so; the judged then suggested, "We have tape recording of the whole process. Why don't we get back to the tape and check what was said ?"

The lawyer duly complied.

Venus

Soon after my experience with the Jupiter, I was asked which planet I would prefer after the Pluto is taken out from the list of planet for the solar system.

There aren't very many choices, and I would prefer the Venus.

Reasons ? Well, there are a few:

1. Venus is the brightest planet. (I agree there are times when Jupiter outshines Venus, but on the average the latter gives more light.)
2. Venus is close to the Earth and, unlike Jupiter (which essentially is a bag of gas), it is a terrestrial planet.
3. Venus could work both efficiently and leisurely - a day on Venus equals 243 days on Earth, but a year on Venus is 62% of an Earth year.
4. Above all, I love gold.
   

PS. Seriously, my opinion is immaterial. The established system of selecting a planet is absolutely democratic: one man, one vote.

I mean only one man could give the vote.

Jupiter

After pondering on some local black box operations, I attended a star party with Vivian and Euterpe.

In short, the kindergarten of my daughter invited a few semi-professional stargazers to give a talk. They also brought their telescopes along so that we could all share a glimpse of the clear autumn sky.

The major character of the evening was Jupiter. Thanks to the explanation of our instructor, I could learn a few interesting things of this lovely star:

• It is more close to earth than Pluto.
• In spite of its heavy mass, it has the fastest rotation of all the planets in the solar system. One day on Jupiter is merely 10 hours on earth.
• Largely because of its fast rotation, its atmosphere is highly violent. In fact, one of the best known features of Jupiter is the Great Red Spot - a persistent anticyclone storm that's been noted for a few hundred years.
• It has no fewer than 60 satellites; 4 of them are particularly obvious to lay observers.
• And, above all, although it is very heavy, its major composition is hydrogen and helium. In short, it is merely a gigantic bag of gas.

PS. Were our friends actually astrologists ?

Punish

Going back to the local political drama, the obvious question is: What next ?

In fact, it is a classical scenario in the study of game theory: the "one-side defect" for cooperation of repeated game with heavy reputation effect .

The idea is simple: Cooperation leads to a tension between what is best for the individual and what is best for the group. A group does better if everyone cooperates, but each individual is tempted to defect.

What about costly punishment (i.e. paying a cost for another individual to incur a cost) ?

You may not believe it, but there has been well conducted experiments on this area. The result ? In short, the option of costly punishment increases the amount of cooperation but not the average payoff of the group. Furthermore, there is a strong negative correlation between total payoff and use of costly punishment. Those people who gain the highest total payoff tend not to use costly punishment.

In other words, winners don’t punish; losers punish and perish.

Go read Anna Dreber. Winners don't punish. Nature 2008; 452: 348.

Blackbox

It is eye-opening to learn a certain noble council member uses the term blackbox politics to comment on the operation of another party. By definition, politics is a blackbox operation.

It is an ingenuous - no, it's not a typo; not ingenious - idea that politics means democracy, election, or referendum. I'm not saying what is good or bad, or should or should not. Just that the game is not played in that way.

Oh, rather than dwelling on the dull drama of local politics, for those who are interested in soiling their hands, may I introduce the best preparatory course before joining the blackbox operation:

I am referring to the boardgame Diplomacy.

No, this is no Risk or other ordinary chess. On the map of Europe, each of the seven players takes the control of one country. Contrary to other games, movement is simultaneous, not by turn; all players secretly write down their moves after a negotiation period, and then all moves are revealed and put into effect simultaneously. The major target of the game is to fight for the fixed number of supply centers (34 in total) - it is a zero sum game; any gains in a player's resources comes at the expense of a rival.

And, you see, the beauty of the game is all for that negotiation phase; all the (important) things happen here. Players form alliances; arrangements and agreements may be made public knowledge or kept secret. Players are not bound to anything they say during this period, and no agreements of any sort are enforceable. Players must forge alliances with opponents and observe them to ensure their trustworthiness; at the same time, they must convince others of their own trustworthiness while making plans to turn on their allies when others least expect it.

PS. It is often said that Diplomacy was the favorite game of Henry Kissinger, and the Kennedy family the game to teach their children. I'm not sure it is a good thing to learn stabbing on others' back at such an early stage, but the map of Europe is certainly an excellent gadget to teach our kids history.

冬日

While talking about the sun, another little story from the ancient China comes to my mind:

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

酆舒問於賈季曰：趙衰、趙盾孰賢？對曰：趙衰冬日之日也，趙盾夏日之日也。
《左傳·文公七年》

(晉‧杜預注：冬日可愛，夏日可畏。)

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

You may wonder why I brought this up - it is plain simple that the winter sun is lovely while the summer one is poisonous.

But, may I remind you, that's the same sun, just that the environment is different.

More importantly, winter is winter exactly because the sun is not working to its full capability.

Same for our professors ?

Sun

In the morning after our crab gathering, Vivian and I brought Euterpe to the Disneyland - Vivian got a few complimentary tickets and my daughter is a fan of Goofy and Pluto.

But I regretted the decision very soon. It was a windy and chilly Saturday morning. Our princess had to hide herself under the overcoat, and it took us some forty minutes to line up with hundreds of tourists from the mainland before Euterpe could take a picture with Mickey and Minnie.

After that, Vivian suggested to have an early lunch. I happily followed.

And it was a brilliant move. The afternoon sun was warm and charming. Our usual energetic daughter revived - I must say I also found my depression disappeared as soon as I walked under the beautiful sunshine.

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

For those who have lived in Britain, the effect of sunshine on our mood is no news. When I was working in Bristol, it was not uncommon to have prolonged consecutive cold cloudy days, and people were overjoyed when they saw the sun.

Alas, I still remember in one particular winter afternoon, the sun emerged from the thick cloud after a whole week of foggy weather, the chief research fellow of my laboratory yelled, "Oh, it's the sun !"

