Promotion

Of course I know very well the comment of PL was the result of the recent happenings at the north-west part of the peninsula.

Many of the visitors of this blog probably know the event better than me, and I shall not describe the details or my opinion here. Suffice to say it is silly to suggest creating more posts for promotion - who is going to do the front line work if everyone gets promoted?

Nonetheless, a quick promotion does create a transient state of euphoria and help easing off the tension for the time being. I would suggest:

• promote all medical officers to assistant consultants
• once a medical officer obtains the fellowship, he or she is automatically promoted to associate consultant
• promote all current associate consultant to consultants
• promote all consultants to senior consultants

When I discussed my idea to CB and KM, the former asked, "How about the senior consultants now ?"

"We can call them premier, or gold, or diamond consultants, whatever you like." I smiled.

And I said to myself, "Following the system of American Express, we should call them black consultants."

That's exactly what inflation of title means.

PS. Did I say increasing the salary ?

Membership

Around the time I finished with the chapter on infectious disease, we held the college membership examination in our hospital.

I would not go through the details of happenings here. My friend VM was the one responsible for the arrangement and everything was remarkably smooth. The only disappointing observation was most of the candidates did not perform well and the passing rate was very low.

And, there comes the interesting difference in opinion: When I told all these to my friends CB and KM, they all agreed we need to brush up our candidates and improve the postgraduate training. But, when I mentioned this to PL - our College secretary - he just worried that with such a difficult examination, even fewer fresh graduates would like to take up a training in internal medicine !

I can only say they both have a point.

PS. One possibility that I did not exclude was the cases we put up were too difficult.

Of course, the simulated scenarios were provided by the College and we claimed no responsibility.

And, to my surprise, our man from Jupiter told me later in the week that our external examiners actually reported to the College that our cases were too easy !

Textbook

While I was puzzled with the norm of the electronic industry, I was surprised to find a similar phenomenon within my own circle.

It goes like this: Many of you may know I have 30 minutes of private study every morning before I start to work. In general, I read some randomly selected textbook or my own notes, and my recent morning reading is the chapter on infectious disease in Kumar & Clark's Clinical Medicine.

Don't be surprised - yet. The really amazing bit is, I am reading the fifth edition of this textbook, published in 2002.

Many of you (including my wife) would yell, "Wouldn't that be outdated ?"

Not quite. In fact, besides a few areas with rapid advance (for example, HIV infection and multi-resistant tuberculosis), the old version is entirely satisfactory, and I would prefer this slightly outdated volume than the 2011 (or even 2012) edition of other less well written ones - to say the least, Kumar & Clark has stood the test of time.

And, by now, the consideration comes back to the old question that I was discussing a few days ago (see http://ccszeto.blogspot.com/2011/02/determination.html): It is not the ability to read (or even interpret) the latest journal publication, but the habit and determination to study a slightly outdated textbook being the critical core value of the life-long learning skill.

PS. Seriously I prefer the even older editions of Kumar & Clark - the chapter on infectious disease was actually better written in the last millennium.

Camera

While I was considering what is timeless and eternal, Vivian and I were actually doing the shopping - to find a suitable birthday present for my sister Jenny.

Vivian suggested a new digital camera; I eagerly agreed. My sister was using her previous one for almost ten years, and the gadget did not work very well when she tried to take photos for niece Seraphe.

Which model to choose? Of course I had very little idea. Vivian was actually more familiar with the electronic industry and, as usual, was responsible to do the pick. This time, she actually rang up HJ, a previous colleague of hers who was also an expert of photography.

"Too bad we cannot have the same model as HJ. His suggestion of model X was really superb. It was ideal for taking picture for children - especially by inexperienced users." My wife sighed after putting down the phone.

"Then, why not?" I asked.

"The model was not new now; it has been around for two years." Vivian said.

"I do not comprehend. True, it may not be the newest model, but, as long as it works well and suites our purpose, we don't really need the last model on the market." I replied.

