Transparent

I was about to write something on the series of so-called medical incidents recently, but I was so much distracted by Euterpe's sickness that I paid very little attention to what's going on.

But the evening news on TV yesterday really touched on my threshold: Why should a mistake in drug dispensary, without actual harm to the patient, deserve more description than what was going on, during the very same day, in the legislative council (which was one of the most colourful days in the history of the council, in terms of language, I mean), or the arrangement of Renminbi international clearing between Hong Kong and Shanghai, or the Indonesia dam burst ?

On the first glance, you may think that's because medical incidents are more spicy and have better attraction to the palate of the general public.

But that's not true. To say the least, many of us would be more interested to hear the original sound track of the vivid conversation between our noble council members.

And it suddenly becomes clear to me that even minor medical incidents appear on the media because we have a dedicated team for risk management.

"Everything must be transparent and we need to make it known to the public," so was it said.

In other words, under their management, risk becomes crisis.

It is really the suitable thing to talk about on the April Fool's Day.

PS. By no means I say medication error should be taken lightly. But, you won't publicize your mistake (at least not before you have well planned ahead for the solution), will you ?

Margin

Once I thought of Rubenstein and Wayne's Lecture Notes on Clinical Medicine, I could not agree more with the wisdom of its original authors - and, unfortunately, the change in the layout of this handy volume mirrors the evolution of medical practice and education over the years.

You know what, the first edition of the Notes was merely 200 pages, with text printed in a single column, and there was plenty of empty space along the side of the printed text.

"... the margins of the pages are intentionally large so that the reader may easily add additional material of his own." So was it written in the preface of its first edition, back in 1975.

Alas, where do we end up now ? Some 400 pages, with text printed in two columns, leaving little space at the margin, and, ironically, the field seems quite less well covered than we had decades ago.

And, the same happens with our curriculum and practice. There's no time for student to ponder and digest, or for busy physicians to talk to their patients.

As TS Eliot says:

• What is the wisdom we have lost in knowledge ?
• What is the knowledge we have lost in information ?

PS. Old bookworms like myself used to believe in a rumor: the material in the Notes was so condensed that every space, comma, or full-stop has a hidden meaning. That is, of course, an over-statement. But it gives us hope, and I am still convinced that the whole of the wisdom for medical practice could be summarized in that tiny space.

Manual

I was having the Penguin Writer's Manual as my bedtime reading recently.

No, it could hardly be called interesting. I bought it some months ago in a sale, and, as a habit, I tried not to have a book bought but left untouched.

Nonetheless, I do learn some small things here and there. The content of this 320-page volume is no doubt an expanded version of the gold standard text in the field of English writing: The Elements of Style by Strunk and White. In fact, it seems unbelievable that the original scribble of William Strunk was merely 43 pages - and it summarized the usage of written English better than any of its long-winded successors (alas, including the latest edition of this very book).

And it reminds me of the first edition of Rubenstein and Wayne's Lecture Notes on Clinical Medicine.

PS. For some years, The Elements was a compulsory text for first year university students (of all faculties) over the other side of the Victoria harbour. Whoever decided to take it away from the curriculum should inherit the position of Prometheus - I mean the position on that rock of Caucasus.

Attitude

During the department board meeting today, there was a hot discussion on how the students should assess our teaching performance, and if there is any need for us "revenge" and assess their attitude.

The problem is: Do we know what is the desirable attitude of a student ?

Friends, don't jump to the conclusion. Let's consider: Do we want a student who is active in asking questions, or one who is quiet and prefer staying aside to observe (and try to find the answer for every of their question by looking up textbook on their own) ?

"Either would be good," you would say.

Then, how could you tell them from students who are merely too lazy to read up the book themselves, or who have severe withdrawal symptoms due to chronic schizophrenia (or, more commonly, autistic personality disorder), respectively ?

"Oh, we are experienced teachers and can tell by looking through their eyes," you may protest.

Well, I also believe I am an expert in mind-reading, but I would never consider that as a subject of genuine science, or rely on it to guide my judgement. (Alas, you would therefore find me in the chronic schizophrenic subgroup when I was a student.)

