Road

Dined with a group of senior physicians and met MT - a consultant of another hospital.

"We have much difficulty in recruiting new trainees. Most think that internal medicine is too difficult a nut to crack, and the few who are stupid enough would choose a university hospital !" He complained.

"Actually not very much better for us. Nowadays, every graduate seems to have a better offer than medicine." I said.

"You know, there's now a road to success in medicine ?" MT replied, smiling in a funny way.

"Indeed ... ?" I was curious.

"R for radiology, O for ophthalmology, A for anesthesia, and D for dermatology. Aren't they fabulous ?" He finished with a twist in his lips.

I made a bad hiccup - an ordinary response when human diaphragm tries to laugh and vomit at the same time.

PS. The reason for my unsightly response may skip your eyes. Not only are the four specialties of limited scope and lead a leisured life, but, more importantly, none of them require a genuine patient-doctor relationship. The former is merely a client who come for purchasing a service.

I shall not discuss the metaphysical implication.

West-west

Don't be taken aback by my hypothetical novel (yet) - I have not gone through the worst part of the story.

Although it sounds plain sailing to have an experiment on the evolution of some artificial life in another planet, reality is never that simple.

Yes, several groups that share the laboratory (the planet, I mean) may not agree with each other and do conflicting experiments at the same time. But that's relatively trivial a problem.

Imagine, what if the funding dries up (say, because of a financial tsunami) and the planet is forgotten ? As we all know, their lives must go on - and experimental beings on the planet continue to thrive and evolve and wonder who creates them.

Or, even more likely, a nuclear war wipes out all of us - leaving the lovely creatures on the other planet continue to wonder: Should they follow our commandments ?

Alas, my idea is not new. At most I add a scientific coating to what Friedrich Nietzsche suggested. Franz Kafka used the same idea in An Imperial Message, and more subtly - but also in a more elaborated manner - as Count West-west in The Castle.

PS. Nietzsche and Kafka actually formed their idea from philosophical considerations rather than scientific possibility; I shall not elaborate further.

Being

One important precaution of doing all those exotic experiments on another planet is: We should not have direct contact with creatures there. We do not want, by any chance, to contaminate our own genome (I agree that's very unlikely, but realistically that would be something strongly insisted by people with a superior moral standard). Neither do we wish - because of the very presence of us - to disturb the behavior of those lovely creatures.

With time, the artificial creatures would evolve (naturally, plus or minus some assistance by generations of our research students) and develop intelligence - the latter is defined as the ability to use tools, have a language, aware of their own existence, and ask themselves the very question: Who creates us ?

You see, we are coming to the center of the problem. Are we going to play god and do the experiment, or are we the synthetic creatures and the subject of an experiment ?

This is, alas, the sketch of a novel that I prepared some 20 years ago. The tentative title is Experimental Being.

PS. My idea actually roots from a very scientific question: Is the speed of nature (i.e. random mutation) sufficient to explain the rate of evolution observed in this planet ?

Experiment

Friends, don't be surprised with my suggestion yesterday.

Imagine, we need two prerequisites, and one is now at hand: an entirely synthetic (or artificial, if you prefer the term) cell.

If our space scientists manage to find a planet that could support life (in essence, it has water, an atmosphere, and a reasonable surface temperature), it would be logical to put the synthetic life on that planet. Funding prospect seems great with project of this kind. We could achieve two things here: On one hand, we could see how evolution takes place in a real life situation. At the same time we could do away with all synthetic life on earth - which is being strongly protested by many moral purist as soon as the news of an artificial cell is made public.

And, the experiment does not end here. With the whole new planet as a gigantic laboratory, we would expect there are research opportunities for millions of generations of PhD student. One could fulfill the requirement of his thesis by simply inserting some new DNA sequence into one strain of the bacteria, put it back to the planet, and see the function of the gene product. Another may spend his three years by duplicating one gene, make a small mutation in one of the copies, and see the result of differential expression. Many many years later, when the synthetic creatures on that planet has evolved and differentiated into millions of species, one could even study ecology and behavioral science ...

Cell

Although the year 2010 has not yet been half way through, I believe we just saw the most influential scientific paper this year:

Gibson DG, et al. Creation of a bacterial cell controlled by a chemically synthesized genome. In: Science Express on 20 May 2010.