"My dear, not for the electronic industry." My wife murmured.

And she was right: We could not find that model in any store.

Sell

Although it sounds depressing to realize nothing is really eternal, the situation is more palatable for the worldly people who do investment.

The logic is simple: Although it is widely publicized that value investors like Benjamin Graham and Warren Buffett buy and hold, and they enjoyed an exceptional investment return, the strategy could hardly be regarded as ideal.

(In reality, Warren Buffett does sell things, and it all depends on the price - see what he did with PetroChina.)

Then, what is the difference between a speculator and a value investor?

The probable answer is this:

• Speculators sell a stock when they achieve a small and pre-defined amount of profit (say, 10% or 20%), or, in response to a fluctuation in the price of a stock, to cut his loss (止蝕).
• Old-school value investors (like Benjamin Graham) sell when the price of a stock rises from a grossly undervalued position (i.e. where they buy the issue) to a reasonable or slightly over-valued one. In general, a day-to-day fluctuation of share price does not trigger him to cut loss, but a fundamental change in the financial condition of a company would - because the valuation changes.
• Modern value investors (like Warren Buffett) sell only when the story of a company (or, actually, the story of the future of that company) does not hold - they won't even sell when the price of a stock (of a good company) is slightly over-valued.

If my description of the two types of value investor is not clear, let's put it this way: The old-school ones buy a so-so company at an excellent price, with an aim to sell it when the price rises to a reasonable level; the modern ones buy an outstanding company at a reasonable price, and keep it as long as the prospect remains rosy.

Eternal

My discussion on the value of clinical skill and ability to continue to learn was, however, a trivial matter (or, I dare say, a microscopic consideration of the problem at hand).

The real problem is: What is of an eternal value in our life?

Oh, I'm not considering a religious answer. As a humble man on earth, I discussed this topic previously on several occasions. (For example, see http://ccszeto.blogspot.com/2009/04/blog-post_12.html and the subsequent entries.) In short, although we graduated from the medical school and had so much specialty training, it is never necessary to stick to our own field - or even to continue to be a doctor.

And I have not changed my opinion.

The unfortunate consequence, however, is that some medical graduates give up a clinical job and migrate to other planets. With their special training, these creatures often become the most unbearable beings. As Theodore Roosevelt said: A man who has never gone to school may steal from a freight car; but if he has a university education, he may steal the whole railroad.

PS. It is at least fortunate that Sun Yat-Sen (孫中山) did change. Otherwise he might have been an inconspicuous doctor at the London Chinatown, and we are still half bald and wearing a plait.

PPS. An obsessive historian may argue Sun did not actually lead the Wuchang Uprising (武昌起義). That's true.

He had a university education.

Determination

Once you come to realize no knowledge or skill has an eternal value, it seems tempting to conclude that only the ability to continue to learn is timeless.

(It is coincidental that one of our little friends made such a comment in his Facebook notes. See http://www.facebook.com/notes/rutherford-sin/depreciation/10150093773727190)

In a sense that is correct. The unfortunate consequence is this idea of having an ability of learning has a cardinal importance is eagerly accepted by many of our educationalists, with an aim to reduce the amount of knowledge to be mastered by the doctors of the next generation. The result is Life-Long Learning Skill becomes an independent subject of our curriculum, as if there is really skill to be taught and mastered.

And, at the end of the day, we have a group of graduates who are able to learn - but have learned nothing (or, to say the least, nothing material).

What has gone wrong in our argument? None, except that it is not the ability to continue to learn has the timeless importance (the ability to read is taught in kindergarten and primary school), but, rather, the habit and determination to continue to learn.

And, habit and determination are humanistic characteristics that could never be taught in the classroom.

PS. That believe of having an eternal learning skill is, in itself, a self-conflicting statement - any skill that could be taught is never eternal. As Lao Zi (老子) said: 道可道，非常道。To take an everyday example, the ability to search in Index Medicus was probably the only life-long learning skill twenty years ago - but you must have graduated in the previous millennium if you have ever heard of this antique system of literature search.

