Grandiose

In general I am quite apathetic to most of the (in my opinion) unreasonable demands and comments from all direction. (I have very little insight, of course.)

But several recent happenings are really remarkable:

1. Written comment from a second year student: (That's the exact wording.) The course is bullshit. The clinical demonstration is very disorganized. Why can't the teacher decide what disease entity should stay in the ward and wait for us ?
2. From a fresh graduate: Why do I score "C" in both medicine and surgery ? I had a higher grade last time.
   
3. From a government servant: Why am I suggested to have a private CT scan (so that I could have it faster) ? I am superior to an ordinary citizen and my condition needs utmost attention.
4. From a university academic: Why does this study need endorsement from the head of the other department ? They do not take part in the study - I just use the patients under their care.
5. From a super-physician: Why don't you keep a close eye on this patient who stays in another ward (and is under another department) ?

Well, the catholic church might have a point and Nicolaus Copernicus must be wrong: How could the universe go around the sun ? It got to go around me !

We need to treat them fair.

Restaurant

We dined in a steak house at TST - it was Vivian's birthday.

SM introduced the place to me some years ago. (I've not seen him since he's out for private practice. By coincidence, his sister also disappeared from the local sensational literature - giving her place to a journalist and some other women.)

In the next morning, a local newspaper used the best value-for-money restaurants as its heading. I would pick the followings:

1. 鳳城酒家 (北角)
2. 華姐清湯腩 (天后)
   
3. 泰豊廔 (尖沙咀)
4. 好時沙嗲 (尖沙咀)
5. 時新快餐店 (紅磡)
   
6. 澳洲牛奶公司 (佐敦)
7. 橫綱 (油麻地)
8. 詠藜園四川菜館 (黃大仙)

There's no Italian or French restaurant - you could hardly expect anything good to be cheap.

No, it's not a list of ten either.

Nothing perfect is natural or genuine.

Time

Watched Angels and Demons with Vivian.

My wife was understandably excited - she had read the original fiction and is a great fan of mystery stores. I must say I was not too impressed. The movie was an enjoyable two-hour, but, nothing more. The plot was in fact much more simple than the Da Vinci Code, and it didn't take long for me to realize who and what was behind the scene.

One notable phenomenon of the two novels is both took place in a narrow time frame. To make the atmosphere even more pressing, Dan Brown kept reminding his readers the time - to the accuracy of minutes. The Freudian interpretation is an over-stressed and possibly obsessive author.

Or, in the words of Agatha Christie, it indicates an orderly mind but boyish character.

PS. The fifth element, other than earth, air, fire, water, in ancient Greek was aether - the heavenly substance proposed by Aristotole. The same name (and, unfortunately a different concept) was latter applied to the hypothetical substance that filled up all space and was believed to be responsible for the transmission of light.

Regret

Met RJ - our new gold medalist - and had a brief chat.

He was not quite happy.

"If not because of this new system of examination, it could never be me." He sighed.

I politely reminded him that the "new" system was a contingency that we were forced to adopt because of the swine flu.

But he was not easily moved, "All the same. If there were real patients, I'm sure a handful of other classmates would have come out better than me. Now, there is always a shade of doubt on that piece of shiny metal."

I was speechless for a moment, reflecting this inadvertent effect in my mind. There was a hue of regret in the atmosphere.

At last, I said, "But what's done could not be un-done. You are selected, rightly or wrongly, willingly or not. All you could is to do your very best in the future. Remember, people around would not judge you as your own self. If you do not live up to the expectation, many of us would be disappointed because it would be taken as the limit that could be achieved from the best of the class. You may not like it, but the reputation of your classmates counts on you."

He nodded and walked away.

That's too much for a fresh graduate, I know.

Swindle

You may say: But, putting names (or other personal data) on an open area would facilitate swindling !

On that, you are having a straw man argument. We start off with an aim to protect privacy, but the outcome of the proposed action merely prevents a crime. Remember, while privacy could be considered as a basic human right and probably deserves much price and effort for its maintenance, prevention of swindling - a crime but merely one kind out of thousands - is but one of the many items on the agenda of a society.

