Diagnosis

After doing the round with Dr. Lai, the consultant whispered a few words to my master - who gave several assuring nods and said, "Yes ... I shall arrange."

I had no time to guess what my master arranged. We saw a few consultations together in the rest of the morning, then I took a short nap while my master had a quick lunch.

The afternoon clinic was exceptionally busy. There were quite a few respiratory patients, and I enjoyed going through each of their back and conveying all those funny breath sounds (or lack of sound) to my master - although I was not sure who I could help in their management.

While I was pondering to whom I could contribute, my friend in the other pocket of my master's white coat - the pager I mean - shouted.

Someone was calling.

My master took my dark-skin colleague and looked at the digital screen; the number was not a familiar one.

He picked up the phone.

"Yes ... I am. Oh ... how could that be ? Yes, yes ... I shall arrange at once ..." He seemed rather apologetic.

After he put back the phone, my master turned to a colleague at the other side of the room and said, "You know what. It's a call from the echocardiogram unit; that woman has atrial myxoma !"

Findings

I lied half-dead in the pocket when the rest of the day passed by, partly because of the call and partly for feeling too embarrassed for missing the murmur. Dr. Lai mumbled something like, "The pulse was probably too fast last night," "you can't expect too much from the night call," and so forth.

In no time there were several dozens of students and medical officers - all coming with an assistant of my species - arrived to see the woman. They were all too enthusiastic to discuss and compare the findings. "It is typical of mitral stenosis," the consultant of the other ward commented to a group of membership candidates.

My master tried to clean me up with some alcohol and tissue paper - I could see his feeling was none the worse.

But neither he nor I was easily defeated. After a good night of sleep, we did round on the same lady the next morning. Oh, yes ! This time there was a low pitch noise yelling at me when I stretched my body under her clothes - its was in fact quite loud.

Murmur

Next morning my master did the round early. There remained the morning clinic and a long day to go. He and I were just overjoyed when Dr. Lai came slightly earlier than he usually did. Dr. Lai was the consultant of my master. Maybe not too up-to-date with the literature, he was probably the ideal consultant that you expect to find: responsible but absolutely non-intruding.

I could see Dr. Lai was in a good mood. Without wasting much time the two doctors trespassed through the cases admitted last night. At last, they stopped by the end of the bed of the woman with atrial fibrillation and a stroke. My master described the story and, to his (and my) surprise, the consultant pick out his stethoscope.

This was, in fact, the first time that I saw this creature of my kind. “Cardiologist’s model with an expensive diaphragm,” I said to myself. No, I don’t want to make friend with him.

The noble did not pay any attention to me either. He quickly found his way under the clothes of the woman. “Got to be a waste of time. Nothing is there.” I said to myself.

But he seemed staying there for ages. Then, he appeared again and dived back to where he belonged to. Dr. Lai made a smile of Mona Lisa … or actually of crocodile ?

There was a minute of silence in uneasiness. Finally the consultant said, “There is a murmur …”

“What … ?” my master almost shouted; I fainted.

“There is a mid-diastolic rumbling murmur.” Dr. Lai was positive and just went for the jargon.

Stethoscope

I wasn't sleeping very well when my master picked me up from the table.
"Time to work ..." he grumbled, and put me in his white coat.
Yes, I am his stethoscope.
I knew my master when he was a third year medical student. It was, I dare say, not a romantic story at all. I came with a hundred of my brothers and was essentially picked up by random. My master was a typical student: hard working, well shaved, always properly dressed, but not very well off.
He graduated two years ago. We struggled through the year of houseman and he ended up as a physician trainee.

It wasn’t long before we saw another admission from the Emergency Department: a 60-year-old woman who came with her son. She was completely well until this evening, when she noticed some clumsiness of her right arm as well as slurring of speech. I had a close look when my master tested her. The weakness was there but rather mild. My master tried the reflexes with the tendon hammer from the ward, and scratch the feet of the patient with the key living in the pocket besides me.

Thank god, I do not have to live with this smelly piece of metal.

My master suddenly pick me out from the white coat. I stretched my exhausted neck and searched for the apex. The heart beat of this woman was very fast. Yes, it was irregular. I conveyed the message to my master.

“I imagine so …” he murmured. Oh, he had already looked at the ECG before waking me up. Fast atrial fibrillation of course. I felt myself useless. After all the work I did not help this woman in any way.

My master was not aware of my feeling. He squeezed me back to the white coat and furiously wrote down nursing orders and other management.

