Story

Some of you may be amazed to find my status on Facebook last Saturday:

"My magic wand would not work - There's nothing in the world that could work against the magic of time."

It's a citation from a Disney story book. Well, I was responding to the International Reading Week (國際閱讀週), which seems more likely a hoax on the internet rather than a genuine global activity to promote reading.

I encountered this when I looked up my Facebook - while I was waiting for Euterpe for her weekly music class. I was reading One Hundred Classical Stories from Walt Disney - Silver Collection, and, naturally, I turned to page #56 and put down the 5th sentence on my Facebook status.

You may ask, "Why do you read this book?"

The answer is simple: To read up some suitable stories so that I could tell my daughter before she goes to bed.

Yes, that may be a trivial issue to an onlooker - but it is one of the most important daily activities of my princess, and, like every matter in our life, we can do well only if we take it seriously.

Papyrus

The entire story is more curious than what I outlined yesterday.

To begin with, the "invention" of paper by China is an interesting topic.

You may say, "Why! It may be true that paper did exist a few centuries before the time of Cai Lun, but it's plain obvious that paper was invented in China."

Oh, do not let patriotism blind your eyes. Yes, there is a wealth of archaeological discoveries of primitive paper in China, and they could be dated back to at least 100 BC. However, almost all of these ancient papers were found in Xinjiang (新疆) and Gansu (甘肅) - not the political or economic center of China in those days.

And, have you heard of papyrus (莎草纸) of ancient Egypt?

Papyrus was first manufactured in Egypt as far back as 300 BC, and had been spreading in the following centuries to middle east and central Asia. Of course, papyrus is, strictly speaking, not paper - but they have very similar ingredients. It seems highly probable that papyrus continued to spread to the East - or brought back to the Middle Kingdom by early Chinese adventurers - and was gradually modified along its journey. (After all, paper reed, the original plant that Egyptians used to make papyrus, hardly exists outside the bank of River Nile.)

By the way, Zhang Qian (張騫) stayed in the Great Yuezhi (大月氏) Empire (corresponding to Afghanistan nowadays) between 139 and 126 BC.

Paper

A minor side track of Zhao Kuo's story may skip your eyes: good at military affairs on the paper (紙上談兵) is a suspicious description.

The fact is simple: There was no paper in the Warring State Period (戰國時代).

The classical description is paper was invented by Cai Lun (蔡倫) of the Han Dynasty, at around the 2nd century. However, Cai was largely responsible for refining the technique of paper-making, and there is a wealth of archaeological evidence that primitive paper existed in China at least 200 years before Cai was born.

In other words, when Sima Qian (司馬遷) wrote the Records of the Grand Historian (史記), paper was around - but the quality was poor and that thin sheet of fiber could not be used for routine writing.

And that familiar phrase of ours did not appear in Chinese literature until the Qing (清) era. No, it was not referring to Zhao to begin with, and the comment was first linked to the story of Zhao Kuo officially in the Contemporary Chinese Dictionary (現代漢語詞典) - the first dictionary of Putonghua published by the People's Republic of China.

History

In the next morning, I met my friends again in the hospital canteen.

When I was trying to swallow down some suspicious solid that was labelled as lunch, WY, who was sitting next to me, asked suddenly, "Szeto, who was described in the history as good at military affairs on the paper (紙上談兵)?"

Yes, we were watching A Step into the Past (尋秦記) on the television.

"Why, that's Zhao Kuo (趙括)." I said, "What makes you ask this question?"

"Oh, nothing. Just that my daughter is studying this period in her Chinese history class," the endocrinologist said.

"That's curious. Is it not the case all our local secondary schools have scrapped the teaching of Chinese history?" I asked.

"True, but my daughter is studying at international school," WY explained, "In fact, she is doing the IB program, and, under that system, if you choose Chinese as a language to study, you have also to study Chinese history." (Szeto's notes: IB stands for International Baccalaureate.)

"In other words, although we are part of China, our children would not have to study the history of our own country - unless their schools are run by foreigners." I pursed my lips.