(I emphasized could be and probably in order to remind me that privacy has not been formally considered as part of human right until 1960s. I am sure if it is such an important piece of our considerations, people should have recognized it during, as Charles Dickens said, the best of the times and the worst of the times in the history.)

The consideration of putting names on public places (for example, posting memo on the student notice board), therefore boils down to the followings:

• how public the place is;
• how much information is put up;
• what kinds of crime could conceivably be induced by making use of the disclosed information;
• presence of alternative methods to prevent those offences; and
  
• benefits of putting up the information in public (which include general scrutiny, honor to or deterrent effects on the involved persons and, lastly, administrative convenience)

I shall not elaborate further.

Secret

You may say: Wouldn't it be respecting a higher degree of privacy if we avoid disclosing the others' names in the public ?

My immediate response is in that case you should not call the name of your friend in the street, otherwise you are impinging on their privacy.

No, the water is deeper than that. By making everyone and everything anonymous to the public, we are working against the original purpose of having the right of privacy: the protection of individuals from dictatorship.

Don't you comprehend that ? By the name of privacy, administrators could, by their own wish or secret agenda, call medical student to attend the viva, give out a piece of land to the son of some billionaire, or arrest anyone - all without being known by the others.

A convenient example is: The government of Burma would not disclose the name of a woman recently arrested for charges not to be disclosed - in order to protect her privacy.

She is Aung San Suu Kyi (昂山素姬), of course.

PS. For a similar reason, I often advise patients with a serious disease to stay in the public ward rather than being transferred to a private one - even though they could afford the charges. For sure they have to sacrifice part of their privacy, but in turn any rapid change in their condition would more readily be noted by whoever passes by.

Privacy

I cannot remember when did we start to covering up other's name in order to "protect their privacy".

In fact, not very many of us know the definition of privacy. Let me give you a formal one, from the US Constitution:

"The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated."
"No warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized."

You see, the concept deals with eavesdropping, tapping of phone lines, and activities of a similar kind by the government or other secret agents (and therefore a protection against excessive power of the government or dictatorship) - not disclosing your name to the public.

For the latter purpose, we actually should never use our name - so that no one would ever know what we do.

PS. The original US Constitution actually had no mention about privacy at all. The current description comes from its Fourth Amendment. You may consider what happens in the other side of the Pacific Ocean may not apply here. True. But, in that case, we can simply do away with this concept altogether - why follow the Americans' footsteps ?

Memo

Towards the end of the final MB, one particular student gave AL - our chairman's assistant - a surprise while leaving the examination hall.

He shouted some incomprehensible words in front of the other students, who were about to come in for the OSCE.

Dumbfounded for a moment, AL finally came back and told me the happenings. I considered for a while, "Do you recognize which student ?"

"Yes, of course."

"In that case let's call him back and ask him to meet me in my office this afternoon." I said, "As a formality, please issue a memo with the same information and post it on the student notice board." I went on and dictated a memo that and there. AL typed it herself and said, "Maureen will ring him up; I shall send this by email on behalf of you."

I was incredulous, "Why don't we make a hard copy and put it on their notice board ? That would be way more deterrent."

"Don't you know we could no longer put up memo of this kind on their board ? A few years ago a student complained that putting up examination result - with their names or student ID - in a public place impinges on their privacy. Nowadays we could only send these things by email."

I could not believe my ears.

PS. The incident also shows that I have also emigrated out of the earth.

Viva

It is the custom that a handful of the best students are invited to attend a distinction viva after the clinical examination - the only difference this year is we do not have the other side of the spectrum being requested for an oral examination.

We had the program this afternoon. Not unexpectedly, we found a few well dressed but somewhat anxious youngsters sitting outside the department library during that time. (Many of our colleagues did recognize the faces - that's a good sign.)

When we passed through the corridor late in the afternoon, however, we found a student - in his T-shirt and shorts - sitting there.

CB commented, after we pushed through the fire-door and went to the clinical side of the building, "Is he also coming for distinction viva ? He looks just different !"

I knew what he meant, but was speechless for a moment - too amazed with the effect of psychology.

