Pattern

The flaw is: Doing things randomly in this situation does not make you very much better off.

(For sure it is better than both sides stick to April all the time. But that's beyond the point.)

The best strategy is, really, to have an easily recognized pattern of alternating between June and April. Very soon, the other medical school across the harbour would get the message and follow suite and choose a different month every year - because it is to their advantage.

In other words, the two sides do not communicate by words, but by their action. It is a cooperative game, and both sides could do better if there is some kind of coordination between them.

Or, in a layman term, we are friends, not enemies.

(One major area of contemporary research in this field is on how to handle - and distinguish if possible - a delinquent behaviour and occasional careless mistake by your opponent in a cooperative game of this kind.)

It sounds very simple, isn't it? But the implication is slightly more profound than what you imagine.

Random

Which month have you chose ?

Imagine, if both sides want to take the edge of 1000 over 800 and pick April, they both end up as losers. But, if one constantly concedes and takes June, the other side would always get that trace of advantage and be ahead - which is not a very good thing.

So ...?

A naive solution, following the analogy of the football penalty kick, seems to be using the mixed strategy. In other words, you should pick the month by random, so that there is 50% chance of not having the conferences clash, and, if your opponent keeps choosing April, they have price to pay.

In an ideal world with the two sides being identical, both would end up with the same strategy, and the model predicts that both sides would pick the month by random.

It sounds great, eh? Do you see the flaw here?

Conference

You think it simple to make decisions at random ? I shall not elaborate on the difficulty of picking a random number of the human brain, but would rather show you another scenario:

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There are two medical schools in a city. Each of them holds an annual medical conference, which boosts up their grandiosity and is a major source of income.

By tradition and for practical reasons, they could have the event either in April or June. (There is the final examination in May.) The problem is: Which month is better ?

To give you a bit more details. If the two schools choose the same month, the number of delegates would be halved (let's say, 500 each) because you would hardly expect any doctor to attend both within that short a period of time. If one pick April and the other June, there is an edge of the former (as the old English sayings, the early bird catches the worm - or, at least, catches more worms), but both would do better than having their conferences clash (let's say, 1000 for the one picks April, 800 for June).

As you know, the two sides do not talk with each other, and they would only know the other's choice when it is announced - by that time it would be too late to change their own decision.

Then, which one should they choose ?

Penalty

(The reporter was amazed with King Solomon's plan.)

"You mention that your team needs to have protocol for everything, but is it possible at all to do so? Life is full of uncertainties. Well, let's take the example that you quoted. Do you need a protocol for the penalty kick ?" The reporter asked.

"Absolutely, absolutely," His Highness replied, "Our players have to specify which side they will choose to kick the ball..."

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

For those who have some elementary knowledge on strategy or game theory, you may immediately recognize this plan of the King is nothing more or less than absurd. The best result of handling a penalty kicking is to use the so-called "mixed strategy" - in short, you randomly select which side to kick. And, same for the goal-keeper, who should randomly select which side to dive.

In fact, even if the kicker has a better technique of shooting one side than the other, he should still do it at random - although not with a 50-50 probability in picking right or left (but should also depend on how good the goalkeeper is at diving to each side).

The calculation has been described in detail by Oskar Morgenstern and John von Neumann.

If you are obsessed with numbers, you may like to read this:

http://www2.owen.vanderbilt.edu/mike.shor/courses/game-theory/docs/lecture05/MixedSoccer.html

Accreditation

(The interview with King Solomon continued.)

"What are you going to do actually ?" The reporter asked.

"I shall ask all players to prepare written protocols for what they do." The wise man said.

"What kind of protocols ?"

"Protocols for everything - all possible and impossible scenarios that they may encounter during a match. For example, how they handle a penalty kick, what they do if they lose the ball to the opponent, and what to do if they sprain their knee during the match." The King explained.

"I suppose all football players know them well ?" The reporter was puzzled.

"Yes, but they have to write it down, and we will have dedicated people to come around regularly and check to make sure they do put down the details on paper. More so, soccer is a dynamic game, and the situation keeps changing. Our players need to update the protocol real time during a match."

