Review

It comes to the end of 2011 - a good time to review my portfolio.

Here is mine on 31 December 2010:

Yes, it was very much diworsified. (Quite against my personality I must say.) On that day, the Heng Sang Index closed at 23035. I had around 21% of my portfolio as cash.

What happened to it after one year? Let me tell you tomorrow.

Rebuttal

In a peaceful afternoon, my friend WY came to my office, rather unexpectedly.

She was obviously not very happy.

“Em… Szeto, does the specialty that you are talking about begin with X?” She asked.

In no time I realized she was referring to my recent blog on specialty board examination. (See http://ccszeto.blogspot.com/2011/12/question.html)

“Oh, yes. What’s wrong?” I felt like a primary school student being caught red-handed by his class mistress after doing something naughty.

“Nothing. Just that the questions you mentioned is not the truth – or, at least, not the whole truth.” The consultant said.

“You mean…?”

“Well, we did ask for specific guidelines and FDA recommendations, but, the discussion began with clincical scenarios related to the routine management of common problems, and what information the candidate would provide to his or her patients in real life.” My friend gave her version of the story – which was the examiner’s account, “But, since some candidates seemed having very little idea how some common drugs are used as well as their important contraindications, we had no choice but needed to probe at specific angles – so as to make sure the candidate really did not know what’s going on.”

I nodded. As always, the same event is described in entirely different manner by two different persons. This little incidence of Rashomon also serves as an excellent illustration of a general principle: Students (or candidates in professional examinations) never fail because they do not know the answer of difficult questions; they fail because they trigger the examiners to ask those questions. As a rule, a student has already failed when his examiner decides to ask some difficult stuff.

PS. The opposite is also true: A distinction candidate is not someone who could answer difficult questions, but the one who could answer simple questions in a confident and seamless manner.

Gen'ya

My recent bedtime reading is Gen'ya (幻夜) of Keigo Higashino (東野圭吾).

This novel is widely regarded as  the sister work of Byakuyakō (白夜行), another story written by Keigo. But, it appears to me not the case. Byakuyakō is, in its heart, a story of romance; Ryoji Kirihara (桐原亮司) and Yukiho Karasawa (唐沢雪穂) were, in the jargon of Agatha Christie, partners in crime, and, although they never met formally in the novel, were in a genuine and legitimate relationship.

In contrast, Masaya Suwon (水原雅也) was a tool of Mifuyu Shinkai (新海美冬) all along. Did Shinkai ever think of having a permanent relationship with Suwon? Obviously not. The plot is not a a variant of Byakuyakō, but really resembles Human Metamorphosis (Ningen Konchuki, 人間昆蟲記) of Osamu Tezuka (手塚治虫), and Shinkai is no doubt a modified (and malicious) version of Toshiko Tomura (十村十枝子).

PS. In fact, before the final combat between Suwon and Inspector Kato (加藤亘), the unfortunate engineer should have rung up Shinkai and asked, "Why do you hide everything from me? Aren't we a duet of crime - just like Byakuyakō ?"

"You read too much Keigo Higashino." A voice with no emotion appeared from the other side.

Antidote

Another rumor about MSG is that one could treat (or prevent) the Chinese restaurant syndrome by drinking Coca-Cola.

On the face of it, that's entirely reasonable. Coke contains caffeine, which would effectively combat the headache induced by MSG; the sheer amount of water obviously relieves the thirst sensation. In fact, a cup of light coffee should do the same.

But, you know what, if you search MSG and Coca-Cola together in Google, the most widely advocated effect is, the combination becomes an aphrodisiac.

Of course that's not true. Neither MSG nor Coke has that effect, and the two certainly do not have a chemical reaction when mixed together. (Otherwise Pfizer could not have make so much money from Viagra.) But, the plot is ingenious - once again, what could make a better advertisement and induce people having that sweet brown beverage when they go to a Chinese restaurant?

Maybe that's the rare occasion when an antidote is the same as an aphrodisiac.

Thirst

You may wonder there might have been a lot of MSG in my food - just that I did not notice.

Well, I consider that quite impossible, because I am actually very sensitive to MSG.

No, I do not have flushing or headache or whatever with it - except an intolerable sense of thirst. In fact, as a traditional Chinese, I am quite accustomed to, and do enjoy, salty food. (Not a nice declaration by a nephrologist, I know.) I could finish with a good serve of salted fish (鹹魚) or pickled tofu (腐乳) without drinking any water.

But, when it comes to MSG, the need of something to drink is irresistible. In fact, I used to tell a distinguished English professor of nephrology that we have glutamate receptors in the thirst center of our brain, and it explains everything.

That's a hoax, of course.

PS. Human brain does have glutamate receptors, but they are found in the learning and memory centers.

MSG

One slight surprise for the several meals that I had during my little trip to the other universe was there was very little MSG in the food.

Yes, I do mean monosodium glutamate, which add to the taste of umami (鮮味) in our food.

Oh, I'm not against the use of MSG - quite the contrary indeed. As Chinese, most of us would expect some scientific additives in the food serve in any restaurant. If it does enhance the flavor, why should we worry about an amino acid?

Many gourmets and food critics are, however, against artificial substance, not because it may be unsafe, but for the very phenomenon that MSG would mask the flavor of other natural ingredients in the dish. Well, scientifically, that's entirely sound. To begin with, it is now known that, in addition to the four primary tastes (salty, sour, sweet, and bitter) and umami, there are other non-traditional tastes - notably for purines and long chain fatty acids. An excessive stimulation of the glutamate receptor would obviously make one be less aware of signals from other pathways. Orthodox neurology teaching actually states that a substantial part of taste does not come from the tongue, but, rather, the nose. It is therefore silly to stimulate just one kind of taste bud and forget about the more important part.

PS. When you swallow, a negative pressure is generated in the nasopharynx, so that volatile ingredients of the food could fill up those tiny air chambers and stimulate the olfactory nerve. That's why we could tell so many kinds of taste despite there are only limited types of taste receptors on our tongue -  we have about 400 types of smell receptors.

Sprout

While choy sum is probably the most common kind of vegetable I have in Hong Kong, my personal favorite is Brussels sprout.

I first encountered this tiny variant of cabbage when I was doing my overseas training in Bristol. It appeared two or three times each week as the side dish in the hospital canteen, and, I must say, the taste was horrible. British people have absolutely no idea how to cook the veg and these little green spheres are always put into boiling water - which invariably results in overcooking.

(Specific for Brussels sprout, overcooking does not only mean making the veg gray and way too soft; it releases glucosinolate sinigrin, a special chemical you find in this tiny green balls, resulting in a repelling sulphurous smell.)

Fortunate for my taste bud, I was not put off by the clumsy chef of the hospital canteen. Soon after I settled, I find this lovely spheres in a local supermarket, selling in discount. I bought some, tried stir-frying them that evening with a bit of soya sauce - and, hooray! There's no pungent smell, and, yes, the center was slightly bitter. But if you like the taste of bitter melon (苦瓜), the little green balls are certainly more chewy, and, because their taste is less sharp, you do not need to mop up the bitterness (and therefore the freshness of veg) by douchi (豆豉) or other strong seasoning.

PS. Oyster sauce was even better than soya sauce for enhancing the flavor, as I subsequently found out.

菜心

A few days after I cast my vote, I went to the other universe to teach a course for some postgraduate students.

I shall not elaborate on what happened, or my view on our alternative universe. But the dinner was remarkable. In the evening after the first day of the course, the host brought the three overseas speakers - me included - to a local restaurant somewhere 10-minute walk away from their hospital campus.

The place looked like an ordinary Cantonese restaurant you find in any public housing estate of Hong Kong. The menu was also a humble one - no shark fin or abalone. Oh, there was a good dish of pan-fried foie gras, but it seemed the residual material from a place famous for roast goose.

The climax came towards the end, when the green was served. (For those not familiar with the custom of a Canton banquet, a dish of green is usually served towards the end of the menu, generally before some carbohydrate - rice or noodles - and then the dessert.)

It was a large bowel of choy sum (菜心) in a clear broth.

I shall not describe how good it was - words fail me. Supposedly it was a delicate mixture of freshness, crispness, and sweetness - or the pleasure of stimulating the taste buds paradoxically by the absence of any stimuli.

"This is gorgeous. What's the secret in it?" One of the overseas speakers asked.

"Oh, nothing. It's just fresh from the garden of our consultant." The host said, blushing a little.

Study

By coincidence, my friend VW also talked about our recent election in his blog yesterday. (See http://vwswong.blogspot.com/2011/12/election.html) He rightly pointed out that candidates were not hiding their choice from us, but from the future winner.

I read VW's blog on my way to the hospital. During that 20-minute bus trip, when I came to think of it, the problem is more complicated than I suspect.

To begin with, the risk of offending the future CE, if you happen to support the wrong side, was actually minimal - and, to balance out, there is always the potential benefit of supporting the correct one early. (It brings the problem to another level of discussion: What is the purpose of running for the Election Subcommittee? Is choosing the future CE an end, or is it for future personal benefit?)