In fact, I recognize the student by face.

"He comes for counseling." I said at last.

PS. I was twice as much amazed half an hour later, when I found another student who needed couseling sitting outside the office of our man from Pluto - you could really tell by the code of dressing.

Argument

Are you impressed with my argument yesterday ?

Don't go that far.

Let's be a moment of Aristotle and consider the possible forms of an argument (or, if you are a fan of EBM, the level of an evidence):

1. Argument by evidence, i.e. proof by well conducted experiment.
2. Argument by example, i.e. proof by a series of observation with similar result.
3. Argument by authority, i.e. expert opinion.
   (On this, we rely on the presumably extensive experience of the authority. Those familiar with philosophy, however, would also recognize immediately that argument by authority is a classical case of logical fallacy.)
4. Argument by precedent, i.e. anecdotal report.
   (It usually begins with: I have seen X happened, therefore we should do Y. For example: I have seen people die of air pollution, therefore we should not breath.)
5. Argument by analogy.

I deliberately put analogy at the end of the list, because it is - unfortunately - the lowest level of an evidence. Yes, analogy could well be the most important kind of evidence (when there is no reliable alternative information, and we call it wisdom), and often the most attractive one - at least to some less educated general public.

After all, Buddha, Jesus, and several other greatest teachers in human history all taught us great lessons by analogy (alas, telling stories), but there are way more crooks in the world - all trying to fool us with the same trick.

Outbreak

You may think my suggestion that prevention of virus spread may lead to catastrophic infection outbreak unbelievable.

Rather than showing you some analogous happenings in history or politics, let me tell you a story on the prevention of forest fire.

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

When the US Forest Service was established in 1905, complete fire suppression was the objective. Before that policy, Giant Sequoia and a few other fire resistant species predominated in the forest of California because fire (periodic ones by lightening, for example) is an essential part of their life cycle - by destroying those shorter and more easily burnt competitors. The aim of complete fire suppression, however, led to an increase in the number of trees such as Ponderosa Pine and Douglas Fir - in short, highly flammable species - in the forests.

What's the result ? The strategy enjoyed some initial years with minimal fire (and the policy makers conceivably proved to the public that they worth their salt). In reality the number of ordinary small fire was reduced, but the few major catastrophic ones remained inevitable. More so, because the composition of forests had changed, these fires were much worse - they became uncontrollable disasters.

(Of course the policy also has a profound effect on the ecology of wildlife, but it is not the subject of our discussion today.)

Go read Collapse of Jared Diamond.

Prevention

Once you consider the effect of isolation on the evolution of virus, you may find the nihilistic policy of some countries on the other side of the Pacific Ocean less annoying.

Well, I am not sure Uncle Sam has such a wisdom to see through the effect of active isolation, or they are stupid enough to stay dumbfounded. It is often difficult to differentiate a great crook from an idiot - there's no difference in terms of the effect, of course. For similar reason, I am often not sure I actually see the Licht of Goethe, or merely making a fool of myself.

Nonetheless, the contrast in the policy between our home country and the Police of the World against this new virus is a vivid illustration on how the two people treat things related to the mouth.

Both for diseases that get in through our mouth, and the voice of a people that comes out from it.

Which is correct ?

I have no idea.

But I could show you an old Chinese saying: 防民之口，甚於防川.

Isolation

The implication of the logic yesterday is: The natural process for selecting a benign virus (to the host, I mean) requires those subjects infected with the benign variant to go around and spread it.

In other words, when we isolate these patients and their recent contacts, we are inadvertently but also inevitably disturbing the natural evolution process of a pathogen - we inhibit the expansion of those host-friendly variants but promote the persistence of virulent strains.

And there would be more from the Pandora Box if you consider from the point of view of that virus: If friendliness to the host is not a survival advantage, which strain would triumph ?

Yes, those virulent ones that could spread more efficiently, probably by methods independent on the mobility of the host - for example, via airborne (rather than droplets), birds, or even some mosquitoes !

(Oh, maybe that's why our senior officials have to clean up the sewage pipes at our backyard.)