"How could that happen ?"

"That's easy. For that eleven players who join the match, I shall assign two to sit down, do the record, and dedicate their time to prepare the protocols !" His Highness finished solemnly.

PS. As a fan of Liverpool, I find it plain enough why the team was not doing well: They do not have enough money, they could not recruit good players, and the club is led by aliens.

Liverpool

While we are all paying attention to the World Club, an exciting news comes from the Liverpool Football Club.

After Rafael Benitez was fired, Martin Broughton (chairman of the club) finds, what he believes, the most appropriate new manager - King Solomon from the East.

And an interview was promptly arranged with a local TV channel.

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

"I think you agree, your Highness, that the football team was not doing very well in the past few years. Many good opportunities were missed, and, more importantly, there were thousands of careless mistakes. There is, in short, risk everywhere !" The reporter began.

"Very true," the new manager was affirmative, "In fact, I have a good plan ..."

"Eh ...?" The reporter had a hallucination that he was talking to Baldrick of the Black Adder.

"Based on my successful experience in the East, I will starting doing an accreditation exercise for the football club." The King said solemnly.

(To be continued.)

Spill

Seeing that I did have some shares of PetroChina a few years ago, I could not refrain from thinking of the recent oil spill at the Gulf of Mexico.

I shall not elaborate on the details, but would rather show you a list of search and news headings that I came across when going through the topic in the internet:

• BP oil spill
• Deepwater Horizon oil spill
• Offshore oil drilling
• United States offshore drilling debate
• US oil politics
• US plan of energy independence
• US financial and public debts
• Global oil reserves
• US petroleum imports
• US Israel relations
• Jews and Arabs

PS. Frequent Google users know very well that as soon as you type a few letters, a list of suggested search items would come up. The very phenomenon is, when you type "United States Israel", the first term that Google suggests to follow is United States Israel relations, while United States Israel policy does not appear on the list.

You see, there is only relation, no policy.

Portfolio

While going through some old personal files, I found my investment portfolio in May 2007 - well before the financial tsunami.

It looks illuminating:

PS. I sold all of them in the following 12 months and bought only one back in the recent year - I won't say which.

Lords

As you know, British parliament is made up of the the House of Lords and the House of Commons.

Unlike the latter, membership of the House of Lords is not attained by election but is instead made up of the Lords Spiritual and the Lords Temporal. The former are 26 senior bishops of the Church of England, while the majority of the latter are life peers who are appointed by the Monarch on the advice of the Prime Minister. During the fifteenth century, the Lords were far more powerful than the Commons because of the great influence of the aristocrats and prelates of the realm. This superior position persisted until the 19th century, and only began to change in 1831, when the House of Commons passed a Reform Bill.

(You may wonder how could the Bill passed the House of Lords. That's easily solved by Earl Grey, the Prime Minister at that time, who advised the King William IV to overwhelm the opposition to the bill by creating many more members in the House of Lords who were pro-Reform.)

I shall not elaborate on the subsequent erosion of the Lords' power. Suffice to say, their right to reject a bill passed by the House of Commons is severely restricted by the Parliament Acts, where certain types of bills may be presented for the Royal Assent without the consent of the House of Lords, and they cannot delay other public bills for more than one year (so-called suspensive veto).

That's how civilized people do things.

Harsh

While thinking about the (lack of) prospect of general internal medicine, there seems a general belief that we are bringing up our medical students and trainees in a more humane manner as compared to twenty years ago. (A vivid story is recently outlined by my friend VW. See http://vwswong.blogspot.com/2010/06/biscuits.html)

I don't think that's a good news.

For example, if one cannot take sufficient care of herself (or himself, no sexual discrimination here) and allow time for her own breakfast before sitting for the final examination (and, at the same time, could not stand that brief period of hunger), how could we rely on this house officer to take care of our patients ?

