Belated

Around a week before my recent birthday, a few of my friends wrote their greetings on my Facebook wall - some obviously thought that they had missed the date.

Seeing this slightly funny happening, a little friend of mine asked me to write a few words in my blog to explain this "early and belated birthday wish phenomenon".

How could I? Notably, the five people who did so are remarkably diverse: a professor of chemical pathology (who apparently started the whole thing), my best friend since secondary school, the Hong Kong record keeper of highest score in MRCP clinical examination, and the two most intelligent persons whom I personally know.

Of course, I shall not be too meticulous in this kind of thing. Greetings, be them early or late, always mean care and concern.

However, it was TS who caught my attention. (Alas, we were recently friends again - thanks to the Facebook.) He was the only one who specifically mentioned "belated" when he was obviously not. And, knowing him for some 30 years, he is an exceptionally careful and sensitive person. He should not have mistaken such a detail.

In that case, I have to take it as a deliberate choice of wording: The greeting was late not for a few days, but we should be saying happy birthday and making friends with each other three decades earlier.

Thanks every much to TS and all of my friends.

It is never too late.

Attraction

During the lunch time, the few of us again talked about the study that JW showed us.

"What's the purpose of all these?" One of us asked.

"Apparently as a selling point for attracting secondary school students to apply for one medical school rather than the other," I said.

"That's absurd," VW said in his humble voice, "How could a naive teenage have an interest on journal publication?"

"Exactly. It would actually be far more effective if we use some famous figures as the selling point." LY nodded.

"You mean we should put up advertisement for some of our star teachers?" I asked.

"No, don't be silly. That would be to the least of the students' interest," the pragmatic professor explained, "We should seek help from some movie stars or celebrities, which we all have a few as our private patients. If they come out and say this or that professor from our university is wonderful, the impact would be dramatic."

"Alas, this tactic sounds familiar..." I murmured to myself.

"Of course, our sister faculty has been using it for ages," our professor of hepatology finished with a twist of his lips.

Number

While I was thinking about the inadvertent consequence of asking our children to read a book each day, my friend JW showed me a study that he recently encountered.

In short, the authors compared the number of publication between some medical schools, with an attempt to conclude which one is better.

I was horrified. Some of our academic administrators have become followers Adolf Hitler: The problem of the quality of an army should only be considered after the problem of quantity has been solved.

JW obviously thought the same and remarked, "I am sure if one of the medical schools has two more journals, for example, Kowloon Journal of Medicine and SAR Medical Journal, they shall have an extra 200 to 300 publications lead."

For that reason, we focus on publishing more papers, and short term research is favored. We will not even try to answer a research question, because an unresolved question is a secure source of more papers.

PS. Do not fancy monitoring impact factor, number of citation, or the h-index would provide a better yardstick of our academic performance. I repeat, if it could be measured, it could be twisted.

See http://vwswong.blogspot.com/2011/09/citations.html

Tiny

Euterpe advanced to K2 of her kindergarten study since this September. One of the major changes was she had to read a book everyday and put down in the record.

This is, of course, an attempt of her school to encourage the habit of reading. In fact, many kindergartens and primary schools have arrangements of a similar kind. Even the public libraries in Hong Kong have their Reading Program for Children and Youth. (Euterpe actually joined this program soon after her fourth birthday.)

How do I feel?

On the face of it, the idea is brilliant. To say the least, it gives my daughter - and probably hundreds of other children - the motive to read some books, which is almost always a good thing.

But, when Euterpe and I tried to work out the details and decide what books we should borrow from the library, I saw the shortcomings.

"My teacher asks us to borrow thin and handy ones, so that we could easily finish with one each day," she said.

That's very true. How else could a kid of four achieve that goal ?

And, therefore, we have to do away with those more substantial volumes. Most of the excellent classic stories have a considerable length and are not suitable. Same problem for books that have a few stories in a single volume. At the end of the day, we can only focus on tiny ones specifically written for children reading.

Alas, anything that could be quantified could also be twisted.

Sick

Met WK in our twenty-year gathering. He had recently moved to the other side of the harbour as a professor.

"How're the things there?" I asked.

"I suppose you know most of the situation," he smiled, "But, I just come to realize we are very gentle to our students in CU."

I was surprised. Knowing WK for over 25 years, I found it difficult to believe he could be called gentle to the students. But, I could quickly think of a reason.