And, you know what, everyone in the laboratory (as Hercule Poirot said, from the duke to the dustman) rushed to the garden and enjoyed a brief moment of sunshine.

It was the rare occasion I found there exists something fair for everyone in the world.

蟹詩

After the hallucinatory interview, Vivian and I had a small dinner gathering with her surgical colleagues - largely for the tasting of Chinese mitten crabs (大閘蟹).

I do not have much to tell from the dinner, but there's a flash back of my memory to some poems I learned from the Dream of the Red Chamber (紅樓夢) by Cao Xueqin (曹雪芹).

(賈寶玉)
持螯更喜桂陰涼，潑醋擂薑興欲狂。饕餮王孫應有酒，橫行公子卻無腸。
臍間積冷饞忘忌，指上沾腥洗尚香。原為世人美口腹，坡仙曾笑一生忙。

(林黛玉)
鐵甲長戈死未忘，堆盤色相喜先嘗。螯封嫩玉雙雙滿，殼凸紅脂塊塊香。
多肉更憐卿八足，助情誰勸我千觴。對斯佳品酬佳節，桂拂清風菊帶霜。

(薛寶釵)
桂靄桐陰坐舉殤，長安涎口盼重陽。眼前道路無經緯，皮裏春秋空黑黃。
酒未敵腥還用菊，性防積冷定須姜。於今落釜成何益，月浦空餘禾黍香。

Alas, "眼前道路無經緯，皮裏春秋空黑黃。" What a description.

The eternal question is: what species of crab was on the table ?

Looking at Lin Daiyu's poem, it should not be the Chinese mitten.

Maybe they're the river ones.

Revenue

You may find my story yesterday irrelevant. By coincidence, I encountered a very similar happening last week. Let me modify the scene a bit and give you a feel.

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(In a job interview for the new lecturer of a medical school.)

The chairman asked, "What's your passion ?"

The candidate solemnly replied, "Oh, I love doing research and teaching medical students."

"Are you interested in seeing private patients ?" The chairman went on.

"No ..." the candidate said. He soon found a dark face in front of him, and he added, "... and yes. I can take some."

"I would suggest you to take many. You see, we are going to set up a private teaching hospital. I think you could have a busy practice there and generate enough revenue."

For a short while, the candidate suspected he misheard the other side, "Enough revenue ... for what ?"

"So that you could employ someone to do the research and teach the medical students for you !"

Rich

In Tim Ferriss's book, people of his kind are called New Rich. That's not entirely correct - Happy Poverty may be more appropriate.

Let me give you a classic story that's recited in the book:

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An American tourist was at the pier of a small coastal Mexican village when a small boat with just one fisherman docked.

Inside the small boat were several large yellow-fin tuna. The tourist complimented the Mexican on the quality of his fish and asked how long it took to catch them.

The Mexican replied, "Only a little while."

The tourist then asked, "Why didn't you stay out longer and catch more fish?"

The Mexican said, "With this I have more than enough to support my family's needs."

The tourist then asked, "But what do you do with the rest of your time?"

The Mexican fisherman said, "I sleep late, fish a little, play with my children, take siesta with my wife, Maria, stroll into the village each evening where I sip wine and play guitar with my amigos, I have a full and busy life."

The tourist scoffed, " I can help you. You should spend more time fishing; and with the proceeds, buy a bigger boat: With the proceeds from the bigger boat you could buy several boats. Eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman you would sell directly to the processor; eventually opening your own cannery. You would control the product, processing and distribution. You could leave this small coastal fishing village and move to Mexico City, then Los Angeles and eventually New York where you could run your ever-expanding enterprise."

The Mexican fisherman asked, "But, how long will this all take?"

The tourist replied, "15 to 20 years."

"But what then?" asked the Mexican.

The tourist laughed and said, "That's the best part. When the time is right you would sell your company stock to the public and become very rich, you would make millions."

"Millions?... Then what?"

The American said, "Then you would retire. Move to a small coastal fishing village where you would sleep late, fish a little, play with your kids, take siesta with your wife, stroll to the village in the evenings where you could sip wine and play your guitar with your amigos."

PS. A very similar story could be found in Zhuangzi (莊子).

4-hour

My recent bedtime reading is The 4-Hour Workweek by Timothy Ferriss.

I brought this book when I was in San Diego last month. When I thumbed through its pages at the Borders, it looked like a book on time management - a favorite subject of mine.

But I was wrong. The book consists of three parts; I was about to give up reading in the first part, which outlined the desirable life style of the author. To put it in modest words, that's not my cup of tea.

Fortunately, Ferriss went on and gave many practical approaches to save time and outsource every aspects of our life, and the last part of the book was full of relevant reference sites. If The World is Flat of Thomas Friedman shows us how the world could operate in the era of internet, Tim Ferriss provides a practical handbook on how that could be applied to the daily life of an ordinary people.

Confidential

I was recently asked to write a recommendation for one of my colleagues - it was kind of a formal procedure for our university.

Although I became an academic staff for over 10 years, this is the first time I write recommendation for this particular purpose. Our campus MBAs (which stands for Master of Bureaucratic Administration) are so productive that the rules keep changing and there is now a standardized recommendation form for me to fill it.

I read it through. Towards the end of the form, it says:

The information of this form is absolutely confidential. Please send the form directly to our office after it is completed. Under no circumstances should the referee release information on the form to the candidate. However, please also note that in order to comply with the Privacy Ordinance, the candidate has the right to request a full copy of this form from our office - with the details of the referee.

Extra-terrestrials do have a different system of logic.

PS. I recently learn that a second type of MBA is Management By Absence. That's another story.

(cont'd)

With the slightly unexpected question from the candidate, the two examiners looked at each other. Finally, one of them asked, "Why do you ask that question ?"

"My written paper and bedside are not that bad," my mentor explained, "I don't think you plan to fail me. On the other hand, I understand very well I'm not good enough for a distinction in surgery. Then, why do we waste our time ?"