Alas, let's better focus on science. Say, amongst that 80 candidates, if one comes out and declare which side he supports, would that give him an edge to win? I presume yes, if there are sufficient number of people who have make up their mind already. In that case, by the game theory, declaring support to the obviously favorable side (be it the pig or the wolf) would become the dominant strategy, and you would expect every candidate to come out and declare the same. By then, the few candidates who refuse to declare their intention would not survive; it doesn't really matter to whom we cast our vote, and there is actually very little glory to become elected.

This is true democracy.

PS. When the bus came out from the Tate's Cairn Tunnel, I came to the conclusion that it might be a good idea to test my hypothesis and run for the election next time with the dominant strategy.

But, alas, no, thank you. I am not that devoted to science.

30

While I was impressed by H's strategy of advertising himself, in the following afternoon, I voted in the Chief Executive Selection Election Subcommittee election.


As an ordinary doctor with dyslexia, it was in fact a trying task to vote this time. There were some 80 candidates running and we have to pick 30 from the list. Although there are a few obvious name lists, candidates of those did not appear in consecutive numbers, and I am sure no medical practitioner could remember a list of 30 names or numbers - people with such an extraordinary memory and intelligence should have found a better job in the financial market.

Therefore, at the end of the day, I picked only seven or eight - there were overwhelmingly so many that I certainly did not want to be elected.

But, as soon as I walked out from the voting center, I regretted. 

Mine was the worst strategy to achieve my own purpose. By the law of game theory, I should pick a full list of 30 - not for the purpose of fully executing my right, but to increase the chance of winning of those who I was not particularly against, so that they could have an edge over H and those who rose to the top but were not the cream.

I shall do better next time.

PS. On the contrary, picking 7 or 8 (when you could pick 30) is the appropriate strategy when there are a few candidates who you definitely want to win, and you do not really care who else on the list come out.

Advertise

Met WC in the wedding banquet of MT.

I did not meet our previous consultant cardiologist for quite some months – and he certainly had not changed.

“You know, it is really eye-opening to see H running for the Chief Executive Election Subcommittee election.” He said. (H used to be an academic staff over the other side of the harbour, but resigned and joined the private market a few years ago. He is a specialist of treating celebrities and wealthy women – or, as it later turns out, so we used to think.)

“To be honest, I could not make head or tail of his move.” I remarked, “I suppose he is not so naïve to believe he has enough friends to vote for him?”

“Lack of insight is a necessary criteria of personality disorder,” WC murmured, “But that’s beyond the point. I’m sure he has achieved his primary aim.”

“Which is…?” I was curious.

“He has gained legal permission to put up posters and banners in almost everywhere in the city,” my friend went on to explain, “I could even find his picture and summary of qualifications in the lobby of some public housing estates! Although hardly anyone living in those places are eligible to vote for him, what could make a better advertisement?”

I finally saw what my friend was getting at. Just like many items in our stock market over the past one year, cheap things could always become even cheaper.

Lunch

That very Saturday proved to be an exceptionally busy one. By noon, once I finished with my presentation in the advisory board meeting and answered a few questions, I had to rush back to the Chung Chi Chapel and joined my wife. It was the wedding ceremony of my little friend MT, who, for reasons that I never understood, asked Euterpe to be one of her flower girls.

Everything in the ceremony went as planned, and Euterpe was overjoyed to make acquaintance of some new friends. The only set back was my daughter and I had to leave before we could take some photo with the bride – It was the music class examination of Euterpe that afternoon.

And, by the time I found myself in a local fast-food store and had the chance of examining a bowel of suspicious semi-solid labelled with much imagination as wonton noodle, it was nearly sunset.

All of a sudden, the famous teaching of Zhu Bo Lu (朱柏廬):

一粥一飯，當思來之不易；半絲半縷，恆念物力維艱。

Temptation

To be fair to my new friend, he finally took my advice and I could use my own slides – certainly with some new additions suggested by him. The meeting on Saturday went smoothly, and it served as an excellent example of Humphrey Appleby’s teaching:

As in all public performances, the real work is done in rehearsal, behind closed doors.

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

Nonetheless, a minor incident in the morning was worth mentioning.

It went like this: I arrived slightly early for the meeting, which took place in the function room of a local hotel. Naturally, I turned on my computer and did some work of my own. A few minutes before the meeting was formally started, a secretary approached me with a little card, "Sir, you need a password for the wireless Internet connection. Here it is."

"Oh, that's very kind of you." I smiled, stretching my arm to take that tiny piece of paper.

But, in no time, I stopped - before I actually reached the card. All of a sudden I saw light and withdrew my hand, "Thank you, I think I don't need this."

"Wouldn't you like to check your email and go on-line?" The secretary looked puzzled.

"Exactly, I would not like to. That's the only way I could do away with all temptation and focus on some serious work." For a moment I was serious.

Advice

(My remarkable evening continued.)

Time flied. I regained consciousness one-and-a-half hour later.

“So, what do you think?” The verbose man finished – at last.

“I suppose I am supposed not to think?” I said to myself. But, instead, I put up a friendly smile and said, “I could not agree with point one of your conclusion…”

“Oh, how could that be?” My new acquaintance was obviously surprised, “Don’t you agree with the animal data that I showed – which are all very convincing?”

“Em… What you showed was your new drug is not toxic to the kidney. It really doesn’t prove that the drug protects the kidney.” I pointed out.

He paused for a moment before saying, “Doesn’t our human experiment also show the same result?” I refrained to comment any further, but, instead, gave him my favorite response of Dr. James Sheppard (in The Murder of Roger Ackroyd), “I must be off home. Thank you for a most interesting and instructive evening.”

“Oh, no. Not yet. Just a moment more,” my Hercule Poirot said, “We have to go through your slides as well.”

I began to wonder why Dr. Sheppard did not try to silence the great detective once and for all.

“Eh… I suppose I know them very well?” I hesitated to suggest.

“No, not now. I made some new slides for you.” He said.

I must say the remarkable director was right – I could not recognize my own slides when they were shown to me. He had not only added a few new slides (if 20 slides for a 30-minute talk are a few), he also changed the sequence of my old slides, choose a new slide layout, and used a different font for the text.

And, as you expect, he certainly showed me how he expected me to present – or what I should say in the presentation.

I believe my memory was very bad and he had probably told me when we greeted each other two hours ago that he came from Russia and he was a former KGB officer.

“Don’t put words into my mouth – not to say idea into my head,” I left by playing Mary Debenham of The Murder on the Orient Express.

My Hercule Poirot was stunned.

PS. I encountered this little incident before my friend VW described in his blog AL's story (see http://vwswong.blogspot.com/2011/12/invitation.html). It is really an honor to be compared to the Queen of Hepatitis.

Rehearsal

(I must have a flight of idea and the story I recalled keep moving back and forth. Let’s go back to that lovely afternoon of our own board examination, which passed quickly and smoothly.)

In the same evening, I was scheduled to have a meeting with two representatives of a drug company in the café of a hotel nearby.

Oh, no. They’re not going to sell any drug to me. On the contrary, they were asking me to join the advisory board for the development of a new product of theirs. They actually made that request a few weeks ago, and we were supposed to have a formal meeting that Saturday – where I would give a brief talk and summarize my suggestions. I gave them the slides a week prior to the meeting, and, to my surprise, the contact person of their local office called me and told me that the director of product development of their headquarters wished to see me in person two days before the formal meeting.

“We just want to go through the slides.” I was told.

I arrived on time, and was met by the director – a verbose middle-age man from some southern state of America, and a nondescript assistant of his.

“Let me first show you the slides that the first speaker is going to use,” he said. (By the way, I was going to be the third speaker, and the second on the timetable was this sales director.)

It turned out that he did more than what he said – he gave the talk, from head to toe literally.

I tried my best not to snore – at least not loud enough to disturb people sitting at the next table.

When I woke up thirty minutes later, he had, apparently, just finished.

“Now, let me show you my slides,” he went on.

I decided I could have a longer nap, and was suddenly thankful for the years of training in medical school – so that I could sleep when I am sitting upright, sometimes even with my eyes open.

(To be continued.)

Question

I am sure many of our HPTs of other specialties would not agree with me and our local board examination is not always easy - at least for a few highly celebrated specialties.

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

Just a few days ago, I met L outside the ward. He caught me in my arm and said, "You know, quite a few candidates failed in the XXX board examination last week."

"That's not news. This is one of the most difficult specialty - at least in terms of board examination," I smiled.

"Have you heard of the questions?" My friend asked.

"Of course not. What's so interesting?"

"They asked details of specific clinical studies, and the latest FDA precautions of several medications..."

"As usual, I would say the problem is in the examiners rather than candidates." I remarked, "There is no point to recite all those specific figures from clinical trials, and even less value to remember word-by-word the FDA documents - they keep changing everyday!"

