Bus

For more than once, Vivian and friends of mine asked why don’t I drive to work – knowing perfectly well that I do have a driving license.

But, I really prefer taking a bus.

True, it takes slightly longer by the public transport. Nonetheless, in a very early hour of the morning, taking a bus remains comfortable and convenient; a few minutes of waiting in the bus stop is also refreshing.

More importantly, during that 20 or 30 minutes of trip I have no traffic light or road condition to worry. I enjoy doing nothing and just allow my mind wonder. You may suggest reading some journal. In fact, my friend KM loves to do so on his way to the hospital, but I find it difficult to concentrate. Many people would also concentrate on their iPhone or other electronic gadgets; I consider that a pathological (and addictive) behavior. If not social phobia and avoidance, why should one prefer focusing on the tiny little world within that 7-inch screen and neglect the real world that occupies the whole of our visual field?

And, in fact, after a good night of sleep, licht tends to develop early in the morning; many of my ideas – grant applications, examination questions, and even topics for my blog – come from this little daily journey.

PS. I am not mad enough to pretend Sherlock Holmes and make the attempt to guess what kind of people there are around me in the bus – well, I did in the past, but have to give up this exercise because there is no objective means to prove my deduction.

Ability

On the face of it, it seems entirely reasonable to pass a student who attends ten percent (or even less) of the bedside teaching but has a reasonable performance in every aspect of the examination. After all, we are looking for good doctors, not obedient students.

But, many of our colleagues are not at ease. The reason is simple: Our system of examination is far from ideal. Although we try all possible and impossible methods to test every conceivable aspect of the desired capability of our student, the system remains artificial and often does not reflect the actual clinical competence of a graduate. In short, it is possible that a student could do very well in the examination but remains a lousy doctor – and this occurrence is not all that rare.

And, at this point, the value of attending bedside teaching becomes obvious: It represents a form of clinical exposure. Medicine is, by and large, a practical subject. Having attended a minimal number of bedside teaching guarantees a certain degree of clinical exposure.

It sounds logical, eh?

Hold on. The point is: Does bedside teaching represent a meaningful clinical exposure?

The answer should be obvious - no, not always, and I would say not often.

And, if a student decides to skip the clinical teaching and stay in the ward so that he could see some patients himself, why should we worry? (Alas, yes, of course, I agree this happening is exceedingly rare.)

On this, the Finagel’s Law suddenly comes to my mind – and I cannot resist the temptation to modify it a bit:

• The system we have is not the system we want.
• The system we want is not the system we need.
• The system we need is not available.

10%

In a recent department meeting, our student representatives and the man from Jupiter had a remarkable conversation on our students' attendance to bedside teaching.

The original idea of our students were, I must say, rather simple and straightforward: They were asked to have their logbooks signed by the teacher after each session of clinical tutorial, and they believed that's silly; they are adults and should have the right to decide how to make the best use of their time. After all, signing the log book could be a pain in the neck for the tutors.

I fully agree.

However, our chairman and a few other colleagues were not at ease - and they had a point. Some of the clinical teaching sessions were poorly attended and it became a headache for the teacher. (More importantly, the attendance may not correlate with the quality of the teaching - it's more related to the timing in relation to our students' panel examination.)

And, at the end of the day, the question boils down to: If a student attends, say, only 10% of the teaching sessions, but performed well in the examination, both written and clinical, should we allow him to pass and practice?

Grammar

I am beginning to believe my understanding of grammar is entirely wrong.

Not too long ago, an alien said, "You guys are too calculating."

Of course we are. We are repeatedly brainwashed by our risk management people and other extra-terrestrials that we should be meticulous with every minute detail and be clear and precise with all numbers.

But, understandably, we're not happy with the comment; we told him that much plainly, just like Drury Lane told inspector Thumm that there was an ugly red nose in the center of the Thumm's face.

In response, the self-confident secretary said, "If my comment somehow hurts your feeling, I an willing to apologize."

And then, you know what, everyone cheered. They all said, " The alien apologized! The alien apologized!"

I had a deja vu feeling that it was the same collection of voices that said the sky is falling.

Did our friend apologize? Alas, he only said he was willing to do so if his previous remark did hurt our feelings - it remains to be verified he agreed our feelings were hurted (knowing perfectly well that he did not agree with a whole lot of barn door facts), and, even if he does agree, he is willing to say sorry. The appearance of that five-letter word in his sentence does not mean that he has already apologized. I have a lot of four-letter words in my vocabulary and it does not mean that you are their target - unless you have an obsessive disorder of mental masturbation.

For that reason, if anyone ask me whether I accept the apology, I would say, "You'd better see a psychiatrist." - Although I know perfectly well the remedy.

Just soak your imaginative fingers with Tabasco.