The two men on the other side of the desk were forced to agree.

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

I believe it was the next morning the moustache man sat for the distinction viva of medicine.

He was led to a long narrow room, with a handful of professors sitting in a line.

Along one side of the room, there was a series of X-ray boxes, all turned on.

On the boxes, there were ten X-ray films, put up as a line.

All were X-ray of the hands (from ten different medical conditions, of course).

His task was to comment on all of them, and answer related questions.

And he got through.

PS. The scene actually reminds me of the Wooden Men's Lane (木人巷) in those Kung-Fu movies. I'm not sure it's good or bad but we could never have this kind of challenging examination nowadays.

Memory

You may find it amazing that I could still remember my "job interview" so well. In fact, that's not a privilege of mine. On the morning after the dinner with my laboratory friends, I met AL - my colleague who recent took the membership examination - when I was going to the clinic.

My little friend sighed, "You know, it's over three weeks, but I'm still having such a vivid memory - scenes of the examination keep flashing back."

"Of course," I tried to be reassuring, "I could still remember scenes of my membership and even final MB examination - even though they were in the last millennium !"

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

Actually, even my previous mentor - the man who used to have a moustache - has the same experience. Here is one little scene that he kept telling his trainees (yes, that's me some 15 years ago):

After the written and clinical examinations in the final MB, my mentor had to attend the surgical viva (a regular event for all students at that time), and was invited to the distinction viva of internal medicine.

The surgical one came first. The moustache man entered the room, sat down, and saw two examiners. The more senior one said, "Well, before we ask you any question, you may ask us one."

"Good," the nephrology professor-to-be answered, "My question is: May I go now ?"

I shall tell you tomorrow what happened to him.

Interview

Two days after the parent meeting, I dined with KB and AC - two friends of mine who are laboratory scientists. AC is a father of two; our discussion inevitably fell to schooling and parenting.

"So you are applying for kindergarten ? How about primary school ? Oh, you would be doing a lot of interviews - you know, nowadays they almost always need to interview the parents ..." AC said.

"Quite right. That's expected." I nodded.

"Oh, when did you last have an interview ?" KB added, "You joined the university 10 years ago ?"

"True, but I did not need an interview when I applied for my academic post," I smiled, "You know, AY, the previous lecturer, left for the consultant post, and they could not find anyone to replace. I was summoned during my overseas training in Bristol - actually slightly after the application deadline. In fact I had not completed my specialist training when I joined the department - I sat for the exit examination six months later."

My dinnermates looked amazed, and I went on, "You know, the only job interview I had in my life was for the medical officer, and that was DCA - the chairman at that time. In fact, I did not have to say anything in the so-called interview, and he only murmured two sentences: We are not particularly keen to get you. We have two posts - but you are the only applicant."

AC obviously had enough of my grandiosity and concluded, "Don't worry, you shall pay back and have as many interview as you like in the coming years !"

Cautious

Had a brief meeting with the class master of Euterpe - it's kind of a regular meeting so that we parents could be updated with the progress of our children in the school.

Vivian and I found ourselves in a small classroom; the teacher was a young chubby lady. My wife sat down and did the talking; I brought my daughter to a corner and tried to play with her - but both of us were more interested in the conversation.

After a brief exchange in thanking, the teacher said, "Euterpe is cheerful and active, but I would say she's very cautious. You see, whenever we brought the class for a new game - seesaw or slide or whatever - she would never be the first to try. She would let a few of her classmates try it, and, after seeing the thing is OK, then she would be happy to join."

"Oh, that's probably because she fell so many times when she was a baby ..." Vivian answered, and she went on to describe a few incidents at home.

Sitting aside, I said nothing. Just that the ordinary interpretation of the meaning of cautious intrigued me. Yes, we feel something safe when so many people did it or are doing it. More often than not we use this as the criteria of safety - rather than examining objectively the task at hand.

Alas, that doesn't always work, and not uncommonly results in a mass catastrophe - for example, in the financial market.

Evidence

You find my discussion yesterday convincing and are about to advocate against organic farming ? I was - until very lately.

The principal assumption is: organic farming is much less efficient (in terms of productivity) as compared to the modern intensive method.

But, what is the evidence ?

I must confess I was quite convinced with the assumption until I prepared to write this blog recently. When I look up for supporting evidence, I find it less assuring.

To put it simply, a number of observational and comparative (not randomized controlled) studies found that organic farms have 10 to 20% lower yields than their conventional counterparts in developed countries. On the other hand, the former have 20 to 30% higher yields than their low-intensity counterparts in developing countries. (The reason is probably a lack of expensive fertilizers and pesticides in the developing world.) When you consider a global picture, there is a slight reduction in productivity, but by a few percents only.

The lesson ? Never appeal to authority. As Martin Ruth advised: You will find it very good practice always to verify your references.

Revolution

The major advance that brought along the increase in productivity of food in the past sixty years was the (so-called) Green Revolution.

Take my mother's poultry experiment as the example: Chickens were expensive in the good old days because they were fed with rice and veges and allowed to walk around. Now, chicks are mostly kept in the barn and fed with a fortified mixture of corn and cereal. Many of them would never see the sun and their biological clock is modified to have an 8 or 12-hour diurnal rhythm - so that they could lay egg two or three times each day.

The same applies - more so actually - to crops. With the extensive use of synthetic fertilizers, global cereal production tripled between 1950 and 2000, but the amount of land used was increased by only 10 percent. In comparison, using traditional techniques such as crop rotation, compost and manure to supply the soil with nitrogen and other minerals would have required a tripling of the area under cultivation.

You see where we are getting at ? Look, organic farming is better for the environment is self-conflicting because organic farming produces lower yields and therefore requires more land under cultivation to produce the same amount of food. To put it simply, the more intensively you farm, the more room you have left for rain forest.