The night passed very quickly. We had several more admissions of GI bleeding, chronic lung and heart failure. I was keen to help but no, I didn’t think I scored in any of them. Why on earth should I attend all these cases ?

(... to be continued.)

Rules

(My friendly colleague made the following reply the next day.)

Dear Szeto,

Thanks for confirming my querries about the RCP approach. But why such rigid rules? Why isn't it enough to inspect by leaning over the bed or couch and turn the head to take in the mid-line perspective? Why sit down in a crowded ward (kneel down on the dirty floor is even worse) when you can raise the bed to maintain the same flow of movement from the shoulder down to the arm, the elbow, the forearm, the wrist, and the hand? ... I was once asked by a colleague and a surgeon of the Royal College of Surgeons of Edinburgh why the recommendation to palpate the abdomen sitting down (or kneeling down). It is not part of their recommendations... The fact is these "rules" are seldom adhered to in day to day practice: not a good way to inspire the next generation of doctors... Should we not encourage our students to learn to understand and not to memorize, to be imaginative and creative, and to be able to put information in the correct perspective?

Sincerely, et cetera.

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

Dear Professor X,

If you want the trivia, here are some:

• Carotid pulse character is better determined by thumb than other fingers because the former have good sensation without "sensory noise" from, say, index finger.
• We kneel down to examine abdomen because, contrary to what you say, we hardly have a bed in general ward that we can elevate.
• We inspect the abdomen from the end because we can compare the two sides without prejudice.

There are many rules that appear to be arbitrary but in fact crystallization of wisdom over centuries.

Sincerely,

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

Don't get me wrong. By no means I think he is wrong and I am right - in fact it is quite the opposite: Medicine could only be interesting because very often rigid rules of practice could not be applied in real life and we have to adjust and modify according to the actual situation and our understanding of the underlying principle. My humble opinion is, however, one could only be creative and flexible after accumulating substantial experience from prolonged practice.

You would not ask a first-day surgical house officer to perform a creative liver resection, would you ?

Alteration

You may find my grumble on dan-dan noodle a bit excessive. Well, the water becomes deeper when you realize the same problem happens in medical practice.

Let me show you some email communcations between two academic staff when we first changed to the new curriculum.

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

Dear all ...

Our students' predisposition to rote memorization of knowledge and skills may have arisen from a misunderstanding of good intentions. Apparently MO's ... have been telling our students that "the only correct way to inspect the abdomen is from the foot of the bed", that "you must palpate the abdomen sitting down at the patient's bedside", and etc... I certainly have not heard of them... If they are true, then basic principles are being ignored. The principle of the first is to inspect from a mid-line perspective and the second, to palpate with a smooth flow from the shoulder down, to the elbow, the wrist, and the palm. If these principles are met, then there are more than one way in positioning onself when performing the examination correctly, each with its own intrinsic advantages and disadvantages. What is required from our students is to perform a maneuver based on underlying principles and do it CONSCIENTIOUSLY, DILIGENTLY, AND INTELLIGENTLY. That is the spirit we should promote, not any set approach. Wether one should palpate the carotid artery with the thumb or the index and ring fingers depents on one's position in relation to the patient. There is no magic in using the thumb!

Yours sincerely, etc.

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

Dear Professor X,

I would clarify that the teaching for ... examination does specify sitting down (or kneeling down) to palpate the abdomen, inspect from the end of a bed, and palpate carotide artery by thumb. They are in fact well described in ... Candidates did fail ... because of not observing these rules.

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

Oh, you may immediately recognize the reply mail was by me. I shall show you more tomorrow.

Traditional

Don't take the change in the dressing of dan-dan noodle too lightly. There are in general two opposing opinions:

1. We should stick to the traditional or original preparation.
2. It doesn't matter - we just want something that taste good.

It is easy to see following the first suggestion would put an end to any possible advance and improvement. The young and energetic generation would therefore agree with the second. Nonetheless, if we follow the latter principle blindly and encounter a restaurant that serves a small bowel of thin al dente type of noodle in a clear soup, topped with shrimp won-ton, and calls it dan-dan noodle, you would be somewhat disappointed however good the thing is.

And life is the eternal difficulty of deciding which alteration means an improvement (in the case of dan-dan noodle, for example, the use of chopped peanut to replace sesame paste and minced port), while another small adjustment could not be accepted because it takes away the soul of the original version.

PS. Of course many great leaders are very much familiar with the creative use of language and would call won-ton noodle the real dan-dan, slavery the real freedom, dictatorship the real democracy, et cetera. That's another story.