Similarly, if you easily lose your nerve when seeing an examiner with his face a black hole or his angle of mouth twists with your answer, are we expecting you to defend your medical error by saying that you meet a nasty relative or quarrel with your girlfriend or being insulted by your consultant ... or being semi-conscious at 4 a.m. ?

You see ? We do not need encyclopedic knowledge - we want someone who still remember basic things when they are half-asleep or having acute delirium.

General

On the day after the farewell dinner, I went to Aberdeen and joined the College's examination on general medicine.

To be honest, the questions were rather difficult this time, and many candidates were taken surprised when they received questions of almost a sub-specialty level.

In the past, trainees from major hospitals had an advantage because they usually had much better exposure to a wide range of diseases. (I still remember one MRCP part II candidate from a peripheral hospital admitted that he had never encountered a real case of acromegaly during his three years of basic physician training.) Unfortunately, the argument seems reversed in recent years; large regional referral centers have so many sub-specialists that the main duty of a general physician is to determine what specialists to consult, and a physician (or trainee) would need to be able to do everything if he works in a small hospital and has nobody to consult.

As Geoffrey Vickers said (in The Art of Judgment):

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.

Euro

Since I slept very little the night before, I had to leave early in the farewell dinner.

When I jumped into a taxi, the driver asked in a smile, "Rushing home to watch the World Cup ?"

"Oh, no," I replied, and then, I said to myself, "Yes, I like football, but I'm hardly enthusiastic enough to watch the game live."

"Right, not everyone likes watching two dozens of people keep running and chasing one ball," the driver continued, "But our famous movie star really makes me mad. You know, when being asked on which team he thought would win the World Cup, he said it would either be Barcelona or AC Milan !"

I chuckled. My memory went to a story I heard from a colleague of mine.

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

One day, when a retiring economist was talking to his successor, the old one said, "You know, the tsunami is not yet cleared, and the financial system of America is still weak. I expect the US dollar would continue to go down."

The latter nodded and agreed; the comment was a Sunday school truth after all.

"Therefore, if you have some spare money, go for Euro." The former went on.

The young academic smiled and remained silent; his friend Warren had told him that much.

The old economist continued, "But, Europe is not entirely safe either - look at the PIGS !"

"Yes ..." the successor became slightly uneasy to keep quiet for so long, "Then ...?"

"Therefore, you should buy only the French or German Euro !" The economist finished with a triumphant twist of his lips.

石頭帽

A hot topic during (and after) the dinner was its very sitting plan.

I shall not elaborate on the details. For those who were there, we found an in vivo proof of Stephen Hawking's theory that black hole could exist in a miniature scale - such as a human face. For those who missed the opportunity of observing this wonder of the world, the incident could be summarized in one sentence: An important person was not assigned to the head table - he was omitted from the sitting plan altogether.

Of course, it is a matter of personality. BT, EK, and a few other senior members of the department also sat in a corner; they enjoyed an evening of happy private conversation. In fact, many of us could never understand what big deal it is to sit outside the head table - where food has to get down to your stomach via a retro-vertebral esophagus.

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

Many of my friends know very well that I have social phobia and always feel uncomfortable to appear in front of a crowd of people in a social function - not to say to sit at the head table. Some years ago, during a casual conversation, a friend of mine commented, "If you were having a chance of getting one magical tool, I suppose your choice would be the disappearing gown of Harry Potter ?"

My answer, even without thinking, was, "No. I would pick the stone-hat (石頭帽) of Doraemon. With the disappearing gown, no one would know you are there. The beauty of the stone-hat is, people around would be aware of your existence, but they would pay no attention to you."

What could be better ?

述懷

There were so many unfortunate happenings recently and, of course, our man from Pluto was not in the best of his mood during the farewell dinner. When he gave his little speech of thanks, he quoted the followings:

滾滾長江東逝水，浪花淘盡英雄。

是非成敗轉頭空，青山依舊在，幾度夕陽紅。

There was more than a trace of bitterness.