Immediate

While listening to the news from Fukushima, a comment was repeatedly made by the authorities:

There is no immediate danger.

Of course there is none. Danger, by definition, is not immediate; it means the risk of injury or death in the future. For example, if you are going to die tomorrow, this is not an immediate danger - after all, I may not be in the office by that time.

Let me share with you a small paragraph about Marie Curie, from Bill Bryson's A Short History of Nearly Everything:

For a long time it was assumed that anything as miraculously energetic as radioactivity must be beneficial. For years manufacturers of both paste and laxatives put radioactive thorium in their products. Radioactivity wasn’t banned in consumer products until 1938. By this time it was much too late for Madame Curie, who died of leukemia in 1934. Radiation in fact, is so pernicious and long lasting that even now her papers for the 1890’s, even her cookbooks are too dangerous to handle. Her lab books are kept in lead-lined boxes and those who wish to see them must don protective clothing.

Or, maybe I should show you this little scene in Casablanca:

Yvonne: Where were you last night?

Rick: That's so long ago, I don't remember.

Yvonne: Will I see you tonight?

Rick: I never make plans that far ahead.

As Zhuangzi (莊子) said: You can never explain what snow is to a worm that does not live beyond the summer (夏虫不可語冰).

Estimation

You think my calculation yesterday was irrelevant? Let's see what our extra-terrestrial friends are now proposing:

• Physicians should be promoted to a senior position 5 years after fellowship, i.e. 12 years after graduation.
• Since the life-expectancy of his career remains 35 years, he wound spend 23 years as a senior.
• This system would only be sustainable if, on average, a physician senior leave the public hospital 12 years after being promoted (and no junior leaves the system prematurely). or we accept a senior-to-junior ratio of 2:1.

The former situation is obviously not what's happening, and it is not going to happen if our pay is too high !

How about the latter? Isn't it what's being proposed?

True. But, the number of front line staff needed is determined by the patient load. If we have two seniors for each junior doctor, we have to either accept some seniors doing front line job (and my friend KM could assure you how difficult it is), or to double the current number of senior post.

I shouldn't say any more.

Different

One important discrepancy in opinion between my friend TW and me is our view on the problem of the local medical circle.

Frequent visitors of this site would know I tend to believe the root of our problem is the shortage of manpower. In contrast, TW concludes, rather succinctly, that it is the stagnancy of senior physicians in the public hospital that causes the roar.

I must say she is correct.

In essence, I see only the short term phenomenon, and my friend has a grip on the root of the matter.

Let me give you the proof in a mathematical way:

• In general, a medical graduate starts physician training at the age of 25.
• If he does not leave the system for the private market, he should retire at 60-year-old.
• In other words, the life-expectancy of his career is 35 years.
• If we accept a one-to-one ratio for senior and junior doctor, we would expect he could be promoted to the senior position after graduated for 17.5 years (or, assuming a training of 7 years, he would be promoted around 10 years after getting his fellowship).

That's exactly what's going on.

Quantity

(The discussion between the two military specialists continued.)

“My friend, you shouldn’t be too worried,” the cabinet secretary tried to be reassuring, “I agree it is by-and-large a problem of manpower. Nonetheless we have increased the number of student in the military school – and we are going to have more. In short, you are going to see twice as many military graduates five or ten years later.”

“I’m not sure that’s good news,” the Commander murmured.

“Alas, you don’t think that is of any help to the current problem, and you worry about the number of teacher in the military school – you said that much previously,” the senior civil servant was confident, “But we are talking about the long term definitive solution of the problem.”

“I am worrying about something more fundamental,” the senior soldier said.

“Which is …?”

“The quality of our soldiers, sir,” the Army General explained, “You know, not everyone is suitable for the battlefield. In fact, with the current number of graduates, we are already seeing a small proportion of the new soldiers obviously not fit for facing war. Having twice as many new soldiers may not translate into doubling the manpower – it could also mean half of the army in the future are not meant for the war!”

“Don’t be silly. Isn’t it a saying that the problem of the quality of an army should only be considered after the problem of quantity has been solved?” The Secretary smiled.

“There’s such a saying alright,” the Commander did not smile back, “But this very statement was made by Adolf Hitler…”

Leave

(Cont'd.)

"I know how you come up with the number of 50 or 55-hour. But that doesn't work in the battlefield." The army general pointed out calmly.

"Why not? We put up the same rule for all civil servants and that worked well. In fact, we have a similar arrangement with the Air Force and they are OK." The Cabinet Secretary was insistent.

The Commander wished to say they are not clerks or secretaries, but he didn't - there might be some truth in it after all. Instead, he replied in a humble voice, "The Army is different from the Air Force. You know, when you are the pilot of a bomber, you can always say the time is up, let's call it a day, and off you go. There is no responsibility as a result of direct contact. However, when you are an army soldier, you could not simply tell your enemy that you are about to off work for dinner - when you are seeing them on face and they are trying to shoot you. By adjusting the duty list, are we going to tell our enemy that we are about to off work and is not responsible for the fighting this hour - please shoot the colleague who is going to cover my duty?"