Oh, the happening was simple. This group made an entirely artificial bacterial cell, which is capable of continuous self replication. In other words, this is the first time man creates life.

I shall not join the debates on whether scientists are playing too much the role of the god this time, whether we are going to create monsters in the near future, or whether the technique would be abused. (Well, what scientific technique could not be abused ?)

But, my very question is, if this synthetic species of bacteria continues with the evolution, and, millions of years later, became creatures that could think and act independently, should they obey to the command of Homo sapiens or descendants of the principal investigator of this research project (Craig Venter, an American biologist) ?

Fertile

Although the British administration in Burma proved highly successful (in terms of economy, to say the least), one important factor was the very character of Bamar people - they may not have all the good qualities that we desire, but the majority of them are calm, obedient, and not calculating.

In fact, they live in a place close to Shangri-La; as long as you plant some seeds onto the field, a good yield of rice could be harvested twice a year. Unlike, say, people in North Korea or Iceland, Burma should naturally be doing well; the current state of poverty is not a fault of its citizens.

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

Every time when I come to think of Bamar people, I find that a similar character is common in this part of the world - Thai, Vietnamese, Malaysian, Indonesian, and a few more. They all settle in fertile soil and excellent weather (for the purpose of agriculture). Protein is not a problem either: There is never a short supply of insects and worms and other crustaceans, so that keeping chickens and ducks is a piece of cake. If that's not enough, just take some supplement from the local river or seashore - there are tons of fish and shrimps and clams, and what not.

A shrewd reader may realize at this moment, the god's praise comes with the demon's curse. With a fantastic environment, people living there for centuries would become more leisured and never worry very much. (There's little to calculate or worry about. By the rule of evolution, those bearing the gene for being suspicious and calculating would see no benefit; by all probability, they are just more likely to die of premature heart attack.)

Alas, they would do well until some aggressive visitors come in ships - often with gun, germ, and steel - or some dictator arises by mutation.

Discrimination

Although Burma is now one of the poorest country on earth, it was - not too long ago - one of the wealthiest under British administration.

Believe it or not, before the Second World War, Burma was the largest exporter of rice in the world. The country claimed independence from Britain in 1948, and, 40 years later, was announced by the United Nation as the the Least Developed Country. True, Rome was not built in one day, but, under appropriate hands, it could collapse in a shocking speed.

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

Oh, no. My interest in the British Burma is not quite related to its amazing capability in making an affluent country (Anglo-Saxon people almost always did well in this aspect), but to how they treat various groups of people there.

You know what, nearly 70% of the Burma population are Bamar (緬族), while over 130 ethnic groups constitute the remaining 30%. Notably, there are Shan (傣族) and Kayin (克倫族).

The catch is, most of the Bamar are farmers living in the central affluent part of the country, while Shan and Kayin (and most of the other tribes) tend to settle in peripheral mountainous areas. Rather than asking for democracy or consensus in any national policy, British administrator used a deliberately discriminating - and highly successful - strategy to run the country: Shan and Kayin people had had a free hand to run their own place (with a very low tax rate), while Bamar paid a higher tax but enjoyed a reliable (i.e. actively managed by the British people) legal and financial infra-structure - so that wealth could accumulate, or, in a less agreeable term, people were breed to become economic animals and forget about politics.

It all sounds familiar, eh ?

Burma

While reading my morning paper on the comment to a local political star by Scholar #19, I noted that Chua Lam (蔡瀾) was planning a trip to Burma.

My mother was slightly incredulous, "What good is there in Burma ?"

"Quite a lot, quite a lot." I tried to explain - although I've never been to this mysterious country, the place is not entirely unknown to me, "Burma has a fine mixture of India, Tibet, China, and Thai culture, and there're many good Buddhist temples to visit."

"Indeed ..." my mother began to see the point.

"Moreover, Burma is famous for producing precious stones - notably jade and ruby. Even back in the Ming era, most of the jade in China came from Burma. You may be able to find some good and cheap ones in their local market !"

PS. My interest in this little place roots from several reasons. Aung San Suu Kyi is one, but, more importantly, the administrative skill of British people - when they ruled this country - was really seminal.

Failure

"It is a failure." I said.

"No, I see it as a success." He retorted.

"That doesn't change the fact. The outcome is abysmal. You failed." I said once again.

"No. We've put up so much effort and many others contributed to the final result. It is a success for everyone who participated." He insisted.