Alas, there must be pearls that can stand time hiding under the sea of information. The painful truth is neither could wisdom be taught nor examined. 

Focus

I might not have to worry too much about the prospect of general medicine. In a warm winter afternoon (actually a few days before I put up my recent blog entries and received the email comments from VW and JW), I participated in the examination of my own specialty board.

It is my strong belief that doctors of a similar personality go to the same specialty, and nephrologists are generally pragmatic and time-conscious. The seven of us lunched together, went through the questions, and, we finished (roughly) on time. Most of the questions are set in a way that it is difficult to fail even if the candidate does not happen to know the specific detail – as long as he or she has been actively practising and knows what’s happening on earth.

My friend JW certainly holds a similar opinion, and he always advises students and trainees against an examination-oriented study. His argument is simple: Examinations are generally easy (we are serious) but the scope is inevitably narrow; it is much more difficult to know enough and be a competent doctor – which, unfortunately, is our ultimate aim.

PS. You may find it difficult to believe examinations are easy – they are, in fact, difficult, but, only for the examiner. Since the voice of asking for a fair examination was becoming ever louder in the past twenty years, questions and scenarios need to be standardized, and there left less and less suitable material for examination of a large class of students (or trainees). The situation is somewhat similar to the steamed fish of a Chinese wedding banquet – it is always cultivated grouper and no one would ever think of wild ones, not because the couple wishes to cut the cost or help the environment, but you could never find twenty or forty wild groupers of a similar size on that very day.

JW's

(The comment of JW followed  two hours later.)

Dear VW,

The lack of interest among youngsters is multi-factorial. In my student days, the academic staff is really more negligent to clinical and teaching duties but we are not deterred from doing research. Amongst various causes, the most important one is lack of peer-group interest / pressure. When I was a MO, we have numerous HPT role models. (Szeto's note: HPT stands for higher physician trainee.) Can you name any now?

Of course, this loss of peer-group force is again multi-factorial.

JW

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

PS. I must say the three of us have very different worries: VW was hot about the behaviour of young academic staff (a stage which I suddenly realize my friend has long passed), JW focused on the foreseeable shortage of clinical researchers,while I put my attention on the widening gap between clinical and laboratory medicine.

And, there's no absolute right or wrong.

Comment

In general all comments to this blog go to an obscure place. Nonetheless, for my recent humble opinion, my friend VW sent me a personal email as comment - which I believe deserves a better attention.

Here you go.

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

Dear Szeto,

Thank you for your sharing, my friend. I have no problem with RAPs, who are dutifully focusing on the job they were assigned.

What saddens me, however, is how clinical staff reacts to the paradigm shift - concentrating on research, flying around to give talks, evading clinical and teaching duties, you name it. In the past I was annoyed that young people were no longer interested in clinical research; now I see things differently. If we look like selfish people who care about nothing but our career advancement, how would youngsters want to become one of us?

Yours,
VW

Split

What's wrong with all these?

First, there actually remains a square one problem to be solved: How to decide which teaching staff to be promoted, especially if they do not do much research?

No, there's none as far as I could see. At the end of the day, clinical teaching staff probably have little prospect of promotion (unless they could lead a team supported by RAPs), and many would take the post as a step stone before entering private practice.

(I shall not comment on their quality or enthusiasm of teaching.)

But, this is, to me, the smaller problem.To me, the more important problem of having research associate professor to work on basic science and clinical teaching staff to take care of students is we are taking the soul away from the body.

I shall leave it to your imagination which side is soul or body.

And, have you heard of the dinosaur with two brains?

Go read http://ccszeto.blogspot.com/2009/10/stegosaurus.html

Research

I have no idea who first invented the term research associate professor (RAP) for a clinical department. He must be the same genius who discovered opium and gave an apple to Adam in Eden. It follows the logic of Adam (what a name) Smith and is a nice division of labour. Clinical staff could direct their effort back to teaching and patient care, and research output of the medical school is guaranteed.

To go one step further, RAP in a clinical department is a positive-feedback system. Since most of them do basic science research, their papers have more citations. As a result, basic science journals generally have a high impact factor. Since only true scientists know what they themselves are talking about, they are the only one to publish papers in these high impact journals. In reality, they form a elite group that any chairman of a clinical department would like to employ when their research output is going to be audited.

So far, so good.

But, there are two problems that may skip your eyes.

Yardstick

What yardstick should we use?

Or, the very question is: Can we use the performance of teaching as the criteria of promoting an academic staff?

For obvious reasons, no. To put it simply, the quality of teaching (or clinical care) could hardly be quantified. (Alas, by definition, quality could not be quantified.) Peer review and examination result are biased, and, if you wish to follow students’ opinion, let me ask you one question: What’s the difference between the Most Popular Actor Award and the Best Actor Award?

And, therefore, medical schools resolved to assessing the performance in research.

No, I'm not going to discuss the problem of impact factor or h-index. My friend VW discussed that not too long ago (see http://vwswong.blogspot.com/2011/09/citations.html). I shall also not discuss the problem of our new generation academic staff, who try to avoid teaching and clinical duty and spend their time on research. (Yes, these are serious problems, but we shall leave them aside for the moment.)

But, once research becomes the yardstick for promotion, funding agencies soon follow and use it as the criteria for resource allocation. At the end, research per se becomes a specialty.

And we enter the era of research professor.

Evolution

While we are seeing the fragmentation of general medicine into various specialties, division of labour in a different domain is secretly taking place.

Let me give you a slightly convoluted account:

Fifty years ago, the department of medicine of a typical medical school had one professor and around a dozen of lecturers. They saw patients and taught medical students, the latter largely by setting examples via their own clinical practice. For the small amount of spare time they had, they did research, be it clinical or laboratory based.

In the following decades, things gradually changed. Our life expectancy lengthened, and the whole health care system expanded. We needed more doctors and therefore had more medical students. The number of academic staff rose.

The inevitable result of having a whole lot of lecturers is they all need a prospect of their career, which, when summarized in one word, is promotion. But, which lecturer should be promoted?

Our extra-terrestrial friends taught us that much: To be fair, we needed to think of an objective yardstick.

That opened a Pandora box.

Division

You may argue specialization, although does make the rich in knowledge eat at very separate tables, is the inevitable result of medical advance in the past twenty or thirty years.

That may be true. In fact, it is quite impossible nowadays to master all aspects of internal medicine by one person. And, seriously, it is actually rather difficult now to stay tuned in every aspects of a single medical specialty – for example, cardiology or nephrology.

(I made a similar comment last year. See http://ccszeto.blogspot.com/2010/10/divison.html)

Or, as Adam Smith put it, the greatest improvement in the productive powers (in the history of human) have been the effects of the division of labour.

But, hold on. Don’t follow our giant of economy blindly. In fact, the author of The Wealth of Nations did not imply that all kinds of division of labour would always lead to an increase in productivity, and, in modern medical practice, division of labour is very often not meant to increase the productivity or efficiency of medical care, but to achieve skill monopoly, or to evade responsibility.

I shouldn't say any more.

Feudal

You may think my little story in the past four days was exaggerating the fact.

I beg to disagree.

The sobering fact is, the evolution of general medicine in the past 30 years was a close analogy to the history of the Zhou (周) empire 2500 years ago.

When King Wen (文王) first began his campaign, it was meant to be a central government. Nonetheless, it was quite impractical to rule an area of over 1.5 million square kilometer and a population of 30 million; inevitably, it had to resolve to a feudal system (封建制度).

(The same problem remains real nowadays. As I alluded to some months ago, despite the advance of Internet and information technology, you cannot kick the ass of someone on the other side of the Pacific Ocean.)

And, with time, the duke or marquis or count or baron or whoever became the lord of his own land and actual leader of his people. The Zhou emperor became on paper the leader of the country but had little land or people  left to himself. He had not much respect from and even less control on his vassals.

Instead, the order of the empire is maintained by the most powerful duke amongst all feudal states.

General

(The young doctor is obviously surprised to hear the idea of a general physician.)

"Don't you know the category of general medicine has been removed from the list of medical specialty?" He asks.

"How could that be? I think you are a physician trainee?" The woman could not believe her ears.

"Yes, I am, but I have my own specialty training." The young doctor says solemnly.

"What is your specialty?" The woman asks reflectively.

"I am a trainee of consultative medicine - a specialty devoted to consult the others... I mean we are the experts who know which specialty to consult." The doctor replies - and his face does not turn red.

Instead, the woman's turns white.

PS. Don't laugh at the young doctor. For us working in a public hospital, we are often surprised to see the complicated medication list prescribed by private physicians (our jargon is polypharmacy). For example, they give a syrup for someone who has a cough, another tablet if the patient also complains of backache, and another capsule if there is also a toe swelling. Many of us are certainly more sophisticated; we consult a respiratory physician, an orthopedic surgeon, and a rheumatologist for the same three problems.

Experts

(The conversation has not ended - yet.)