The cabinet secretary tried to say something, but words failed him. Although he was also in the army in the past, he left it for another planet decades ago.

The senior soldier continued, "You see, our soldiers do not want more money - at least that's not their primary objective - but they wish to have a reasonable quality of life and career prospect. Exactly for that reason, it is meaningless to define what a reasonable working hour is - they know it well and, by the nature of human, they would have worked out a way so that they could work not that long if there is a simple solution at hand. It still boils down to the basic problem of too many enemy or too few soldiers as the root of the problem; only by solving this problem of manpower - rather than defining a standard working hour - could we reduce their duration of work."

"As Albert Einstein said, in human problem, the shortest distance between two points is always not a straight line." The civil servant was forced to agree.

Hour

Some of the frequent visitors of this site may recall the remarkable discussion between the Chief Commander of the Army and the Secretary of Defense of the cabinet. (See http://ccszeto.blogspot.com/2010/01/armor.html and http://ccszeto.blogspot.com/2010/05/blog-post.html)

They had another meeting recently.

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

"You know, our soldiers are on the verge of revolution. They are really stretching their limit and could not work for that long an hour any further." The Chief Commander said.

"Don't worry. I have just submitted a brilliant proposal to the cabinet to solve this problem," the senior civil servant tried to pacify his colleague, "In short, every soldier would have a fixed standard working hour each week."

"But, we are in the middle of a war!" The military professional gasped.

"I'm not saying we put up a maximal working hour; anyone who works longer than the standard hours would get extra pay - and a decent one, too." The Secretary explained.

"Em ... It's not the problem of money. They do not have the right to refuse that extra pay, however decent that is, and leave the battlefield after having done with the standard hours," the Commander murmured.

"Don't try to fool me. I've some calculation of my own and it is perfectly workable to put up a 50 or 55-hour-week and covers everything - the need of extra hour is minimal if you put some effort to adjust the duty list." The civil servant was not moved.

The Chief Commander was startled; he found he was talking to an alien.

(To be continued.)

Wind

While thinking about the Kamikaze (神風特撃隊) recently and seeing the disaster at Fukushima (福島), I could not stop recalling a little history of Japan.

Many of you may know Kamikaze means wind from the god. In 1274 and 1281, Kublai Khan (忽必烈) tried to conquer the Japanese islands after defeating the Korean army. The situation was particularly critical in the spring of 1281, when the Mongols sent two separate forces with over 4000 ships and 140,000 soldiers altogether. The Japanese army, on the other hand, had no more than 40,000 people.

But, the defence of Kyūshū (九州) was successful: A massive typhoon came at the convenient time and the Mongols lost up to 75% of their troops. Kublai Khan was forced to give up his plan of invasion, and the Japanese regarded the typhoon as a wind from the god that would defend their country.

Alas, it is snowing in Fukushima. If the god is still there, please bring a major snowstorm to the nuclear plant and cool down the reactor.

PS. It is now recognized that the destruction of the Mongol fleet was inevitable even without a typhoon. Most of the invasion force was composed of flat-bottomed ships that were designed for sailing in river. Such ships (unlike ocean-going ones, which have a curved keel to prevent capsizing) were difficult to handle in the sea and would collapse in a modest breeze.

As the old Chinese sayings, men should help themselves before the god could help them. (人必自助，而天助之。)

Cookery

After having some excellent dinner dishes, the next morning Vivian seemed very excited.

“Look. Your classmate is on the morning paper,” my wife yelled, pointing at a column of that famous fruit.

“What’s that all about?” I said.

“He’s talking about cookery and stress management.” Vivian finished in a tone of admiration.

I returned a polite smile and said no more; a scene of my recent conversation in the private clinic came through my mind.

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

The patient was a lady in her late 20s, who always came with her mother. (Given the severity of her previous illness, I considered that entirely appropriate.) After the usual routine and serious medical advice, she said, “Doctor, should I have crowding of my teeth (箍牙)?”

Her mother chuckled – but said nothing. I was slightly surprised, “Why? They looked perfectly fine to me.”

“Certainly not,” my patient insisted, “The two front teeth are a little too bulging.”

“Hardly, I think they look cute,” I smiled, “Who cares about that little protrusion?”

“Exactly! Nobody cares! Doctor, you know, I have no boyfriend." She said, smiling in a funny way.

I sat back and considered for a moment. She may not be the prettiest girl I ever met but is certainly fair and charming. She has a master degree and a decent job - working in some government department as an Executive Officer or something like that. In fact, there is no short of chance for her to meet and make friend with some young man.