In traditional Chinese description, we call it asking the barbarians for a tradition that you have lost (禮失求諸野).

Self

The lunch was, in itself, an enjoyable one.

Unlike the days when we were trainees, it has actually been a long time before the few of us were out for lunch together - a somewhat sobering phenomenon, implying that our quality of life has not improved as we become more senior.

On our way back, LS and JW also shared the same opinion.

"You know, I am busy enough in the hospital," LS sighed, "But I have not finished with a day's work when I get home. It is equally, if not more, tiring to take care of my sons!"

"Same here. In fact I decide to keep a short period of private time for myself everyday." JW said, "What I do is to go for swimming for 20 minutes each day after work."

"Alas, I wake up 30 minutes earlier each day and do jogging - it's healthy and quite refreshing before starting a day's work," LS nodded, and she turned to me, "How about you? I don't think you do any exercise - oh, yes, you write blogs."

"Oh, I usually write my blog on weekend," I put up a bitter smile, "But I have 30 minutes bedtime reading every evening after my princess go to bed."

And true, we all need a brief moment each day to rediscover ourselves.

Important

We were silent for a moment.

WY, who was also in the car, suddenly said, "Is it all that important to admit students with 8 or 9 distinctions in the HKCEE?"

"Of course not. You should never look down upon someone who only gets 6A." I chuckled.

"No. You don't really need a very high IQ to get through medical education. It is actually more likely that those crème de la crème are pretty dumb; they are just good at book work - or, what we call <高分低能>." LS added.

"Looking at some of our own graduates, as well as some from our sister faculty, that's probably the case." One of us said.

"Once again it boils down to the question of ourselves," JW said, "As long as we are admitting reasonable - though not necessarily exceptionally high-flying - students, how good a doctor they become really depends on the medical school."

I could not agree more.

Attraction

"You mean, we shall be admitting many more students, but, we would be having many more..." I began to see what JW was trying to get at.

"Yes, exactly," my friend nodded, "The major topic of our meeting was to consider strategies of attracting the top tier students."

"So, what do you come up with?" I asked.

"Just the usual stuff. I am beginning to believe I am no different from an investment banker and am going to do a whole lot of roadshows for an IPO," our professor of gastroenterology could not stop putting up a bitter smile. (IPO stands for initial public offering.)

I was about to say that's a perfect job for our Warren Buffett in medicine.

"In fact, I suggested none of those strategies," my friend continued, "I made only one comment in the meeting."

"Eh...?" LS and I asked at the same time.

"No strategy would be successful in attracting good students if it could easily be copied by our sister faculty across the harbour!" JW said with a twist in his lips.

PS. My friend was absolutely right, and copying is always the best strategy of market leaders. For those interested in this field, go read Competitive Strategy of Michael Porter.

Competition

(My conversation with JW continued.)

"There would be competition - or an internal conflict - between the two years," the professor of gastroenterology said.

"What do you mean?" I asked.

"In the past, students with a good result in the HKCEE got admitted via EAS," my friend went on, "Now, the HKCEE is scrapped; students finish with six years of secondary school and get to the preparatory year. In other words, we will not see those smart students in the class that started with the traditional Year-1 in September 2012 -and we have many more students. You know what I mean !?" (For those who are not familiar with our system, EAS stands for Early Admission Scheme.)

"Do you mean, in the future, when we see a doctor, we have to check which year he or she graduates at?" LS, who remained silent in the car, interjected.

"Shouldn't that always be the question already?" I smiled.

"Szeto, you missed the most important point," JW said.

"Eh?" I was puzzled.

"We are admitting 420 new students - and our friends across the harbour would be doing the same!" He explained.

Number

We had a small luncheon gathering organized by JW.

On our way to the bistro, the professor of gastroenterology said, "You know, we had a small meeting a few days ago about the strategy of admitting new medical students - there will certainly be a whole lot of problems next year."

"Why's that?" I asked.

