Review

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

Here is mine on 31 December 2010:

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

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

Rebuttal

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

She was obviously not very happy.

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

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

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

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

“You mean…?”

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

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

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

Gen'ya

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

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

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

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

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

Antidote

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

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

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

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

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

Thirst

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

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

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

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

That's a hoax, of course.

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

MSG

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

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

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

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

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

Sprout

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

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

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

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

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

菜心

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

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

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

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

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

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

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

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

Study

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

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

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

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

This is true democracy.

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

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

30

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


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

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

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

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

I shall do better next time.

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

Advertise

Met WC in the wedding banquet of MT.

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

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

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

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

“Which is…?” I was curious.

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

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

Lunch

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

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

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

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

一粥一飯，當思來之不易；半絲半縷，恆念物力維艱。

Temptation

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

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

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

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

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

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

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

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

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

Advice

(My remarkable evening continued.)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My Hercule Poirot was stunned.

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

Rehearsal

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

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

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

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

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

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

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

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

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

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

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

(To be continued.)

Question

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

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

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

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

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

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

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

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

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

Focus

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

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

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

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

JW's

(The comment of JW followed  two hours later.)

Dear VW,

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

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

JW

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

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

And, there's no absolute right or wrong.

Comment

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

Here you go.

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

Dear Szeto,

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

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

Yours,
VW

Split

What's wrong with all these?

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

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

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

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

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

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

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

Research

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

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

So far, so good.

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

Yardstick

What yardstick should we use?

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

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

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

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

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

And we enter the era of research professor.

Evolution

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

Let me give you a slightly convoluted account:

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

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

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

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

That opened a Pandora box.

Division

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

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

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

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

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

I shouldn't say any more.

Feudal

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

I beg to disagree.

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

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

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

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

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

General

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

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

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

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

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

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

Instead, the woman's turns white.

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

Experts

(The conversation has not ended - yet.)

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

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

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

"What do you mean?"

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


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

Report

(The discussion continued.)

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

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

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

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

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

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

“!” The woman is dumbfounded.

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

Film

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

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

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

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

“Yes, very likely,” the doctor nod.

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

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

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

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

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

Share

(Overheard the conversation between two persons.)

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

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

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

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

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

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

Equal

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

"You look puzzled." L said.

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

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

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

"Exactly," my friend nodded.

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

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

I could not help nodding.