“Not that bad. We can have everything before sunset, I hope.” The doctor tries to be reassuring.

"And you can finally do something by then?" The woman asks.

"Well, yes and no. It looks as if your father needs some medicine to prevent the blood from clotting. But, as I emphasized, we should be cautious to protect... eh, whoever." The doctor replies.

"What do you mean?"

"I mean, we need to consult a drug specialist and make sure there is no inadvertent interaction between the drug that we want to give and the others than your father used to be taking," the doctor goes on, "We need the assessment of a swallowing specialist to check if your father could safely swallow the tablet - so that you won't sue us if your father chokes and aspirates. By the way, it doesn't mean that your father could have his dinner if he could swallow; we will have to wait for the report of our diet specialist to determine what dinner your father should have..."


The woman interrupts, "My god, couldn't all these be done by a properly trained general physician - or actually anyone with a common sense?"

Report

(The discussion continued.)

“How long does it take for the rad… specialist, whoever he is, to give the report?” The daughter pushes further.

“Don’t worry, our Chief Executive has promised on behalf of their Chief-of-Service on behalf of the front line radiologists that it would be available within one hour,” the doctor explains, “But, before that, we need to wait for our virtual technology specialist to go through the films and confirm their quality to be suitable for reading and reporting…”

After another moment of dead silence, the young woman says again, “Well, once we get hold of the report, can you start some treatment ?”

“No, not that fast… I mean, don’t jump to the conclusion that quickly. We need to see all the other results.”

“Yes, of course. I suppose ECG and blood tests are simple matters?”

“Alas, simple as they seem, we need to be very cautious to protect ourselves - I mean, our administrators - oh, I actually want to say, our patients.” The young doctor hurries to explain, betraying himself subconsciously that he is not sure which party his is trying to protect primarily, “After several recent incidents of missing an abnormal ECG or blood test result - all labelled as our malpractice and negligence - recently, our CE decides to have all the ECG read by a heart specialist, and blood tests interpreted by an expert of laboratory chemistry.”

“!” The woman is dumbfounded.

The exclamation mark represents what she looks like, not what she says.

Film

(Medical ward of a regional hospital, some time in 2012.)

“Doctor, what’s wrong with my father?” An anxious young woman asks the on-call medical officer.

“Madam, I suppose you know what’s happened,” the young doctor says monotonously, “Your father was jogging in the playground this morning when he sudden collapsed.”

“Is he having a stroke?” The daughter asks.

“Yes, very likely,” the doctor nod.

“Does he need a CT brain?” The daughter goes on.

“We had one a moment ago. In fact, we also have arranged an ECG and some blood tests for him.” The doctor replies.

“What’s the result of the CT brain? Does my father have bleeding in his brain?”

“We need a bit of time – I mean we need to wait for the radiologist to go through the film and give a formal report…” The doctor hesitates. Since the CT films are going to be read by a specialist and what a physician trainee finds does not count, he has not actually seen the films himself.

And, since he knows from his very first day of training that he does not hold responsibility of reading a film, he doesn't know how.

Share

(Overheard the conversation between two persons.)

"The new arrangement is insane. It is the worst kind of communism!" A hook-nosed middle age man began.

"I haven't read the news. What's that all about?" His friend, who had a childish face but a lot of grey hair, asked.

"Just think of this analogy," the hook-nosed explained, "In the past, you have your own purse and I have mine. Every now and then you may overspend a bit, and you can borrow from me in order to get through the difficult time. The new arrangement states that, since you are in debt most of the time and I have a decent saving, we should share the same purse - so that you can caste away as much as you like and there's no need to worry!"

"Yes, that may be true," his grey-hair friend said slowly, "But, since we two are living under the same roof, shouldn't we be less selfish and try out best to help each other?"

"There is more than a fine line between asking for help and evading one's own responsibility," the hook-nosed said, "After all, we should help people who put up their very best effort to help their own self. For example, it is absurd to ask Angela Merkel to foot the bill of Silvio Berlusconi for his visits to brothels!"

I was confused. Were they talking about the European PIGS, or some local ones?

Equal

(I remained silent for a while in order to digest what my friend just said.)

"You look puzzled." L said.

"Eh... I mean, your discussion seems to be leading to somewhere. But, what are you trying to get at?" I asked.

"Alas, you see that finally," my friend smiled again, "Very simple, contrary to what those so-called pioneers of democracy declare, the system of our CE election could actually be entirely satisfactory without much modification of the present system. All we need to do are to minimize the time between the Election Committee Subsector Election and the actual CE election, and to have all candidates running for the Election Committee declaring which side they are going to vote for."

"Em... Isn't it how the Americans choose their president?" I asked.

"Exactly," my friend nodded.

"But, that's not entirely democratic; it is not one man, one vote!" I exclaimed.

"No, but, you know me well enough. I am a fan of George Orwell. All animals are equal!"

I could not help nodding.

Who

Met L on my way home. He seemed absorbed in his own thoughts.

“Hey, man. What’s up?” I tapped on his shoulder.

“Oh, nothing. I was just going through the advertising pamphlets of our coming CE Election Committee Subsector Election," my friend said, "Boring as they seem, there is an amazing thing between the lines - or should I say between the pictures?"

"Eh...?" I made an inviting grunt.

"Since you are so fond of psychology, look, there is something which should be there but is not." L smiled.

“What’s missing?” I scratched my head literally.

“None of the candidate says which side they’re going to vote!” My friend explained, “Very simply, is it the pig or the wolf?"

"Isn't it the whole purpose of democracy to elect some wise people so that they could make the decision for us in important matters?" I asked.

"Unfortunately, this time is the rare exception." L explained, "The only job of this Election Committee is to vote for the new CE. In other words, it is quite useless to advocate how good looking they are, or what policy they are for or against. Most of us have our own preference for the new CE, and we want our representatives to vote for the one we like – as simple as that. If someone come out and say it openly he stands for the side that I prefer, I shall vote for him; it doesn’t really matter if he was the root cause of the SARS outbreak or being literate only in four-letter words!”

Conscience

(The doctor continued with his explanation.)

"There are many subtle hints of declining well in advance. For example, the CEO of this #9413 sold his Porsche last week, the floor of its reception lobby is covered with an inch thick of dust, and its web page is still showing the information three years ago. Aren't all these sinister signs?"

"Well, ah ... yes," the stock broker was forced to agree, "But they are only proved indicative with hindsight. The problem is usually not we have insufficient information, but we have too much and could not distinguish genuine signal from environmental noise in a jungle of information."

"All the same," the doctor was not a trace more forgiving, "You are the professional. You are supposed to be the expert to extract valuable information and make the decision. What you are telling me is you do not only lower your standard of practice to the adherence of practice guidelines and standard procedures, but you also bring down your level of conscience so that you won't feel guilty as long as you have followed all those amulets written by extra-terrestrials!"

The stock broker was speechless. In a sense his client was right, but, on the other hand, he had no idea how he could pass his days if he were not to lower his level of conscience.

Maloccurrence

(The discussion between stock broker and his client continued.)

"I still believe it's your fault. You've not done everything that could prevent my losing money," the doctor insisted.

"No, we've done everything we should do from our side - and we are entirely satisfied with our performance," the stock broker remained calm and content, "True, you did lost money all the same. As you always say, this is a known complication of investment."

"I know what you mean," the doctor replied, "You've followed all practice guidelines and standard procedures. Every move was documented, conversation recorded, and consent signed. Yes, you have satisfied the administrator or whatever regulatory body there is, but, it is quite a different question to satisfy your own conscience - if you have any."

"What do you mean?"

"I mean, have you been staying alert to all trivial information and hints that would indicate the risk was going to materialize?" The doctor said.

(To be continued.)

Investment

(Discussion between a stock broker and his client.)

“Gentleman, I must say the situation is grim,” the broker began, “You've put your money on Neptune Opportunity, and, my goodness, the price crashed by 95% this morning.”

The client, a middle age physician, remained expressionless. Contrary to the common belief, he was barely literate, and could not comprehend any logical argument of more than twenty words. He had no idea what's the difference between, say, PE and PB ratios, or what kind of company Neptune Opportunity actually was – all he remembered was he was advised by the man sitting opposite to him to buy a stock with the code #9413.

Oh, there’s one thing he knew: He had lost money. Big money he earned by sweat and blood.

After another five minutes of dead silence, the doctor said, “It must be something you’ve done wrong, or information you've hide from me. It's a negligence or your side, or I should call it malpractice.”

"No," the stock broker remained calm and content, "This is not malpractice. This is maloccurrence."

Age

(A real story in my private patient clinic recently.)

"Doctor, you look really young. I never imagine a professor of medicine has no grey hair." The wife of my patient said before she left the consultation room.

"Oh, thanks for your compliment," I smiled, "But there are actually so many young professors of my medical school nowadays ..."

(I was about to say the title professor deflated a lot in the recent years, but I refrained to say so in front of my patient.)

"You are too humble," she went on, "Let me see, you must be far from 60-year of age. Are you 53 or 54?"