"It's kind of a perfect storm," my friend explained, "To begin with, it would be the change-over to the 3-3-4 system next year, and we shall be admitting two classes of medical students: the senior ones enter traditional year 1, the youngsters begin with the new preparatory year."

"Quite true." I nodded.

"Then, there comes the legislative council of increasing the number of medical students. We shall have 210 students, from 160 now, for each class. In other words, we will suddenly have 420 new medical students in our faculty."

"Oh, that's horrible," I was forced to agree, and I said to myself, "Are there so many teenagers suitable for being doctors?"

Immunosuppression

But, it is important to note, transplantation to academic staff does not solve all problems.

There is always a risk of rejection, and you have to take immunosuppressive medicine life-long.

In general, there are three kinds of drug to take:

To start with, there is the steroid of clinical duty. Everyone from the administration say that it is critically important to have some steroid. Nonetheless, one will certainly have rejection if he takes steroid of clinical duty alone. Many of my fellow patients are, therefore, very keen to try a steroid-free regimen - or to stop (or minimize the dose of) steroid themselves without anyone knows.

Next, you have the azathioprine of student teaching.

No, I don't mean it works. Just that it's kind of bread-and-butter stuff; everyone who has a graft kidney is advise to take some azathioprine, and every academic staff is expected to do some teaching. Many of my fellow colleagues use it for the steroid sparing effect - teaching medical students is always a good excuse for not doing clinical duty.

And, finally, the major drug that could prevent an academic staff from rejection is the cyclosporin of research.

But, cyclosporin is a difficult drug to handle; the absorption fluctuates a lot: A few fortunate (or actually clever) ones need only to take a small dose but would have a satisfactory blood level; many others may take a huge amount but the drug could hardly be detected in the blood. On some good days, without much effort, we could publish a paper in a journal with high impact fact. More commonly, however, our work is no more than tracing our own tail and all our efforts go in vain.

Transplant

I must say I am an uncommon and fortunate one because I had preemptive transplant - before my kidneys fail and need any dialysis.

To begin with, I knew very well the chance of having a kidney in this center was not high, and, when my kidney function was rather advanced, I planned for emigration to the other side of the harbour. It was therefore a great surprise to me when S, the newly appointed transplant coordinator at that time, rang me up on a August morning and told me a kidney was available.

In fact I had the agreement to emigrate on my desk and was about to sign and fax the documents back later that day. If that were done, I would decline the kidney and my life in the past twelve years would be very much different.

Maybe I would have died after a few years of dialysis.

PS. I must say I had early transplant not because I was treated favorably; it was a marginal kidney and the two persons ahead of me on the waiting list declined the organ.

Dialysis

My friend VW described recently a vivid story of liver transplantation (see http://vwswong.blogspot.com/2011/08/letter.html). Following that logic, I must consider myself not only a nephrologist but a recipient of kidney transplantation.

Nowadays, on the average, one needs to wait for around five years before a suitable kidney becomes available, and their lives could only be sustained by dialysis - not a pleasant treatment I must say. Of course, some patients do not have to wait very long; it's kind of luck. However, there are many other fellow patients who do not live long enough and leave for another universe.

And, similar to liver cirrhosis, you won't die (from uremia) with dialysis, but you still have a lot of symptoms: malaise, poor memory, hand (and buttock) itchiness, generalized swelling (if your diet compliance is no good), high blood pressure (in response to stimulation), and a foul-smelling mouth.

PS. Unlike liver transplant, there is now well defined criteria for kidney allocation. In short, it depends on your age, duration on the waiting list, as well as how well match it is between you and the organ. If there is a full match of clinical need, you jump the queue of waiting, and, on several occasions, the organ may be given to someone from another cluster.

Part

(The senior consultant continued with his story in Inner Mongolia.)

"Did the City of Hohhot (呼和浩特) appear calm and safe?" I asked.

"Yes, of course," PL said without any hesitation, "You know, Inner Mongolia is rather different from Tibet (西藏) or Xinjiang (新疆). There's hardly any voice for getting independence."