擔擔

To most of us, Dan-dan noodle has a thick spicy soup with minced peanut as the dressing.

This is, however, a modified version. The original preparation in Sichuan has no peanut; instead it uses sesame paste, together with Sichuan pepper (花椒) and a good spoonful of minced pork. Yes, the dressing is a close relative of the Little Dan noodle (擔仔麵) you now find in Taiwan - except there is not a small shrimp on the top and the serve is much bigger.

If you think further, it is quite easy to understand the change (alas, evolution) of this Sichuan version once it came to Guangzhou: the numbing effect of the Sichuan pepper does not suite the palate of most of us, and what else could be better than peanut to replace both the flavour and crunchy texture of sesame, as well as the oily richness of minced port ?

PS. Experienced gourmet would immediately note that the Little Dan noodle nowadays has its own tract of evolution from late 19th century - around the same time when Dan-dan noodle first appeared in Sichuan. Their resemblance probably represents a lively example of convergent evolution in the history of cookery.

Noodle

Vivian was on call last Saturday and I had to lunch alone. I decided to take the first bus that I saw outside the hospital, and in no time I found myself in a Sichuan restaurant at WTS.

Of course I ordered dan-dan noodle (擔擔麵).

Like many of the traditional Chinese dishes, each restaurant seems to prepare the noodle in a very much different way. The one served here may not be absolutely traditional, but is definitely original - it has a character of its own.

The restaurant was somewhat dingy and meant for the grass root class, and I had to share the table with two friendly ladies - one of them was no doubt an experienced gourmet. One dish that they ordered was yellow peas cake (碗豆黃). When asked by her friend what she thought of the cake, my new table-mate gave a remarkable answer:

"It is not (the traditional) yellow peas cake at all; but if you forget about the name and just take it as a kind of dessert, it is gorgeous."

As Shakespeare said (in Romeo and Juliet): What's in a name ? That which we call a rose. By any other name would smell as sweet.

Author

Receive a mass email from my previous boss; he is advertising his two new books.

I shall leave aside my puzzle on to whom the books would benefit, a concern that I discussed several times in this blog. The pyschological fact is: Writing a book of mine is one of the most common dreams that people have, and highly intelligent or successful people are not spared.

Alas, the dream is now more easy than ever to fulfill. A number of word processing software are free, and it is not that difficult to find a publisher to put your work in press - provided that you could afford a small sum of money. (Well, I have some experience with the last point after I becoming a journal editor some years ago.)

And Vivian always reminds me that you could always publish on-line.

The real problem is, of course, the more easy to get a book published, the less serious the authors are. For some gourmet readers, it is indeed quite a torture to visit large book stores and try to discern which few are worth thumbing through.

PS. I won't be too critical. Many of you may know I write a small electronic book on my own specialty.

解說

The question was: The shortest way to walk from place A to B is to go south for two miles, and then to the north for two miles. How far do you have to walk from place A to B by going east ?

It should be 6.28 miles.

Please see the following figure:

















Note that the first sentence of the question could only be true if S at the mid-point of a straight line joining A and B, and the definition of "east" is a circle that centers around the South (or North) pole. In fact, after walking for two miles and arrive at the South pole, any direction that you go further would be to the north. Nonetheless, the shortest way to go from A to B is by passing through S, A-S-B is therefore a straight line (in other words, theta equals 180-degree).

Selection

On thinking twice, human beings - not only financial tyrants but more so medical scientists - must be schizophrenic when they pay tribute to Charles Darwin.

You know what, there were no CEOs of dinosaur species to fight for a change in climate policy so that reptiles who were ill-fit to the new environment would give way to others with a suitable design. Similarly, there was no Dinosaur Right Group to struggle for an equal opportunity of reproduction for some small group of reptiles that were born with blood cells that had a funny shape, sputum that kept obstructing their lung, or enough cholesterol to block up their heart before they could lay any egg.

Oh, in Homo sapiens, we call them sickle cell disease, cystic fibrosis, and familial hypercholesterolemia (or any other form of premature coronary disease).

And there are countless number of other examples.

Yes, we are working against natural selection and try to preserve bad genes.

Maybe eliminating good ones, too (just take a look on the variation in birth rate between different countries).

PS. Don't be mistaken. By no means I am against what we are doing - at most I'm somewhat puzzled. By the time Adam ate the apple of intelligence and opened his eyes, we were walking away from god and left Eden forever.

Catastrophe

With the recent financial tsunami, you may say free market is not perfect. How could god allow this kind of thing happen ?