At the end, I smiled back and said, "Young man may not pay that much attention to the appearance of a girl."

"You think so!? That's certainly not true." She frowned her face.

I really found I was acting as a father, "Alas, young men with good quality do not, but they are more interested in the character and other internal quality of a girl. Well, let's say, for example, can you cook ?"

Her mother laughed - so much so the ceiling of my consultation room almost fell off.

"Is boiling a kettle of water part of cookery?"

PS. I shall leave it to your imagination who asked that final question.

Birthday

Although I was engaged in a flight of idea and the weekend was not a time to be happy, it was nonetheless Euterpe’s birthday. I took a day off and went to a local theme park with my princess.

The place was recently renovated and now becomes very commercial. I must say I am slightly in favor of the situation 15 or 20 years ago, when the park was having difficulty to keep the book balanced but could do what they believed to be appropriate. Yes, the park is now making money – and a considerable sum too. But, for the exchange of profit, it is giving away its character and personality.

I begin to think of Faust.

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

In the evening, we had a small family gathering. The menu was humble but entirely enjoyable:

• 炸鯪魚球
• 元肚竹絲雞湯
• 煙燻帶子
• 富貴雞
• 麒麟星斑卷
• 萬壽果牛肋肉
• 腰果素雞丁
• 欖菜玉珠
• 牛油果海鮮炒飯
• 蛋白杏仁茶
• 生日蛋糕

Thoughts

Some flight of idea after the earthquake:

• Muammar Gaddafi should be very happy – nobody would now have the time and pay any attention to his doings.
• It was Chile (February 2010), then New Zealand, and now Japan. Following the geography of the earthquake belt, the next stop should be Los Angeles. (Oh, I may have exaggerated a bit. By serious geology, the more likely next should be in the middle of Pacific Ocean, at the opposite side of the Philippine Plate, or the Alaska, which is over the other side of the Pacific Plate.)
• The price of petroleum (and coal) would rise despite a (transient) downturn of the economy, not only because much is needed for the rebuilt of a country, but, more importantly, there would be a halt in the increase in usage of nuclear power.
• Impressive political leaders tend to emerge from an admirable people after a catastrophe. Adolf Hitler was elected by the Germans in the despair of the Treaty of Versailles. Our friends also had Hideki Tojo (and a list of other prime ministers from the navy and army) after the Great Kantō earthquake.
• In fact, the most efficient way to boost up the economy is, unfortunately, to start a war – or, to say the least, to be involved in one. (See how the Americans came out of the Great Depression.)

Couple

The house of that old couple living at the far side of the village collapsed.

Like many of you, I live in this village of a hundred people. Although I visited their house once or twice in the past (and a very lovely one I must say, full of artistic antiques and natural wonders), I am no close acquaintance with them.

There were rumours that their parents were children of my family but they just ran away and set up their own house. I'm not sure how true it is, but my mother does not like them: When this couple were young, they were rude to us and, on several occasions, set fire on the others' houses. Some years later, they were less mad, but remained an arrogant duet after earning much money from their business.

But, the time has changed. The couple's company was less prolific in the recent years. Although they still appeared decent, I am sure they were having a hard time even before their house collapsed. However, tough time is the best test for the character of a people - and, in them, I see a hardworking and meticulous husband together with a polite but determined wife. I suddenly realize I have forgiven their wrongdoings in the past and our arguments recently. We are actually close to each other in this village.

I am not religious, but I shall pray for them.

Donor

Our faculty is about to celebrate the 30th anniversary. Just so happened we had another luncheon discussion.

"Have you heard of the donation?" LS asked..

"No, or I should say not yet," I said (knowing perfectly well that I had not heard of many faculty matters), "What's up?"

"You know, they are trying to set up a fund of HK$1M to support some of the student affair," my friend explained, "Their plan is to solicit ten donations, each of ten thousand dollars, from the first ten classes of our school - so there would be one hundred donors altogether."

"It sounds great," I said, "What exactly is the money for?"

"Alas, they have not fixed up the idea - yet," another one around the table twisted his lips.

I pursed mine, "Brilliant. But I suspect they could easily find that one million dollar by asking our final year students to do away with their graduation dinner and use their money in a better way. I believe the dinner for two years would amount that much."

"You said that in the past already." VW pointed out, "I've read your blog. But that's not the point." (I suppose he was referring to http://ccszeto.blogspot.com/2009/02/donation.html and the subsequent ones.)

"So ...?" I could not see his.

"Would you apply for a grant and say that you have not fix up what you are going to do?" The young professor of hepatology chuckled.

"I see. Nonetheless some of our colleagues may have to volunteer and donate - although the former verb may have to be used in the passive voice." I murmured to myself.