"Why's that?"

"Well, first, they have the excellent example of Outer Mongolia. It is plain simple to see the difference between Ulan Bator (烏蘭巴托) and Hohhot. Who would argue with their own purse?" PL continued.

We all nodded. (I looked up from the internet later. The GDP of Mongolia was around US$2200, while that of Inner Mongolia was close to US$5000 - excluding subsides from the central government.)

"And, there's another consideration," our senior consultant went on, "Mongolians did rule the entire China in the Yuan Dynasty, and they considered themselves as part of Chinese. The situation is similar to Jurchens (女真). After the Qing Dynasty, they all considered themselves part of us - and I must say most of us, the Hans (漢), think the same. Have anyone heard of Manchuria trying to get independent?"

Bird

During a recent casual conversation (after a serious business meeting), PL, our senior consultant, told us about his recent trip to Inner Mongolia.

"We had a free afternoon and were taken to an old government office for a short tour. It's a building from the Qing dynasty and is now converted to a small museum. The exhibits were not entirely exciting - except for the government official uniform that was displayed."

"Those form the Qing empire?"

"Yes. You know, in those days government officials were divided into administrative (文官) and military (武官) types, each with nine classes, and every class had a different logo - birds for the administrative staff, and beasts for military officers."

"Quite right," we said.

"And, the one displayed was an uniform for a class 8 administrative officer - quite low a rank I must say," PL continued, "But, the catch is, do you know what kind of bird was used as the logo?"

"Eh...?" Of course we had no idea.

"It's a quail (鵪鶉)."

It really reflects the truth.

PS. That evening, TM, our new trainee, told us that in the Qing dynasty, physicians of the royal family were, according to the system, class 8 administrative staff - and therefore all quails.

Plant

Some of you may remember the story I alluded to a few months ago about the silly man who tugged up the leaves of a little flower (see http://ccszeto.blogspot.com/2011/04/blog-post_06.html).

I am not aware of the second chapter of this classical story - until very recently. It goes like this:

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In the next morning, the son of that farmer went to the field and saw if there's anything that could salvage the dying flower.

To his surprise, the flower was not there.

He searched around, but could find no trace of the little plant. Confused and disappointed, he returned home - only to find his farmer sitting in the living room.

"Don't worry," the father said, "A friend of mine moved the flower to a different soil last night."

"My god! I hope that's good news, but, let's make sure the pity flower does thrive in her new home," the son said.

"Oh, yes. But, I think the more important thing is to make sure the media do not get hold of the news so that everyone in the village won't laugh at me," the old man replied.

The son was taken aback by his father's comment. He looked at the man in front of him, and was not sure this man whom he knew for over 20 years was a real farmer, or actually a politician.

Lemon

You may say the idea of acquiring successful small drug companies may not be a bad idea for the general public, because the cost of new drug is reduced, and, hopefully, we may enjoy new treatment at a lower price.

Alas, in the short term, that may be the case. However, the detrimental long term effect would gradually surface with time.

Where's the catch? Just imagine, small firms with a really promising product would not be eager to sell their business - they would prefer a ripe time to maximize their profit. In contrast, firms with an apparently good product would only be happy to sell it early to big companies if the small owner know, behind the closed door, that their new product would likely fall apart in the pipeline. Since big companies could not distinguish good products from bad ones, they would only be willing to pay an average price. With time, good products are driven out of the market by bad ones.

Alas, this is, in fact, a classical example of information asymmetry in economics. It is also called the Market of Lemon hypothesis after George Akerlof, who, for his work in this area, won the Nobel Prize in Economic Sciences in 2001.

PS. You may ask: How about the really good products that are kept by the small companies? Alas, either they do not have the resource to get it fully developed, or their launching would be hindered by regulatory bodies, which, in general, favor big companies.

You think the regulatory bodies and big companies are all but one group? Well...

Development

A more fundamental problem may skip your eyes. Having a few winners get all, with small successful companies being acquired, is, in itself, harmful to the industry in the long run.