"Did you really shed sufficient sweat and tear on this matter ?" I remarked, trying my best to refrain myself from using the word blood. After all, the matter shouldn't involve violence. And I continued, "You keep asking people to help, but did you treat them as your ally ? Did you make a corresponding contribution ?"

"Anyway, I will not concede that easily. Let's wait for the next time." He said, and his confidence seemed coming back.

I walked away, saying to myself, "Alas, there's a fine line of difference between having perseverance and being obsessive. It is silly to pursue on something beyond your capability, but it is an even worse sin to keep asking for another chance - without treasuring any of them."

PS. As Alan Greenspan once said: If you think you understand what I'm saying, you've definitely mistaken.

Success

(Discussion between the two friends of us continued.)

"Let's forget about consulting a Mao Shan specialist for the moment and focus on the problem at hand. What should we do with the vocational training school for our new recruits ?" asked the army general.

"I know that they are starting a new system so that young soldiers learn all military technique in a laboratory; they do not have to go to a battlefield before they graduate." The senior civil servant replied, "It sounds great because everything is under control and perfectly organized. What's the problem ?"

"The problem is," the soldier murmured, "there's hardly anything under control or perfectly organized in a war. No, I shouldn't worry about this. My real concern is people would soon realize the training is defective - many of the soldiers could not fire a gun or drive a tank. That becomes our problem !"

"Don't worry. That's been well thought of," the secretary of defence tried to sooth his friend, "You know, whenever we start a new project, the first thing - and often the only thing - we have to plan ahead is how to prove it successful. As to our vocational training school, I have asked the headmaster to show that their graduates look more confident when holding a gun, and could sit comfortably in a wheeled vehicle !"

The seasoned soldier almost fainted.

PS. The cabinet secretary was successful. A few years later, the school was running in perfect order and every graduate score full mark in the examination - as observed by my friend VW recently. See http://vwswong.blogspot.com/2010/05/test.html

符

(In another meeting between the Secretary of Defence and the Chief Commander of the Army.)

"You see, there's another incident. How could we accept so many accidents in a professional institute ?" The seasoned soldier roared.

"Isn't it natural ?" The senior civil servant tried to calm down his friend, "As the Murphy's Law says, any disaster that could happen will happen."

"But we got to do something and stop it !" The army general is of course a supporter of actionism.

"OK, OK. Maybe we can invite an expert and see to the problem." The Secretary conceded.

"What kind of expert ?"

"Well, we have two options," the civil servant continued, "First, we could ask an expert of Feng Shui (風水) and Mao Shan (茅山)."

"Could that help ?" the army general was incredulous.

"Absolutely. He will come and see to the problem. After that, he would write down special incantations - actually he would draw special Taoist magic figures that no one could or would read - on piles of papers. As long as you keep them safe in your drawer, and post a few everywhere you work, you can be protected from further mishaps."

"That doesn't sound really reassuring. What's the second option ?"

"That's our senior administrator," the secretary put up a wicked smile, "He would do the same thing and give the same remedy as our Mao Shan specialist - except his incantations are called guidelines and protocols !"

Vote

My mother voted on Sunday.

It's a slightly convoluted story. During the election two years ago, there was a mistake in her registration - so that she missed the chance to pick her favourite council member. This time, as soon as she knew there's a re-election, she was secretly overjoyed to exercise that right.

The problem was she spring her knee a week earlier, and was still walking with a limp on this very Sunday. Nonetheless, she insisted to go. As a result, Euterpe and I became the accompanying persons.

"Are you going in?" She asked me outside the vote station.

"Nop. You know, both candidates supported general election - which I am against. My original plan was to write that down on the vote. But that's useless. Our nominal supporters to democracy would still count mine as supporting their proposal." I explained.

The process took no more than 5 minutes. I took the opportunity and showed Euterpe what a vote station looked like. Alas, I wished so much to explain to my daughter what election and democracy is all about, but she's certain to young to comprehend.

And I should not expect too much - many die hard supporters of the day do not understand either.

Quality

Every time when I think of the King's surprise attack, I could not help disagreeing.

Shouldn't we base only on a candidate's performance to determine his result, and do away with ethical judgement on what he does in the spare time ?