I made a loud hiccup - the inevitable response when one tries to laugh and vomit at the same time.

Delay

(The discussion in the resuscitation room continued. Oh, yes, the blood pressure of the unfortunate young man continued to drop.)

"Damn, we are not against transfusion, but how could you be sure the blood is safe?" The grey hair man took over. He obviously was in the habit of using a colorful language.

"We always perform some necessary testings. Nothing is perfect, I agree. But the situation is urgent." The doctor explained.

"Stop that kind of bull shit. You ain't know anything of this testing business." The grey wolf roared, "In the old days, the standard way is to have the potential donor passing through six stages and fifteen tests before the blood is accepted. Now, you just check hepatitis and AIDS. That's not enough."

"That's picking bones from eggs," the doctor said to himself.

But, he did not say it aloud. He hesitated for a while, and then he continued, "All I could say is: Delay no more."

"What!?" Both the monkey-face and the grey wolf jumped.

"Alas, don't be paranoid. I am speaking English." The doctor was forced to say.

Bleeding

(The story in the resuscitation room continued.)

"Gentlemen, let's make it straight. The situation of your brother is critical. If he does not have some new blood in the coming hour or so, the chance is he would not make it." The doctor was grave.

"I don't think he needs any blood," the monkey-face said, half smiling, "I see that you are no short of water. Just give him more fluid to support the blood pressure."

"Let's face it. What he needs is new blood; the old blood won't do much better with more water." The doctor insisted.

"No, I don't think he is short of blood. All he needs is a better distribution of blood flow to each organ, so that some organs would not be deprived of blood while another gets too much." It now became clear that the smiling face was taking charge of the discussion.

"Alas, I agree there may be some organs better perfused than the others, but it does not mean that your brother has enough blood!"

"Well, even if he is hypovolemic, transfusion does not solve the root of the problem. You need to find ways to stop the bleeding." The monkey-face changed the topic.

"No, but transfusion is an important supportive treatment. If we do not give blood quickly, your brother may soon pass the point of no return, and he could not be revived even if we do stop the bleeding."

Shock

(In the resuscitation room of the Emergency Department.)

"Oh, this is horrible. He must have bled a lot. What is his blood pressure?" The doctor was examining an unconscious young patient just arrived and was obviously soaked in blood.

"Eighty over forty; pulse one-thirty." The nurse replied.

"Thank god we have a drip running. Let's give him some blood." The doctor ordered while looking for the site of bleeding.

"Hang on. We do not agree." An unexpected voice emerged behind the curtain. The doctor looked up. Two middle age man appeared besides the bed. One of them had a face like a monkey, and the other was full of grey hair.

"Who are you?" The doctor asked.

"We are his brothers." The monkey-face man said, pointing to the patient.

The doctor somehow hallucinated this man was smiling.

"Oh, my god - I mean oh, I see," the doctor tried to conceal his surprise, "Your younger brother has bleeding from somewhere. He must have lost one third, if not more, of all his blood. We need to give him transfusion, or he may die."

"Fxxk, we know - we are doctors ourselves," the man with much grey hair spoke with the voice of a wolf, "We've given him a shot of erythropoietin injection - his hemoglobin will increase a few months later."

(To be continued.)

Memory

While reading this horrifying story of George Orwell, as a middle-age man brought up by the colonial education, I could understand the worry and confusion faced by Winston Smith.

To begin with, there is always a vague memory of the old days and old system that we used to live with. Alas, now, we are not having a better system. In contrast, we are repeatedly being reassured that the things we are seeing are the same as the one we used to have, say, twenty or thirty years ago. (It is in its own a curious objective when a people refuse to improve, which always involve some difference, but insist to remain unchanged.) Each time, when a regulation is breached or a rule is modified, we are told that the rule is not new but has always been the same - although rather often we need to seek someone higher up to clarify the interpretation.

And, our memory is failing us. History study is ridiculed. Like the Department of Truth, our government is actively wiping off everything that triggers the memory of the colonial days. The portrait of the queen vanished and becomes the logo of bauhinia. Royal turned into People's. Nothing seemed to have happened in this fishing village for 100 years, and, according to the textbook of our children, the place suddenly became a metropolis and returned to its mother country in 1997. That's why by 2046, nothing would have changed, because no one would actually remember what this place was like fifty years ago.

As to the few who happen to believe they remember, their memory must be wrong.

They would be taken care of at room 101.

Orwell

My recent bedtime reading was Nineteen Eighty Four.

I bought the book last Christmas as a present for the winner of the grand round quiz. Nonetheless, I did not give it away and, as a general principle, I would not leave a book on my shelf unread. (See http://ccszeto.blogspot.com/2010/12/1984.html)

You may be surprised to find I did not go through this classic of George Orwell before, while I have read Animal Farm for at least three times - first as a secondary school student.

But, in retrospect, I find it an excellent arrangement. Big Brother is probably too much to be understood for someone below the age of 40.

Alas, maybe that's why Winston Smith had so much problem.

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

You may think this horrifying story of Big Brother is outdated after the fall of the iron curtain. But, I find it more real now than ever. Orwell had the wisdom of seeing the world ends up with three super-powers. You may call it USA, EU, and China.

Or, more likely, Google, Apple, and Microsoft.

Ross

Let me tell you a slightly irrelevant story.

In 1932, Barnaby Ross, whose name was never heard of before, wrote a book titled The Tragedy of X. It was a fiction about Drury Lane, a Shakespearean actor who had retired from the stage due to deafness and was consulted as an amateur detective.

The book proved a best seller, and, shortly afterwards, when his second novel, The Tragedy of Y, was published, Ross became the superstar of detective fiction. To add oil to the fire, Ross's novels were openly criticized by Ellery Queen, another famous crime novelist at the time. The two of them subsequently staged a series of public debates, pointing fingers at each other.

In order not to be recognized by the others, both of them wore masks when they appeared in front of the public.

The problem is, however, no one had ever seen Barnaby Ross - not even his publisher. Since his skill and plots appeared too sophisticated to be a new comer, it was suspected from the very first day that Barnaby Ross was the pseudonym of someone well known.

Alas, you could guess that much: Barnaby Ross and Ellery Queen were one and the same. I did not say one person because the two pseudonyms were used by two cousins, Frederic Dannay and Manford Lepofsky, who wrote novels in a combined effort. During the public debates, one took the role of Ross and the other Queen.

Lancashire

A recent hot topic amongst the cultural circle is a famous local author put up her own photo in her blog.

If you do not know who I am talking about, just visit the Lancashire Road. I must say I am quite far away from being cultural, but Vivian is a fan of this young lawyer. In fact, my wife was rather excited when she saw the picture of her favorite author.

"Oh, she really looks like a movie star!"

"Alas, that may be true, everything just sounds slightly unreal," I said.

"What do you mean?" As usual, my wife did not know where I was getting at.

"Oh, I don't mean that her face is a product of some plastic surgeon," I smiled, "But I have a gut feeling that the girl in the picture may not be her, or be the complete her."

"But, she said in her Facebook that many of her friends and aunties recognize her and ask why she suddenly comes out." My wife said.

"That's exactly the curious bit," I explained, "Nowadays the internet is so far reaching. If you put up the picture or video of anyone on to the web, in no time the face would be recognized. People appear from every corner and declare being the neighbour or classmate or friend. But, this time, they just write to her - or so it was said. We see nobody come out and say Hey, I know this woman; we belonged to the same hostel in the university."

PS. You may still be puzzled what I meant by the complete her. I shall explain tomorrow.

Match

You may think my worry was far-fetched because genuine bribery in election remains uncommon, and not all policies involve long term benefit.

But, unfortunately, the general idea remains - and is happening more often then you could imagine. There are innumerable topics of a society that people concerned are unable to grasp the whole picture to make a wise decision, while a small group who hold some critical information also have their own agenda.

The best example at hand is the public health policy, or, specifically, the recruitment of overseas medical graduates.

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

I shall not elaborate my opinion on that very last topic any further. Frequent visitors of this site would know just too well. Nonetheless, it really touched my nerve when Vivian told me our noble council representative said that manpower allocation was not even across all government hospitals and every department.

"That may be true, but I would be most enlightened if you could give me five examples that a department in a government hospital has a surplus of manpower. I can only name one - the headquarters."

"But, for the same specialty clinic, the waiting list is one week in a hospital, but 15 months in another," my wife tried to defend the surgeon.

"Does it mean that the hospital with a one-week waiting list has an over-supply of doctors, or their chief-of-service is an expert of torturing his staff?"

Mismatch

You may argue, based on the previous example of a benefit twenty years later, it is logical to ask only those who are potentially affected (i.e. those below 60-year of age) to vote.