Exclude

After the lunch, I received message from BT about the questions for the coming final examination. All of a sudden I recollect a email communication between us some years ago on the same topic.

Here you go:

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

Dear colleagues,

As in previous years I have been asked to coordinate the MCQs and short notes questions for the final MB examination. I would therefore like to request that each Division should submit some new MCQs and a “short notes question” with a model answer as soon as possible.

I have obtained some MCQ questions from the database. Please select some MCQ questions that cover the areas of teaching in your Division ...

Best regards, et cetera.

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

Dear Professor,

Please see the enclosed file. The few questions I highlighted in purple are NOT appropriate (usually because they are outside the scope of nephrology). For the rest and majority, they may not have been directly taught in our curriculum but are all reasonable for final MB examination. Thanks a lot.

Szeto

PS. I believe we are not supposed to test how much the students have learnt from our teaching, but how good they would be as a doctor.

Even

Met a few other colleagues during lunch.

"We are offering too much teaching to our students. You know, it is actually difficult to fix up a time to have bedside teaching with them - their timetable is just too packed." TL said.

Almost everyone around the table nodded.

"Exactly. Many of our overseas elective students also commented that our local students have so intensive a teaching that they have never heard of in other medical schools," another of us added.

"Is that the case? I don't think so." KS, our professor of neurology, seemed incredulous, "I think we are only teaching our students once."

"What !?" I was startled.

"But true. The group of students that attend my tutorial keeps changing. For each medical student I would only see once - sometimes none what so ever, until the final examination. It is actually difficult to know our students nowadays." He sighed.

We were forced to agree. VW said, "In the old days, each student attached to a particular teacher for a few weeks. That seems a more satisfactory arrangement."

"That depends on your point of view," I smiled, "If a student is assigned to a good teacher like you or TL or KM, they would obviously learn a lot. However, if he has to follow some autistic malicious nephrologist, it would be a waste of the student's time. When we were in the old system, some students complained that the system was no fair, so every student has a chance to be taught by each teacher - usually once in the final year."

"Yes, we call that communism of education." The professor of neurology concluded.

Delegate

I must say I agree totally with what my friend ML said.

"As some extra-terrestrials said, in order to ease off the manpower problem, maybe the administrators should first reduce the workload of our front line doctors and delegate simple tasks to other supporting staff." I said to myself.

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

After the lunch, I attended a symposium arranged by some pharmaceutical company.

The talks were so so. Towards the end of the afternoon, when the symposium closed and I was about to leave, I overheard the conversation between the manager of that company and IC, an exceptionally senior nephrologist who was holding the university post that the man who used to have a moustache is now about to retire from.

"Aren't you joining us for dinner?" The manager asked with some eager.

"No, thanks," IC said, "I've got to get back to the hospital."

"In such late an hour? What's up?"

"Oh, nothing. I just want to remove the dialysis catheter for my patient." The nephrologist replied - his voice was slightly embarrassed.

"Couldn't that be done by nurses? I think they used to be doing so."

"Yes, they did, but they do not agree to do it any further because of the recent incidence of stroke after the catheter was removed." The senior nephrologist sighed.

Alas, contrary to my hope, there is actually upward delegation over the years.

Adapt

While ML and I were discussing about the possibility of forcing most of the medical graduates to become physician trainees, a scene of the Second World War came through my mind:

The Battle of Midway Island has often been called "the turning point of the Pacific War". Between 4 to 7 June 1942, the Japanese Navy lost 4 aircraft carriers. In fact, only two standard carriers - both did not take part in the battle - remained. (There were a few small ones in addition, but their contribution to the overall military capability was relatively trivial.)

Yes, aircraft carrier is essential for the war. But it takes time to build new ones. In fact, there were three large and no fewer than 16 small carriers along the Japanese construction pipeline. (None was actually completed and became operational by the time of atomic bombing at Hiroshima.) What could be done to improve the situation immediately?

A military officer came up with a brilliant idea (alas, I am not aware of the fact that there are extra-terrestrials in Japan): Let's convert some of the other battleships into aircraft carriers.

And the proposal did come true. For example, the construction plan of Shinano (信濃號) was modified. From the start, Shinano was supposed to be a battleship built identical to the famous Yamato (大和號). Now, to suite their purpose, the rear armor was removed to give place for the flight deck.

It sounds great, eh?

But, limited by the original design, the length of the deck was too short for aircrafts to land - Japanese bombers therefore could only take off from Shinano and never return.

Right, they became Kamikaze (神風特擊隊).

PS. Serious scholar of history would point out my account on the origin of Kamikaze is incomplete and may not be at all correct. Well, that's what came through my mind during my discussion with ML - I am not in the habit of reciting textbooks.

Team

After revising the Wealth of Nations, I was about to conclude government expenditure on health care and education are two contrasting extremes of how the money could be spent.