PS. I don't think we should add credit to the student's attitude assessment if they are active in answering questions; they would be properly awarded in the final examination - if their answer is correct.

Dentist

Visited my dentist last week. There's some long standing problem with one of my molars and, after some hesitancy, I squeeze up my courage and have it fixed (alas, removed in reality).

I saw this dentist since I graduated. He is no big name but just a humble one working near to where I used to live. To him, I must be one of the most disobedient patient - appointments of regular check and cleansing were always defaulted, and I only turn up when there's something urgent. Being a physician myself, I must admit my poor adherence to his advise no doubt contribute to my weak rusty yellow teeth. (My mother apparently took quite some tetracycline while she was pregnant. That paved the path to my characteristic colour.)

You may wonder the university does provide dental service for academic staff, why on earth did I have to visit a private one ? Nonetheless, teeth are no less private a body part than anywhere else, and it is comforting to see someone whom you trust.

Conscience

On two separate recent occasions, I heard some senior officials made a curious comment, "It really depends on your conscience."

(Many of our colleague would recognize one incident being our recent briefing session on the new computer system, and the other was the events related to our pharmaceutical industry.)

As Philo Vance said (in the Benson Murder Case), "I could understand why the general public have such a feeling. But, when senior and professional people feel the same, it is really horrible."

Let's say, what would happen if we take off every legal requirement from the society ?

You could imagine that much: the majority of us would still be good humble citizens (at least initially). The problem is that a minority would stir up the water and do whatever they want. More so, seeing the consequence (or lack of consequence) of those malicious neighbours, the good humble ones would follow suite.

That's what we called the Broken Window Theory in sociology.

PS. Ironically, those senior officials who asked for the conscience of the others would not say to their boss, "I shall not fix up my salary; it really depends on your conscience."

A truly conscientious (oh, or merely conscious) employer would give them a bill.

Science

Although it is a good idea from the research point of view to merge our anatomists and physiologists and other related people to form one department, I am not all at ease with the idea.

The very question is: Who is going to teach our students basic anatomy and physiology ?

"By those who come from the responsible department," you may say.

But staff may change with time. How could new academic staff of this establishment of molecular science agree to teach a subject that they know absolutely nothing ?

Of course you would recognize the loophole of my argument: things are no better at this moment.

No, things could be worse. If there remains a department called anatomy or physiology, their teaching would be evaluated, and teachers would have the incentive to try doing a better job. We lose this last line of defence once we combine everything.

But you are completely right. I still find it difficult to understand why it is impossible to ask surgeons to teach all the anatomy and physicians physiology. That's another story.

Big

One major news that our man from Pluto told us during the research retreat was the establishment of the Department of Basic Medical Science.

(I'm not sure how new it is - we heard of it for quite some years.)

From a research point of view, it seems a good move. After all, hardly any anatomist or physiologist nowadays do conventional research in their own discipline. Modern medical journals would never accept a paper that describe any change that could be observed by bare eye - they prefer molecules and markers and p-values that are invisible with the best microscope.

Alas, as Hercule Poirot remarked in Murder on the Links, evidence of 1-foot long could be as important as another of 1-inch in length. Unfortunately, most of the extra-terrestrials are too much taken in by the magnifying glass of Sherlock Holmes; they see small things but deliberately neglect big ones.

My limited knowledge in neurology tells me that the sign is called simultanagnosia (see small objects but not big ones due to failure of integrating information from peripheral visual field), and the disease Balint’s syndrome. Oh, you could learn that much by reading Harrison - another huge object that most of us try to neglect.

Retreat

Had the department research day last Saturday.

Those who are around for some years would remember the event has secretly changed its name from research retreat to research day - no longer do we go to some exotic place for a "relaxing" Sunday, but merely stay in house for a sordid afternoon.

But, I'm not surprised. People just lose their interest in attending a talk unrelated to their own specialty. Say, why should a nephrologist be interested in what a geriatrician's work on dementia?