"You mean, you met K?" I tested my hypothesis. K is a professor of hematologist of our sister medical school, a serious teacher, and a vigorous examiner.

"I was the co-examiner with him in the final MB, and I had no choice but to play dove," WK chuckled - and so did I. In my mind I saw a scene of the wolf with sheep's clothing.

"Was K that ... impressive?" I tried my best not to laugh.

"Well, let me tell you a story we had," my friend said, "Early in the morning of the first day of clinical examination, a student rang up the department office and said that he was sick - and apparently he really did sound so. Since the clinical exam lasted for a few days, he asked if he could have the clinical examination deferred."

"So ...?"

"The secretary checked with the chairman, and then they told the student that they could make the arrangement and he could sit for the clinical examination on the next day - but he would be examined by K."

"Alas. Did the student faint?"

"Not that bad. But he said immediately that he was not that ill and would prefer taking the original slot of examination!"

Twenty

In that evening I went to a gathering of my university classmates.

Yes, it's twenty years since we graduated.

There were some 110 of us in 1991, and we saw 90 coming that evening. Since there are three of us working overseas (actually four, but Jimmy did come back for the evening), one jumped (maybe two, my memory is not accurate), and one in jail, the attendance was remarkably high.

Certainly better than any of the lectures that we had when we were students.

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An unexpected difficulty of organizing this event was, you know, how to define a classmate.

It goes like this: There were around 80 of us when we began with the pre-medical year. It became 120 when we entered year one (some new comers after the A level examination, as well as a dozen of repeaters). By 1991, actually only 86 of these 120 young persons graduated - the others fell back to the next class, or chose (maybe in the passive voice) to leave the medical school. Along the years we had another two dozens of friends joining us from the previous class.

Difficult times those might seem when we were in it, on looking back, our memory did a wonderful job; only the sweet fragments are left for us as the aftertaste twenty years later.

Joke

Rather than being too serious all the time, let me just tell you a real joke I recently encountered in the ward:

(During the team round on a Saturday morning.)

"Hey, man, you look really like Dr. Li," a newly admitted patient, lying on a corridor bed, pointed to PL - our senior consultant - and said.

"Oh, I am Dr. Li," PL smiled.

"No, I mean you look really like that Dr. Li we see on the television," the patient said.

"Which Dr. Li are you talking about?" The senior consultant was puzzled.

"The one whom we see so often in children programs..."

"Alas, she means Dr. Lee Ka Yan (李家仁) !" One of us said.

"OMG!" PL almost fainted.

PS. That patient was, of course, psychotic. Well, even if she was not, we should make the diagnosis that and there.

PPS. Would PL agree to sing again in the Christmas party ?

Human

A more important question that comes up when we consider the risk and benefit of cultivating GM soybean may skip your eyes:

Is it an effective way to solve the world food problem (in other words, to eliminate famine in mankind) by increasing food production?

On the face of it, yes, of course.

Oh, don't jump to the conclusion that quickly. Thomas Malthus was not infallible. There is at least some evidence that we are already producing enough food to feed everyone on earth - just that there is so much inequality in the distribution that some have a surplus of supply while many others hardly have any to fill their stomach. Warfare, dictatorship, and inappropriate exhaustion of natural resources are the main reasons of hunger, not that we have no crop of a sufficiently high yield at hand.

The same argument was, as you may note, put forward by many of us as the explanation of coal mine incidents or railway disasters in some rapidly advancing countries.

But, when you think of it again, aren't these human problems originate from too many people competing for limited resources?

Alas, it becomes a philosophical question.

PS. I cannot recollect who made this intelligent remark:

Everything happening to you have been fixed by the eternal arrangement, and, with all the intricate causes, you and your destiny will be intertwined together and turned into another form of existence.

Maybe Georg Hegel.

Illusion

After my brief Internet search, I was about to conclude we should actually encourage the use of genetically modified soybean (and probably other GM foods).

The advantage is obvious: The yield would be increased, so that we can feed the world population, and, at the same time, save more forest and wildlife.

But, I was wrong.

To begin with, although most studies found an increase in crop yield from GM soybeans, confounding factors are common in those studies. Detailed analysis showed that much of the improvement in production came from other concomitant advances in agricultural technology, and the direct contribution of the GM bit is no more than a few percent (after all the hassles!).

So, what's the conclusion?

Alas, like the lyric of Wednesday Morning 3 A.M. by Simon & Garfunkel, the harm seems unreal, the benefit an illusion.