The typical example is pharmaceutical company - or other sectors that involve much research and development.

The logic is simple: Developing new drug (or any other product that needs innovation) is a risky business; success does not only depend on an incredible amount of effort - which is nonetheless indispensable - but also a determining contribution of luck. A successful new product is, therefore, often unbelievably expensive, not only because it has to cover the cost of its own development, but also the money spent for another dozen that failed along the pipeline.

(The word dozen was carefully chosen. At the turn of this century, around one in twelve new drugs that entered pre-clinical trial was eventually launched. The chance, unfortunately, goes very much lower by now.)

So, what could big companies do to save the cost of R&D? One common strategy is to cut down the research department of its own, and rely on small private companies to explore new products. If a promising drug comes up from a small firm, either the patent of that drug - or, more commonly, the entire business - would be acquired by the big company. By this tactic the big company could continue to have successful new products but be able to minimize the cost spent on unsuccessful new drugs - which is, unfortunately, now covered by those people who use their own money to start a small business.

PS. One remarkable example recently is Pfizer, which, in February this year, announced that its entire research and development facility at Sandwich would be closed in the coming two years.

Viagra was discovered in this laboratory.

SPSS

While I was pondering about a flattened world and a few winners get all, VY, my new summer student rang me up.

"Do you have some time? I've got a problem here."

"What's up?" I asked.

"I can't find that SPSS software, which you asked me to download, from the internet," the other side of the phone said. (For those who are not familiar of our life, SPSS stands for Statistical Package for the Social Sciences and is the most popular computer software that we used for data analysis.)

In no time, I went to his office and search in Google. And, my student was right; there's no SPSS now.

It becomes IBM SPSS.

The original company SPSS Inc was acquired by IBM in mid 2009 (for US$1.2 billion). From 1st October 2010, SPSS was fully integrated into the IBM Corporation, and is now one of the brands under IBM Software Group's Business Analytics Portfolio.

Yes, it joins one of the winners who gets all.

PS. I must say although I try very hard to accommodate myself to new changes, the new IBM SPSS version 19 is too much for me. Many of the features in the older versions disappear, and the layout becomes very similar to SAS, its major competitor.

Unify

Don't get me wrong. I'm not trying to suggest everyone should be equal. Nonetheless, I am worried to see the distribution of wealth gets increasingly skewed.

And the advance in technology plays a critical part. (Yes, in the terms of Thomas Friedman, it's because the world is getting flat.) For example, fifty years ago, you could set up a family business and sell soy milk. As long as you are honest and your sugared liquid is good enough to the taste, you may get local reputation and your company would be reasonably successful. Your market would be confined to 100 miles around where you live, which forms the base of your wealth.

But, now, your company has to compete with every carbonated beverage around the world. At the end of the day, only one or two brands would dominate all markets around the world - the bases of their wealth are way bigger, but the number of business that could come up with this magnitude of achievement is hopelessly small.

Alas, for the rest of us, we shall have to, like the other 7 billions of people, share the same kind of drink, eat the identical hamburger, and have a monopolized computer software to process our thoughts - if we still have an individual one after brainwashed by a single ultimate propaganda machine.

I mean the internet.

Inequality

I must say the Pareto principle was not originally designed for the audit of our endoscopists' workload.

The first observation was, in fact, related to population and wealth: Pareto found that 80% of Italy's land was owned by 20% of the population. (Rumors say that he derived his idea and started the survey after noting that 20% of the pea pods in his garden contained 80% of the peas.)

And the rule still holds nowadays. For example, in 1992, as reported by the United Nation, the richest 20% of the world's population control around 20% of the world's income.

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So, are we coming to the conclusion that the distribution of wealth is what we expect?

I would be cautious. In the past 20 years, the inequality in economy has actually increased markedly. Specifically, income growth is largely confined to those with the education and skills required to take advantage of new technology and globalisation (for example, those who could afford as well as understand Thomas Friedman's books). The benefits of economic growth during this period of technological bloom have largely been taken up by the top 1%, rather than 20%.