And that's a global trend. When the Nature divided itself into Nature Medicine and a dozen of other journals, medical scientists are no longer interested in the nature - but only their problem at hand (for example, the next round of audit on their number of publication).

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

PS. Maybe I should have another pair of glass to look for things slightly more far ahead.

Donor

Many of our students (and probably colleagues) are completely taken aback when they learn of the proposal by certain Feng Shui specialist, who suggested to donate HK$10-billion to our medical school - with the condition that we change our name to XXX School of Medicine.

That's rather horrific, I agree.

But, on a second thought, that may not be an entirely bad idea; it depends on how you use the money.

I would suggest the following:

• Retain $6-billion for internal use.
• Give $2-billion to our sister medical school so that they could return to the one who donated $1-billion to them in 2005. (Let him have a generous interest; he is a businessman after all.)
• Donate another $2-billion to that sister medical school so that they could be renamed to "XXX School of Medicine - Hong Kong Island Branch". (You could sue them for sexual discrimination if they do not accept: they accepted a worse term four years ago from a man.)

For those obsessive with business terms, this is acquisition, not merge.

Opinion

While I just finished with my grumble, I met VW in the computer room and he asked, "So, what's actually your opinion on how the new generation doctors choose their subject and specialty ?"

"Oh, I have decided that I do not need to have any opinion." I tried to be evasive. My opinion is what I often call a level zero one.

Alas, that's the most fundamental question that we often forget when we try to understand or have an opinion on something: Do we need to understand or have an opinion ?

For those who are not familiar with the field, the whole system roots from the classic Black Cylinder Experiment of Edward de Bono, which is described in his book Practical Thinking (the most important book of de Bono in my view, but unfortunately also the least popular one).

And, as soon as you realize there are many things that we do not have to understand or have an opinion, we could lead a much more simple life - and could spare our energy to the few things that are really important.

PS. Of course I have my opinion on the question that VW asked me, but I have a habit of expressing serious opinions between the lines and in some empty space that I leave behind. Please bear with me.

Effort

Now, you see, the inevitable conclusion of our discussion is: It depends on what subject you have the so-called interest, or, in other words, you are prepared to infuse your sweat and enthusiasm.

But, once we talk about putting up painstaking effort in doing something, there are in theory three kinds of people:

1. Some are born to be hardworking (if not obsessive) - they would be successful whatever they choose.
2. Some have enthusiasm concentrated in the Broca's area, hypertrophy in the pain fibers, degeneration of the motor cortex, and intermittent flights of idea; I shall not elaborate on their future.
3. Some are obsessive and hardworking in one particular area but not others; they would do well only when choosing a job they are interested in.

That sounds simple, right ? The leg-pulling bit is: very few people are truly category #3.

This is because hardworking and obsessiveness represent one human character on their own - independent on the area of personal interest, and most of us fall somewhere between the continuum of category #1 and #2.

The problematic observation is, however, hardworking and successful people often tell their followers that they are interested in the subject that they work on - without realizing the fact that they would be equally successful (and have the same degree of interest) if they chose an entirely different thing from the beginning. Just consider my friends: KM could be an equally eminent neurologist, JW a surgeon, or VW a musician, if they made slightly different decisions years ago.

(Alas, for the third scenario, you may consider that a great loss to our liver patients - but that would not be a loss to VW himself.)

PS. The last part of this series is not my invention. I derive it from the classic text of Daniel Goleman - Emotional Intelligence.

Achievement

The obvious conclusion from our discussion yesterday is: We choose a subject that we have interest because we are more likely to be successful in that area.

On this, we must first distinguish interest from talent. Mozart had so much talent in music that it would be a loss to mankind if he did not make use of it, and I doubt very much if he could even be a third-class surgeon if he chose medicine. Did Mozart have interest in playing piano ? To say the least, not more than his enthusiasm in making money, playing billiards, or mixing up with women.

But, if not because of talent (at least not the case for most of us), why are we more likely to be successful in something that we have interest ?