PS. You may argue in the future, with further advances in technology, we may have dramatic increase in crop yield from the new generation of GM food. At the same time, scientists may be able to product soybeans with animal proteins with inadvertent effects.

Both may be true, but, I should follow the usual practice of politicians, and would not put up too much effort to answer a hypothetical question.

Modified

To be honest, neither my friend nor me had too much idea about what genes were actually modified in those GM soybeans; I looked it up from the Wikipedia that evening.

To my surprise, there are only two - both from bacteria and are supposed to confer resistance to herbicides. In fact, over 75% of all soybeans around the world, and close to 95% in USA, are genetically modified; it has become, let's face it, the standard species.

And, what's the worry? Extrinsic DNA will be digested, and same for that extrinsic protein (or, "gene product" for the technical jargon). Fear of allergic reaction or other inadvertent reactions is, by all probability, unrealistic - you are exposed to that two particular proteins anyway, as the bacteria is everywhere. Tens of millions of people had it for over 10 years.

Yes, there remains a small possibility of adverse effect in the long term.

But, if we follow this principle, FDA should not pass any new medicine unless the item at hand has been marketed for 10 years. (What a logical statement!)

By the way, strictly speaking we are all genetically modified animals because all of us have 37 bacterial genes, from a parasite in our body, which supplements our own genome.

We call it the mitochondria.

PS. Biology quiz: Can you name a eukaryotic organism that has no mitochondria?

Soybean

Met my friend L again in the evening. He was, as his usual habit, reading the morning paper.

"What's up?" I smiled.

"Nothing interesting," my friend sighed, "I suppose that's why they put up the soybean story."

"Eh, what's that all about?" I did not even read my morning paper.

"Simple. After detailed analysis, our Consumer Council found that over 50% of the soybean milk on the market contains genetically modified soybean."

"So ... what?" I asked.

"Exactly. So what," L smiled, "In the small prints they said many samples contain only 0.2% to 1.1% of GM soybeans - obviously a contamination along the line of production - and they called the result positive. And they went on and declare that although there is no medical evidence that GM food is unsafe, it remains possible that there could still be undesirable effects to human body or the environment many years later."

"Logically they are correct," I nodded, "But I know what you mean. Unlike poor university academics who dread for fame and public attention, as an organization financially supported by the government - and regulated by a dedicated ordinance - they should not add too much spices to their press release."

Teach

Although Robert Frank mentioned that his method of teaching economics to undergraduates came from the narrative theory of learning, he outlined another more impressive method in his book.

The idea is simple. Take learning a foreign language as the example: You can never learn, say, Spanish, if you only had a series of lectures on Spanish words and grammar. In contrast, you could master it rather quickly if you hear a few simple Spanish sentences (preferably directly related to your daily life), try to repeat them yourself, and then expand and extrapolate to other sentences.

I'm sure the same argument also holds for medical education.

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As to learning a foreign language, I have a specific personal experience.

When I was newly graduated from medical school some twenty years ago, there were a lot of Vietnam boat people in Hong Kong, and they accounted for a substantial portion of our workload in public hospitals. Although we had no formal teaching on speaking Vietnamese, almost all of us, after working in the ward for a few weeks, could speak at least a few broken sentences.

And, after this historical legacy disappeared since 1997, I had no chance to practice and had forgotten almost all.

Well, maybe except two phrases: lie down and put down your pants.

I said them for thousands of times in the obstetric ward.

Naturalist

My recent bedtime reading was Economic Naturalist by Robert Frank. It was, in fact, my birthday gift last year from my sister Jenny.

The origin of this book is in itself remarkable. It was not intentionally written by this Professor of Economics from Cornell; it represents a collection of his classroom assignment. In short, each student was asked to pose an interesting question from their observations in daily life, and then write a 500-word narrative to explain the phenomenon by some economic principle.

And, this book is the collection of all those interesting questions - with answers mostly re-written by the author himself.

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While I was considering how Robert Frank taught his students economic principles by asking them to tell stories, I suddenly came to realize we are doing a similar kind of thing during bedside clinical teaching. We ask medical students to present history and physical findings.

And, there may be good reasons why our undergraduates don't like it - the narrative theory of learning is only meant for adults.

PS. Many of you may know each of our third-year student needs to submit a few case histories, summarizing the patients that they have seen. One of the two most common reasons that I put down when I fail a student in this assessment is Fail to tell a coherent story.