As stated in the Bible: For to all those who have, more will be given, and they will have an abundance; but from those who have nothing, even what they have will be taken away. (Matthew 25:29)

Pareto

Don't be frustrated with the mathematics and statistical jargon. Our original question was simple: If we accept not all men are equal and there is always a certain degree of uneven distribution of workload, how uneven a distribution should we consider not acceptable - or not expected under normal social circumstances?

Yes, it becomes a philosophical question. Nonetheless, I suppose we have a convenient solution at hand.

Let's follow the Pareto principle.

Oh, I scared you by the jargon again. The principle is also commonly known as the 80-20 rule.

For example:

• 80% of the your effort is spent on 20% of the patients
• 80% of what you learn in a medical school comes from 20% of the curriculum

And, here, 80% of the urgent endoscopy requests are covered by 20% of the endoscopists.

Maybe we have to accept that's life.

PS. Mathematically, when something is shared among a large number of people, there is always a number x between 50 and 100 such that x% is taken by (100 − x)% of the participants. The number x may vary from 50 (in the case of absolutely equal distribution) to nearly 100 (i.e. one winner gets all).

Cooperative

You may argue, like many other things in life, urgent endoscopy requests are not independent happenings - If a particular endoscopist is easy going or have a pair of gifted hands, we tend to consult him more.

In other words, one either receives no request, or a few in a go. For readers with a biochemical or medical background, it is similar to how oxygen molecules bind to hemoglobin: Most of the hemoglobin molecules either have none or four oxygen molecules, somewhere in between is uncommon. Yes, we call it cooperative binding.

Therefore, if we observe a substantially skewed endoscopy request amongst, say, five endoscopists and we conclude it does not happen by chance, the most likely explanation is a cooperative phenomenon.

In fact, based on the skewed observed distribution, an abnormally obsessive mind can actually compute the degree of cooperativeness. It is similar to what our textbook of biochemistry told us: By looking at the oxygen dissociation curve, one could actually predict a hemoglobin molecule has four oxygen binding site.

PS. What is an abnormally obsessive mind? By definition, anyone more obsessive than me is abnormal - I am the upper limit of normal.

Probability

One minor point about our previous discussion on the chance of having five urgent endoscopy request in one day may worth further explanation:

If you consider this unfortunate happening as a single incident (i.e. not five in a row), turn the table around, and ask the question: I’ve been doing emergency call for ten years and have never been so unfortunate, given that I may just be lucky, how uncommon could I confidently say this happening is?

The answer, again based on the Poisson distribution (but I shall leave the details of calculation aside), is often known as the Rule of Three. In essence, if you have been observing for 10 years and see no event, you could be 95% confident that the true incidence of the event is no more frequent than once every 10 years divided by three, i.e. once every 3.3 years.

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Alas, of course our discussion does not solve the root problem: Is he being unlucky? What one could prove by statistics is, after all, whether an observation is likely explained by chance.

And, by our general understanding, if it happens by chance, you have a tough luck - what else could it be?

PS. To go one step forward, you may even conclude my previous calculation serves no purpose - except being an intellectual masturbation.

As Albert Einstein said: It would be possible to describe everything scientifically, but it would make no sense; it would be without meaning, as if you described a Beethoven symphony as a variation of wave pressure.

Poisson

You may notice I calculated by counting the total number of event during a period of time, while VW tried to focus on the frequency of a rare happening: being called 5 times in one night.

Of course the former method is generally preferable by statisticians because it considered all available information. (In their jargon, there is no inadvertent data reduction.) Nonetheless, let's look at the problem from the angle of our hepatology professor, and focus on the distribution of urgent request between call days rather than endoscopists.

In other words, during that year, what is the probability of being called 5 times a night?

Let's follow the simplified estimation and assume there are 300 days in a year. In other words, the average chance of being called in each day is one-third.

Now comes the critical question: What is the chance of being called twice?