Ironically, that's the real threat our senior officials are keen to warn us repeatedly.

Virus

Once you come to understand how the data of some new infection come about, and the logic of the discussion by VW (see http://vwswong.blogspot.com/2009/05/outbreak.html), it becomes obvious that we should not worry too much about new pathogens.

By the law of evolution, they should evolve to suite the host and kill less frequently. On the other hand, if a new pathogen has an exceptionally high mortality, it should have caught dramatic attraction of our attention and would not last long.

(SARS is, of course, the typical example of the latter scenario.)

The logic is simple. In general, when a virus is highly lethal, anyone become infected would succumb quickly; there is not much chance to spread it around. If there evolves a strain of less pathogenic virus, the infected subject would be less unwell and could therefore get around and show it to everyone.

The inevitable, but less well understood, implication is: We - the host - take part in the evolution.

Do you see the problem here ? Let me tell you tomorrow.

Dressing

On a second thought, I should not be too critical on some medical practitioners who treat their patients by mysterious (Fend Shui equivalent) regimens.

Because many more would try to impress the medical circle as well as the general public by the same thing - albeit with slightly more attractive dressings such as science or statistics.

(Don't get me wrong. Science and statistics have no problem on their own - it just depends on how you use it. Fire is the greatest discovery in the history of human beings, but you won't set fire everywhere, will you ?)

For example, when a new virus appears, we create some data and show that the mortality is high; when the heat is over, we go on and show that the virus is very common. Jove, these two very features - in general - won't happen together. (For the reasons, see the blog of my friend VW, in http://vwswong.blogspot.com/2009/05/outbreak.html)

Why do we make a fuss ? Come on. What do you think all those Feng Shui masters are after ? Money, when dressed with science and statistics, is known as resource or funding.

Alas. Don't be paranoid, I could be talking about HIV rather than swine flu.

Maybe science and statistics are lamp posts and meant for illumination, but most of us are insane alcoholics and merely use them to support our own weakness.

Four

To be fair to our ancestors, there’s quite some serious science in the four disciplines other than medicine.

The most obvious one is the relation between physiognomy and psychology.

The better developed but less well known one, however, is astrology.

You know what, there were the so-called seven major and four minor stars (七政四餘) in the Chinese astrology.

The seven major ones are, of course, the sun, the moon, the Venus (金), the Jupiter (木), the Mercury (水), the Mars (火), and the Saturn (土).

The amazing part, however, comes with the four minor stars.

In Chinese, they are: 氣、孛、羅、計.

Translating into modern scientific English, they could be represented as the asteroid belt (小行星帶) (alas, “氣” means gas !), the Uranus, the Neptune, and some residual small ones.

(計: by calculation and estimation.)

PS. One of the most famous experts in Chinese astrology was Yelü Chucai (耶律楚材), at one time the political advisor of the early Mongol Empire.

His son was the factitious character in The Return of the Condor Heroes (神鵰俠侶) under Jin Yong (金庸): Yelu Qi (耶律齊).

Five

Like many ordinary Hong Kong citizens, I find the recent story between the billionaire woman and her (possibly) Feng Shui master highly entertaining.

But, in fact, I should not laugh. Have your heard of the five disciplines (五術) of Taoism?

They are: 山、醫、卜、星、相.

For those who are not familiar with the field, "山" means feng shui (and measures to communicate with the other world), "卜" fortune telling for specific events, "星" astrology, and "相" physiognomy and palmistry.

And medicine is merely a humble subject amongst the others.

Of course we have advanced a lot with science. Nonetheless, even some modern practitioners of medicine have not evolved beyond the domain of the five disciplines. Just some days ago, one of my private patients told me how wonderful she received an infusion from a private clinic - the medicine was said to be good for post-operative malnutrition, major depression, heavy metal poisoning, athletic performance, and so forth.

Scum.

Aspirin

You may think I'm not altogether satisfied about the reluctance of our students in trying some aspirin themselves. (That may be true.) On the other hand, I should be very thankful for not having that chance when I was a student.

Because I have aspirin allergy.

Oh, to be specific, I have a history of bronchospasm after taking aspirin.