Persistent

The real problem of focusing on knowledge and skill that has persistent value is not that quality could not be quantified, but, what makes up a persistent value.

For example, although we agree a fellowship or PhD degree does not worth much as more and more people bear the title, does it mean a certain collection of clinical skill (or, using the jargon of our educationalist, core competence) is timeless and should be mastered by all medical students?

On the face of it, yes. Otherwise it would be silly to conduct a clinical examination.

However, when you think of it again, no single technique is critical and indispensable, not to say the importance of which would not change with time. For example, it is not that necessary for a final year student to be able to pick up a heart murmur if he decides to become a surgeon or psychiatrist. Well, it really isn’t important if the student misses a murmur even if he intends to be a cardiologist – because he would certainly learn echocardiogram in the future. In fact, with the advance in technology, stethoscope with an amplifier is now widely available, and it is not difficult to detect a murmur even if he is almost deaf. (The real problem often is, of course, as Sherlock Holmes said, you hear, but you do not listen.)

You may argue the ability to take a full history and performing a competent physical examination remains the core competence if a medical graduate determines to be a clinician, because he may be working in a place that has not advanced technology. Well, that argument only proves that the ability of performing echocardiogram or reading a CT scan has no eternal value – because you may be practicing in a place without these facilities. However, it does not prove that being able to detect a murmur or performing a complete neurological examination has a timeless value – because you may also be working in an institute where you always need to objectively prove a physical sign by technology.

Value

I must say I cannot agree more with JW's advice.

The only difficulty is, of course, what is of persistent value.

In the field of finance and economy, it was rightly pointed out by Adam Smith (in The Wealth of Nations) that neither money nor precious metal serves as the infallible yardstick of value; only the productivity of labour does.

Unfortunately, productivity could never be objectively quantified.

The problem becomes more serious when we talk about capability. Yes, it seems easy to advocate students to focus on knowledge and practical skill rather than examination and professional qualification. (As the traditional teaching of Buddhism: 萬般帶不去，唯有業隨身。) However, it is the examination score or title of fellowship, not the quality of a person, that one could quantify.

Alas, by definition, quality could not be quantified.

PS. The above argument is part of the reason why I always support an open book examination for clinical medicine: One could bring (electronic) textbooks in their pocket, but examiners would always uncover the candidate's deficiency as soon as he tries to practice.

Inflation

Recently, my friend JW had an opportunity to share his "humble" view on inflation with our students. I must say I missed the opportunity to be an audience. Fortunately, I found the content of that speech in the Facebook Notes of one of the students. (For technical reasons I do not include the hyperlink to that notes.)

Here you go:

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

Today is the farewell party for the final year medical students. Quite a few of our distinguished professors including JW were asked to give a speech.

Being the Warren Buffett in our faculty, JW started by emphasizing the importance of making early investments. He stated that with proper investment strategies, by the age of 40, your capital should be able to generate more value than your income. This, of course, drew admiring and envious eyes.

By proper investment strategies he meant we should avoid assets that suffer from "inflation". Assets that are readily reproducible by a printing machine are bad investment options. "Poor quality currency" like US dollar, the shares of a you-know-who telecommunication company in Hong Kong, bonds from some irresponsible treasuries, are all on the list.

Here comes the highlight. He turned to the phenomenon called "diploma inflation". Nowadays diplomas and certificates are easier and easier to obtain. The toilet of MRCP and FRCS are rare and precious in the past, but now their holders are everywhere in the job market. These qualifications no longer guarantee a bright career prospect. And as if it is not convincing enough he reminded us of the story of the MPhil graduate who have to live on social security. We should not be distracted by the inflatable pieces of papers, but should invest in assets that persist.

I discussed about this with a number of friends. One interpretation is that we should not focus solely on exams, but should develop our knowledge and learn practical skills useful for our daily practice.