Some of you may argue we need to have doctors with an acceptable standard of ethics. That's certainly true. However, professionalism is often independent of one's private life - a competent and caring doctor during office hour may still like to mix up with women (or men, no discrimination here) or ill-treat his father the rest of the time. If identified before he is graduated, should the medical school take any action and terminate his study ?

And that's the time I become schizophrenic. My neocortex says no, but my limbic system obviously opts otherwise. (Alas, not to say sex scandals, but merely to some student with golden hair. See http://ccszeto.blogspot.com/2010/04/blog-post_19.html)

I shall not elaborate any further.

PS. I am always skeptical to anyone who claim to represent (or exercise) justice - not only because I am not sure if objective justice does exist, but, more importantly, because a belief of this kind is the single most potent mutagen (and teratogen) to human neuron.

The result has been extensively published in textbooks of world history, as well as millions of tombstones in Siberia and its south.

Judge

Talking about surgical viva, it is well known to generations of our medical students that the King of the Round Table - at least when he was the chairman - would specifically do the clinical examination with a few selected candidates and offer a fair assessment.

(For those who are not familiar with the definition of fair, please refer to http://ccszeto.blogspot.com/2008/07/complaint.html)

In general, we did not worry that much; the King would pick only a handful of students who regularly skip the class. On one occasion, however, he did make a surprise attack and chose to examine a particular student (who almost always attend tutorials and lectures on time, and was one of the regular scholarship winner) in the most serious manner.

Many of us were suspicious and had very little idea what's going on. It was only some time later when we came to realize that particular student was mixed up in a scandal (to be accurate, a series of scandals) with several women.

PS. That very student passed, by the skin of his teeth literally (or with his skin on the King's teeth ?) - so much so he had to give up the plan of becoming a surgeon.

I suspect that's all what the chairman wanted.

Cohesive

Contrary to medicine, we also had a black-and-white viva list for surgery, duly posted on the student notice board the evening after we finished the clinical examination.

In other words, both fortunate and unfortunate candidates did have a whole night for preparation.

I still remember when the viva list of our class was out, we segregated into a few groups:

• Classmates with distinction viva would hide and study.
• Those who need to attend pull-up viva studied in the common room.
• Those who were free would help to brush up the knowledge and practice viva technique with the unfortunate ones.
• (None actually enjoyed the evening with ease outside, because the medicine viva list was not out until the next morning.)

Take aside all the stress and psychological trauma, the system did serve as an excellent cohesive force for a class of 120 students.

List

There's actually very little to say for the examination. As usual, before the viva list was out, some students turned up to my friendly colleagues and asked for some hint - or counseling in reality.

Many of you many not know 20 years ago there was no viva list of medicine after the examination. The chairman called the whole class of final year student to come to the lecture theatre the morning after clinical examination was completed, and announced the viva list. In fact, students who were requested to attend the pull-up viva had only 15 to 30 minutes for preparation - enough for nothing but putting on a tie or tidying up the dress so that one would look less miserable.

Alas, those were the sweet old days when the word privacy had not yet appeared in our dictionary.

PS. After my own examination, I had the opportunity of asking GN - the chairman at that time - for the purpose of such a short notice. His response was seminal:

We want to check how much they master, not what they could take in by short term memory.

Organizer

Finished with the final MB examination.

It would be the last time we have our man from Pluto with us. Fortunately, things went smoothly under the hands of JW, BK, TL and VM (who took much effort to take care of a delinquent examiner).

I would not elaborate the details of the happening here. Just that towards the end of the week, after finishing with the morning session, I was walking with one of the external examiners back to the main hospital block, and she asked me, "So, you've organized this thing for several years?"

"Alas, I began doing this since 1996 !" I put up an embarrassed smile, and diverted our discussion to another topic.

PS. In 1996, I was still a higher trainee. It should actually be KL organizing the examination (the duty of a newly promoted lecturer), but our later-to-be professor of gastroenterology had to attend an overseas meeting and recommended the malicious nephrology trainee to take up the task.

And the rest is history.

Maths

Believe it or not, my recent bedtime reading is How to Solve Mathematical Problems by Wayne Wickelgren.

It sounds amazing, eh ? However, my glory would dime down if you know the title of its previous version: How to Solve Problems - Elements of a Theory of Problems and Problem Solving. The author was a professor of psychology at MIT.