Oh, the other is Fail to exercise common sense.

30-minute

Like most of my colleagues, I used to leave an automatic reply message in my email server while I took a long leave.

During my recent absence to cover for the holiday of my Indonesian maid, however, I decided to do something different: I left no message and pretended that I was still around.

Oh, I did not let all messages ferment in my mail box. In fact, I got up half an hour earlier each day (i.e. before my daughters woke up and I had to start my day of housework) and used that bit of time to reply important mails and work briefly on critical matters.

Yes, this is an idea I learnt from Tim Ferriss, which I described previously (see http://ccszeto.blogspot.com/2009/11/4-hour.html).

"Does it really work?" You may ask.

In fact, I had the same question before trying.

But, to my surprise, it worked out extremely well. I suddenly realize all my urgent-and-important matters (that is, class one items as defined by Stephen Covey) could be tackled by spending 30 minutes each day. If I were not on leave, I am sure my day would be very productive.

PS. My laptop computer at home is not connected to the Internet. Each morning I had to plug it to the board band cable of my wife's computer before starting to work. The procedure is complicated and I always needed to stop as soon as Adler - my younger daughter - cried for her breakfast. For those who are addicted to online games, it is also a good way to get abstinence.

Indispensable

Although I consider the tactics of how HSBC cuts that 3000 jobs in Hong Kong horrible, it is why the old lion chooses firing people as the strategy being catastrophic.

Their attitude is simple: No one is indispensable.

In other words, they (believe they) could always hire another lot during the next economic upturn and our local market needs expansion. To them, employers to a company is no different from the finger disc or portable CD player of their laptop computer - when there is a port, you can always plug-and-play.

But, the traditional teaching of no one is indispensable is in itself outdated. The modern school of thought is everyone is indispensable. This motto is particularly important for business of which the success hinges on person-to-person interaction - or a team of professional and dedicated workers.

And, banking is a typical example.

Unfortunately that's difficult to be understood by someone brought up from treasury and capital trading.

PS. The best example "business" that one should emphasize everyone is indispensable is - you know what - the health care system.

When I was a trainee, I used to say, despite they were brought up as physicians, administrators could never take good care of our patients because they did ward round to the bed (number), but not the patient. Now, I come to realize there is also no way to improve our patient care if administrators consider doctors as headcounts on the duty list.

Why

But, there is a particular reason why I felt sore for the cut in Hong Kong this time.

For those who are familiar with financial news, you may recollect when the wounded lion first announced in early August its plan to lay off 30000 staff globally, Hong Kong was specifically reassured to be minimally involved - because of its excellent performance as well as potential of further expansion.

And, in a month time, the promise changes.

There are two possibilities:

1. They did intend to cut so many jobs in Hong Kong. The promise in early August was a modern version of the Munich Agreement. (I dare not say who played Adolf Hitler in this drama.)
2. They did not initially, but were forced to do so because it is far more difficult to lay off people in Europe and America. In order to meet the quota of global cutting, Hong Kong has to contribute a lion's share. Alas, in that case, administrators of the world's local bank had certainly put the cart in front of the horse, and mistaken the means as the aim. (I am sure JW would say at this moment: Would you put your money on some bankers who have such a confused mind?)

Which one is the case? I have no idea. But, once again it proves the point: It is usually difficult to differentiate an ingenious crook from a complete idiot.

Saving

I might not explain very clearly why I thought it would be an insult to stupid people.

Of course, it is slightly immaterial to talk about the correct tactics of firing 3000 people. A slightly more basic question is: Does it help to achieve the goal?

Alas, I suppose the goal is to cut the cost, in order to maximize the profit.

In that case, the entire plan of cutting 30000 jobs (mostly middle grade and supporting departments) would, after all the hassles, only improve the profit after taxation by less than 10%. Isn't it more easy to cut everyone's bonus by half, or doing away with 6000 senior administrators?

Oh, yes, I applied the 20-80 rule.

PS. The situation is somewhat like calling a meeting within the Hospital Authority with an aim to cut the drug expense.

HA could save more money by simply firing every staff who have the time to attend the meeting.

Fire

Let's take aside whether the strategy is correct for the time being and focus on the tactical consideration: How to fire people in a company?

Well, if the target number is small (for example, 100 amongst the total of over 20000 employees of HSBC Hong Kong), the best way is to do it secretly.

I mean, there's no need to make any public announcement.