It came to my attention when I was half way through my houseman rotation. On one occasion, I was badly hit by a severe flu, for which I had to take a day of sick leave (a very rare happening in those days). While struggling alone in the hostel with chills and aches, I found myself using up all my stock of panadol (which I usually keep a lot for my headache), but there was a few tablets of aspirin leaving behind.

I bought them in order to try and see if it is any stronger than panadol.

Yes, it gives a much louder breath sound with a high pitch - we call it wheeze.

The lesson ?

Don't try new things when you are in a series of bad luck.

Drug

While I was about to finish with Barbara Backer's book, NT called for a meeting to review some panel teaching of our (year 2 and 3) students.

For historical reasons, I was in the group to represent clinical pharmacologist. (It always puzzles me who made the nomination.) After we went through the students' comments and feedback, one point was raised by our pharmacologist:

"Is it necessary to continue with this practical session ?" He pointed at one line of the timetable.

We all came across and looked, but, for a moment, had some difficulty to figure out what he meant.

"Oh, this one - on pharmacokinetics." He went on, "In the session, students are asked to take a drug and have their urine collected to see the profile of drug excretion."

NT asked, "It has been there for ages. Why do you want to change ?"

"Em ... very few students agree to try the drug themselves and have their urine checked in the experiment." The scientist hesitated to explain.

"What drug are the students asked to try ?"

"A tablet of aspirin."

PS. As sort of a bystander, I humbly suggested to use a can of beer, instead of any drug tablet, for the experiment.

They all gave me a cold stare.

Curriculum

My recent bedtime reading is The Weekly Curriculum Book by Barbara Backer.

Oh, it has nothing to do with our teaching on medical students. The book describe how to plan the curriculum for a child - I just want to have a glimpse on how it is done.

Although I am always skeptical with kindergarten education, this little volume is an eye-opening experience. To say the least, I learn what are the aspects to be covered (i.e. language, physical, craft work, and so forth), and how to touch on every aspect when a particular topic (for example, the Mother's Day) comes up.

Rather similar to the planning of a medical curriculum.

Alas, I always go back to where I start.

PS. I bought the book last year during my trip to Kuala Lumpur as an invited speaker. There was a huge bookstore within 5 minutes walk from the convention center, and I used the small honorarium to buy a gift for myself.

Say's

You may find my grumble yesterday irrelevant, but the water is much deeper once you consider other similar scenarios.

One simple example that I learn recently is the housekeeper:

One hundred years ago, there was only the broom for one to work with, and it took quite a bit of sweat and energy to make your house clean. When the vacuum cleaner (and numerous other similar gadgets) became available, did it reduce the manual work ? True, the house became much cleaner than what a broom could do, but our expectation was also higher. In other words, the electric toy could achieve a level of cleanliness by broom with less work, but it took the same work for the housekeeper if he has to get the place clean to the standard of a vacuum cleaner.

Similarly, when we had to write our own clinical notes and discharge summaries, we all used the KISS principle. With the invention of copy-and-paste, it saves us time to write, but we probably use the same amount of, if not more, time to read others' notes and summaries - because they are now much longer than 10 years ago, and the useful information almost always buried in the jungle of words copied from everywhere.

That's the Say's Law in economy: Supply creates demand.

PS. Haven't you heard of KISS ? It stands for Keep It Smart and Simple.

Go read Steven Silbiger.

iPhone

At the end of the day, I had a new iPhone - my wife made it as the present for the coming Father's Day as well as my birthday, although the latter will be five months later.

(Vivian is always careful with our expenditure. We got an exceptional discount from some Superman, and had the toy sold at less than HK$1000.)

How do I find my new mobile ?

Well, my feeling is somewhat like the owner of a small factory who wishes to hire a simple clerk but ends up employing an MBA from Harvard who could do, in addition to the ordinary paper work, all the corporate finance and international trading and strategic planning and what not. Yes, he has absolutely no problem with the task that I assign - but it seems a bit of waste if his owner does not make the full use of his capability.

The result is simple: It drains some of my time to explore and learn what it could do - and to think of appropriate tasks for it.