You think this argument crazy ? I shall not object. But the line of thinking is not new - it was first proposed by Norman Borlaug, who won the Nobel Peace Prize in 1970, exactly for his contribution through increasing global food supply.

Go read Trewavas A. Urban myths of organic farming. Nature 2001; 410: 409.

Difference

You may wonder why should poultry had an inflation rate of 4.5%, while salary and property rose by 8%.

The explanation is simple: Over the past sixty years, there was a dramatic improvement in the productivity of poultry and other agricultural products - by technology, mass production, and so forth. In short, the amount of labour and other cost of breeding a chicken is much reduced now than 60 years ago.

In contrast, there are entities that advances in technology could not actually improve the productivity. For example, the amount of space that we need to live, or the number of patient that a physician could see in a morning clinic. For those who are obsessive with terminology, this phenomenon is known as the Baumol's curse.

But, one point may skip your eyes: Technology has a limit; contrary to the opinion of a certain rocket scientist who recently deceased, we can never go beyond the law of physics and increase the number of chicken bred by a farm of a finite size indefinitely.

And, I suspect (well, yes, I suspect, I could be wrong - hopefully) we are close to the limit.

In that case, we would expect the price of our needs of daily living (food, clothing, etc.) would go up more quickly that they did in the past sixty years.

Another reason for not leaving our spare money idle.

Return

What's the implication of 4.5% and 8% ? Let me give you a slightly convoluted explanation.

Many of you may have encountered those advertisements of our Monetary Authority: the return of an investment is proportional to its risk.

The point is, as Benjamin Graham pointed out (some 70 years ago, in Security Analysis), the return of any risk-free investment is expected to be roughly equal to the nominal inflation rate, which is around 4.5%. (Graham himself used the US treasury bonds as the example of a risk-free investment, which we may not agree nowadays. That's another story.)

How about a business with an average risk (alas, so-called market return rate) ? According to Graham, the expected return is 8% in the long run.

The inevitable conclusion is, therefore, to meet the requirement of the real-life inflation, one must go for business with an average risk and should never do ordinary saving or any so-called risk-free gadgets (including government bonds).

PS. JW, TW, and other friends who are experienced investors would recognize I have done away with jargon such as Beta and Market Return Rate.

By definition, beta is one for an ordinary business. The above calculation indicates that the deviation is 3.5% (i.e. 8% minus 4.5%). For an investment with very high risk, beta equals 3, and the expected return is 4.5% plus 3 time 3.5%, which makes 15%. An investment with expected return above this figure is unrealistic.

Interested beginners are encouraged to read The Intelligent Investor by Benjamin Graham or The 10-Day MBA by Steven Silbiger.

Inflation

You may think the little story of my mother interesting, but there's actually more serious implications that may skip your eyes.

To begin with, the story happened 60 years ago.

Now, let's see: it cost 5 dollar for a chicken and 10 cents for an egg at that time. For those who do not go to (super)markets yourself, the price today is around 12 to 15 times higher.

Of course that's because of inflation.

The point is: What was the inflation rate ?

My BA-II calculator tells me that it is 4.2 to 4.6% per year - a figure very close to what the government officially announce.

But, at this point, you may notice immediately that not everything has its price raised in the same rate. Sixty years ago, a small apartment in some marginal area cost $10,000, and the average household income was $150 - both increased by around 100 folds now.

And it means an inflation rate of 8%.

The implication ? I shall elaborate tomorrow.

Chicken

During a casual dinner chat, Vivian asked my mother, "Have you ever kept any pet - say, chickens ?"

"Why, I did keep some chickens when I was a child. I remember very well, there were seven of them." My mother was always precise with numbers, "You know, the result was gorgeous."

"Result ?" My wife and I were confused.

"You know, I bought them as little chicken at a cost of $1 each. They were kept at practically no cost - one of my neighbour was a vegetable vendor, and I used those broken leaves and stems left in his trash, as well as our own leftovers, to feed the chicks. When they grew up, my mother used one for the Winter Festival, another for the New Year, and so forth. We were so happy - a 2-catty chicken was sold at $5 at that time. Without my little farm, my family could hardly afford any poultry for the celebration."

"Ah ..." I gave a meaningful sigh, and she continued, "And there's more. They were all hens and, not too long after I bred them, they started laying eggs. You know, eggs were sold at 10-cent each at that time."

"Too bad you did not keep more and sell them for a profit," I concluded, "Otherwise you could well be another Warren Buffett !"

Chinese

After a whole morning of discussion, we lunched with our friends from China. The casual conversation inevitably touched on the problems faced by our next VC.

The man from Pluto sighed, "You know, one question that kept coming up when I saw the students, alumni, as well as teaching staff is: Should we use Chinese for teaching ? After all, we are the Chinese University ! Many alumni and senior members also pointed out that one of the mission of our university is to promote Chinese culture."

As an onlooker, I said nothing. Nonetheless, I consider it a straw man to advocate teaching in Chinese because we want to promote our culture. The two does not have a direct link - in fact, they could be quite independent of each other.

After all, even the most vigorous fans of Chinese culture would not insist on preserving our tradition of foot binding (纏足) in women. Right, we remove the barbarian traits from our culture and keep the nice bit. Chinese language is good for poetry and literature but less desirable for scientific communication. Why should we waste the effort on our weakness when there are better ways to show our edge ?

PS. I forget who told me this very truth: a people must be confident with their own culture before they could be open-minded to the others - look at the Tang (唐) empire.

Visitors

A group of senior physicians from a major medical school of our country came and visited our department – with an aim of exploring potential aspects that we could have some collaboration.

We ended up having a small meeting of a dozen people. After a brief introduction, our chairman showed a video to introduce our faculty – it was a short film specifically prepared by the university for visitors from the mainland, with narration in Putonghua.

After that, our friends from China decided to show a little movie to introduce their hospital – it was in (perfectly spoken) English.

All through the morning, I had a deja vu feeling of reading Fortress Besieged (圍城) of Qian Zhongshu (錢鍾書): People outside the fortress wish to get in, but those who are inside want to come out.