After all, people come and go in a big corporation.

Obviously, that's not possible if you want to do away with 3000 workers, i.e. over 10% of the entire company.

In that case, the best approach is the Blitzkrieg tactic: Announce which 3000 you are going to lay off and send them away; reassure the remaining staff that you are not going to cut further in the coming two or three years, increase their salary a bit, explain to them that the company is in a tough time but you appreciate their foreseeable effort to work harder in order to compensate for the people who are leaving.

The rationale is simple: This is the only way to preserve the morale of your remaining staff.

(The analogy is also straight forward: Human body tolerates a big wound best if it is a quick and clean cut - such as a surgical incision.)

In contrast, if you tell everyone that you are going to dismiss an undetermined 3000 people in the coming three years, everyone in the company would develop paranoid idea and none would focus on their work.

In addition, the more capable ones in the company (i.e. those who you do not want to fire) would soon leave for better opportunities - because they are well planned ahead and don't want to compete with the others in the job market. As a result, you would meet the quota of cutting by eliminating better people.

Alas, it seems not appropriate to call him stupid - it would be an insult to all the other stupid people.

PS. My advice is not an novel original one - it is taught in many business course. For those who are familiar with the Three Kingdoms Period, Guan Yu (關羽) died for the same reason: He left Mi Fang (麋芳) and Shi Ren (士仁) to defend his military base, the Jing Province, but announced that he would charge them for incompetence when he returned from his campaign at the north.

Mi and Shi would be plainly stupid if they did not surrendered to Guan's adversary.

Cut

While I was worrying about the losing battle when we try to focus on the core value, HSBC announced its plan to cut 3000 jobs in the coming three years in Hong Kong.

Frequent visitors of this site may remember I have a special interest on this dinosaur of finance. (For example, see http://ccszeto.blogspot.com/2009/10/back.html and its related entries.) This time, once again I was so impressed with this ingenious move - both in terms of the strategy as well as the tactics - that I lost my nerve. My friend JW wrote on his Facebook the next day that he was fortunate for not being a shareholder of this company. Neither am I. Nonetheless I remains its customer - and am therefore equally concerned.

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I shall not join the discussion on Corporate Social Responsibility, or whether it is moral for a company to maximize its profit by all legal means. Alas, I have a very low moral standard, and I always suspect there is an equal number of, if not more, widows and retiring persons who could only make a reasonable living if the wounded lion increases its dividend.

But, to begin with, there are better ways to fire people.

Let me explain tomorrow.

Losing

But, there’s a deeper water in the enthusiasm of talking about core value.

I see it as the whistle of a lonely walker at night – to give ourselves (useless) reassurance in an immense danger.

In other words, people begin to focus on core when they have lost all the flesh and blood.

Maybe the soul as well.

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The shift from enjoying a diversity of culture to the core value of a society actually reminds me of a little story during the Chinese Civil War:

When the Chinese Nationalist Party (中國國民黨) first began what it called the Counter-insurgency War against Communists, they started with what they called a Full-Scale Attack (while the Communist Party took the passive defense strategy).

Later, when the wind changed and Mao Zedong got the upper hand, Chiang Kai-Shek (蔣中正) changed the slogan - in an impressive sequence - to Focused Attack, and then Full-Scale Defense (and, finally, I believed when I was a student, to Focused Defense).

A losing battle, of course.

Core

While I was thinking about the modern use of benchmark, I came to realize another horrible word that we are using more is core.

For example, we talk about the core curriculum of a medical school, or the core value of a declining city.

“That’s nothing wrong with emphasising the core value. We have to focus on critical elements of our society, or of our medical education.” You may say.

On that, my first response is such a belief represents an example of the classical trap in logics: The core value is a necessary condition, but not a sufficient one, for a people (or city or university or what not). Frequent visitors may recognize the line of thinking is the same as the brief discussion that I made a few months ago on the flaw of using a “minimal standard” marking scheme for clinical examination. (Please refer to http://ccszeto.blogspot.com/2011/05/standard.html)

After all, the analogy is simple: The core is critically important for the subsistence of apple as a species of living organism – but not to everyone else.

And, when every animal is turning away from apples with only a core, the species would never prosper.

Benchmark

You may say I over-reacted and there's nothing wrong with using benchmarks to improve the performance of our medical care system - or an academic institute all the same.