But yes. In the free market of evolution, god does allow catastrophe.

The one best known to us is the collapse of dinosaur.

You know what, from the Triassic period to the early Cretaceous period, the world enjoyed a warm weather for some millions of years. Rainfall was high and ferns (the major type of plant at that time) grew at great speed.

In such an environment, a huge body size is of course advantageous (to fight for food or mate). That's why those ancient reptiles got bigger and bigger ... until some bad day came.

(The problem was not only food. Although the climate remained warm, these cool-blood animals couldn't warm up their body and get going when the sunshine was short, which was the critical component of the hypothesis of Deccan Traps as well as the Chicxulub crater.)

It was, alas, probably the biggest bubble in the history of evolution.

Now you see, it was a catastrophe for the dinosaur, but we should be all too thankful because there were no CEOs of their various species who went to the White House of the heaven and asked for assistance or a change in weather policy. Otherwise there would only be those gigantic reptiles gasping on earth now, and Homo sapiens would have never appeared.

PS. Once I think of this, it seems sad to admit that this year is ill-timed to celebrate the bicentennial birthday of the giant on natural selection.

Design

As soon as I come to appreciate how fish fins turn into feet, the difference between the genuine god and human pretending god becomes immediately obvious.

Alas, the latter would plan for the fish and try to design the optimal femur and tarsal structures good enough for weight bearing, attach to them with flesh strong enough for the being able to move around, and prepare a piece of dessication-proof cover called skin. A few of the designers may call a meeting before coming to the conclusion that their product should have a name leg. (We shall leave aside the question how often this carefully designed structure could function properly - that's a topic on business administration.)

To the true god, he just provides an environment that you need to walk - the organism would figure out the rest.

In that sense, god is the first supporter of a free market.

PS. Don't laugh. People before Darwin's time did seriously believe that the former pathway with careful planning - by the god that they believed in, of course - was the actual mechanism that drives evolution. As the old Chinese saying: 以己之心度人(神?).

Dry

Why did some freshwater fishes decide to move on to the shore but marine ones didn't ?

If you think of it, the answer is simple: Ocean is such a big and nice place that its inhabitants never needed to consider any drastic move. If a part of the sea becomes not suitable for their subsistence, the fishes could always swim to somewhere else.

But, the environment of freshwater is different. Many lakes dry up intermittently - leaving just an area of swamp; rivers often run a slightly different path every few years and the level depends very much on the rain fall (or snow fall). Vertebrates swimming in this kind of environment are forced to get up on (alas, develop) their own feet.

PS. Of course many fishes could not adapt to the change and died of dessication. It was fortunate that our pantheistic god is not some modern hospital administrators - otherwise these terrestrial beginners would be confined to the water forever because their apparatus (alas, fins) would always be considered not suitable for walking.

Water

My discussion yesterday may seem entirely reasonable and logical, but there is one major loophole in the assumption - and the actual fact as well.

The very point is: terrestrial vertebrates did not come from marine animals, but freshwater ones.

Of course freshwater fishes originated from the sea. Nonetheless, by settling in an environment free of sodium chloride, the animal is adapted to an entirely opposite logic to handle minerals - to conserve ions, and get away with the water.

(Honoured to be a nephrologist, the latter adaptation results in the development of glomerulus - the very structure that filters a huge volume of blood and excrete it as some dilute solution. Seawater fishes, on the other hand, have no glomerulus; metabolic waste is actively secreted by kidney tubules - an ability that most terrestrial animals still preserve.)

The real problem, therefore, becomes: why should freshwater fishes - rather than marine ones, which obviously out-numbered the former - get to the shore and start walking ?

Sea

One niggling problem on evolution that troubled me for some years is: Why couldn't we - most of the terrestrial vertebrates, I mean - drink seawater ?

On the face of it, the ability is obviously advantageous: the supply of freshwater is very much limited as compared to some sodium chloride solution.

But we could not.

The simple answer is, although there is a surplus of sea water on earth, most of the in-land source, i.e. river and lake, is freshwater. To explore the land, terrestrial animals must be able to drink pure water.

But that's beyond the point ! If animals on land originated from marine ones, they should be able to drink seawater to start with. They may gradually learn how to tolerate lakes and rivers when the species explore the land, but what we are seeing is their selective loss of an ability that they used to have - and a very valuable one in terms of competition.