No, it is not one-in-nine (1/3 × 1/3), as my friend tried to suggest. For uncommon events that happens this way, it follows the Poisson distribution, and the chance goes like this:

while p is the number of event you expect for that period, n is the actual event that happens, and e is the base of natural log. For things that we expect happening one in every three days (i.e. p equals one-third), the chance of having it twice in a single day is 0.0398 (i.e. 3.98%).

And, for n equals 5, the chance is 0.0025% (i.e. around once every 40000 days, or every 110 years).

So, VW, let's face it: You are the chosen one.

Luck

Let's ask the question again in a mathematical manner: Was our professor of hepatology doing urgent endoscopy more frequently than that expected by chance?

The calculation should be done like this:

• Let's assume there are x endoscopists on the list, each sharing the same number of call.
• For a defined period of observation, there are n urgent endoscopy request, and each of them is independent from another.
• For each urgent endoscopy, therefore, the probability of a particular endoscopist to be called would be 1/x; let's call this probability p (in other words, p = 1/x)

For example, if we have 5 endoscopists sharing the duty, the probability of being called for each one in a particular case would be 20% (i.e. 0.2). If, as suggested by VW, there are 100 urgent requests in one year, each endoscopist would be expected to be called around 20 times. (The statistical jargon is: this is the mean value.)

Now, here come the critical step: How many times would be too many to be expected by chance (or random distribution) ?

Simple. The allocation of event (of urgent request) to independent categories (i.e. endoscopists) follow the binomial distribution, and the calculation goes like this:

• For that one year and 100 endoscopy request, the variance of allocation is n × p × (1-p)
• The standard deviation (SD) is the square root of the variance, and
• the upper limit of expectation (i.e. 95% confidence interval) is 1.96 (or 2) times SD.

In this case, therefore, the variance is 100 × 0.2 × (1 - 0.2), i.e. 16; the standard deviation is 4. In other words, the maximum number of request that you would expect to encounter by chance during one year is 20 + 2 × 4, i.e. 28.

Lucky

For more than once my friend VW noted that he got the lion's share of emergency endoscopy. (See http://vwswong.blogspot.com/2011/08/unlucky.html for the most recent example.)

And, probably not by coincident, many of my outstanding colleagues also remark that they are particularly busy and unlucky (for them, but certainly lucky for our patients) while on emergency call. Some of us even conclude that there must be a higher power behind the clouds (or the curtain) who takes a close eye on us and manipulates the work load.

Of course our professor of hepatology is a scientist, and he goes on to review the situation by mathematical means. I must, however, say that he was not doing the calculation in the most meticulous manner, and, from what he showed, one could not conclude whether he was exceptionally poorly treated (or well-treated, as he tried to convince himself).

The problem could be examined in an entirely scientific manner.

Let me show you tomorrow.

PS. Of course you may not need to be too scientific. A knowledgeable doctor could pick up problems that an ordinary one miss; a responsible colleague generally would be more proactive and do things eagerly; and, above all, only those who know what they are doing would remember what happened during a call !

Year

In a recent incident, my colleague FP got a surprising question from the new bunch of third-year medical students: "Which year did you graduate?"

I must say the question was, as Bernard Woolley usually put it, entirely correct - literally, and the students were probably using it for really benign reasons (for example, out of admiration for seeing an apparently young doctor capable of teaching them).

Our surprise was, in contrast, a result of our crooked mind because adult physicians usually hardly ask their questions directly. For example:

• If we wish to know the year of graduation of another doctor, we would search from the Medical Council web site, or ask his colleagues.
• If we ask someone directly his year of graduation, we are not interested in the numerical answer - we just want to get at a better psychological position and start a fight with him.

However, it is also a wrong idea that senile professors do give better teaching to the students. More commonly it is quite the opposite. After all, who are the ones living on earth and know better the daily running of medical practice?

Byakuyako

My recent bedtime reading was Byakuyako (白夜行) of Keigo Higashino (東野圭吾).