Because we are more willing to infuse our time to explore such an area. Let's face it: Nearly all of the subjects and specialties are meant for ordinary human beings, and, as Adam Smith put it, we could all achieve a reasonable degree of dexterity after suitable training and sufficient practice. The situation is somewhat like trying to run up-slope in a down-going electric stairway. To begin with, there is a period that you seem to make no progress. However, once you pass the threshold and reach the upper level, you could stay and rest comfortably.

And, once you reach that level, you begin to enjoy seeing liver cancer successfully removed, or acute pulmonary edema promptly resolved. There is then a positive feedback, and you would be eager to spare more time for your profession and go for another level.

As Thomas Edison said, (most of the so-called) genius is one percent inspiration, ninety-nine percent perspiration.

Interest

You may ask, "How about if I really have an interest in that particular subject?"

Good. Let me take you through a slightly circumventing argument:

Why should people choose a subject that they have interest ? Simple. They would enjoy the process, and there is a greater likelihood that they would be successful.

The former argument is nothing more or less than a blind. Most of our happiness does not come from the job per se, but from our family, friends, and hobbies. (If you happen to need a particular job purely for pleasure, you'd better see a psychiatrist.) Yes, we often have much satisfaction from the work, but that's almost always because of our achievement in it. For example, hardly any one would have pleasure from standing in the operating theatre for several hours (as I said, go see a psychiatrist); most surgeons would feel happy because, after all their hardship, the cancer patient is cured and walk out of the hospital.

As Hercule Poirot said (in Murder on the Links): If you do not see the difference between the two, you could not see anything.

PS. The reverse of this argument, however, is generally correct: Many of us would have a few subjects that we definitely feel sick with the process, and it goes without saying that we should avoid doing that job - however good the prospect is.

That's why I could never be an administrator.

Choice

The topic that brought up the roar in the meeting was an old one: Some specialities are piled up with trainees while the others hardly have any.

Don't be mistaken. Most of us agree to respect the free choice of candidates, but we have to face and tackle the resulting skew in the workload. Of course I am always puzzled why graduates and trainees often rush to the same specialty or sub-specialty at a time. Nonetheless, most people also buy the same stock at around the same time - if not, how could there be any bubble ?

For the new generation doctors, however, the eternal question remains: What criteria should we based on when choosing a specialty ?

"Follow your heart (or interest)." Most of us would say, while pretending to be neutral.

But no. At least that's not the only important thing to consider. Otherwise many would choose to do nothing but eat, drink, and be happy. I have even more objection if the so-called interest is not actually in the particular subject, but for the naive reason that there is a great prospect of promotion (who could tell what the world would be three or five years later ?), or that many of your peers pick the same thing - so that you would not feel lonely.

For that very last reason, just think of the old Chinese saying: 相見好，同住難。

Predictors

After more than an hour of colourful discussion, what was the conclusion of the meeting ?

Of course there was none - I expected that much before I could find my chair in the conference room.

For those who are not familiar with this kind of business, there are a few predictors for a hopeless meeting:

1. The meeting involves more than 10 people. (Think of our Executive Council.)
2. The meeting is regular and more frequent than once every year.
3. There is no agenda.
4. The minutes of the previous meeting is used as the agenda of the next one. (Alas, they keep talking on the same things without making any progress!)
5. The first item on the agenda, i.e. confirmation of the minutes last time, needs to be seriously discussed. (If they could not even agree on what have been said, how could you expect they agree on anything else ?)
   
6. The secretary could not prepare a draft minutes before the meeting. (I claim no credit on this point; Humphrey Appleby taught me that much.)
   

PS. You may wonder why an autistic academic like myself needs to attend meetings of gangsters. The story began in 2003, when that famous ward of our hospital was closed down for SARS. A few weeks later, our man from Pluto decided to open the ward again, and he had to find (whom he believed to be) the least superstitious physician to take charge of the running of the ward. Naturally this selected one had to sit in all those administrative meetings.

And why did I accept taking up that ward ? In such a period full of unknown danger, I could just follow what Gu Long (古龍) advised: 最危險的地方是最安全的。

Expression

A few of our honorable legislative council members had a seizure attack while the financial secretary was going through the annual financial planning. (They have their point: Although you need to exercise more muscle fibers to move your arm, the number of neuron involved is paradoxically fewer; to most people with an average intelligence, the action is also easier to comprehend.)