Yes, the pages are full of difficult mathematical formula - which I was completely at a lost by the final one-third of the book. Nonetheless, the techniques are generic ones, and could equally be applied to non-mathematical problems. In short, Wickelgren described the component of problems, and outlined six general methods to solve them:

1. inference
2. use sub-goals and action sequence
3. method of hill climbing
4. method of contradiction
5. method of special example
   
6. working backward

More importantly, the author also showed how to choose the appropriate method by analyzing the type of the problem.

It is always a pleasure to learn something that is entirely useless.

Drug

Don't get me wrong. I have nothing against Coca-Cola.

But it is really annoying to know, in addition to caffeine and high-fructose corn syrup, there is another addictive substance in the drink. In fact, this very material fulfills the criteria of an abused drug - it is both addictive and detrimental to health when consumed in excess.

Let's examine the characteristics of this substance more closely:

• After regular use for some time, a person would start thinking of another dose in 4 to 6 hours.
• If somehow he does not get a booster at once, he would certainly crave for it in 12 to 24 hours.
• Withdrawal symptoms include dry mouth, loss of skin turgor, agitation, and, finally, kidney shut down.
• Most abusers take it by mouth. If an excessive dose is consumed, the patient would develop adverse neurological effects, manifesting as confusion, convulsion, and, eventually, death.
• Occasionally, the substance is taken by the inhaled route. It could be lethal by inducing respiratory failure and cardiac arrhythmia.
• If a pure form of the drug is given intravenously, it would cause immediate hemolysis and occasionally death.

Scared ? More seasoned readers would now recognize, that very substance in question is our good old water.

Now, would you have more sympathy to Sherlock Holmes, and consider modifying your definition of an abusable drug ?

PS. The above discussion is not my invention. Have you heard of the dihydrogen monoxide hoax?

Cocaine

Many of you may know that cocaine, derived from the coca leaf, was present in the original version of Coca-Cola in 1861, and was taken out from the recipe nearly 50 years later.

Why ! Cocaine was legal in that era, and Sherlock Holmes was one of the most famous habitual users. It took several decades before it became clear that the substance is addictive and is detrimental to our health.

Alas, that's natural. Who knows without a hindsight ? As George Berry, formerly the dean of Havard Medical School, said: Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.

Even if we take our Coca-Cola as the example at hand, without cocaine, it remains addictive (for it contains caffeine). As to any possible detrimental effect to our health, it may take another 50 years before the effect of high-fructose corn syrup (HFCS, the sweetener that it uses since 1985) is completely clear.

By that time, it may be plain obvious that McDonalds in Tokyo is the most terrible revenge for Pearl Harbor.

PS. The famous statement of George Berry implies that there exists objective right or wrong - a courageous assumption in itself.

Secret

One subtle news that caught my attention recently was the claim of finding Noah's Ark (again) in Mount Ararat of Turkey.

I must say I am a non-believer (which has a fine line of difference from atheist; I shall not elaborate) and should not be too excited. Nonetheless, I was. And an entirely different story flashed back in my mind.

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

Fans of cola would know that Coke has a slightly different (or, you may say, attractive) taste from versions by other companies. It is widely recognized that the Coca-Cola company has a secret recipe, known only to a few senior executives, which gives its distinct taste. To add to the mystery, that few persons (probably 2 or 3) are not allowed to stay in the same hotel, or travel or dine together - so that if anything disaster happens, the formula would not be lost.

It sounds terrific, eh ? But, if you have the chance of taking a peep on the recipe, it may not be at all surprising - the attractive taste comes from our hope of enjoying a drink with some secret, rather than any physical substance in it.

A marketing strategy.

Ninja

My friend TW was furious recently with some youngsters who asked for government subsides so that they could buy their own house. (See http://hk.myblog.yahoo.com/cal-culator/article?mid=249)

I shall not elaborate my opinion on this matter. Just that a story of Bill Clinton came to my mind.

It went like this: Increasing home ownership was one of the major goals of Bill Clinton when he became the president of USA. As you would expect, it was particularly difficult for those new American immigrants who had a low income to afford their own house. Obsessed with multiculturalism, the Democratic president turned his effort to the private banking system. (The major one was the legislative changes in mid-1990s in relation to the Community Reinvestment Act.)