But, I'm sure you see it plainly that's quite impossible, for obvious reasons:

1. Most importantly, the group most benefited (that is, those below the age of 20), is often quite incapable of making a logical and appropriate judgement.
2. It would be seen as a discrimination of age - a taboo that we don't want to get near to.
3. In real life, it is often difficult to tell how long it needs to wait for the benefit.
4. And, in reality, we do not vote for policies one by one (and we don't want to anyway - otherwise we would not need a representative in the council), we vote for persons, or, a choice of different bundles of policies.

Specific for point #1, you may now come to realize it is an inherent problem of democracy: There is often a mismatch between those eligible to vote and those who actually get the benefit, and the temptation is more than real for the former group to choose a policy (or, a candidate or political party) than would benefit themselves rather than the entire society. To put it simply, they balloon up their own purse by taking money from those who do not vote, or vote for the opposition.

Remarks

There are some remarks I have to make after the recent discussion.

First, genuine support to democracy does not mean voting for Party D. A well informed and calculated voter should vote whatever he prefers.

And, don't be too serious with my example of bribing voters by cash money - all elections are bribery of one form or another.

In most cases, however, the transaction is more subtle than the famous Four Great Inventions (蛇齋餅糉). Sometimes they fight for a better social welfare, rising our salary, cutting working hours, limiting competition from new immigrants - be they Filipino maid or British doctors. Yes, between statesmen or parties, politics is negotiation. But, between backbenchers and their constituents, politics is always benefit or bribery - depending on how you call it. For each candidate running for an election, they represent a mixture of policies and proposals sold in a bundle; even a wise voter could only choose a better candidate by balancing the gain and payoff.

It is, in short, the rule of the game.

Oligopoly

The problem is: Why should bribery of the election be so profitable?

Because the cost is very low for a selected group. (In our previous example, those over 60-year of age.)

But, if this group of voters do come to realize their true value, they would ask for a higher price. In reality, if there exists another malicious Party C2 and is willing to pay twice as high (i.e. $2), both Parties D and C would lose the election to the new comer. In a free market, by the law of economy, the final price to bribe these people would eventually be much higher - or, to put it in a more palatable language, the underprivileged group would enjoy more benefit.

However, politics does not often operate in the setting of a free market. In the jargon of business, the admission threshold (入場門檻) to form a Party is high, and, for us, since there is another invisible hand behind the scene, the choice is limited. In other words, it is a form of oligopoly (寡頭壟斷) - with the inevitable implication that the bargaining power of an ordinary citizen is very low.

Profit

I might be going too fast yesterday and the profitability of bribing an election may skip your eyes.

Let's suppose there are 6000 citizens in a country with a smooth distribution of age; voting for Party D would generate a total benefit of $600,000 to the society twenty years later. Equally shared by each and everyone, it means $100 per head. For simplicity, we assume the life expectancy is 80-year, and citizens could vote after the age of 20.

Now come the critical moment: A malicious Party C would try to take all the benefit for their own ($0.6M twenty years later, or around $128,700 immediately - assuming a discount rate of 8%). To bribe a sufficient number of vote, and suppose everyone could be reliably bribed, the cost would be:

• First, we need to get all 2000 votes from citizens over the age of 60. We can pay $1 for each, and the cost is $2000.
• The present value of $100 in 20 years is $21.5. Since we need another 1000 votes to win the election, the cost is $21500.
• Therefore, the total cost to win is $22500, and the net profit, if cashed immediately, is $106,200.
• (In fact, if we take it as a present investment of $22500 and a return of $600,000 twenty years later, the yearly return is 17.8% - as good as the performance of Warren Buffett.)

In reality, the cost would actually be lower, because the turn up rate of voting is never 100%. A detailed mathematical model predicts that the money Party C needs to bribe a sufficient number of voter actually falls rapidly if the turn up rate comes down to 50%. Readers with an obsessive personality disorder can try to work out the numeric details yourself.

Here, a determining factor of this profitable business may not be immediately obvious. Let me tell you tomorrow.

Expectancy

You may disagree with my attempt to understand the phenomenon of bribery in election; I myself is slightly suspicious. To say the least, the traditional discounted cash flow method does not take into the account of the interaction between time and life expectancy.

It goes like this:

Let's suppose voting for Party D would generate a benefit of $100 twenty years later. Assuming a discount rate of 8% (the standard rate of return for a business with an average risk, as suggested by Benjamin Graham), the present value is $21.5. In other words, a calculated voter could be bribed by paying him $22.

But, in reality, you can do away with paying that much for many of the people in the community.

Why? If the expected life span of this country is 80 years, the future value of voting for Party D would be zero for anyone above the age of 60. In layman's term, they would not live that long to see the benefit - and, therefore, they could be bribed by an amazingly small sum.

Say, $1.

What's the conclusion? Alas, it means that bribery in election is a highly profitable business!

PS. In real life, many senior citizens do vote for the benefit of their children and grandchildren, and one could always join the dinner (or take whatever benefit that is offered) and vote for the other side. If you could think of all these, you would hardly be fooled by any politician. Unfortunately, most people are honest and do keep their promise.

Discount

You may think I am short-sighted and do not appreciate the long term benefit of supporting democracy. Well, let's analyze the problem from a business point of view:

First, please accept all long term gain could be converted for immediate cost-benefit analysis by the discounted cash flow (折讓現金流) method. The principle is simple. For example, in 1990, if Alan Greenspan promised to give you $100 ten years later. Given his creditability, we take 4% as the annual discount rate. It would imply the effect would be the same if our previous Chairman of the Federal Reserve gave you $67.6 in 1990 that and there. (Try it with your own calculator.)

But, if Ben Bernanke made the same promise to you in 2010, the financial environment (and, I am forced to say, the person) changed. The future is more risky, and the discount rate needs to be higher - let's say, 8%. In that case, you may prefer cashing away $46.3 from the chairman now, rather than having to wait until 2020.

The idea is, therefore, simple: The more uncertain and risky the future, the higher the discount rate, and, as a result, the lower the present value one would take as being equivalent. And, as pointed out by Albert Einstein, compound interest is the most powerful force in the universe. If we have to wait long for a huge wealth, we may as well get a tiny sum immediately. (For example, for 30 years and a discount rate of 12%, $100 becomes $3.3 only.)

Therefore, don't blame people who vote for the candidate that brings them to dinner; they have very little idea when democracy would bear fruit, and, since pursuing such an exceptional virtue has a very high risk, the discount rate should be huge.

Now

(The conversation between the old man and the pioneer of democracy continued.)

The politician then asked, "Why didn't you use your vote to support democracy?"

The old man said, "Why on earth?"

The politician scoffed, "Democracy is so important! With it, you can really reflect your opinion and affect government policy."

The old man asked, "But, how long will this all take?"

The politician replied, "Oh, 15 to 20 years - maybe slightly longer."

"But, even if we achieve eventually this ultimate aim of real democracy, what then?" asked the old man.

The politician laughed and said, "That's the best part. Old people like you can ask for more social welfare - for example, free flu vaccine or even free dinner party!"

"What do you think I am having in my hand?"

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

Do you think this old man is short-sighted and does not appreciate something more important in the long run? I would not go that far. After all, democracy should not be the goal - it is a means leading to a better life.

As Hercule Poirot emphasized (in Murder on the Links): If you do not see this point, you could not see anything.

PS. Exactly for this very reason, if democracy leads to a foreseeable adverse outcome, I would not support democracy.

Election

While I was considering to whom I put my vote in the medical council election, we have another one for the district council.

Like many others, I live in a place where there are two persons running this time: The original council member, who has done a lot of work on local affairs but has a suspicious party background, and a young man who, to keep my wordings modest, is more vigorous in pursuing democracy.

I shall not mention which side I support. In fact, an entirely different story of a fisherman came through my mind (see http://ccszeto.blogspot.com/2009/11/rich.html).

Let me modify it a bit:

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

A pioneer of democracy passed by the garden of a public housing estate, where he found an old man sitting there, with tickets to some dinner banquet and free influenza vaccine in one hand, and a voting paper in the other.

The politician complimented the old man on his support to the election, and asked which side he would vote for.

The old man replied, "The ally of Napoleon, of course."

(To be continued.)

Vote

During a casual chat, I suddenly realized many of our junior colleagues did not vote in our recent election of the medical council.

"Why! Rather hopeless for us to change anything," AC, my own registrar, said, "It's just a game for the insiders."

I was forced to agree. A sound economic principle actually lies here: If we consider our own personal benefit, we should never vote: There is no benefit because a single vote of us would not affect the result, but it does cost a trace amount of time.

Nonetheless I did vote. I took it as part of the duty of a doctor, and, if everyone believes we couldn't do anything, nothing would eventually be done.

Seriously, I have no favorite candidate.

I am just against one.

Modify

On a second thought, chopstick is a lingua franca of the Chinese culture.

Like everything else in life, it got modified slightly wherever it goes:

In Korea, chopsticks are generally made of metal (iron or silver); using wood or bamboo ones are considered as a sign of poverty.

In Japan, chopsticks have pointed tips (as compared to the blunted end of traditional Chinese chopsticks, which remains the standard design of disposable ones in Japan). For that seemingly trivial modification, there is, in fact, a substantial difference in the proper way of holding them.