Prediction

One remarkable story about Charles Darwin I learn elsewhere recently is his prediction of the existence of some gigantic moth:

"In madagascar there must be moths with the proboscis capable of extension to a length of between ten and eleven inches ... The pollinia would not be withdrawn until some huge moth, with a wonderfully long proboscis, tried to drain the last drop."

Yes, that's a wonderful theory and logical prediction. Nonetheless, when the author of On the Origin of Species died in 1882 (still believing in the existence of this extraordinary moth), no trace of it had never been found ...

... not until forty years after its original prediction.

It was officially named Xanthophan morgani praedicta - in honor of the prediction by the man we shared the legacy today.

PS. The masterpiece of Charles Darwin took (10 months to write but) 26 years of data collection; his prediction took 40 years to be proved. Both are impossible happenings nowadays - even if he were awarded of some research grant, what could he put up in the progress report every year ?

Darwin

Read the yearly supplement of The Lancet during the weekend. The subtitle of this year is Darwin's Gift - it is a collection of papers celebrating the bicentennial birth on the giant in evolution.

(The supplement is, somewhat surprisingly, the most enjoyable one in the past five or six years.)

It is often stated that the author of On the Origin of Species was the pioneer of the theory of evolution. That's not entirely correct - the hypothesis of evolution had been around for half a century before his time. His real breakthrough was the proposal of natural selection as the cause of evolution. The theory always reminds me a saying of Arthur Schopenhauer:

All truth passes through three stages:

• First, it is ridiculed.
• Second, it is violently opposed.
• Third, it is accepted as being self-evident.
  

PS. In his blog, my friend VW is beginning a series on evolution. Interested readers may like to have a look. The address is: http://vwswong.blogspot.com/

Quiz

It is the Chinese Valentine's day today. I shall put up a quiz for you to ponder:

The shortest way to walk from place A to B is to go south for two miles, and then to the north for two miles. How far do you have to walk from place A to B by going east ?

I may well provide a Chinese translation: 從A地到B地最短的方式是先南向行兩英里，然後向北行兩英里。問:從A地到B地，往東行有多遠?

PS. Don't be paranoid. This is a question on mathematics, not some leg-pulling IQ test.

Poison

Having a lovely book The Science of Sherlock Holmes, a gift from KM, as my bedtime reading.

In essence, it is a book on the history of forensic medicine, and covers various aspects of the discipline - poison, firearm, footstep tracing, blood stain identification, and what not - with frequent reference to the sayings and doings of our great detective. To an admirer of the Victorian London, it is simply an eye-opening experience.

A small point that I noted while thumbing through this enjoyable volume was the easy availability of poison a hundred years ago. In fact, senior medical students were allowed to prescribe and it seemed a custom to ask these later-to-be-physicians to treat simple conditions.

Of course, the down side was it also provided an excellent means to do away with any difficult wife or mother-in-law.

But, to our friends outside the solar system: Yes, students did make treatment orders, not to say house officers.

As Publius Vergilius Maro said: Possunt, quia posse videntur.

Temporary

After reading my blog yesterday, don't be mistaken: I never think we should focus on or increase the amount of "science" covered in the medical curriculum.

Yes, our students' plate is quite full already.

But more than that. The real problem is: After (theoretically) well nourished with the science and theory of medicine for five years, what do we ask our graduates to do ?

In the past few years, we have done away with much blood taking by house officers. For legal reasons, they are not allowed to admit patients by their own (without the patient being seen by the medical officer within a finite period of time). Many of the procedures are taken up by more experienced doctors.

In one recent meeting outside the solar system, it was further decided that our house officers would no longer be allowed to enter the code of diagnosis into the hospital computer system - because they are "temporary staff" and may not be able to appreciate a case properly.

Then, what's left for the new comers ? Filling in forms for bureaucratic purposes, ordering test label in the computer, copying drug prescription sheet ...

Come on, let's have a clerk.

PS. Talking about temporary staff, many of our senile colleagues would recollect our previous professor of cardiology began his position in the university as a visiting scholar. In a casual meeting some time later, he was asked about his title in the department. His answer was seminal:

We are all visitors.

Humanistic

I am impressed to learn that our sister faculty over the other side of the harbour decides to put up some 20% of their teaching time for ethics and humanistic matters.

Well, let's leave aside the discussion on whether knowledge or ethics is more important for a good doctor. One major concern is: Does ethics teaching of this kind really improve the humanistic quality of the graduates ?

But, even that is not the most important problem. Let's face it: Most of our medical students are enthusiastic and know just too well what should the heart of a good doctor be. It is the years of examinations and calls and numerous torture (or temptation) in the world of real life that rusts their brains and sores their hearts. It doesn't help by increasing humanistic teaching at the undergraduate level.