Yes, I've probably gone too far. While still digesting this matter in my mind during the Saturday lunch, I met ML - a university classmate of mine who is now a consultant surgeon in another hospital. After a brief casual chat, our discussion inevitably came to the manpower issue.

"Are there a lot of trainees leaving in your department?" My friend asked.

"Quite so. We have lots of vacancies to fill in the coming July - and there aren't hardly enough applicants." I said.

"So are we," ML nodded.

"I hear that the extra-terrestrials may try to cut down the number of new recruitment in other departments so that more fresh graduates would have little choice but need to take up internal medicine." I uttered slowly.

"Don't be silly. That won't happen," he said, "Otherwise it would be catastrophic."

"You mean many of the fresh graduates would turn to the private market ?" I asked.

"More than that," my friend said grimly, "Let's think of it. You work in a large department of a hundred staff; a few people down would easily be tolerated - and sometimes not even noticed. But, many departments and specialties are operating as small teams - for example, my division has six doctors, team head to house officer included. If one of us resigned and there's no replacement, we do not only have to cut down the service - we could not find enough names to fill up the monthly call list !"

Expenditure

You think my citation yesterday selfish and microscopic? Our giant of economics went on in his masterpiece:

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As the one mode of expense is more favourable than the other to the opulence of an individual, so is it likewise to that of a nation. The houses, the furniture, the clothing of the rich, in a little time, become useful to the inferior and middling ranks of people. They are able to purchase them when their superiors grow weary of them; and the general accommodation of the whole people is thus gradually improved, when this mode of expense becomes universal among men of fortune. In countries which have long been rich, you will frequently find the inferior ranks of people in possession both of houses and furniture perfectly good and entire, but of which neither the one could have been built, nor the other have been made for their use... In some ancient cities, which either have been long stationary, or have gone somewhat to decay, you will sometimes scarce find a single house which could have been built for its present inhabitants. If you go into those houses, too, you will frequently find many excellent, though antiquated pieces of furniture, which are still very fit for use, and which could as little have been made for them. Noble palaces, magnificent villas, great collections of books, statues, pictures, and other curiosities, are frequently both an ornament and an honour, not only to the neighbourhood, but to the whole country to which they belong... though the wealth which produced them has decayed, and though the genius which planned them seems to be extinguished, perhaps from not having the same employment.

The expense, too, which is laid out in durable commodities, is favourable not only to accumulation, but to frugality. If a person should at any time exceed in it, he can easily reform without exposing himself to the censure of the public. To reduce very much the number of his servants, to reform his table from great profusion to great frugality, to lay down his equipage after he has once set it up, are changes which cannot escape the observation of his neighbours, and which are supposed to imply some acknowledgment of preceding bad conduct. Few, therefore, of those who have once been so unfortunate as to launch out too far into this sort of expense, have afterwards the courage to reform, till ruin and bankruptcy oblige them. But if a person has, at any time, been at too great an expense in building, in furniture, in books, or pictures, no imprudence can be inferred from his changing his conduct. These are things in which further expense is frequently rendered unnecessary by former expense; and when a person stops short, he appears to do so, not because he has exceeded his fortune, but because he has satisfied his fancy.

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

Yes, this is all common sense.

But, as it was long pointed out, common sense is not common.

Spending

It becomes a hot topic between my lunch companions how best to spend that HK$6000. All of a sudden I recollect a little paragraph by Adam Smith.

Here you go:

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The revenue of an individual may be spent, either in things which are consumed immediately, and in which one day's expense can neither alleviate nor support that of another; or it may be spent in things mere durable, which can therefore be accumulated, and in which every day's expense may, as he chooses, either alleviate, or support and heighten, the effect of that of the following day. A man of fortune, for example, may either spend his revenue in a profuse and sumptuous table, and in maintaining a great number of menial servants, and a multitude of dogs and horses; or, contenting himself with a frugal table, and few attendants, he may lay out the greater part of it in adorning his house or his country villa, in useful or ornamental buildings, in useful or ornamental furniture, in collecting books, statues, pictures; or in things more frivolous, jewels, baubles, ingenious trinkets of different kinds; or, what is most trifling of all, in amassing a great wardrobe of fine clothes, like the favourite and minister of a great prince who died a few years ago. Were two men of equal fortune to spend their revenue, the one chiefly in the one way, the other in the other, the magnificence of the person whose expense had been chiefly in durable commodities, would be continually increasing, every day's expense contributing something to support and heighten the effect of that of the following day; that of the other, on the contrary, would be no greater at the end of the period than at the beginning. The former too would, at the end of the period, be the richer man of the two. He would have a stock of goods of some kind or other, which, though it might not be worth all that it cost, would always be worth something. No trace or vestige of the expense of the latter would remain, and the effects of ten or twenty years' profusion would be as completely annihilated as if they had never existed.