*Szeto's note added on 21 February 2011: the link of the original post is http://www.facebook.com/notes/rutherford-sin/inflation/10150091178867190

Audit

A real story from a surgeon (well, yes, I add the seasonings):

After attending the audit meeting in the headquarters, the Chief-of-Service called an urgent meeting with his young consultant, who happened to be still living on earth.

"Look, we're not doing very well here," the COS began by pointing at a particular diagram in the report he got from the headquarters meeting.

"Yes ...?" the junior consultant became anxious as soon as he followed the finger of his boss and realized that the diagram was about the operation lesionectomy - an operation that was almost entirely done by himself.

"You see?" the senior surgeon was inpatient, "The operative mortality of this procedure is 2.4% in our unit, much higher than the overall result in city, which is 2.0% only!"

For a moment, the young surgeon hallucinated that his boss was Columbus, who landed on Cuba but believed himself discovered the New World. After a moment of silence in discomfort, trying to pull his thoughts together, he murmured slowly, "That difference between 2.4% and 2.0% was, in fact, one patient ..."

He thought the explanation was quite enough.

But, the Chief-of-Service was not satisfied, "Then, why did that patient die ?"

Well, I don't know what that particular patient died, but I am sure the young consultant died of a seizure.

燈謎

As usual, I put up a quiz on the Chinese Valentine's Day:

劉邦聞之喜

劉備聞之悲

(猜一字)

PS. I claim no credit for this one, which I learned during secondary school.

Construction

You may think I am coming to the conclusion that all human (economic) activity causes pollution.

By and large, that's what I mean.

Nonetheless, there is a reason that I am particularly concerned with construction and infra-structure projects: Because their economic benefit is typically skewed in favour of the exceedingly rich and business leaders, while the poor people often do not gain much - and sometimes have an enormous price to pay, especially in societies where the corruption rate is high.

Oh, I am not inventing all these. You know, there is now good evidence showing that construction industry is particularly prone to the effect of corruption. For example, over 80% of all deaths from building collapse in earthquakes over the past 30 years occurred in countries that are anomalously corrupt. (See Ambraseys N. Nature 13 January 2011, p. 153-155.)

Seriously, I don't think that needs a study.

PS. The reason for the tendency to have corruption in the building industry roots from the very nature of the business: oligopoly market, subjective tender and bidding process, and a complicated government-business interaction.

Go read The Art of Strategy.

Janus

You may argue there exists a possible balance between environment protection and prosper in economy.

On that, I would say the line is not fine – it is ignis fatuus. On a superficial look, yes, we could be careful and pay attention to the effect on our environment while developing the economy. However, as stated by the Second Law of Thermodynamics, all processes would result in increase in entropy (or, in layman’s term, the degree of disorder), and all economic activity would inevitably result in cost to the environment.

(By the way, although human are political animals, all human activities are economic ones.)

Don’t you see the point? Take paper cups and plastic forks from our fast food stores as an example. True, they end up in the trash after being used once – and are about to fill up our country parks in the near future. However, are fine china cups and silver forks more friendly to our environment?

Yes, as long as you do not wash it with soap and detergents and water after using.

Similarly, does it cause less air pollution by abandoning coals and petroleum and use hydro-electricity? Let’s consider the dams north to Yunnan.

Alas, I am not saying we should forget our environment. There are genuine situations when we damage the Earth without doing any benefit (for example, turning on the light when nobody is in the room). However, there are far many more scenarios where people see just one face of Janus.

They are the ones outside the door, of course.

Labour

While I was secretly happy with the cheap labour around the world and the declining price of laptop computer over the years, our famous alumni mentioned in the morning paper that our city is short of construction site workers and, as there are so many infrastructure projects along the pipeline, the government should encourage the younger generation to join.

(See http://hkm.appledaily.com/Home/ShowArticle/ed3d2fb0-f8cf-4406-a9e8-c2ea09366ee8)

I must say my feeling is ambivalent.