No, I shall not comment on their sickness; I am actually more uneasy when seeing (supposedly) well educated medical professions doing a similar kind of thing - and unfortunately I have to see it quite often ever since I was asked to sit in some regular administrative meeting a few years back.

One vivid example is the meeting I attended just now, when two HA consultants and one professor had an hour of absolutely colourful discussion on a personnel matter. I have almost mistaken myself as sitting in the cinema and watching Election of Johnnie To (杜琪峰). (Well, to be fair, the three parties did try to exercise excellent logic and were aware of one simple fact: the enemy of my enemy is not necessarily my friend.) To give you an idea on how hot the environment was, our secretary tried to tape-record the whole discussion for her preparation of the minutes, but she could retrieve nothing from the tape afterwards.

I'm sure the tape was burnt - we could not see the fire because the recorder was simultaneously drowned by the saliva.

PS. Could anyone teach them how to play the board game Diplomacy ?

Disney

Vivian and I brought Euterpe to visit the Hong Kong Disney on her birthday.

Contrary to her usual self, my wife had an exceptionally careful planning of the trip, and it turned out very enjoyable to all of us. Euterpe is a big fan of Goofy and Pluto (not our chairman, don't be silly), and her face just brightened up when she saw her idols in flesh and blood - not to say to have a chance and take some photos with them.

True, the place is rather small when compared to the other local theme park, but it is enough for spending a few hours.

And, looking at the souvenir shops, I begin to realize why many people think Walt Disney is such a good investment.

PS. In the evening, we had a small family gathering in a traditional Canton restaurant at Tai Wai. The menu was a self selected one: 椒鹽蝦, 炸乳鴿, 鶏腳螺頭湯, 香酥鴨, 枝竹炆杉班, 蝦醬蒸五花腩, 煎釀豆腐, 海鮮雜菜煲; (complimentary) 木瓜果盤. No, there was no abalone or shark fin. But we were all exceedingly happy with the tasty food as well as the good time together.

Who says that we need at least HK$400 per head for an acceptable Chinese menu, or an exquisite hotel ballroom for celebration ?

Present

It was Euterpe's birthday yesterday. Following the advise of Warren, the present I bought for my daughter this year was one-lot of Construction Bank of China.

Don't be silly. It is not the kind of education fund that I save for my daughter. I always consider that kind of financial planning an excessive micro-management. Why on earth do we set up one fund for children's education, another for our medical need, yet another for retirement ... Shouldn't we just put all savings together and get some benefit of the scale ?

But I do buy Euterpe some stocks - not for the money per se, but for setting her an example of serious investment and planning for the future. It is a brutal fact, but a fact nonetheless, that we should mind our expenditure and prepare for bad days.

And having some stock of your own is an excellent way to raise your interest in what's happening on earth. (I mean the financial tsunami or local employment status, rather than why that pop-idol took some explicit pictures.) Although human beings are political animals, human activities are largely economic activities.

PS. You may wonder why I choose #939 amongst all other companies with an equally good quality. It's just a random pick - the names sounds suitable for a birthday present.

Brand

Once I think of CIC, I come to realize that China remains the hope of the world economy.

(Yes, I'm a bit thick, if not only stubborn.)

The usual suggestion on how our country could get out of the financial tsunami is to boost up the internal demand - so that the living standard of Chinese people could continue to improve, and our economy could be less dependent on export. (Unfortunately, the same suggestion on internal demand is often put up for Hong Kong - without recognizing the difference in the scale of economy. Alas, parrots are everywhere.)

On the first glance, it seems very plausible. Take the States as an example: it could produce almost everything for her people; if the daily need of everyone increases, the whole of her economy would prosper. Although the Chinese land may be less fertile, it seems sufficient to feed 1200-million population. Moreover, a substantial proportion of Chinese people have much in their living standard to be improved. If the original plan of Deng Xiaoping (鄧小平) does work out, the affluent people in coastal cities would create demand, and therefore employment opportunities, for the in-land residents - so that the latter could improve their own living.