(See The Wealth of Nations, Book II, Chapter III.)

Combat

You may argue: The bond does not aim to finance our government; it is meant for helping the Hong Kong citizens to combat inflation.

Alas, the idea is innovative - again defined by Humphrey Appleby.

The teaching in course-101 of economics states that inflation is the decline in purchasing power of all the money within a system. What good is there to have a tiny proportion of that sum being free from inflation?

The macroscopic fact is, at the 3rd quarter of 2010, the M1 - narrow definition - money supply was HK$1.07 trillion, and HK$5 billion of inflation-indexed bond is proposed - which is 0.5% of the whole system. The microscopic layman consideration is, if you have HK$100,000 of saving and is (generously) allowed to buy the bond for HK$10,000, does that save you from the trouble of worrying about the remaining 90% of the money?

PS. Frequent visitors may know I am always suspicious about the reported inflation rate - even if it is calculated in the most meticulous manner. My argument has been elaborated previously. (See http://ccszeto.blogspot.com/2008/01/inflation.html)

PPS. I deliberately omit the more important topic and serious consideration here: If the inflation rate is high and our government holds so much reserve, is it having an effective means to protect the erosion of that HK$70 billion?

Bond

To my surprise, one disturbing component of the budget proposal did not catch very much attention.

Let me explain in a slightly tortuous way:

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I suppose many of you have repeated experience of the nuisance of being called by banks or other Credit Service Company and asked if we are interested in borrow some money.

Similar to the answer of most people, my reply is, as a rule, negative. I am not rich but do not urgently need some cash either. Why should I want to ask for a loan ?

For the same argument, why should our government - in the presence of a gigantic surplus and an astronomical monetary reserve - propose to issue new bonds?

I mean the inflation-indexed bond suggested by a certain Mr. Tsang.

In short, if such a bond is profitable, there would be commercial bankers doing it - and the government should not run a state-owned business to seize the money.

If the bond will lose money and our Mr. Tsang aims to subsidize the citizens (the bond-owners, I mean), why should it be done in the most inefficient way so that a substantial part of the subsides goes to the pocket of the fund manager?

PS. I have no bias against people working in the Monetary Authority. As pointed out by Humphrey Appleby, there are two kinds of fund managers (both private and public sectors): they are either honest idiots or smart crooks.

Redeem

You may argue our financial secretary is not doing all that bad this time: He gives every citizen HK$6000 and redeems the same amount of income tax in addition.

Alas, I won't discuss the problems here - be they political, economical, or administrative ones. Just that I have a déjà vu feeling of reading the classic novel of Jin Yong (金庸) - The Deer and the Cauldron (鹿鼎記):

On one occasion, Wei Xiaobao (韋小寶) fell into the hands of a group of his adversaries. In order to escape, he threw a whole pile of cash (銀票) into the air. In no time, all his enemies were too busy to catch the flying money and lost their eyes on this Xiaoguizi (小桂子), who managed an easy escape immediately. (見鹿鼎記第十二回: 語帶滑稽吾是戲, 弊清摘發爾如神.)

Well, I know it is not appropriate to compare our senior government official to a pseudo-eunuch of the Qing time.

It is an insult to the the Duke of Deer Cauldron.

PS. There is actually a fine line between tax redeem and reduction of tax rate that may skip your eyes. In short, the former is a policy of communism while the latter provides incentive for the population to be independent.

I won't elaborate further.

藏富

(Cont'd)

On the other hand, a responsible government should start the whole process from the other end: It first defines what minimal social responsibility it has to take up, and then plan the income (and, therefore, cut it down) accordingly.

The result is easy to imagine: The tax rate is lowered.

You may wonder this policy would benefit only the middle class and the very rich people.

But no. When these people pay less tax, they would have more money to support their own need (for example, medical care or children’s education) – so that the underprivileged would get a better share of the public resource. And, in addition, exactly because not everyone is equal, there would always be the incentive for the people to move upstream.

That's the original meaning of keeping the money in people’s own pocket (藏富於民).

PS. It is a naive idea that everyone should be equal - problem that I discussed long time ago. (See http://ccszeto.blogspot.com/2008/07/thermodynamics.html)

Tax

Maybe I was not very clear yesterday and you may wonder why planning a financial budget by income (in the presence of a surplus) should turn a society into communism.

It goes like this: If the government sees a huge income and decides to take up more social responsibility (that is, spend more money), the system – and I remind you, that’s the most inefficient system of all – would continue to grow. Since it is very difficult for a government to give up a social responsibility that it has already taken up (just think again what Margaret Thatcher did), in the bad years it would run into deficit and inevitably has to explore additional income.

A few years later, when the tide changes, the extra income turns into surplus, and the government needs to explore other social responsibility to take up in order to spend the money – the vicious cycle would continue forever.