Yes, on one hand, a frothy (alas, no bubble) property market and prolific infrastructure projects would not only boost the local economy but create jobs - with a reasonable pay, as pointed out by our famous alumni - for many semi-skilled workers. After all, not everyone in the society is suitable for a university education, and, one of the major difficulties of a modern government is to find a means for them to earn a living and have a subsistence with dignity.

(By the way, that's exactly the mistake of some Mr Tung: an intellectual type of economy could never improve the life of the majority - which, by definition, does not have the intelligence.)

Yet, on the other hand, putting up too much emphasis on bricks and buildings almost always means tearing down some good old public memory or inevitable damage to the environment.

And, the worst bit is, it's really the opium of economy: If a large proportion of the working population earn their living by being construction site workers, as soon as the property market turns bubble and bursts, the crowd would roar and press the government to put up more projects on rail or highway - so that they could continue to earn their salt.

That actually happened once shortly after 1997. Don't you remember ?

Made

At the end of the day, I bought a Fujitsu LifeBook.

It costed HK$11000 (when Hang Seng Index closed at around 23000). In fact, I chose the more advanced model with touch-screen function; ordinary ones were sold at around HK$7000. (My friend KM actually bought one around the same time at HK$4000.)

Why did the price decline over the years? Simple. For those who have not read The World Is Flat by Thomas Friedman, the manufacture of a laptop (and many other daily utilities) are much less expensive nowadays - as compared to two decades ago - because the production lines have moved to developing countries (notably mainland China) that have cheap manpower.

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

While I was wandering around the computer store to pick a desired model, my wife reminded me, "You know, there are two kinds of Fujitsu: some are made in Japan, others elsewhere. Watch out."

I could not help but smiled, "It really doesn't matter. Although I admired the precision of Japanese workers, there is no genuine made-in-Japan computer as such. Those with such a label on the top merely mean that they are assembled in Japan; it is equally likely that their parts - battery, CPU, monitor, DVD drive, and so forth - are made in other exotic countries."

Alas, the same problem applies to almost everything in our life - and, the sobering truth is, the term self-sufficient has disappeared from the dictionary of modern man.

Models

My new laptop is my seventh portable computer. It represents a vivid example of deflation and history of the electronic industry.

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

I had my first laptop in 1994, shortly after I passed my membership examination. It was a second-hand Philips from my friend SM; I bought it for HK$12000. At the same time, the Hang Seng Index was around 9000.

You could hardly find any sane person using Philips' laptop now.

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

In 1997, shortly before I set off for Bristol, I bought a Texas Instrument Travelmate for HK$22000 (when Hang Seng Index was 13000). It was the newest model and, like all products from TI, had an arm-breaking weight.

The next month after I had this third laptop of mine, TI sold the entire production line to Acer.

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

I was slightly cautious with Taiwan manufacturers and began using Toshiba since I came back Hong Kong. Most of the models appear a bit thick, but the Japanese company has excellent quality control and the products are durable. The last one I had was sold at HK$14000, when Hang Seng Index was 18000.

The problem is, only two kinds of product (and, unfortunately, also person) prosper in this world: those who are trendy and smart (like the Apple), and those that are cheap (I won't specify which or who). Humble hardworking ones like Toshiba just fade away: its global market share dropped from 9.8% in 2006 to 5.3% by the end of 2010.

I ended up being unable to find any Toshiba computer in the store this time.

Computer

Another thing that I did during the Lunar New Year holiday was buying a new laptop computer.

The existing one of mine was in use for over four years. I must say it was still in perfect function with its Windows XP and Office'97. (Difficult to believe, eh?) The only reason that I need to find a new one is that my father-in-law is quite fed up with his lap top, which is still running Windows ME (I know you may not have even heard of this antique operating system), and he would not accept a brand new one.