That sounds great - the only flaw in this link is those rich Chinese people do not impose a higher need of their local products. Be it milk, food, cosmetics, automobile, or any other consumable that you could think of, products from some foreign country are always preferred. They are safe and you would less likely be poisoned by melamine, mercury, Sudan red, or some other funny chemicals that no one knows how to pronounce.

And therefore an increase in internal demand could only be translated to a proportional rise in the trade deficit.

Oh, don't look down upon Chinese people. We are not alone - look at Uncle Sam.

HSB

While hearing the result announcement of HSBC, an idea suddenly struck my mind: Would they sell HSB ?

For those who are not familiar of the field, I am not talking about selling the first three characters on the logo; I mean the local bank that it acquired some decades ago.

Yes, it sounds unbelievable. (When I told Warren my idea, he took quite a while to be sure I was serious.) Nonetheless, it was equally, if not more, unbelievable twelve months ago to talk about the Citibank being nationalized. Although the gigantic bank would lose a major cash cow by this trading, there are a few conceivable advantages:

1. It means a HK$50000 million cash - around one third of the amount from the new shares.
2. It takes away the duplication of business in Hong Kong.
3. It provides some dressing on the profit / loss account in the next year (while continuing to write off a huge sum from the States).

Who has the capability of buying such a cow ? I suggested the name of an international bank when discussing with Warren.

On a second thought, wouldn't CIC be a better candidate ?

Bank

While talking about HSBC, I would be selfish if I keep to myself two recent emails from my friend.

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

Dear Szeto,

I have glanced through the report of 5 and do some simple calculations on the right issue.

Although the “actuarial” earning of 2008 is much better than reported (YOY down 30% rather than 70%) and the right issue will ultimately be a very bargain one in 5 years time, the projected figures are in fact extremely unfavorable in the coming 2-3 years.

That means, if I accept the right issue of HSBC, the opportunity cost will be very high because I will miss the chance of having at least 30% equity + dividend growth through investing on China Construction Bank in the same period (modest estimate of 1.5 times of GDP= 1.5 x 6.5% in the next 3 years).

So I will decline the offer and put the same amount of money to CCB instead.

Warren

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

(Email to another friend of mine.)

Dear L,

With further meltdown of financial system in US and Europe, those foreign banks will beg you to buy their holdings of CCB at very bargain price in the next several months. There is no need to rush.

I am still confident that HSBC’s economic franchise and monopoly will ultimately be realized with the fall of all other international banks and even insurance companies….. but there is mounting evidence suggesting that the worst of HSBC hasn’t arrived yet and the proposed price of right issue is actually unsafe. I am also quite disappointed with the decline in its corporate governance, which does not match its track record in 20th century.

If it falls further, I am sure the 3 big brothers (CCB, BOC and ICBC) will become the major shareholders of HSBC before British government can take any action (because it will be going bankrupt as well).

How can we Chinese find a better way to revenge the Opium War by acquiring HSBC as a Chinese bank?

Warren

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

I may not absolutely agree with what he says, but there seems much truth in it - and Warren is usually right.

HSBC

I sold my small fortune on HSBC the day after its result was announced.

No, it's not because the profit is disappointing (seriously I have not gone through the report in detail); it is not even because shareholders have to chip in more money for its running - but it was because of the simple reason that it would be a 5 for 12 rights issue.

It indicates that Stephen Green and other HSBC administration are drowned by details and lose the touch with reality.

Otherwise the arrangement should be 1 for 2 (or 1 for 4, while changing the lot size from 400 to 500 shares), so that most of the humble investors, like me, could keep up with round number of share. At present, to end up with a round number, you need a minimum of 4800 shares (or its multiple !) - and you will have 2000 new shares after all these torture.

(Jove, I need to work out this number by my TI BA-II Plus calculator. Thank you.)

And therefore I sold it all for their failing in a simple arithmetic test.