PS. During the meeting, we each took turn to give a brief presentation on our own division. Most of us spoke in Putonghua, but I had no choice but had to do with English - of course our friends from China could understand alright.

I'm sure we should emphasize our difference, not similarity.

"Ah-Q," I could hear you whisper.

Topics

Invited to do a tutorial on medical ethics for our students – it sounds like asking Franz Kafka to teach in a Sunday school. (Well, apparently our organizer had asked many of my colleagues but was constantly being turned down. Maybe he asked Socrates, Hume, and Schopenhauer.)

I must say I had very little idea what to teach. Surprisingly the students had prepared some cases for discussion, and, towards the latter part of the session, the organizer chipped in and offered several extra scenarios for us to ponder.

And they were illuminating ones too. For example,

• What to do if your senior give you an obviously wrong instruction?
• What to do if you find your senior giving harmful treatment to his patients?
• What to do if your male colleague is suspected to have some inappropriate behaviour to female patients?

Alas, interesting as they appeared, I could not see the value of including these into the medical curriculum. Yes, our doctors-to-be may get a glimpse on some difficulties of practising medicine on earth, but it is merely the romantic idea of some extra-terrestrials that medical students would become better clinicians by teaching of this kind. After all, behaviour is determined by the limbic system, not neocortex.

Maybe they should really ask Schopenhauer.

Democracy

Soon after I was back from San Diego, CB invited me to his office and have some coffee.

After some casual conversation, my friend, who happened to be the council member of our society, asked for my opinion on a recent proposal in the society council. (The detail of the proposal is irrelevant.) As you would expect, I said I didn't need to have an opinion on that particular matter.

But CB did try to insist for one, "Why, this is democracy ! I represent you guys and have to ask for all your opinion before I vote in the council."

Well, it became my turn to be obsessive and start a small lecture on democracy:

"Democracy is about our right to vote for our representative. In essence, we believe a particular person shares our own view, is capable, and has the vision, and we put a tick at his name. Other than some rare occasion of a controversial topic, this elected representative should act according to his own judgement and discretion - he has all the information and should be in a better position to decide for his citizens. I consider my representative not doing his job if he has to ask for my opinion on every matter."

"But, nowadays, many people would ask for more involvement in every decision - both the council and our society as a whole !" CB commented.

I said, without even any thinking, "We call them 刁民."

PS. I don't think I have to touch on the very fact that, in a democratic system, if the representative is not doing his job well, we can get rid of him and vote for someone else in the next election.

Social

For my friends in the medical field, you may think the theory of Soros sounds great but has very little practical value.

On that, you are wrong.

It is a romantic idea that medical science falls within the category of natural science. But no. In terms of research and how we advance our knowledge, clinical medicine is by and large a social science - and, as the great hedge fund manager pointed out, people's opinion frequently affect the objective fact.

"How could that be ? We have objective means and elaborated statistical methods to test whether a new treatment or diagnostic test is useful." You may argue.

But no. One notable problem is we are not free to design any clinical trial. For example, if there is a moderately effective treatment for a certain disease, any new treatment should be compared to this supposedly gold standard rather than placebo (otherwise it would not be ethical to the participants). In fact, if the existing treatment is very effective, it is more common to test the additional benefit of a new treatment - on top of the existing one. We would never know the value of that new drug on its own.

Alas, do you now see the point ? Yes, it is in fact easy to tell whether a subject belongs to natural or social science: If a research project needs approval by an ethics committee, the topic falls into the latter category.

PS. I shall not elaborate on the more serious problem that, when the majority of the experts within the field holds a particular opinion, the result of any new research would be interpreted (or publicized) in favor of that opinion - irrespective to what the data actually show.

That's another (sobering) story.

Reflexivity

Traditionally, we assume there exists an objective fact that could be validated, and knowledge is the process of our gathering of information and synthesis of idea to understand the objective fact. Our great hedge fund manager reminded us that, at least in the field of social science, our idea often form the basis of the objective fact.

(I said remind because the idea is not entirely new. A very similar theory was proposed by Aristotle over 2000 years ago.)

For example, Barack is a man is a scientific description, which has objective criteria and could be validated (to be either true or false). The important point is: whether Barack is a man or not does not depend on your opinion or description.

But, when we consider the description Barack is our enemy, it becomes a different ball game. Yes, there remains criteria for validation, but the objective fact could in itself be altered if we accept the description. In other words, if we see Barack as our enemy, he will sure be. It is, in essence, a reinforcement cycle and self-fulfilling statement.

Soros called it reflexivity.

PS. The best example by the hedge fund manager is, of course, if everyone believes that the stock price would go up, it sure will.

PPS. Seasoned medical students would find my example somewhat familiar. As Virgil said, Hos successus alit; possunt, quia posse videntur. (Success nourished them; they seemed to be able, and so they were able.)

Soros

As usual, I brought a book with me for long flights.

This time, my companion was The Crash of 2008 and What It Means by George Soros.(It was my birthday present from my sister.

Honestly I did not have high hope to begin with - the thing looked explicit and lack something delicate. (In retrospect, the title was probably coined by some pragmatic publisher rather than the great hedge fund manager himself. As Confucious said: 以貌取人,失之子羽.)

This time, I was fortunate to find my suspicion on a false ground.

There are two parts of the book: first about Soro's own theory of philosophy, followed by his view on the financial market. Although you may consider it slightly strange for a financial tyrant to talk about philosophy, I agree with the author and find the first part of the book more impressive.

Soro's discussion was largely on epistemology (a branch of philosophy concerned with the nature and limitations of knowledge). His idea was rather simple, which I shall elaborate tomorrow.

Paradox

My recent stay in San Diego brought my memory back to an old paradox.