It is in fact no fun to have a new computer at my age: I need to move all the personal files from my previous computer to the new one, and re-install every software. Contrary to your imagination, my personal files are not that much (around 7GB, because I have very few videos and not many photo) and it's not all that difficult to make a copy. The real difficulty is for the software: I have the habit of personalizing the Windows' setting and customizing Office toolbars. It is quite a nightmare to do it all again every few years.

PS. I always keep two copies of every personal file: one in the desk-top of my office, another in the lap-top at home. The last thing I do in my office everyday is to copy all files that I worked on that day to a finger disc, so that I could upload them back to my computer at home. Yes, there is a bit of trouble, but the price to pay for losing my working files is too high to risk.

Easy

In contrast, it is actually not all that difficult to alter the behaviour of the others by subconscious means - especially if you do it repeatedly.

The simplest form is widely known as post-hypnotic suggestion. In short, it is the induction of a person into a behavior or thinking pattern that makes itself manifest after he has come out of the hypnotic state. An altered sense of perception or behavioral pattern may be "programmed" into the person under hypnosis; certain sequences of events may be set as triggers to enter or exit the post-hypnotic pattern.

The more elaborated form is also well studied. For example, if, while asleep every night, you hear a repeated voice to tell you eat more cookies, you would soon find yourself turning into that blue monster of Sesame Street. (OK. I am exaggerating a bit.)

In practice, this phenomenon becomes what is know as suggestion therapy: a therapist uses carefully worded "suggestions" to help the person to bring about a positive change. It is often used for treating habits, such as nail biting. Well, many of our dying patients also have their family showing them Sutra sound clips. It remains unknown whether that would help the comatose subject passing the Modoribashi (The Bridge to No Avail, 奈何橋) more easily.

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

Contrary to post-hypnotic suggestion and related tricks, subliminal stimuli, as a form of subconscious suggestion, is largely a myth.

The original idea was attractive: Visual stimuli are quickly flashed (usually in 0.2 second) before an individual's mind could process them, and the potential use in advertisement was widely publicized by marketing experts in 1950s. However, subsequent research has been unable to replicate these marketing claims beyond a mere placebo effect.

Difficult

You may wonder why I pretended to be Charles Dickens when I commented on the possibility of implanting an idea to another person.

Alas, it is the fault of Christopher Nolan.

In short, to fix up an idea in someone's mind by one dream, however florid it is, is exceedingly difficult, if not impossible. Yes, a single traumatic experience in real life often affect our behaviour permanently - especially if it happens during our childhood. You can consider it as a scar of psychological.

But, not a dream in solo.

The difference would be particularly prominent when we consider the type of idea. In general, a negative effect - that is, not to do something; you can also call it a deterring effect - is often resulted after a major event. For example, some of us avoid getting too close with the others after being hurt by a close friend of ours.

In contrast, it is far more difficult to induce a positive effect, such as working to ruin the family business as described in Inception.

Inception

While I was reflecting the impact of psychology on our behaviour, it was the Lunar new year holiday; I had a brief moment of free time and took the opportunity to watch Inception. (Vivian borrowed the DVD from a friend of hers.)

I must say I was fully (or probably) primed in advance and know about the plot. The result was I found the story much less complicated than I expected. Yes, it was an exciting and enjoyable three-hours (and I found Ellen Page very lovely), but the story lacked a bit of substance. It became a showcase of Christopher Nolan - or, really, his technique, but there could exist a more profound meaning and lasting message.

Like what The Matrix achieved.

PS. The very task that Leonardo DiCaprio was asked to do was to implant an idea into the subconscious mind of his target. This is the most difficult mission, this is the easiest deed - depending on how you see it.

Psychology

During a recent incident, a little friend of mine was amazed how we assess our students by subtle behavioural tags. (See http://rayleung2709.xanga.com/740174987/印象分/)

But, I must say, that practice is in itself a usual psychological phenomenon. In general, we form our opinion (on a person, or on any particular matter) within the first minute or two, or during the first encounter. For the rest of the time, we just look for evidence to prove that our initial impression is correct.