The result was simple. In short, even people with no income, no job or asset (so called "ninja") had a good chance of obtaining a mortgage to buy their own house. Well, it took almost 20 years before the bubble burst and it became obvious that those ninja should not buy something that they could not afford - even if someone lend them the money.

It was, as we all know (and suffered), the sub-prime mortgage crisis.

PS. Of course our local ninja did not want to get support from banks; they prefer to squeeze it from the government's pocket.

I'm sure the crisis would not develop in our banks.

Clear

(The story continues.)

CK was anxious; he was eager to know the questions, but he could not put up enough courage to ask the professor again.

He decided to find two companions to go with him, for psychological support, as well as for being independent witness - so that he would not be accused later for hiding crucial information from his classmates. (We all knew he would not, but CK was certainly the most careful person of our class.)

The two classmates that he chose were TS (who later turned out to be our gold medalist of surgery) and myself. When CK told us his plan, TS and I looked at each other; our eyes exchanged a quick understanding message, and we said together:

We think that PC's talk was very clear !

I still remember CK almost fainted.

PS. TS and I subsequently wrote down for the rest of our class what we believed was the secret message. In retrospect, there were seven questions in the paper, and PC gave us hint on six - obviously leaving one so that TS could score his gold medal.

Subtle

My friend KM was slightly disappointed: He had to write a warning letter to our interns, and he decided to use less offensive wordings; many of us disagreed.

Although love to say things in a subtle manner, I was one of those who tried to persuade him to use more explicit a language. (See http://drkmchow.blogspot.com/2010/05/wording.html)

While all these were happening, a little story that happened shortly before I took my final MB examination came to my mind.

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As a tradition, our class invited professors of surgery to give us revision lectures. (I suppose you know what these revision lectures were all about. If not, you are probably working in a non-medical field.)

The one by PC, our professor of orthopedics, came first. He gave an one hour talk in the lecture theatre, touching almost everything in the field, apparently without any focus.

Our class (most of us, at least) was perplexed. That evening, when we went back to the hostel and met in the common room, the confusion eventually crystallized into one point: What question was he actually going to put up for the examination ?

You see, that's serious. It was the primary purpose of the revision lecture, and a life-or-death situation. Our class immediately decided to ask CK, our class representative, to pay a visit to PC's office and clarify what he was trying to say.

(To be continued.)

Miscellaneous

Quite a number of interesting things are happening around the world.

The Shanghai Expo 2010 began. In the opening ceremony, Andrea Bocelli sang Nessun Dorma. This was the first time I missed Pavarotti.

Gordon Brown is ruined by that bigoted woman. What may skip your eyes is Nick Clegg is equally, if not more, damaged - because David Cameron now has a real chance of getting a solo win.

A woman collapsed on the surgical table in the office of a private gynecologist. Ambulance men were accused of delaying resuscitation and intubation. What about those fully trained doctors at the scene ?

A 4-hour radio program was sold to a political party; the owner of the radio channel received much criticism. But, is it not democracy all about respecting the right of people to say things that we do not agree ?

PS. Unfortunately, we also have to face their occasional annoying behaviour of not respecting our right to say things that they do not agree.

Story

I took a half-day leave on a Thursday morning and went to Euterpe's kindergarten to tell a story.

Yes, to a class of pre-nursery children.

(For those who are not yet parents, it is actually very common for kindergartens to invite parents to take turn and tell stories in the class. Kids love seeing their parents in the classroom; the parents would also like to have a glimpse on what's going on in the school.)

Kids of that age do not have very long attention span (but who has ?) and we have to finish with a story in 15 minutes.

The deed was not that difficult. I borrowed a picture story book from the public library, did some rehearsal (just to make sure of the time-keeping), and there I go. In short, I met a class of 10 or 12 lovely kids sitting in a line, and showed them the pictures in the book while going through the story. None of them ran around or cried. They were eager to say what they think, but were absolutely non-disturbing.

On my way back to the hospital, the scene of teaching our first year medical school two weeks ago flashed back in my mind (see http://ccszeto.blogspot.com/2010/04/blog-post_19.html).

I am sure I give today the best lecture in my past 10 years.

Know

You may think it is a basic right for our patient to know the pros and cons of every treatment option so that they could make their own decision.

True, it is a right that we, as clinicians, should respect. (A shrewd reader would note that I did not say facilitate.) However, it is, to say the least, silly to exercise this right when we become patients. We know just too well the consequence from the Genesis, when Adam exercised his right and ate the apple in Eden.