The story went like this:

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For obvious reasons, I chose a small hotel with a moderate price. (It took me a 30-minute walk every morning to the convention center - the rare occasion that I had to do some genuine exercise.) To my surprise, the room was exceptionally well equipped: In addition to those ordinary gadgets, there was a coffee machine (so that I could boil some water for my own consumption), a spacious fridge, and a microwave.

And, above all, there was free wireless internet service.

When I mentioned this to PL (our senior consultant who lived in a hotel twice as expensive as mine), he became half mad.

"Why ! They charged me US$14 each day for the internet !" He complained.

And that's the paradox. It occurs to me that cheap hotels are often more generous in providing free internet service, while expensive ones often charge their tenants.

I'm sure there's a simple principle in economy that explains all these.

Tutorial

"Who wrote the first textbook on gynecology in Chinese medicine ?" Came the first question of my previous mentor for his dinner tutorial.

(I must say I could not be more happy. Everything seems going back to the good old days.)

I shake my head, playing my part as a humble student.

The answer was, as it turned out, illuminating on its own.

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The first textbook on gynecology in China was 《女科》, written by Fu Qingzhu (傅青主).

Fu was no ordinary gynecologist. He was an outstanding scholar at the turn between Ming (明) and Qing (清) dynasties, and an expert in medicine, philosophy, literature, calligraphy, as well as martial arts.

For that very last aspect, he appeared in the classic fiction The Seven Swords of Mount Heaven (七劍下天山) by Liang Yusheng (梁羽生) - Fu was one of the Swords.

The same character also appeared in the movie Seven Swords (七劍), directed by Tsui Hark (徐克), who casted Liu Jialiang (劉家良) as our legendary gynecologist.

Lobster

While in San Diego, I was fortunate enough to dine with the man who used to have a moustache. Alas, it was a small gathering at a brilliant seafood restaurant, arranged by a certain third-party. We were there together with a few other colleagues from Hong Kong.

The teacher and his malicious student were sitting at the opposite side of a long narrow table. Inevitably we ended up having some causal talk. My previous mentor was exceptionally elated; he was just too eager to share his wisdom with the others at the table.

• How to choose some expensive and exotic dish that does not appear on the restaurant's menu ?
• Why order a 3-pound-plus lobster (after a seafood platter and some heavy clam chowder) ?
• How to attend a meeting only if the dinner is held at a Michelin 3-star restaurant ?

Oh, did I say share, or demonstrate ?

Scope

During an academic conference, it is my habit to attend symposium that has very little relation to my work. For exactly the same reason, conference of the American Society is particularly attractive to me - they often invite speakers from some unexpected field.

For example, the first plenary lecture was delivered by Roger Tsien (錢永健) - the 2008 winner of the Nobel Prize in Chemistry.

Yes, chemistry. Although Tsien focused on the practical aspects (that is, in vivo tissue imaging) of his work on GFP (green fluorescence protein) and skipped much of the technical details, I could appreciate why his prize was on chemistry. (For example, he did explain a little how the side chain of GFP was modified to achieve a different emission wavelength.)

What's the use of all these ?

What a question.

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Most people know very well that one could look far away by standing on the shoulder of a giant.

But, when there's no giant around, we could look slightly farther by keeping our back straight.

And, however far away you could see, make good use of your atlanto-axial joint and look around - you could better appreciate the beauty of the world.

On a few occasions, you may also find an unexpected trail to the place you want to go.

Lag

I set off to San Diego on a public holiday. Vivian took the chance and brought Euterpe to the airport. Our girl was, of course, overjoyed.

As an academic staff, I am a rare specimen of infrequent traveler - in fact this was the first time I went for an international conference this year. (I always hold the opinion that most of the academic conferences actually have very little academic value. True, they remain essential because of the commercial value - but that's not a reason to attend.)

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Take aside a few exceptional circumstances, jet lag is hardly ever a problem to me. I could sleep alright the airplane, and my addiction to caffeine helps a lot. You know what, every time before going overseas, I stop drinking coffee for a day or two as well as throughout the journey. On the first morning that I am in another country, the first dose of caffeine would be resumed, follow by a regular twice-daily dose.

PS. As a rule, I drink Starbucks only when I am away for a conference. Somehow, this year, their regular coffee tastes less strong than previous years - and the price is 5-cent lower than the small shop nearby.

Not a good sign for its shareholders.

School

After reading my calculations yesterday, you may come to the same conclusion of certain Mr. Tsang and suggest that an average couple should buy a flat in some less privileged areas. If the unit price is down by 50% (i.e. HK$2000 per square foot), they could afford an apartment twice as big.

It sounds great - until the parents have to find a suitable school for their children.

For those who are not familiar with the system, primary schools in Hong Kong are allocated by two major criteria:

• where the parents graduated from
• where does the family live

I don't think I need to elaborate on the variation of school quality in our city. It follows that the chance of receiving a reasonable education does not depend on the capability of the child, but who the parents are and whether the family could afford an expensive place to live.

It doesn't take long for the society to segregate into two layers: the cream (alas, or the scum) and the sediment.

PS. Even if a few exceptionally gifted children from average families do get through and entered some prestigious schools, have you consider the time to be spent in the traffic for these kids ?

Numbers

While I appeared to be in favor of TW's opinion, let's shift our attention and consider some realistic figures.

Let's consider an average Hong Kong family with a median monthly income of HK$15000 (the official one for 2005, which I found in Wikipedia). It plans to use 40% of the income to pay for an apartment, and a mortgage of 20 years is made. If the interest rate is 5%, what is the amount of the loan ?

My BA-II financial calculator tells me that it is HK$900,000.

If the mortgage equals 70% of the price, the apartment is sold at HK$1.3M.

It follows that if the unit price of the flat is HK$4000, the area is 320 square feet - for a family of four.