And it does not apply only to medicine and examination. As Richard Dennis observed, for many stock traders, the source of their first big profit determined their subsequent behaviour: people tend to be perennial bulls if they had their first bucket of gold from buying and holding, others become life-long bears if the first victory comes from short-selling.

Or, as Albert Einstein said: Common sense is the collection of prejudices acquired by age eighteen.

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

With this, my memory goes back to some 16 years ago, when I first organized the final examination. One particular candidate did not do quite well in the short cases, and, in those days, the regulation stated that he needed to be re-examined (immediately) by another pair of examiners.

One of the was the man who still had a moustache.

Before my mentor began the (supplementary) examination, he whispered to me, "This boy would fail."

"How could you know ?" I was puzzled.

"Look, he just peeped and squeaked like a horrified chicken. How could we take this kind of people as doctors ?" He murmured.

"You may be right, but you have not examined him," I said.

"Don't worry. I can always prove myself correct."

"Er ...?" I was startled.

"I shall show you how ..." my mentor finished with a curious smile.

With this, he set off for the examination.

Cause

You may argue my comment on the duration of training was not entirely fair.

To begin with, a longer working hour and seeing more patients (within a finite amount of time) do not imply a more intensive training - it could well be the opposite. In fact, many educationalist and a few overseas Colleges openly state that physician trainees should restrict the number of patients to be seen and must not have to long a working hour, so that they could see each patient to a greater detail, and have the time to reflect and read up the relevant topic.

I must say I could hardly agree with this argument: Trainees could see fewer patients now because their time is directed to paper work and computer formalities, and, just ask yourself, are you using the extra half-day off to study, or just let it pass between your fingers because of minutiae ?

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

No, I was dwelling on a minor point. The more important consideration is: Is it really the case that the older generation used to work harder and therefore they have a better prospect of promotion ?

Or, is it possible that, seeing little prospect of promotion and moving up-stream, our new generation doctors become more concerned with immediate personal benefit (for example, limiting the working hour, or having a good half day sleep after an overnight duty) ?

Does chicken or egg come first ?

Exposure

Why's there much higher a hurdle to promotion now?

Alas, there are many good reasons on paper: Medical knowledge has vastly expanded and clinical practice is much more complicated nowadays than that 20 years ago. Moreover, there is a continuous attempt to improve the quality of care to our patients and it becomes more and more demanding before a doctor could call himself a fully trained medical specialist.

(This last sentence is so carefully worded that I begin to believe I have the talent to become an administrator. Alas, it is possibly the sugar-coated palatable translation of some inconvenient truth.)

But, I am not all for the younger generation (because of the obvious reason - I am not one of them). Let's think of it: Do the doctors nowadays have a longer training ?

On the face of it, yes. It was around 5 years two decades ago, but 7 to 8 years now.

But, 20 years ago, a physician trainee worked five-and-a-half day per week, usually had to do 5 overnight calls each month, and had no half-day rest after the call day. In those days, almost all clinical doctors worked over 65 hours a week - while less than 10% doctors are now working for such a long hour according to Shane Solomon before he left.

And, in 1980s, each physician trainee took care of 16 to 20 beds (as compare to 10 to 12 nowadays), and saw at least 20 patients in each clinic session (as compared to an average of 15 at the moment). If you compute the among of clinical exposure - in terms of both contact hour and patients seen - the training was quite the same between the two generations of doctors, just that it used to be more compact and intense.

Upstream

One of the hot topics that kept coming up in our lunchtime discussion is the difficulty to move up along the social ladder for our young generation.

I must say the opinion is often split amongst the table - and not uncommonly within one's own mind. (Yes, that's what you call schizophrenia.)

Maybe I could illustrate by the career prospect of our young doctors:

Twenty years ago, a physician trainee is entitled to apply for a post of Senior Medical Officer (equivalent to the Associate Consultant nowadays) as long as he has been graduated for 5 years, and has passed the membership examination of the Royal College. In fact, many doctors were promoted with that qualification. In contrast, it is exceedingly lucky if you could get an AC job after graduated for 8 years, with three college examinations and four annual assessments along the course.