You may think it is necessary to weight the pros and cons for our own decisions. But no, as patients, we are not in the best position - we are often biased and blinded, and, as King Nikochan's servant loves to say, do not see the whole picture. We need someone cool and objective to balance the risk for us.

That's why we need the doctor, who does not only treat our disease and relief our suffering. Equally important, he takes the trouble and worry of knowing everything from our shoulder, so that we could sleep well under his hands.

In other words, I prefer to exercise my right not to know.

Go read Foster C. Autonomy should chair, not rule in Lancet 2010; 375: 368.

Right

Many of my friend would have the same experience of being asked to give medical advice on topics entirely outside our own specialty.

(Although having a grandiose personality disorder of knowing everything, I must admit, to say the least, I do not have the necessary detail. As Hercule Poirot always said, it is risky to form a conclusion before having sufficient information.)

Maybe I should show you my reply email.

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

Dear Sister,

The situation is no good, and I could understand her frustration. My opinion is there is no need to give too much thought to the pros and cons of various forms of treatment. If I were the patient, I would stick to the advice of the single best specialist that I could get. (I am no expert in cancer and would not be in the caliber to give a better advice.)

Szeto


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

You may think I am not giving a concrete response.

On that, you are wrong. My very solid advise could be condensed into five words: Do not think, just follow.

PM

My sister Jenny is not in the best of her mood recently.

Her best friend, PM, whom I also know personally, has colon cancer at the age of 40.

To complicate the matter, our friend is living alone in another country. (She communicates with my sister largely by SMS and emails.)

From what I was told, surgery was done a few months ago, which was followed by chemotherapy. Nonetheless, the tumor seemed to have spread to other organs. The decision now is apparently whether she should have another surgery or further chemotherapy.

"A losing battle," I said to myself.

But it is not easy to ask our friend to surrender. She does the best of what an educated patient could do: gets a detailed explanation from her doctor, searches for relevant information from all on-line resource, reads up medical books (she is a chemical engineer by training and has an exceptional capability of understanding jargon), and weights carefully the pros and cons of the two treatment options.

And, naturally, she also asks for my opinion via my sister.

Letter

In the afternoon that I was back from Chengdu, Vivian and I paid a visit to her secondary school - it was the open day to celebrate its 120th anniversary.

We didn't stay long. There's actually not very much to see. Nonetheless, in the school hall, we found an interesting letter in display - it was the original letter that a local official wrote to the Hong Kong governor at the time, proposing to set up a public girls' school.

The document was quite long (it gave details to the number of students planned, the proposed school fee, and so forth) and it took us a moment to finish. The letter was concluded in this sentence:

I have the honour to be, Sir, Your most humble obedient servant.

You find it outdated ? True. In fact, we are now often satisfied with Yours sincerely or Yours faithfully, and have done away with this kind of lengthy finale for ages. (I usually go one step further and conclude with the single word Sincerely. Well, who else could I be talking to ?)

However, wordy letters do not mean that people in that era were inefficient - quite the opposite in fact. The school was established a few months after the letter, without further paper work for surveying others' opinion or obtaining a consensus.

Good old days.

PS. The only opportunity that we could have a glimpse of elegant letters of this kind is to read Sherlock Holmes.

Leader

You may wonder why should our applicants with excellent academic record tend to give boring answers to the interview questions - they should be bright students after all.

The obvious answer is students with a good examination result may not be always the smart ones. They may simply do well in book work but have autistic personality disorder. (Many people do believe that these two traits have a correlation.)

But that does not explain the entire phenomenon. In fact, judging from their subsequent performance in the medical school, many brilliant and shrewd students do - deliberately or subconsciously - give as dull and answer as possible to interview questions.

Why ? It is because they have very good chance of getting in the medical school anyway. The only thing that they need to avoid is irritating the one over the other side of the interview table. A brilliant answer, in that case, is not a good choice - because there is always a remote possibility that it does not suite the palate of that particular professor. A dull generic answer would score you no extra mark (which the applicant does not need), but it will never trigger a negative response.

The situation is a variant of the "reversal of follow-the-leader strategy" in competition analysis.

Go read James Miller, Game Theory at Work.

PS. Once again, it proves my prejudice: It is often difficult to tell an ingenious crook from a complete idiot.