The story was about a man, Ryoji Kirihara (桐原亮司), and a woman, Yukiho Karasawa (唐沢雪穂). In essence, they have a mysterious relation and appear to collaborate in numerous criminal events along their life.

Don't be mistaken. This book is hardly a detective fiction. You do not have to guess what happened or who did it, and there is little logical deduction. Nonetheless, the way that the story is told is remarkable - it reminds me of the paintings of Pablo Picasso during the period of analytic cubism. At the first glance, the picture seems fragmented. But, as you turn the pages and the story gradually unfolds, you would appreciate Higashino is trying to get you see a complicated story from multiple angles.

Of course the story is not flawless - but which one is? In this instance, if what Ryoji Kirihara told Noriko Kurihara (栗原典子) about his physical disability was genuine, he could not have helped Tomohiko Sonomura (園村友彦) in that hotel incident.

PS. The first few chapters of the novel also reminded me of The ABC Murder of Agatha Christie. But the difference between Higashino and our queen of detective fiction is obvious - if Byakuyako were written by the latter, I am sure all the murders and assaults were orchestrated by a third party behind the curtain.

How about Kazunari Shinozuka (篠塚一成) ?

Obituary

Professor John Vallance-Owen passed away on 23 July 2011, at the age of 90.

JVO, as people usually called him, was the founding Professor of Medicine of our university. He took up the post in early 1980s after retired from UK. I met him once or twice as a pre-clinical medical student, and, when preparing for my membership examination, had the honor of attending one of his bedside tutorials.

I shall not elaborate on his achievements here. But a small piece of his information I learnt from the man who used to have a moustache is remarkable:

As our department chairman for over 5 years, JVO never held a single department meeting. No, there was no division head meeting, department board, teaching subcommittee, or whatever. It was long before the days of email. Every problem could be solved by talking face-to-face within his office or along the corridor. Things would happen as said, and there was no need of documentation - people simply took the words of the others.

He is, alas, the all time idol for people with a distaste for hypergammaglobulinemia and granuloma.

PS. For those who are not familiar with administrative immunology, please refer to http://ccszeto.blogspot.com/2008/01/lymphocytes.html and http://ccszeto.blogspot.com/2008/01/granuloma.html

Nationalize

I was horrified with Sir Humphrey's idea, "Would that happen to our city as well ?"

"Don't be silly," the senior civil servant chuckled, "Your ex-colonial government is actually going to the opposite direction."

"You think so!? I suppose our freedom of speech is not getting better." I sighed.

"You've misunderstood me. Yes, the Corporation could very well work for the Big Brother. That may happened in a country which tries to know who are speaking against the government after earthquake or train crash - just imagine the Komitet Gosudarstvennoy Bezopasnosti (KGB) is run by a private company."

"True. But couldn't that also apply to our government?" I asked.

"Alas, rather than privatizing national business, your Donald - or the Legislative Council as a whole - is doing the opposite and actually trying very hard to nationalize private organizations," the retired cabinet secretary suddenly became serious, "Don't you know your government is now doing charity work - which is, by the nature of the thing, a task that should be run by the private."

"Oh, do you mean the Community Care Fund (關愛基金) ?"

Privatize

I found myself fortunate and was not eating while Sir Humphrey was making that last remark, or I would have died of suffocation.

"You know, although Mr. Murdoch seems to be in hot water at this moment, I consider that as a kind of road show and he probably did impressed some potential customers," the senior government official continued.

"I think the sales of all his newspapers dropped after the scandal was out?"

"Oh, I mean bigger business than that."

"Such as...?"

"Such as offering their service to governments that treat some people more equal than the others, or countries whose economic and technical advances are running far ahead of their humanistic quality."

I was silent, pondering to digest his meaning. All of a sudden, George Orwell's Nineteen Eighty-four came across my mind, and I exclaimed, "You mean, the Big Brother could delegate his work - or get privatized !?"

"Privatization. That's exactly the word." Sir Humphrey smiled, "Wasn't that the reason why the old man supported Margaret Thatcher right from the beginning ?"