On that last point, I shall not elaborate on the actual techniques. Suffice to say, a skilled user of the Chinese chopsticks could easily use his instrument to cut out a piece of flesh from, say, a whole fish – a task that is not meant to be done by the Japanese equivalent, however dexterous the user is. Of course, the explanation is obvious: We serve whole fish or other cuisine in big dishes, and there is often a need to dissect the object for sharing; in Japan, meals are generally served individually.

(Another contributing cause is that Japanese rice is slightly more sticky – or, in scientific terms, has a higher content of gelatin – for which it is less messy to use chopsticks with small pointed ends. Just try it yourself.)

PS. It is a common belief (and in fact quite scientifically proved) that chopsticks take part in the spreading of infections that could be transmitted via salive (notably Helicobacter, the cause of peptic ulcer). However, the blame is not entirely legitimate. A noble Chinese with an appropriate upbringing should finish with his dinner without soiling his chopsticks – each piece of food is diligently put into the mouth by a non-touch technique.

Chopstick

It was a Wednesday morning. When I received my lunch box after half way through our unit meeting, I found something important missing.

And I grumbled, "Gosh. I am a traditional Chinese, and I definitely need a pair of chopsticks for my lunch."

"So, did you bring your own pair when you went to England for study?" Someone asked.

I smiled, "That's really a story - I did not, or, I should say I forgot to do so. To make things worse I was in Bristol, not London, and I had no idea where to buy a new pair." (During that time, to be honest, I had either to dine in the hospital canteen - it is perfectly OK to eat fish-and-chips with knife and fork - or to use a spoon for everything if I decided to prepare my own dinner.)

"How did you get around the problem?"

"Alas, I rang up WY, who happened to need to be in London later that month for a meeting, and I asked her to bring me a new pair!" I smiled.

By the way, I am still keeping this very pair in my office - to remind me of the good old days.

Conversion

You may ask: How do I find my Kindle?

Not bad. To say the least, the screen is soothing and there's no flash light. (Good for someone with migraine, like me.) I tried the Wifi connection and bought a novel from the Amazon site. Everything was plain sailing. Nonetheless, to save the battery power, I turn off the wireless most of the time, and, if I need to buy new books, I could do it on my desktop computer and move it to the device via a USB cable.

The major difficulty, however, came when I tried to read journal articles. To begin with, it could only open HTML or DOC files after conversion - not convenient. If you download a paper in PDF and pass it to the device, the file could be opened, but, since the paper size is usually A4 or standard letter, you need to zoom in and it is rather complicated to move around a page. The next thing I tried was to open a paper as full text and then print it to PDF after adjusting the paper size to A5. Alas, it comes up perfectly well on the Kindle screen - just that the files are amazingly big (often 15 to 20 MB for each article).

PS. You can also open a full text, save it as HTML only file (rather than a full web page), and then print that file to PDF as A5 pages. The file size becomes much more manageable (generally 300 to 500K). But the process is slightly complicated.

PPS. Which book did I buy to test my new toy?

Why! For sure it was The Murder of Roger Ackroyd.

Kindle

My recent new toy is Kindle.

I bought it on-line as a bargain item. Although I am slightly uneasy with virtual bookstore and a paperless system (for example, see http://ccszeto.blogspot.com/2011/10/choice.html), there is an objective need for me to have an electronic reader. It goes like this:

Since our wards moved to the new hospital block last year, it becomes quite a nuisance to people like me who have our office staying in the old block. (The root of the problem is, of course, when the new block was designed by some extra-terrestrials, no office space was planned for academic staff.) Although it takes no more than 5 or 7 minutes to walk from our own office to the ward, it becomes neither here nor there when we have, say, 15 minutes of spare time in the ward (for example, after the morning round but before a bedside teaching).

For that reason, many of us bought iPad in the past one year. Well, after reading Tim Ferriss, I am not fond of checking emails all the time, but it seems a good idea to have some documents or journal articles at hand.

PS. Another brilliant design of the new hospital block is that the largest blind spot for mobile phone connection is the lift lobby - exactly the place where you need a mobile.

Manpower

(The gangsters' meeting continued.)

"We need more doctors."

"Don't be silly. We won't have more graduates until 2014. But, by 2017, we would have loads of them, and the pendulum would be back to the worry of having unemployed medical graduates!"

"Shall we hire some from overseas?"

"Alas, the problem is more complicated than what you think."

"Well, yes, our friends in the medical council are all against the idea - and for obvious reasons. They always say we should hire more part-time doctors. What a suggestion!"

"Some of them do pretend to apply to help for the out-patient clinic, but that's quite beyond the point. What we need are doctors to do the ward round and on-call duties."

"But, going back to the plan of employing overseas doctors, it's not only our friends in the medical council blocking us; our lovely extra-terrestrials are putting hurdles just as much."

"What hurdle?"

"Quite simple. Let's say an overseas applicant has some training in internal medicine and wish to apply for a post in our department. For sure we are eager to accept. However, aliens outside the solar system come to the conclusion that our emergency department is more in need of manpower, and insist that new employees must spend their first 6 months in the A&E. That's quite enough to put off the applicant."

"In that case we should never try to improve our service - we should actually make it worse, so that we would be regarded as in need and get more resource!"

PS. For those who were also in the gangsters' meeting, you may not be able to recall some of the conversations I outlined above. That's entirely expected.

I dozed off in the middle of the meeting and had a nice dream.

Well, maybe not such a nice one.

Diffuse

Shortly after the two jokes, I attended another gangsters' meeting.

The focus of discussion was, of course, the manpower problem.

Let me show you some bits and pieces.

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

"Is it possible to cut down the admission?"

"But there are so many patients need to be admitted."

"In that case, can we confine the overflow cases to a few wards so that we don't have to see one or two cases in each ward. It is really leg-breaking to conduct a ward round for all overflow cases."

"No, the hospital won't allow such a thing. Otherwise we would soon find ourselves occupying two or three wards entirely - and officially we should not have more medical wards."

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

You think the argument sounds awkward? Yes and no. From the doctors' point of view, the idea is certainly absurd. But, it is far easier to ask nurses of surgical or orthopedic wards to each take care of one or two medical patients. If one particular ward is filled with medical patients, the nurses would just resign in no time.

Risk

It must be a season of joke. The next morning after CB showed me the fabulous emails, I met W in my ward round.

W has been under the care of us for quite some years. To cut the medical information short, this time, she was the night before for some urinary infection. The problem was, one regular medication of hers was a new long-acting version, but, when she was admitted, she was prescribed with the ordinary short-acting form. This mistake, which I considered minor and entirely understandable, was noted and immediately rectified by the on-call physician that evening.

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

I talked to W, did a brief examination, and decided to go through her hospital notes and medication sheet - which, to my surprise, could not be found anywhere in the ward.

I asked the nursing officer, "Where's the medication sheet of this patient?"

"Oh, the incident last night was reported to AIRS," the ward sister was most apologetic, "The risk management people just come around and take away the case notes and medication sheet for detailed scrutiny ..." (For those not familiar with our system, AIRS stands for Advanced Incident Reporting System.)

"In this hour of the morning!?" I gasped, "Please go and tell them, I am now doing ward round and have the priority to look at the patients charts and records. The risk is real if they still keep all those documents at this critical moment!"

The nursing officer hurried away. I did not have a chance to elaborate the risk I mentioned was to the patient or some other extra-terrestrials.

Recurrent

(Email communication between a colleague of mine and the consultant of another department, about a recent administrative incident.)

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

Dear X,

We just had this discussed ... The management of your side violated the long agreement between your department and mine from very early days.

Thanks, et cetera.

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

Dear CB,

This is a recurrent issue and has stirred up a lot of heated discussions in our department. What I can say is these were isolated incidences, and I would do my best to handle the issue.

Best regards, et cetera.

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

Fabulous !

Difference

On my way home after the training day, I was still reflecting my conversation with CS. All of a sudden, a recent discussion with TW flashed through my mind.

It took place on the recent annual scientific meeting of our society:

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

"You know, there's a huge difference between physicians and surgeons in the public hospital," TW began.

"Which aspect are you referring to?" To be honest, I was not sure what she meant.

"Just imagine, if you are a senior surgeon in a government hospital and you are tired of what you are doing, the temptation of joining the private market is huge: You either earn twice as much if you work equally hard, or you have the same earning but are just working half-time," my friend explained, "And, therefore, they do move, creating vacancies for the juniors to be promoted. In short, the system is relatively healthy because most of them sees a future."

"Quite right." I nodded.

"In contrast, senior physicians are a different story." She went on, "They don't have to do much clinical job under the government's umbrella. If they become private physicians and keep the same workload, their income would probably be the same as a medical officer. In contrast, the middle grade physicians - I mean the new fellows - have all the incentive to go for private, because they are the most hardworking group. If they keep up with that workload in the private, they would have a consultant paid."