Alas, a new toy.

Phone

My mobile phone broke down recently.

It did so in a remarkable way: I could use all the function, but, when someone calls in, I could listen only by the hand-free mode.

Vivian was the first one to notice the problem. (She is, of course, the most frequent one who rings me up.) She pressed me to buy a new mobile, but I was reluctant. The old one was just over 3 years in use, and I love its simplicity (i.e. few useless gadgets and functions), which is not easily found nowadays.

I tried to justify by a (to me) excellent excuse: 事無不可對人言.

But, for sure, wife always wins an argument (if you are silly enough to raise one).

And, during the holiday, we were out to find a new one.

PS. Seriously I have difficulty to convince myself with the excuse.

"When a person reaches the stage of having their own secrets, it means that they have grown up." (from The Setting Sun of Osamu Dazai)

Milk

Using a can of goat milk powder for my coffee recently.

The milk powder is a kind of nutritional supplement that Vivian bought for our daughter; I could see the latter screwing up her face with the first sip.

Alas, in order not to waste anything, I have to take it up for my own consumption.

And it doesn't take long before I know why Euterpe doesn't like it - you could smell the mutton flavor a mile away. For a while a scene in Mrs. McGinty's Death flashed back over my mind; I looked at my cup, and, following Hercule Poirot, forced the suspicious brown liquid through my throat.

But, it's not the Black Coffee - it's not poisonous, and it wasn't even bitter at all. The grease of goat had a strange chemical reaction with caffeine and made it way stronger. After the cup I felt a gush of joy - just like the ancestor of the ruminant that gave rise to the milk powder, when it first ate some berries in the highlands of Ethiopia.

Show

With the announcement of our CE, the scar of our behaviour surfaces once again. (See my blog http://ccszeto.blogspot.com/2008/03/scar.html)

Alas, we hurried to give advice on personal hygiene, wearing masks in public places, scrutinizing port entrants, massive cleansing of everywhere you could think of. It seems logical, eh ? I shall take you through some politically incorrect considerations:

1. Are the measures useful ? If it is not transmitted by fomites, what's the value of cleaning everything with clorox ? (More so, if it is not transmitted by mosquito, why on earth do we ask our senior officials to tackle sewage pipes in our backyard ?) In fact, if there comes more evidence that the disease is airborne (rather than via droplets), are we going to ask everything to wear N95 ?
2. Let's assume the measures are useful or important, why do we do it now - but not earlier or regularly ? Is it because we have evidence the swine flu and ordinary ones are biologically entirely different diseases, or because the former has a much higher mortality?

Come, let's enjoy the show.

PS. An old Chinese duilian (對聯) suddenly comes to my mind: 上台須念下台日, 看戲無非做戲人.

Announcement

Just learned from the urgent evening news that the first case of swine flu in our city was confirmed.

And this ground-breaking information was announced by no one but our CE. (I must say it is quite a bit of fun to hear him reading out the case history; I have a deja vu feeling of conducting a junior clerkship tutorial.)

But, why does it need the head of our government to do the deed ?

It sounds like asking Mr. Hu to tell us the biochemistry of melamine, or President Obama to do the press release and explain the financial details of the Chrysler, which filed for Chapter 11 just lately.

More than ever I find Chen Ping (陳平) of the Han (漢) empire a real genius.

"自有負責人."
(典出: 史記•陳丞相世家)

PS. Of course Mr. Tsang might not want to do this kind of thing either - there is so much pressure by our council members and the general public that he should come out and do something.

Lakeside

Read Lakeside (湖邊凶殺案) of Keigo Higashino (東野圭吾) during the weekend.

Yes, that's the same author of the TV series Galileo (神探伽利略) and the movie Yōgisha X no Kenshin (容疑者Xの獻身) - both of which I did not have a chance to watch.

But, the Lakeside is good. It has the typical layout of "plot-within-a-plot", which - to my knowledge - was first used by Agatha Christie in Murder on the Links. The trick is no doubt the favorite of Higashino, and he plays it well this time. (I shall turn a blind eye to its so-called ambition in sociological meaning that so many book critics put forward. It is parsley on the dish - it looks good, gives a bit of flavour, but most of us would put it aside before swallowing the fish down our throat.)