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

While our chairman was expressing himself by Chinese poetry, I kept thinking of an old piece by Wei Zheng (魏徵):

中原初逐鹿，投筆事戎軒。縱橫計不就，慷慨志猶存。

杖策謁天子，驅馬出關門。請纓系南越，憑軾下東藩。

鬱紆陟高岫，出沒望平原。古木鳴寒鳥，空山啼夜猿。

既傷千里目，還驚九逝魂。豈不憚艱險？深懷國士恩。

季布無二諾，侯贏重一言。人生感意氣，功名誰復論。

《魏徵: 述懷》

PS. Do not over-interpret. In fact I do not have a very high opinion with this political advisor of Li Shimin (李世民). Yes, he was straight and loyal, but he was not that much involved in the success of the Tang Empire - which was run by many other more capable people.

Hell

In the evening after I stayed up all night for kidney transplant, I attended the farewell dinner for our chairman.

There were a handful of important guests and the evening was very formal (an educated seasoned palatable polite synonym of boring). The King of the Round Table was there. As always, he was the one who made the best speech. This time, he just told a simple story:

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

I dreamed that I was dead. I went to the heaven and met St. Peter at the gates.

I asked if I could go in.

"What have you done on earth ?" He asked.

"I was a surgeon and saved many lives."

"Surgeons just cut up people - they should usually go to hell." He said.

"At one time I was the Secretary for Health, Welfare and Food in the Hong Kong government." I went on.

"Then you are a politician. For sure you should go to hell." St. Peter was not moved, but, seeing that I looked sincere, he went on, "Is there any other thing you did on earth that may help you entering the heaven ?"

"Well, I had been the Vice Chancellor of the Chinese University for some years." I reluctantly admitted.

St. Peter smiled, "In that case please come in - you had enough of the hell already."

Bean

Another thing that I did in my office in the middle of the night while waiting for my transplant patient was watching Mr. Bean.

Yes, the good old Rowan Atkinson; it's all available on the You Tube.

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

Like many people in Hong Kong, I first watched this comedy series in our local TV channel. In fact, I was not particularly impressed until I started my overseas training. On my BA flight to London, there was the movie Bean: The Ultimate Disaster.

No, it was not the best comedy - not even as good as many of his plots on the TV. Nonetheless, I watched it at the perfect time; anything that was remotely funny would cheer you up when you are on a lonely journey - and I became a fan of Atkinson since then.

PS. Another masterpiece of Rowan Atkinson is Black Adder - introduced to me by my friend TW some years ago. If you learn the history of the Three Kingdoms Period by reading Luo Guanzhong (羅貫中), this BBC comedy serves well as the textbook of the history of England.

Planner

After some self-struggling and ambivalence, I ended up buying a Moleskine 18-month weekly planner.

You know, I used to keep my appointments in my Google calendar. I could synchronize the information with my iPhone, in which I also keep personal notes, things to do and various ideas. It works well for a while, but typing on a iPhone screen is often painful.

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

The main problem of having a new planner is certainly transcribing all appointments from the old software. It must be my luck because I just have a few hours at night having nothing to do in my office - waiting for my patient to finish with the transplant surgery. What could be better ?

And, in fact, during the process, I suddenly realize my life is not all that complicated.

Thank god.

Police

Met my friend L recently and had a brief chat. (For my relation with L, see http://ccszeto.blogspot.com/2010/01/landlady.html)

"How's your landlady recently ?" I asked.

"Nothing new - she keeps making the same kind of news. You know, she treats her son so badly that I have seriously thought of asking help from the police living at the other side of the street ..." my friend said.

"Indeed ...?" I saw his hesitancy.

"Well, I did not. To be frank, I'm not as fond of him as I was a couple of years ago."

"Why ? I know this neighbour of yours. He seems a good lot and did help out people in need." I said.

"You know, he is heavily in debt." L whispered.

"That's no news." I wasn't moved.

"He's mixed up with the gangsters who attack the flotilla recently." He added.

"Em ..." I knew the fact, but did not ever take it seriously; I began to feel uneasy.

"And, when one of his tenants - an entirely respectable old woman - commented that he should not support the gangsters, he beat her up badly so as to keep her mouth shut !" Checkmate.