"The outcome is obvious: A fault - or a gap - forms inevitably. Very senior physicians are high up and stagnant, and they only have very junior trainees all the time," I was forced to agree.

Responsibility

Later that week, we held the College membership examination.

I shall not elaborate on the running. Our secretaries and nurses are highly experienced, and things were always smooth under the organisation of RM. The only difference we had this time was, on the Saturday after the examination, the College asked us to organize a "training day" for those candidates who planned to sit for this examination in the next year or two.

CS, the representative from the College, came and visited us that morning and saw to the things.

After the program started, we had a leisured moment of casual chat.

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

"You know, I'm slightly fed up with arranging this," he began.

"Oh...!" I put up an inviting smile.

"Alas, this program is entirely for the benefit of the candidates, and it's practically free - the small amount of application fee is almost always covered by their department training fund. However, few of them applied. We actually had to extend the deadline of the application and keep reminding department heads of every hospital to encourage their own trainees," the professor of rheumatology finished without a second breath.

"Time has changed," I murmured, "It's now not the responsibility of a trainee to learn, but a duty of us - consultants and the College - to teach. It's quite like teaching our own children: Unless we do away with our own sense of responsibility, they own take up theirs."

Apps

(Our dinner conversation with CM continued.)

"You know, as a rule, I do not allow medical students come to my clinic - there's very little to learn anyway," our visitor, who was actually a senior lecturer of his own medical school, remarked.

"Well...?"

"And I was slightly disappointed when I found a final year student sitting in my consultation room last month - he obviously did not ask his classmates which doctors not to follow," he continued.

"Was he just very keen to learn from you?" We asked.

"Quite the opposite," CM smiled, "In fact, he didn't even look up when I entered the room; he was just absorbed in playing with his iPhone."

We all chuckled, "So, did you ask him to leave?"

"No. I sat down, picked out my iPhone, and pretended to press the button eagerly."

"What's the point?" We were curious," and, did the student notice that?"

"Well, after two or three minutes, the student obviously found things were not going in the right direction, and he asked what I was doing." Our friend said.

"What did you tell him?"

"I told him that I was looking for an Apps to make a medical student disappear!"

Touch

In the next afternoon, CM (our research collaborator from England) actually came around and visited our unit. It goes without saying we dined together that evening.

I must say he was most entertaining in social chats:

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

"You know, not too long ago, the infectious disease control people came to our dialysis unit and did a hygiene check and all that to all of our staff - doctors, dialysis technicians, hospital amah, et cetera." He said.

"How about the nurses?" One of us asked.

"Oh, they were not screened - our nurses never touch patients. They just do documentation and paper work."

"In that case, many of our colleagues could be excused if we have such an infection control screening!" I said to myself.

Host

It proved to be an exceptionally busy weekend. In the next morning, I took the earliest flight to come back from that crooked universe, and, before lunch, I was safe in the function room of a five-star hotel in Kowloon.

It was the annual scientific meeting of our society.

The event was so so. (I needed to attend because CM, one of the invited overseas speakers, was our research collaborator.) In that evening, I went to Aberdeen for yet another meeting: It was the briefing session for the membership examination of the College in the coming week. I went there to represent the hospital, which was going to be one of the host centers.

You may ask: Isn't it a meeting for the examiners (and I am not)? True, but, the sobering fact is, amongst the 6 legitimate examiners within the department, none of them came for the briefing - and none actually did the examination held in our hospital.

And, ironically, every time when we hold the department board meeting, we always say the college examination is a big thing. "We should do this" and "we should do that". In this very Sunday evening, I suddenly had a déjà vu feeling of reading Gongsun Long (公孫龍), who claimed that a white horse is not a horse (白馬非馬).

Very true, because I am not one of the we either.

Universe

I stayed in Chicago for two days and was back Hong Kong on Friday evening. In the next morning, I was summoned to the universe that has a different set of law of physics.

I must say my bias against the other parallel universe of ours is quite well known. The man from Pluto used to suspect my name was blacklisted. KL simply thinks that I am over-reacting.

Nonetheless, I still believe my bias are entirely justified. To say the least, it is rather disheartening to work with those apparently lovely creatures: They could not keep a promise, and therefore they would not believe you could keep a promise. They do not give you genuine respect, because they don’t actually respect themselves. When you say a scientific paper or clinical trial shows some particular result, they would tell you their octogenarian division head has a different personal experience. In this world, the way is full of bush, truth is fake, and life pennyworth.

And, therefore, don't blame the landlady - it's all problem of the tenants themselves. Don't look down upon that 18 persons who did not help the girl after she's knocked down by the car - just look at what the others did on the old woman who tried to help.

Alas, pudet esse unus ex eis.

Defensive

You may say that’s no big deal. It could even be considered as an advance – improving public scrutiny or what.

But I was horrified. For newspaper is not law court, events are not reported according to objective facts but presented as stories seasoned with emotion.

(Do you still remember that famous quote from one of our soap operas? “This is not the law court. We do not have to talk about evidence. My eyes are the evidence.” Yes, sometimes you could do the justice easier, but, just imagine you are an innocent suspect.)

And, to make things worse, the test is a self-conflicting paradox: When it is on the newspaper, they don’t really give you the chance of defending. As a result, we don’t actually ask Can you defend your action if it is reported on the front page of the newspaper tomorrow? but, rather, What should I do to avoid the remote possibility that it would come up to the front page of the newspaper?

Alas, welcome to the era of defensive medicine.

Newspaper

My dinner conversation with SP continued.

“You know, we are in business and are not free to do whatever we want – even if something is legal. Our legal advisors often ask: Can you pass the newspaper test?” The company president sighed.

“What’s that?” I asked.

“Simple. Before you do anything, just ask yourself: Can you defend your action if it is reported on the front page of the newspaper tomorrow?” She explained.

I was chilled. All of a sudden a piece of classical teaching on clinical practice flashed across my mind.

If you are not sure what you do is correct or not, just ask yourself: Can you defend your action if it comes up to the court?

In no time I realize medical practice has also moved to the era of doing this newspaper test to ourselves. After all, we are really at risk of having what we do on the front page of morning papers.

Market

In that evening, I happened to dine with a group of people from all corners of the world.

The host was SP - an obviously well-to-do business woman, who had the special capability of entertaining all her guests throughout the night by, as people often say, talked the talk.

“We got to listen to what the others say – customers, legal advisers, and experts such as you guys.” The company president said.

I suddenly thought of Steve Jobs.

“And it’s absolutely necessary!” She continued. “We all know the story of Motorola Razr, don’t you? After the initial success of their first model, the engineers put all their effort to enhance the function and add new gadgets into the next model –they just didn’t listen to what the customers said! And the rest is history. The new model was a disaster, its market share dropped by more than half, and Motorola almost got bankrupted.”

I was speechless. For a moment I was not sure if there exists a fine line between insightful leader and an arrogant dictator without judging their outcome from hindsight.

Choice

You may say the fall of Borders and other conventional bookstores is the inevitable consequence in the era of on-line shopping.

Quite true. In fact, I just bought my new edition of Harrison's from Amazon two weeks ago.

And the process was plain sailing! Fast, simple, and quiet - I didn't have to talk to anybody. (Think of that for someone with an autistic personality disorder like me.) More, there are literally millions of books for you to choose, hundreds of times more than that you could find from any brick-and-mortar shop.

But, I tell you, this is the worrying bit.

For, with that seemingly vast number of choice (and without physically displaying them in front of you), the list for our consideration is, ironically, more limited.

Take my recent purchase as an example, I did not look around and find a book - I knew what I wished to buy right from the start. If there's actually another good one around, I would never know it, and, if that were the situation 25 years ago, my initial romantic encounter with Tinsley Harrison would never happen. (For that story, see http://ccszeto.blogspot.com/2008/04/harrison.html)

And, even if you have no particular book in mind and go to, say, Amazon for on-line "shopping", as their old customer, a number of titles would be automatically recommended - largely based on what you bought previously. Yes, it is very much more convenient. Nonetheless, it also means we are channeled to our own small world.

Borders

My trip to Chicago was entirely business. Thank goodness I arrived a few hours before the meeting started, and I took the opportunity to have a short walk.

After a while, I found a familiar name on the wall of a tall building around the corner.

It was Borders.

For those who'd not been to America, Borders was one of the largest retail bookstores. For a moment I was confused, because it is my usual practice to check for bookstores nearby my hotel every time I go for an overseas conference, and I could not remember I found Borders in this place.

Naturally I moved forward, and, before I tried to push the door and entered, I found that the shop was empty.

Why, I suddenly remembered. Borders filed for Chapter 11 earlier this year, and all stores were closed down two months ago.

Right. It has lost its business to information technology - not Steve Jobs this time, but Amazon and other on-line bookstores.

I kept reflecting this unexpected encounter on my way back the hotel, and, all of a sudden, a sense of coldness passed through my back.

Let me explain tomorrow.