One of the best plots built out of this framework was The Tragedy of W (W的悲劇) by Natsuki Shizuko (夏樹靜子), yet another Japanese novelist. Ironically, the Tragedy has a superb plot clumsily told, while Higashino has his story brilliantly presented - although I think he could have made the water a bit deeper.

(How about that teacher - making use of his students as a blind ?)

Necessary

While we are on the benefit of those minute things, one common question that we encounter in the clinic is: Can I eat this ?

(And the this could be anything - salted fish, candy, ginseng, abalone, and what not.)

My usual answer is: It is not poisonous - you won't die by taking a little. Of course, that often means the patient ends up taking a lot and has all the problems.

For the same reason, many (male) candidates ask: Is it necessary to wear a tie for the examination?

Of course not.

In fact, it is not necessary to shave, comb your hair, wear a white coat, bring your own stethoscope (we can always provide a spare one), or even be polite to the examiner. By definition no one could fail for any of these reasons.

But you could imagine the result if a candidate does all of them (or, seriously, just the last one).

As RK, our previous chief of neurology, says: They are all useless. But, when you put all these useless things together, they may become useful.

And if you put many things with no value together, they may become invaluable.

One

In fact, my advise yesterday does not apply only to professional examination, but almost every aspect of our life - for the vast majority of our problems and activities are scored in the same four point scale, and it is usually impossible to change a particular thing from failure to successful because it often depends on luck and circumstances and many other factors that we cannot control.

But that's not a reason to give up.

We can always do something to make thing change from hopeless to marginal, or from good to better. The only question one need to ask themself is: What can I do to go one step further, or make the situation less bad ?

No, we are not asking for a miracle to change something bad to good. But there is almost always something solid for making it less bad.

Remember, life does not depend on one, but is an aggregate of many four-point scores. At the end of the day, you will always have a gratifying result if you keep scoring 2 or 4 - instead of 1 or 3.

Score

You may say, "But the Blitzkrieg tactic won't work now ! We see several examiners (six to ten, depending on which examination you talk about), and each of them gives us a blinded score with an equal-weight."

True, but there are other ways.

You know what, the major component of our current marking scheme - be it final MB or MRCP - is a list of 4-point scores (which add up to give an overall score): It is 0 to 3 in final MB, and 1 to 4 in MRCP; in the latter, 2 being borderline fail and 3 borderline pass. If you get that component right, you score 3 or 4; if wrong, 1 or 2.

That's the point ! No trick or teaching could move a candidate from 2 to 3 (i.e. fail to pass) if they make a mess, but one can always do something to move from 1 to 2, or from 3 to 4. If you fail, do something so that the examiner think you are wrong at a certain point but not completely hopeless; if you pass, show that you are thinking or doing one step further.

And it is the one extra point here and another there that gives you a higher score overall, which not uncommonly changes fail to pass.

You think it just the truth from a Sunday school (老生常談) ?

管輅曰：「老生者見不生，常談者見不談。」
(資治通鑑, 第75卷; 亦見 三國演義, 第106回)

PS. On the last bit, please refer to the modern translation by Bo Yang (柏楊）; most of the others you find from the Internet probably mistake the original meaning of our great fortune teller.

Blitzkrieg

If you are still keen to have some practical tips for clinical examination, I could show you one that we used in the old days.

I call it the Blitzkrieg tactic - which I first learned from the story of Adolf Hitler, when he conquered Poland and France in late 1930s.

In the old days, the major hurdle of a clinical examination is the short case, which the candidate had to face two examiners. Usually one of them being much more senior than the other, and had naturally much influence on the actual scoring. The marking scheme was, alas, the time-honoured impression marking - the examiner could give you anything between 45 to 60 in the final MB, or 0 to 12 in MRCP.

In other words, you only have to impress one person in order to score high.

And you only need to impress that one in the first two or three minutes; once they are taken in, everything you do they feel satisfied.

How ? I shall leave it to your imagination.