Musketeers

It is a common misconception that Les Trois Mousquetaires of Alexandre Dumas is a story of three musketeers - as the name implies.

There are, in fact, four: Athos, Porthos, and Aramis are the three that correspond to the title, but it is d'Artagnan - the fourth one - who is the main character. The story is actually about d'Artagnan joining the group and having a series of adventure thereafter. (I read the Chinese translation a few years ago. For even a modern reader like me, the book is not entirely boring.)

In a sense, Dumas was an author exceptionally ahead of his time. You know what, the Mousquetaires, and many of his other books, were mostly not his own writing; he employed a huge group of supporting staff to collect information (alas, those were the days before you could find everything from the internet), prepare the draft, and proof-read. Yes, he did contribute - not too a small part - in the final manuscript, but his major role is to present as a figurehead and create some kind of popularity in order to market the book.

Doesn't that sound a familiar trick ?

Yes, in the software industry, he is known as Bill Gates.

Who

Watched Slumdog Millionaire with Vivian.

It is an excellent plot, with the story brilliantly told, and topped with spectacular photography. No wonder it becomes such a phenomenon.

There is one thing I noted from the questions put up for Jamal Malik: They always ask Who.

"Who was that movie star ?" "Who wrote that song ?" "Who was on the bank note ?" "Who kept that cricket record ?" "Who was the third musketeer ?" And so forth.

Yes, in a sense it is unreal. Questions would never be put up like this in the genuine TV show. Nonetheless, I see it a Freudian slip (or possibly a careful calculation) of Danny Boyle, indicating his passion and emphasis on human beings on top of other material facts.

PS. Ironically, it is in fact the musketeer bit that makes the story somewhat unreal to me: It is exceedingly unlikely that The Three Musketeers, written by our giant in French literature, would be taught in the primary school of Mumbai, a previous English colony. That should really be Charles Dickens, and Jamal Malik being Oliver Twist.

Do

You may find my blogs in the recent few days schizophrenic. Am I for or against improving the health of a society? Was I actually making a circumventing method to support the new candidate who runs for the council ?

I am not sure.

And the old saying of Finagel's Laws comes to my mind:

• The data we have are not the data we want.
• The data we want are not the data we need.
• The data we need are not available.

It seems most appropriate to modify these laws by now:

• What we are doing is not what we want to do.
• What we want to do is not what we need to do.
• What we need to do remains uncertain.
  

Cost

I am not of a habit to copy-and-paste in this blog, but once we talk about improving the standard of medical care, this article from the recent issue of Clinical Medicine (formerly the Journal of the Royal College of Physicians of London) would be an exception.

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

‘Charles, I sometimes think that some people, many distinguished in their fields, might benefit from your wisdom!’ I started.

‘Coe flattery gets you nowhere! What on earth have you been reading?’

‘We are repeatedly told that unless we improve, and spend more on our public health preventative services, the NHS costs are going to be astronomical.’

‘And what if we do? You know the answer!’

‘They will be just as astronomical!’

‘And possibly more so! Although the medium-term cost of illness might be reduced, any consequent improvement in survival would inevitably increase long-term NHS and social costs. That is unless you can arrange for the majority of 90 year olds to die of a coronary during their daily jog!’ Charles added with a smile.

‘Or game of tennis! But you are not opposed to all this type of expenditure?’

‘No I am not! Sixty years ago, it was excusable that Nye Bevan did not realise that successful medicine has long-term costs, but the authorities should realise by now that total cost might be even more astronomical if we do improve preventative services. The point is that saving money or even human resources should play no part in the equation. These measures should be judged on what they are trying to do, which is to extend healthy lifespan!’

(from Clin Med 2009; 9: 95-96)

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

Well, I find it often difficult to tell whether someone is joking or using a laughter to cover the grim fact, or to tell a clever crook from an idiot.

Consequence

You may consider my worry yesterday somewhat excessive; let's take aside those butterfly effects and focus on the problem at hand: Does more liberal investigation of medical incidents (in government hospitals) improve the standard of care ?

There would only be one effect: the reputation and trust to the public hospital go down.