I was speechless. As George Orwell said, I look at the police and the landlady, and find it difficult to tell which is which.

1795

On 8 February 1795, Emperor Qianlong (乾隆) abdicated in favor of his son, later known to be Emperor Jiaqing (嘉慶). It was a filial act of Qianlong, in order not to have his reign longer than his illustrious grandfather, Emperor Kangxi (康熙).

Despite his retirement, however, Qianlong retained ultimate power until his death in 1799 (making him in reality the longest reigning Emperor in Chinese history).

The plot was simple. Most of the senior government officials were appointed by Qianlong and, by regulation, could not be changed by the new emperor. To make the system even simpler, the old dictator needed to control only one person - Heshen (和珅).

Now, you may come to realize why could Heshen become the most wealthy courtier in the history of China. Qianlong was not all that thick and unaware of all the wrongdoings of his prime minister - the wealth from corruption was the price for the loyalty.

Qianlong was certainly not an economist.

PS. Six days after Qianlong passed away, Heshen was arrested and forced to commit suicide - that's probably Jiaqing's only correct decision throughout his 25 years of reign.

Substance

While talking about being politically neutral, I must declare I do very much prefer to support the political reform proposed by Donald.

The problem is I do not know what I am actually supporting.

Yes, our senior government officials do put up much effort (and resource) in promoting the issue. They are here, there, and everywhere, busy distributing pamphlets and getting away with the oppositions. I see a new dressing by a remarkable mother, a pair of elegant dancers, and three council members reminding us to act now. But, what's in the proposal ?

"It's all written black and white. You can write to the responsible government department to ask for a hard copy, or go on-line and download from their web site." You may say.

But I have dyslexia; I am one of the many simple naive poorly educated barely literate ordinary Hong Kong citizen who hardly ever read anything. Can his Highness kindly tell me what I am supposed to support ?

PS. For the same argument, the principal question that seems to skip every one's eye is: What actually is the topic of debate between Donald and Audrey ?

Yes, it is about the proposal. But, what exactly is it ?

Balance

To go one step further, would it be necessary to have a balanced expression of opinion from all parties (as I suggested a few days ago) ?

Let me show you another article by Jerome Kassirer.

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

Over the years we have received numerous queries from readers and reporters about controversial editorials... The confusion centers on two questions: Whose opinions do editorials represent? And why don't we regularly seek "balance" on controversial issues?

... When we select opinion pieces for publication, therefore, we consider the importance of the topic, the novelty of the argument, and the logic and persuasiveness with which the argument is made, but we do not ask whether it conforms to today's dominant view, nor do we necessarily agree with it...

... We also believe that trying to balance one point of view with its opposite each time we feature a controversial subject would be insulting to our readers. It would imply that they cannot evaluate an argument on its own merits or retain and modify it in the light of later arguments...

... We cannot afford to be too concerned about whether some people or groups will be offended. As Benjamin Franklin said, "If all Printers were determin'd not to print anything till they were sure it would offend nobody, there would be very little printed."

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

Go read Kassirer J and Angell M. Controversial Journal editorials. N Engl J Med 1997; 337: 1260-1261.

PS. Jerome Kassirer was later fired by the Massachusetts Medical Society, I know.

Influence

Rather than dwelling on the debate of being politically neutral, let me share with you an old article written by Jerome Kassirer, formerly the editor of the New England Journal of Medicine.

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

When Dr. E. Ratcliffe Anderson, the American Medical Association's executive vice president, announced on January 15, 1999, that he had fired the editor-in-chief of the Journal of the American Medical Association (JAMA), he said that an important factor in his decision was the publication of a research article ... had been advanced ... ahead of schedule with the intent of influencing a major political debate ...

... In my view, a medical journal should not be a dusty archive of clinical studies and review articles, but a lively forum for exposure and discussion of important issues that involve, even indirectly, health and medicine. Articles on ethics, legal issues, health policy, human rights, and health economics published in a respected medical journal can have a bearing on ongoing political decision making at the state, national, and international level. Because of the enormous range of issues that are brought to the attention of medical editors daily, they have a unique opportunity to contribute to such debates ...