Isn't it much more tough for the trainees now?

Three

After my recent reference to the Beggar Party (see http://ccszeto.blogspot.com/2010/12/beggar.html), there was much unexpected development.

I shall not elaborate on the happenings. The event, however, could be considered as an excellent illustration of game theory (or corporate political strategy, if you prefer to call it that way). Specifically, the scenario is: How to seize the power as the fourth man when there are already three figureheads in the party ?

Let me tell you a story of the modern China:

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

After Sun Yat-Sen (孫中山) died in March 1925, there were three figureheads of the Chinese Nationalist Party (國民黨): Liao Zhongkai (廖仲愷), Hu Hanmin (胡漢民), and Wang Jingwei (汪精衛).

In a game of four, how to gain control and eliminate the dominant three ?

Well, in this case, the procedure was ingeniously planned and masterly executed: Liao was assassinated before the Party's Executive Committee meeting in August 1925. Rumour was spread so that Hu was generally considered the suspect (and, in fact, arrested for a brief period). Wang, whose determination and calculation was considered the weakest amongst the dominant three, was taken as an ally throughout this process.

You see, in no time, it became a game of two.

And the rest is history.

Advertisement

During a casual conversation with CJ, our visiting scholar from the mainland, we inevitably touched on Mr. Hu's recent tour to America.

"Our country is really getting strong," my friend said with admiration.

"Alas, the Americans are just doing business," I murmured.

"Well, that may be true," she continued, "But the reaction of the Americans - and other westerners - really amazes me. You see, when we were weak, they called us Sick Man of East Asia (東亞病夫). Now, we are strong, and they consider our country a threat !"

"You have a point there, "I was forced to agree, "Nonetheless, I still find it difficult to understand why Mr. Hu has to make so much an effort and put up the advertisement. Well, it is entirely acceptable to bring big business to them, but to ask several dozens of celebrities to come out and say how brilliant they are would hardly help the image of a country."

"Quite right. The effect may actually be the opposite."

"After all, we judge a people by what they do, not what they say - or what they claim themselves to be," I continued, "As Margaret Thatcher said: Being powerful is like being a lady. If you have to tell people you are, you aren't."

Fourth

"What's the other side of the opportunistic cost you meant?" I went on.

"We have to consider the resource of conducting a trial. If drug companies put their effort on a few gigantic trials to prove the marginal benefit of some products, there would inevitably be less emphasis on areas that also need attention."

"And, as you used to call it, there is humanistic opportunistic cost as well," I began to see the point of my friend, "The number of suitable patient is often a limiting factor. If most of the eligible subjects participate in one mega-trial, there would not be enough patient for another potentially more important study."

"Quite right," my friend said, "And, from the society point of view, if more money is spent for drugs with marginal benefit, there would be less for other important function - education, social welfare, and so forth."

I found it difficult to find an appropriate reply.

And my friend continued, "The inevitable result is, therefore, by offering that marginal benefit to your patient at hand, you run the risk of jeopardizing the benefit of someone whom you may never meet. We call it a damage to the fourth party - the first three parties being the doctor, the patient, and the drug company."

I considered what he said for a while, "Your argument sounds familiar. Where does it come from?"

"You're right on that. Have you read the latest issue of Conversations with Charles in Clinical Medicine?" L smiled.

"Yes, right, that little article by Coemgenus. It used to appear on the last page of that official journal of the Royal College of Physicians of London." I said, and, after a moment of silence, I added, "Too bad Coemgenous is now retired and that fictitious Charles died on Mont Blanc."

"Very sad. Another Licht goes off." With that final remark, I found L walked away and gradually disappeared in the darkness.

Alas, unlike Charles, I am sure I shall see my cynical friend again in the future.

PS. Interested visitors should also read Clinical Medicine 2010; 10: 645-646.