And the consequences are not difficult to imagine:

1. More patients would move to the private sector.
2. More (capable) public doctors would move, too.

(The reason for the second point is obvious and I would not repeat here.)

On a first glance, the two effects seems balancing each other. But, look, public hospitals employ less than half of all the doctors, while taking care of over 90% of the patients. If 10% of the doctors and patients leave for the private, it would just be a small increase in the number of private doctor, but a double in the market.

Oh, is it the real objective ?

And I feel needless to elaborate on the quality of care for those patients (the vast majority, unfortunately) who remain in the public sector.

Candidate

A friend shows me the news that a famous private doctor is going to run in the election for the council chairman.

Of course I am not surprised. The previous chairperson seems to have stayed in the post forever, and many people would like to see some change.

But he real thing that amazed me is what the new candidate (claims that he would) plans to do:

"I shall investigate major medical incidents in government hospitals proactively - before receiving a formal complaint."

Does any one in his right mind would agree to allow the police (or ICAC) having the authority to investigate the whole of your life - without a formal case?

You don't really need to have police or ICAC to have that authority. Imagine some other professional bodies (say, of lawyers and accountants) ask for the same right. Does that protect an average citizen, or put them at more risk ? (It is not only the problem of privacy; it puts an end to all negotiation and, above all, our right to choose who takes care of us.)

Gestapo !

Key

That night, while I was pondering on the philosophical question of the value of my existence, a glaring creature on the table drew my attention.

He was the key living in the next pocket - my master somehow left him on the table.

"Hei, man," I yelled to the smelly piece of metal, "What's funny here ?"

"Oh, nothing. Just trying to take a good breathe after all day's work. But you look gloomy. I suppose you should be happy with the recent happenings of that woman ?" My neighbour said.

I told him what's in my mind.

He considered for a while and said, "I don't think we are here to detect romantic abnormalities and make exotic diagnosis - not for me at least. It's grass root kind of work. But I am handy and immediately available, and our master won't do away with me - he cannot carry a CT scan with him in the ward. I suppose you are more sophisticated and could be of a even better use ?"

"You mean deciding whether someone has lung crackles or rhonchi or bowel sound ?" I tried to make a joke - probably onto myself.

"Don't you think they are important ? How many times did our master rely on you to decide whether someone has heart failure or bronchospasm, and bowel obstruction or ileus ? Oh, I should the one feeling jealous !" He smiled.

I said nothing, but began to see the truth in his words. Yes, I should be happy with my grass root but material achievement, rather than wasting my time to crave for some glamorous moments.

"Maybe you're right," I said, "Oh, the pocket that you lived has a hole in it. Do you want to share mine with me tomorrow ?"

He nodded eagerly, and I was sure it would be the beginning of a great friendship.

- THE END -

Depression

I have very little recollection of what happened for the rest of that afternoon. My master did rush back to the ward and made several phone called, and the woman was transferred to a tertiary heart surgery center before sun set. I never saw her afterwards - my master and I were soon attracted by other patients and the membership papers.

But I do remember very well the happy footstep of my master when he was rushing back to the ward. (In fact the next time I found him walking in the same joyful manner was nearly two years later - when he knew he passed the Royal College examination.) Yes, it was the kind of footsteps that come with a combination of relief, self satisfaction, and return of confidence.

And I remember after my master secured the woman in the ambulance and saw her departure, Dr. Lai tapped on his shoulder and said, "Well, after all, your stethoscope did not let you down, and it was most probable that there was really no murmur on the night of admission. Atrial myxoma classically has rapidly changing murmur because ..." For a moment I was just too happy to listen any more.

When I cooled down at night, however, I became less sure whether I should really be satisfied. Yes, I did provide correct information to my master - but what did I actually contribute ? The disease was confirmed by the expensive creature with a digital screen downstairs rather than some humble rubber tubing with a metallic bell like myself. Worse still, the noble was operated by his master who did not (have to) complete five years of medical school - my master used to call him some "technician". Alas, if I had never met my master, he would have make the diagnosis by simply asking an expensive creature to visit that woman.