And, the end result is a gigantic governmental structure that most of the citizens have to depend on. (The very example at hand is: Almost everyone in our city depends on the public health care system.) Everyone receives a equal treatment (except, of course, a few more equal ones) – exactly the road to serfdom as pointed out by Friedrich von Hayek.

(To be continued.)

Surplus

While I was considering the manpower problem within the medical circle, a certain Mr. Tsang announced the budget proposal of the next financial year.

I was so impressed that I lost my nerve.

But, I shall save all my four-letter words and three-word phrases. There are thousands of excellent suggestions on how to make the best use of that 70 billions of surplus, or what the best way is to give everyone HK$6000. The basic idea appears simple: our government should be working on the principle of deciding the expenditure according to the income (量入為出), and, with an astronomical surplus, more money should be spent to help the underprivileged.

I beg to disagree.

In fact, it is a fundamental misconception that a government should decide its expenditure according to the income – the policy is meant for a government that always overspend and raise lots of debts (like the Americans). Otherwise, it should actually be the opposite (量出為入).

Yes, I mean a government should make the decision what the necessary (and only necessary) things to do are (for example, to provide a basic social welfare, medical service, and education), and then work out the income accordingly. (The inevitable conclusion is, with a large financial surplus, to cut down the tax rate.) If the planning begins from the income, the inevitable result is it would maximize the amount of tax and create a big surplus (like what are now). The end result is an ever-expanding government which tries to take care of each citizen and everything.

Or, in short, a genuine (not nominal) country of communism.

PS. The above discussion obviously comes from my neocortex. My amygdala and other parts of archicortex, however, continued to have seizure activities. To quote one example, I was almost mad on the morning after the budget proposal was announced when I saw a patient in the clinic and had to ask her to pay for a self-financed medication which costs three dollars each day.

License

If increasing the number of medical student does not meet the immediate demand of more doctors, what could be done?

At this point, it seems unbelievable to me that no one – neither medical professions nor layman – think of this simple straightforward solution: Why don’t we allow more overseas medical graduates practice in Hong Kong.

I could hear you gasp.

But I am serious. Yes, there are no fewer than a dozen of problems with this suggestion; nonetheless, it serves well for the short term problem. Why do we yell on one hand because of having not enough doctors, but, at the same time, we put up so many hurdles for graduates from medical schools in other countries – even if they are Hong Kong citizens?

Alas, I can understand why the medical council or our representative in the Legislative Council did not make such a suggestion – there is a conflict of interest. The unexplainable bit is why’s there no layman council member or patients’ right group put this up?

You may say a substantial proportion of these graduates have a horrible standard – I know just too well after organizing the local licentiate examination for some ten years. Nonetheless, there are also many candidates who have a reasonable standard but could not get through the complicated examination system lay down by the Council. After all, if the law allows our universities to hire overseas graduate as clinical staff by offering limited license for practice, why can’t we extend the law and allow Hospital Authority to do the same?

PS. From the government point of view, it is actually more cost-effective to facilitate the practice of overseas medical graduates than increasing the number of local medical students, because the former simply pay for their own expensive education.

Supply

You may think I was mad with such a suggestion of promotion.

Not necessarily. In fact, it becomes entirely workable and would probably be materialized if the plan is slightly modified (for example, promotion to assistant consultant after passing the membership examination) and spread out the promotion exercise to two or three years.

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But, let's discuss the more serious problem: How about employing more doctors?

Alas, that's a naive idea - there just aren't enough supply.

(One of my colleagues told me that for the public sector alone, there would be nearly 500 vacancies in the coming July - but there are only around 250 fresh graduates.)

Of course we can easily blame the current problem to our noble but thick-headed council members (alas, many of them did not get elected again), who decided to cut down the number of medical students some years ago. It takes a few years after you increase the number of medical students before you could have more medical graduates.

"But we shall be seeing more graduates in the coming few years, and there are an increasing number to come." You may argue.

In fact, I was thinking of the same. But, when I mentioned the inevitable need of increasing the number of medical students to KS (during the coffee break of the membership examination), the professor of neurology said grimly, “You know, it’s not that simple.”

“Why?” I asked.

“The workload of our academic staff is quite heavy already. If you wish to recruit more medical students, you also need to employ more teaching staff.”

“I suppose that’s quite natural?” I could not see his point.

“Alas, where do all these new professors come from? If you think a clinical job in the public hospital is not attractive for new fellows, junior academic posts are distinctly repelling!” He sighed.

“I know what you mean now,” I was forced to agree, “They have a equal share of clinical duty as their counterparts in Hospital Authority, they have to do more teaching, and, the worst of all, their prospect hinges on neither of these two tasks, but their research output – which they hardly have any time to do.”