Alas, you could be right, but let me tell you a conversation (between two women) I overheard recently:

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"My daughter is always the cause of my depression," a woman with heavy make-up sighed, "You know, she is having private classes on violin, swimming, calligraphy, and Japanese. Oh, I'm not asking for very exotic talents! But, everyone would believe I am slaughtering a chicken when she practices violin at home, and the only Japanese that she could say is sayonara!"

"Oh, don't compare with her classmates," the other woman tried to sooth her friend.

"But I have to - that's benchmarking!" The first woman explained - I began to realize she might be working in a public hospital, and she went on, “I have to find out in what areas my girl is weak so that she can work harder and improve.”

“That sounds logical – but, isn’t it more fruitful to quit the classes that your daughter is not good at, and focus her effort on those she really has the talent? As a girl, I don’t want to be all-rounded – a synonym of humdrum and lack of character – I want to outshine the others in one area that I excel and enjoy!”

“Very true. Even from the point of view of the society, it is preferable to have individual person, or hospital or whatever, to be different and each have their own edge.” I could not help and said to myself.

Indicator

One major topic that afternoon was the plan to identify some indicators that reflect how well each individual unit is performing.

A friendly creature from Neptune tried to explain the whole idea and reassured lay persons (like me) that the project was not meant for resource allocation, with very simple reasons:

• If more money is given to those not performing well (so that they could improve), no one would have the incentive to do excel.
• However, if they reward the winners, it may end up a vicious cycle; those who lag behind would never be able to catch up.

“Then, what’s the purpose of all these?” You may ask.

“We put it up so that centers could compare themselves with each other and identify areas for further improvement. In other words, we try to set up for you guys some benchmarks.” They explained.

I woke up on that very last word and had a few jerks.

God, how could I have nightmare during day-dreaming!?

Movie

Believe it or not, I actually watched two movies on the same day.

I mean, after Cars 2 in the morning, I attended a meeting with some extra-terrestrials that afternoon.

Yes, I am on leave. Nonetheless there are commitments that we cannot do away with by putting up holiday as the excuse. As long as our flesh-and-blood is physically around, we have to make a presence. Heart and soul? No, those are not necessary – people there probably don’t have any. Brain? My motto is to try my best not to use it for work.

And, don’t try to imagine I did not stand for my own right – I had another enjoyable two hours.

To say the least, I came to realize our friends who emigrated to Neptune have their own difficulties.

Notably, they could not communicate with aliens living outside the solar system.

Cars

My Indonesian maid took a 2-week leave to celebrate new year at her home country. Vivian and I have to quit our work during this period.

I took the opportunity and brought Euterpe to watch Cars 2 on a weekday morning. It was almost the end of her summer vacation and she had not gone to the cinema for even once - not to say a trip to some remote resort. No big deal I agree, but not an entirely satisfactory happening I must say.

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Neither my daughter nor myself watched the original Cars. Nonetheless we had an enjoyable two-hour. The story was smooth and there's no problem of getting used to who's who. The film is, in essence, a cartoon version of James Bond, and I'm sure Pixar was deliberately putting emphasis on this impression by having the last one-third of the story in London, and making Finn McMissile an English spy.

My only disappointment was they used a little post-script of the Toy Story 3 as the appetizer - the cost is minimal and it should be the time for something innovative so that one could test the response of the audience.

A sign of lack of creativity; that's worrying.

PS. I subsequently learnt, slightly to my surprise, that it is Pixar's worst reviewed feature film to date. It is also the studio's lowest-grossing film in North America since A Bug's Life.

Vertical

The idea of vertical integration sounds great, eh?

Many followers have the same romantic idea of controlling the entire supply chain of a product - from raw material to production to retail selling. In real life, unfortunately, this strategy is hardly successful (and the Apple Inc is the rare counter-example).

The reason is simple. When every step is under the same final boss, the sales of an upstream step is guaranteed, and there is no motivation for improving the performance; poor quality product, or service, would persist because there is no extrinsic competition.

Oh, yes, you see that: The most dramatic example of vertical monopoly - and its pitfalls - in macro-economics is communism. When the government owns every steps of the economy and the steel from your backyard furnace could find a buyer, who would have the incentive of trying a better method?

In that case, why is Apple successful?

There are several reasons:

1. Apple Inc is not truly vertically integrated; production of hardware is outsourced. (By the way, that's the achievement of Tim Cook.)
2. Vertical integration typically works well when the industry involves high investment and great uncertainty.
3. And it works best when the final product has a disproportionate brand name.