Alas, realizing this, those die-hard fans of poultry education would no doubt advocate some kind of program to improve the ethical standard of practising doctors.

Shall we call it Continuous Ethics Education (CEE) ?

Does it mean going to the church every week, or to the Wong Tai Sin temple (or Che Kung temple) yearly ?

What a horror !

PS. The whole thing is not new, because our man from Pluto did have a suggestion of similar kind not long ago. Interested readers may like to go through my blog on 13 September 2008 and thereafter.

Ability

Do you notice I deliberately omitted yesterday the possibility that most of our students are rich ? (I mean they come from affluent families.)

That may well be true.

Unfortunately, that's the even more worrying bit.

Let's consider: Who could get into a medical school ?

Creme de la creme, we hope.

In other words, if capability and intelligence are evenly distributed in a society, we should expect an equal proportion of our students coming from every social class.

But we do not.

Which means:

1. There is a substantial inequally in the chance of having reasonable education between children from different social classes (so that school children from poor families are less likely to obtain a good enough grade in public examination and get entrance to a medical school); or
2. children from rich families are preferentially selected, hopefully via formal rather than some backdoor procedures.

I shouldn't say any more.

Dominate

I might have a flight of idea yesterday and did not make it clear what the worrying bit is.

No, it is not (only) a daddy's kind of concern about overspending children.

Let's come and think of it: Why do our students appear so well off and choose a grandiose place for the graduation dinner ? (I presume it is plain obvious that they do understand they don't need an expensive meal to impress their teachers, as I discussed yesterday.)

There are only two possibilities. Either most of our students are really having a surplus supply of money, or there is a selection bias. The latter is pretty easy to imagine: money is an excellent loudspeaker and, in a group of people from all walks of life, the opinion of the rich often dominates.

But if we see it in an university classroom, that's worrying.

PS. Ironically, poverty is the best loudspeaker in our society. That's another story.

Expensive

You may ask, "What if our students could afford a grandiose place ?"

Quite true. Looking at their clothes and accessories and places they dine, many of our students seem to be very well off.

I tell you: That's the real worrying bit.

***********************
Another usual argument that people put up for choosing an extravagant restaurant for the graduation dinner is that's how our students could best express their gratitude.

Come on, don't be silly. By our age and profession, we've been through many exquisite meals. We are impressed by the character of people, not their makeup.

And, if a teacher needs an expensive restaurant to be satisfied, he does not worth any praise.

Concept

You may argue I am just outdated and the event is never supposed to be a Thank You Dinner (謝師宴) - after all, who wants to thank you ?

In that case soliciting sponsorship from us, the possibly well-to-do seniors (many of us, unfortunately, are not), seems entirely justified. As I mentioned, we have a custom to support events of this kind by the nurses, secretaries, and patients.

But no. Nurses and secretaries work for us. More often than not we just cannot find enough opportunity to thank for their contribution and effort to ease us from numerous troubles.

How about patients ? To an university teaching staff, medical students are no different from patients to the doctors - we are supposed to care and support and encourage their independence. Yes, I donate, most happily, every year to the dinner hosted by the patient support group. However, our patients, and also nurses and secretaries, come mostly from the middle and lower class. They are content and always hold their dinner in local restaurants.

And I would be equally uneasy to write a cheque if they book a table at the Gaddi's or the Petrus.

As JW always says, even if you are a rich dad, you need to cultivate the correct concept of money for your children, rather than allowing them to overspend even before they could earn any.

Otherwise your children would become Americans.

Donation

Receive a thank you letter from the organizing committee of the graduation dinner this year - for my donation to it.

It was in fact a small sum of money and to me it is no different from contributing to the gatherings and parties of our nurses, secretaries, or patient-support groups. Nonetheless there is a sense of uneasiness after I gave out the cheque. (Seriously I had the same feeling for some years - but every time I thought it seemed impolite to spoil the enthusiasm of our students.)

I have that uncomfortable feeling because the dinner is, I suppose, not meant to be a gathering of our graduates - for fun, saying sayonara to fellow classmates, or simply a feast - but to express their gratitude to teachers (if there is any; alas, that's why I never attend).

My goodness, we are not autistic office girls who, without a boyfriend, have to buy rose for ourselves and show off.

PS. By and large this blog is much belayed. I wished to write something about it when I first met the students, but my attention was soon attracted to other matters.