And we have not considered the followings:

• the possibility of a fifth person living together (for example, a Filipino maid or a grandparent, who help taking care of the kids)
• a building area (建築面積) of 320 square feet may actually be 220 square feet in saleable area (實用面積)
• how to make up the down-payment
  

箕子怖

Another story from ancient China:

昔者紂為象箸而箕子怖。以為象箸必不加於土鉶，必將犀玉之杯。象箸玉杯必不羹菽藿，則必旄象豹胎。旄象豹胎必不衣短褐而食於茅屋之下，則錦衣九重，廣室高臺。吾畏其卒，故怖其始。居五年，紂為肉圃，設炮烙，登糟邱，臨酒池，紂遂以亡。故箕子見象箸以知天下之禍，故曰：“見小曰明。”
(韓非子·喻老)

Oh, maybe I should provide some translation:

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Soon after Zhou (紂) became the emperor, he ordered his courtiers to make a pair of ivory chopsticks for him. Jizi (箕子), his uncle and political advisor, was horrified. His theory was ordinary bowl and plates would not match the pair of expensive chopsticks; jade or rhino horn would be necessary. It went without sayings that all these precious utensils should only be used to serve exotic dishes, followed by corresponding improvement in clothing and palace ...

And the rest is history.

PS. The theory does not only apply to individual; it works well for governments.

Price

You think my story point to a certain direction ? Hold on; you do not notice - something is missing.

The husband of the sister died just a few years before the couple could retire.

Yes, the sister became a well-to-do widow - but a widow all the same.

She will no longer watch a movie or dine with her loved one, although she could afford all these now. Alas, she never had, and will never have, a chance to travel with her husband and see the world. Believe it or not, she has never visited Lane Crawford; all her knowledge about Harrods came from some fragmented stories told by her husband. (In fact, she has joint pain here and there, so that nowadays she won't even agree paying a visit to the local theme park.)

True, she should have done all these when she was young ...

... but the price to pay is she may have to count every penny and worry about her living at the age of 70.

Sister

(continue)

The sister married an industrious workman. The couple had a chance to apply for government housing, but they decided to buy their own flat.

It was in the early 1970s. Although things were very cheap (by today's standard), they could only afford an apartment of around 400 square feet in an, at that time, suburban area. It cost $30000. (Just for reference, the salary of an ordinary policeman was $1000 at that time.)

They made $10000, which was all their savings, as the down-payment, and used much of their salary to pay the mortgage. (In fact, the husband had to paint the house and make many of the furniture himself - they had no savings left.)

The difficult time lasted a few years. The mother had to do some outsource work at home for local factories. When their son was nine, the mother got a part-time job - the son became responsible for preparing lunch. The couple finished with the mortgage in a few years, and continued to make more savings.

The years passed and they continued to live in their little place, until the flat was eventually sold in early 2000s - at $650000.

Together with her savings and all the others, the sister actually retired very comfortably off.

Brother

When I read the story quoted by my friend TW (see http://hk.myblog.yahoo.com/cal-culator/article?mid=81), a similar one came through my mind.

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It was about a pair of brother and sister, some fifty years ago.

Both of them attended the primary school only briefly, and started working in local factories at their teens. They were both hardworking and soon saved some money.

The brother married a colleague of his and moved into public housing. He used the savings to start his own business, and was rather successful in the following 20 years. To his credit, he foresaw the decline of local industry, sold his factory in 1980s, and decided to have an early retirement.

The problem was, throughout the years, he stayed in his original public housing - the price of property has gone up so much that he would never has his own flat. Before he eventually goes to meet Chairman Mao, his biggest wish is, in fact, to leave a place for his son to live.

But we know it just too well it could never come true.

(to be continued ...)

Flat

A hot topic during our lunch time discussion recently was the story of that young lady doctor and her fiance lawyer.

(For those who are not familiar with this topic, I am talking about the couple who expressed their difficulty in buying their own flat.)

The opinion amongst my friends is divided. Some are very sympathetic and could not agree more (a succinct summary of the argument could be found at http://doctorfat.wordpress.com/請特首回答我/); others are more skeptical and put it down to the unrealistic expectation of the couple (as mentioned in an article quoted by my friend TW; see http://hk.myblog.yahoo.com/cal-culator/article?mid=81).

You may ask: What's my opinion ?

My immediate response would be: I don't think I need to have an opinion on this matter.

PS. Seriously, I agree with both sides. The former does point out an important social problem that we face, while, ironically, the later should be the attitude we treat ourselves in response to the problem.

Congratulations

Our man from Pluto was back on time. He was obviously in a good mood.

We saw to the venue and went through the arrangement together. (It was too late to wake up each patient and check for specific signs.) Time passed quickly and we all hurried back home.

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I shall not elaborate on the happenings of the examination. The marking scheme as well as the set up of one station were new to us, but they were not at all interesting.

After a busy day, all examiners gathered at the department library and went through the score of the candidates. Towards the end of the meeting, one local examiner said to our man from Pluto, "So, this would be the last time you being the host examiner ?"

The chief external examiner raised his eyebrows, "Joseph, you're moving higher up ?"

"Oh, not confirmed," our chairman tried to confine himself to the facts. His face turned slightly red, and he went on, "I am nominated to be the Vice Chancellor of our university. Stupid am I ?"

"I see ..." The chief external from Scotland made a meaningful twist of his lips. We could all hear the comment in his throat: That's a trying task.

There was a moment of silence.

"Well, maybe we should still say congratulations !" Another external examiner suggested.

We all laughed.

Nomination

Soon after I pondered about the disappearance of our house officers, we actually held the membership examination at our own hospital.

As usual, the evening before the examination was the most critical period. BK, as the first time organizer, was immensely effective, and most of the patients and paper work were ready before sunset.

But, at around 6 PM, AL, our chairman's secretary, gave me an unwelcome news, "Em ... JS could only be back by 10 PM to check the things. Would you stay and join him ?"

"Well ... I shall be back slightly before ten." I didn't ask why, but was obviously unhappy.

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I went home, dined with Euterpe, and was back on time. The man was, supposedly, still in Pluto. AL seemed to be in a chaos. I knocked on her door and asked, "Are the things alright ?"