Resign

While I was admiring the superb marketing skill of various substitutes and bioequivalent products, a rumor that has been around for some time became the news heading.

Steve Jobs resigned.

Well, I am no fan of the Apple - neither the computer giant in California nor the media company close to where I live. (I always fancy anyone who tries to sell their product by using that poisonous fruit in Eden as their logo is a serpent under innocent flower.) Nonetheless, I use iPhone, and I am impressed with this thin piece of metal.

Although the resigning CEO of Apple is often regarded as a genius of marketing, his most remarkable achievement (in terms of business administration) is serving as the classic successful example of vertical monopoly (or, more humbly, vertical integration) - so much so that it will certainly invite many clumsy imitators now and in the future.

For those who are not familiar with this field, vertical integration means owning a company that controls that all steps of a supply chain. Take iPhone as an example, Apple Inc controls the processor, the hardware and the software.

PS. You may argue the hardware itself is not manufactured by Apple but some third-party manufacturers at Shenzhen or Taiwan, Steve Jobs literally specify all minor details of the production.

Equivalent

You may say I was twisting the facts - those fake eggs are a small aggregate of harmful chemicals.

Alas, that may be right, but I was presenting the fact - though not the whole fact.

Well, who would? Even if we confine ourselves to food chemistry, there're no short of examples. When margarine was first made, it was meant for the low cost and ease of storage. (This hard cube of modified plant fat is actually more environment friendly as compared to the traditional butter, but somehow no one use this point for marketing.) Nonetheless, it was promoted to the public by its appeal of being more healthy than butter - low saturated fat and cholesterol...

... until the problem of trans-fatty acid surfaced.

And, this is not an isolated incident. Saccharine was first widely used not by dieters but during World War I when sugar supply was limited. No good, true. That's why when the price of cane sugar surged again in mid 1970s, high-fructose corn syrup (HFCS) became popular.

Therefore, don't call the eggs invented by our bare-foot chemists fake; they are healthy eggs - and in no time some new ones would be proved to be bioequivalent.

As Zhuangzi (莊子) said: It you steal a hook, you would be called a crook; if you steal a country, you would become a Duke (竊鉤者誅，竊國者侯).

Fake

During a recent lunch time discussion, my colleague LY told us about his recent trip to Yunan (雲南).

"You know, things in China could be horribly expensive nowadays," the professor of hepatology said, "I tried to buy some Pu-erh (普洱) tea leaves at Lijiang (麗江), but, when I looked at the price - they're just not meant for us poor Hong Kong tourist!"

"But, the real problem is, even if you are willing to pay for that astronomical price, it doesn't guarantee that the stuff you get is genuine - the bare-foot scientists of our home country could fake anything and everything," one of us said.

"Alas, don't look down upon the scientists of our great country," I smiled, "Their skill is superb - just that they need a better marketing skill.'

"What do you mean?" LS was curious.

"Let's take our famous fake eggs as an example," I explained, "If you sell it as genuine eggs, people will soon find it's nothing more than a coagulation of gelatin and other chemicals. But, if you are honest with your invention - or if you are histrionic enough - you would come out and tell your customers you are making a new generation of healthy eggs: It looks 90% like the real one, but is more healthy, for it has no fat or cholesterol - oh, it may not have any calorie as well."

Letter

Frequent visitors of this site would know I try not to discuss topics directly related to clinical medicine. Nonetheless, I recently encounter a referral letter which I really found admirable.

Here you go:

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

Doctor in charge

HA

Dear doctor in charge,

Re: XXX, Male / 61 Y

I would be grateful if you could see the above named patient with suspected OSAS and hypertension now noticed increasing malaise, on and off exertional chest discomfort and abdominal discomfort with change in bowel habit. Latest Ixs in private showed elevated creatinine Cr 105 (+ve history of kidney stone), alkaline phosphatase 74 & total bili 21, CEA 2.0. Ixs including sleep study, USG liver and kidneys, CT coro, colonoscopy may be considered in his condition.

Thank you again for your expert management.

Best regards, et cetera.

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

(A reply letter that the malicious nephrologist decided to keep it for himself.)

Dear referring doctor,

Thanks for your referral. Given that almost every organ-system of this gentleman seems going wrong, and his family is very concerned about having multiple tests (even though they do not have to pay for all those), I believe the single gold standard investigation that we could solve all his mystery is an autopsy study.

Sincerely