... Editors should be sufficiently humble to appreciate that what we write or publish may have limited influence on political debates. Usually, we have little idea of the effect. Nonetheless, I believe that medical editors have an obligation to publish not only articles that are well reasoned, informative, and carefully reviewed, but also ones that are sufficiently timely to contribute to the development of public policy.

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

University professors should think the same.

Go read Kassirer JP. Should Medical Journals Try to Influence Political Debates? N Engl J Med 1999; 340: 466-467.

Nihilism

Maybe I shouldn't be too cynical.

But, let me make it clear, neutralism is not nihilism.

In other words, keeping politically neutral does not mean that one should not support a candlelight event - unless the university would collapse in a year or two and could support only one event. Being neutral should mean that it supports a Dove-club meeting in June, a debate between Donald and Audrey next month, a ballet performance of The White Haired Girl (白毛女) after next, and so forth. Politically neutral means that the view of each minority group (or, actually, each individual) would have an equal chance of expressing - not that if not everyone could express their view at the same time, no one should say anything.

Of course, our friends are not nihilistic actually. As George Orwell said, they are just more neutral to one side than the other.

PS. The problem is many of our die-hard fans of the Statue do not appreciate the point either. Voices against them are brutally brought down by loudspeakers or bananas. I am inclined to believe guillotine would be back on the market if they do seize the power !

Neutral

I am impressed with the decision to uphold political neutralism.

(Maybe they would, for the same argument, also ban our senior government officials from coming to the campus and promote the proposal for political reform.)

But it is your fault; you are all mistaken - and do not comprehend the meaning of neutralism.

It means they are standing on the central point (alas, neutral) of the field, or, in other words, sitting on the fence.

Therefore, if one side seizes power and dominates, they belong to the winning side.

Of course, if the wind changes in direction and the opposite side takes its turn, they would still fall on to the winning side.

Haven't you heard of market economics ?

PS. Don't laugh at my definition of neutral. It is not my invention. You may not know, but the United States Senate is chaired - according to the regulation - by the Vice President, who should in theory be neutral. What it means is he would not vote, which, in reality, implies that he only stands on the winning side.

Examiner

That evening, when we sat around the dinner table and had a few glasses of champagne, the air seemed cool down a bit, and we could devote ourselves to some less colorful discussions.

"You know, we do not have enough examiner for the membership examination." Our man from Pluto said.

"Quite so. In fact, we have even fewer examiner doing the annual and exit examination for the College." I murmured at the other side of the table.

"Indeed ..." JW was sitting next to me and looked curious.

"The College examination is now almost entirely conducted by consultants of peripheral hospitals. There is hardly any academic staff from the two medical schools sitting there. That's understandable: The examination takes quite a bit of time and is rather boring. I don't see any reason why a university professor would like to do it." I explained.

"There's in fact no reason why any one should have the incentive to become an examiner," LY, sitting at the other side of JW, added, "If a candidate passes, he would take the credit. But if he fails, the blame would go to the examiner. What a easy way to create antibody ! If you fail one candidate each time and do the examination twice a year, throughout the whole of the 25-years of your professional life, you would have 50 die-hard enemies in this profession - many of them may have take some senior positions. Just imagine the result !"

Paradox

I should not have said our government always hold the purse tight for health care. During the department dinner, I met YK, a previous colleague who moved to the government recently, and RW, another friend of mine who has regular interaction with extra-terrestrials.

"So, the life is good in the government ?" RW asked.

"Quite so, quite so," YK humbly replied, "The life is leisured, and the prospect seems not bad."

"Not bad ? What a term ! You are working in the most remarkable part of the entire health care system." RW chuckled.

"Eh ...?" The two of us made an inviting grunt.

My friend continued to explain, "Extra-terrestrials use a different system of logic. You know what, if their job ends up a mess, the conclusion is they do not have enough resource and manpower. In return, the government chips in more money, more people are employed, and more senior posts are created for promotion - so that they could make a bigger mess, and the cycle repeats."