"Just too many phone calls to handle," she had no time to talk more.

I went to my office and turned on the computer. There were a collection of congratulating messages on the Facebook.

And it was all on the news.

Our chairman was nominated to become the next VC.

Pass

Seasoned medical practitioners would recognize the college examinations are changing.

"We need a fair, objective, and reproducible assessment." So was it said.

But, you cannot draw a rose by a ruler. For the same reason, a rigid test is only good for new comers of the field.

And, therefore, we call it an entrance examination nowadays.

In the (not all that) old days, the college examination was meant to signify completion of training, and there were only two ways to pass:

1. The candidate is smart; or
2. The candidate is one of us.

However blur they appear, these time-honored criteria did make sure most of the successful candidates had sufficient experience and their practice conformed to the conventional standard, while at the same time provided allowance for a few high-flying personality-outliers.

Leave

It was a busy morning - a few of us are leaving for the States for a meeting next week, and the morning clinic was badly over-booked. We were forced to start the round a bit late, and, ahead of us was another crowd of in-patients.

After seeing the first patient with FP and BK, I suggested some management. FP replied, "We'll take care of that."

I was about to say, "This kind of thing could be done by the houseman."

But, before I could actually ask the question, BK gave me the reply, "Most of our house officers are on leave today - it is the part I MRCS examination."

I looked around and realized a familiar face was absent.

"Are there so many young doctors interested in being a surgeon ?" I murmured.

They replied, "Of course not. But, without the part I, you can't actually apply for any surgical post. It's not only surgeon. The same thing apply for gynecology and a few others."

"In that case, why do we need to have final MB at all ? We could outsource the work to individual college." I said to myself.

MI

During a casual conversation, my friend KM said that he cultivated a habit of keeping all emails that he wrote overnight before sending out.

"Just to make sure I am cool and do not send out something that I cannot withdraw." said our great teacher.

I cannot agree more, "Too bad there is no function that (the sender could pre-determine so that) the mail is removed spontaneously a few days after it is received."

"True ..." KM thought for a while, and added, "In fact, the function should be self-destruction after the receiver opens the email; copy and forward would not be allowed. That would really save a lot of hassles."

"Like the self-burning letter that Tom Cruise received in Mission Impossible ?" I could not stop smiling.

Negotiator

My recent bedtime reading is How to be a Better Negotiator by John Mattock and Jöns Ehrenborg.

I bought it during a trip to Taiwan some years ago, but I kept having some other books to attract my attention.

And I was entirely correct - the book was so-so. Well, after How to Win Friends and Influence People, you can't really expect anything better.

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I read the classic of Dale Carnegie when I was in secondary school. At that time, there was a rumor that the book was the third best-selling one in history - only after The Bible and Quotations from Chairman Mao (毛語錄).

That's a myth, of course. The third is Qur’ān.

By the way, the three best selling novel in history are A Tale of Two Cities by Charles Dickens, Lord of the Rings by JRR Tolkien, and And Then There Were None by Agatha Christie.

All English authors.

Proposer

To me, the most impressive bit of that appealing candidate was his proposer.

That is our noble council member.

In fact, I still remember quite well the two argued with each other when they were both running for the council seat a year ago.

But, as the old British sayings, there is no eternal enemy in politics.

And the reason is obvious ! Making friend with this representative of private doctors would help to establish another source of vote in the next election. You think their platforms are different ? (For example, I still remember our alumni is fighting for shorter working hour and more manpower in the public hospital.) It doesn't matter. After all, who would remember the platform of a candidate after the election ?

"Come on, that's politics !"

Quite true.

But that's also the rare occasion that I could distinguish an ingenious crook from a complete idiot.

Proposal

Appreciating the candidates' information of our recent council election.

The proposal of one of them was particularly impressive:

• The number of medical student intake should be reduced to ensure job security and training opportunity for all young graduates.
• To delete the legislation governing annual declaration of no conviction to obtain the annual practising certificate.

(There are several other points that are less controversial. I'm sure you're not interested.)

I would refrain from giving my opinion to these suggestions. For sure they are appealing to practising private doctors - less competition, and they could do whatever they want !

The eternal dilemma of being a member in council of this kind, however, is there is often a conflict of interest between the general public and the profession per se. Should they represent those who voted for him, or the society as a whole ?

Nomenclature

Following my discussion in the past two days, you may come to the conclusion that studying new diagnostic test or prognostic score is the most inferior type of medical research.

But no.

Many of the university academics do serious medical research to advance our knowledge and patient care. Just that the activity - alas, I mean publication - generated from serious research alone would not be sufficient to fulfill the appetite of whatever software that their faculty uses. To secure their own job (and the opportunity to continue with their own serious work), they need a steady source of publication.

The sobering truth is, even if we take aside this consideration, my answer remains no - there are things of even lower a class.

Imagine: If you are working on a disease that no new treatment exists, and there even lacks a new diagnostic test or prognostic scoring, what could you do ?

Let's give a new name to the disease.

Well, I'd better not to give specific examples to hurt your feeling.

PS. The usual circumstance that a new name is put up for an existing disease is during international summit or those so-called expert panel meetings. A conference report is published to announce the new name, and all experts get their names on a paper.

The homework is done.

Scoring

You may not agree with my discussion yesterday and argue, "There is at least one thing novel in this kind of research - the test per se. Be it imaging, blood marker, or genetic test, it'd got to be new."

Quite right.

And, therefore, running out of the supply of a novel test for their study, many ingenious researchers come up with the brilliant idea: Let's lump up a few conventional markers and call that a new scoring system - and we can do everything as if we have a new test !

The result is, like what my friend VW described, some investigators come up with a scoring system which is no different from a check list of points to pay attention to during history taking and physical examination.

Alas, there's nothing new under the sun. Go read Hampton JR, et al. BMJ 1975; 2: 486-489.