I could not help smiling - thinking about what could rise to the top besides creme de la creme.

Expenditure

Fans of human right may argue: Indications of treatment should be based on medical evidence rather than working backward from the available budget.

The idea is not new. In response to the Great Depression, John Keynes argued that government spending should not be limited by the amount of taxation income, but be determined by the need of the society. It was proposed that a high government expenditure would boost the economy, and there are ways to cover the fiscal deficit.

I am no expert to comment on Keynes' hypothesis. But, to say the least, it was put up as a remedy for recession. By the law of mathematics, the accumulated deficit could not growth endlessly. Yes, during the bad years we may overspend a bit to keep the ball rolling, but the book needs to be balanced again when the drought is over.

Alas, some European PIGS used Keynes' strategy of over-spending during the period of economic growth - I don't think I have to elaborate on the result.

PS. Of course it is always a curious phenomenon that our government overspends in some areas (for example, bidding for some international games) while holding the purse tight for health care. That's another story.

Deficit

The very method of paving our way to hell seems everywhere. On the evening of the consultant interview, I attended a celebration dinner of my department. Our man from Pluto was slightly late. Soon after he finally arrived, he was involved in the discussion with FC on our drug budget.

It is no news that we have an astronomical deficit.

The cause of the problem is, maybe to your surprise, rather clear. There are a number of diseases (I won't say one) that, over the recent years, creatures outside the solar system decided to follow the international standard and loosened the criteria of using several expensive medicines - which was followed by a corresponding surge in the prescription of these items, of course.

The catch is: The total drug budget was not increased.

What would happen ? Imagine a gigantic dinosaur: Its legs (and ass !) agree to fled from the Tyrannosaurus near by, but the heart (controlled by the autonomic nervous system - remember, autonomic) declines to increase the blood supply to the muscle.

The result is - please excuse my language - an inevitable PK.

PS. As a response to the deficit, our man from Pluto actually suggests to use the strategy of working backward to define the indications of those expensive new gadgets: See how much we could afford, then set up corresponding criteria so that the estimated number of people would fulfill. (After all, as always proclaimed by the government of our mother country, we do not have to follow any so-called international standard.)

This is one of the rare occasions that I fully agree with my chairman.

Interview

While I was thinking about the difficulty of recruiting suitable trainees, several friends of mine attended an interview for the new consultant post of my department.

One question that appeared was: Do you think it important to set up an emergency service for the treatment of X ?

(For discussion purpose, X could be any acute medical condition that could be treated by an on-site specialist - take aside the need of some dedicated beds, skilled nursing support, and money.)

When one of my friends told me this question, I commented, "Right, the emergency treatment under question has proven value by clinical study. Nonetheless, I would insist to answer NO. There are only two or three sub-specialists in the region to offer this treatment. Setting up an emergency treatment service today would mean their resignation tomorrow. At the end of the day, we couldn't even offer the treatment on an elective basis."

PS. Unfortunately, extra-terrestrials have a different structure in their nervous system, and my opinion is in the minority. As the old proverb says, the road to hell is paved with good intentions.

Choice

Although not directly (and indirectly) involved in the process, I must say I understand very well the difficulty of recruiting new physician trainees as mentioned by MT.

In fact, it is quite a positive feedback and vicious cycle: If the department is well run and in harmony, everyone would like to stay; promotion prospect diminishes and there would be fewer place for new comers. The good thing is only the best applicants would be selected.

What you may not notice is the inadvertent effect: Consultants of those less advantaged hospitals (a term of my invention, hope you like it) tend to accept mediocre applicants - because, even if interns with an excellent academic record and working performance accept the job, they would inevitably default and take up a "better" offer.

PS. The unexplainable fact is, some consultants of those more advantaged hospitals continue to have a peculiar taste of picking new trainee - and do not see the simple fact that a healthy department needs people of different skills.

See what Florentino Pérez achieved in Real Madrid.