Never

For some political reasons, I was summoned to a dinner gathering by the godfather of medicine.

The man who used to have a moustache was also invited but he came late. As usual, he led the conversation around the table as soon as he made the appearance.

“You know, I am busy with some internal audit,” he said.

“And what do you find?” We all asked.

“Alas, I wouldn’t quote specific incidents,” he smiled, “Nonetheless, I see very well that many medical schools are not healthy nowadays.”

We made an inviting grunt – I’m sure he was not pinpointing at the one north to the Lion Rock Tunnel.

“Let me tell you an incident I overheard,” he went on with the following story:

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

Shortly before the final MB examination, a final year student told his classmate, “You know what? I met the external examiner in the loo.”

His classmate was surprised, “How do you know that’s the external examiner? How does he look like?”

The student described a formally dressed, serious-looking old man, and added, “After all, I could not recognize who he is.”

“Why!” His classmate yelled, “He is our professor of surgery! We have not seen him because he never teaches any student!”

How

Shortly after the talk on orphan diseases, we held the membership examination in my hospital.

My friend TL was responsible for the organization and everything was absolutely smooth. While we had a brief moment of casual chat during the break, however, the star neurologist caught my arm and asked, “Szeto, there’s something I wish to ask for your opinion – I know you are never short of opinion.”

“What’s that?” I asked; my mind was pondering about his meaningful remark.

“I read your recent blogs. I just want to ask, in your opinion, how could the faculty determine the performance of a clinical academic staff – especially in the situation when we have to compare a clinical professor to a basic scientist?” he said.

It seems that TL is another friend of mine who finds my fancy story on the big toe specialist disturbing.

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

I shall not tell you my response to TL’s question – or whether I made any meaningful response at all. To my surprise, I heard shortly afterwards a very good answer from my mentor.

I mean the man who used to have a moustache.

Subsides

A commonly used but seldom recognized means of paying for expensive treatments is government subsides on medical research.

The idea is simple: If government contributes to part of the R&D cost of a new medicine, the final price could be reduced. At least in theory, explicit agreement could be signed to limit the final market price of a new product when the research bears fruitful result.

It sounds great, eh?

The problem is, however, a conflict of local versus international interest. As a government, the aim is to help its own citizens. In other words, a new drug whose development is subsidized by, say, the American government would be affordable for patients in the States but remains astronomically expensive for other countries. After all, why should the government contributes even more for the R&D so that the price could be lower for every other people on earth?

It follows that affluent countries with more resources for R&D would enjoy dual benefit. Their people enjoy cheap technology, and their companies earn a gigantic profit from everywhere in the world.

Alas, you see, this phenomenon does not happen only in medicine, but also computer, mobile phone, and almost all fancy gadgets of our life.

Pay

I don’t think I have to discuss the problem of asking patients who could afford an expensive treatment to pay for themselves, but letting the government to pay for those who do not have the money. Interested visitors may like to read http://ccszeto.blogspot.hk/2008/07/thermodynamics.html and related posts.

How about asking the government to pay for everyone, including those who are rich enough?

No, that would mean absolute communism – a road to serfdom.

Why? Because communism discriminates against the rich. Essentially the policy could be written in this way: If the government cannot afford a treatment and pay for the poor, the rich could not have it either.

There is, however, another indirect way of paying. 

I shall elaborate tomorrow.

Philanthropy

Fans of Milton Friedman may ask: What’s wrong with market economy and let only those who could afford the treatment have it?

No, there’s nothing wrong – just that I’m afraid the actual market would become even smaller and there will be very little incentive for drug companies to develop any new treatment for uncommon diseases – because the stake is high but the chance of making a good profit is slim.

(You may ask when I am so keen on supporting research and development. No, not because I am a fan of science, but, rather, for a worldly and pragmatic reason – I shall leave the discussion on this topic of supreme importance later.)

But, let’s go back to the original question: If many patients could not afford the expensive treatment, who should pay for them?

Some would suggest a somewhat philanthropic approach: For those who have the money, please pay for it so that the company could make a profit. For those who are not that well off, the drug company has an obligation to provide the treatment.

Alas, I should not tell you my comment on this suggestion directly, but I would like to remind you it is a naive idea to believe drug companies are owned by tyrants with morbid obesity living in Miami or Zurich – many of the shareholders are humble ordinary citizens, widows, retired persons, or your mandatory provident fund.

Expensive

Don’t get me wrong. I’m not at all against a (practically) long patent period. In contrast, I believe drug companies would only have the incentive of developing new treatment for uncommon diseases when the potential profit is huge.

And, after all, it is a mathematical truth that treatment of rare diseases need to be expensive because much of the cost for the development of a new drug is fixed – no matter it is meant for common or orphan conditions. The cost (and the expected profit) to be shouldered by individual patient is therefore much higher for rare diseases.

The real problem is: Who should pay for the drug?

If you ask for my opinion five or ten years ago, my response would be simple: Some men are more equal than the others. For those who have the money, treatment is there. For the others, sorry, life is tough.

Frequent visitors of this site may remember I made an elaborated discussion on this problem some years ago. Go read http://ccszeto.blogspot.hk/2008/07/equal.html and related posts.

But, I’m not that sure now.

Patent

You may argue the hypothetical situation that I put up yesterday would never happen, and I’m too mean to patients with orphan diseases.

Very true. The flaw of my argument is obvious: Not all treatments of various orphan diseases appear on the market simultaneously. At any one time, only a few of them have effective but expensive treatments.  New drugs (with an astronomical price) for other rare diseases may appear one by one years later, but existing treatments would become less expensive during the same period because they lose their patent.

But, hold on. Would they lose their patent that easily? Not that much as you think. It is naive to believe a new drug applies for one patent – there are dozens if not hundreds or thousands. In fact, for many drug companies, the main duty of the R&D department is to explore modifications (usually in the manufacture and packaging) of an existing patented product so that new patents could be applied and the monopoly of that drug could be everlasting.

And, even if the patents are all expired, would there be a competitor to make a generic product? The incentive is not that high for a rare disease, simply because the market is small. (Readers with some knowledge in infectious disease could certainly cite a handful of examples that are used for treatment of uncommon infections.)

Afford

On the face of it, you may think my question doesn't make sense: Although the treatment is expensive and we have to use 1% of the budget for a small group of patient, it is obviously affordable.

But no, because there are more than one kind of orphan disease.

To be exact, the European Organization for Rare Diseases (EURORDIS) estimates that as many as 5,000 to 7,000 distinct rare diseases exist, and as much as 6% to 8% of the population of the European Union is affected by one.

In other words, you expect some 500,000 Hong Kong people have one rare disease or another.

You see, if the treatment of every orphan disease is equally expensive, the total cost would be HK$800 billion per year - 20 times of the entire health care expenditure of Hong Kong.

Worth

Frequent visitors of this blog would know I am very skeptical to argument of this kind.

In fact, you could easily find some relevant figures on this area.

For example, there is one case of Gaucher's disease - the problem at hand - in around 40,000 population. In other words, for Hong Kong, there are roughly 200 patients.

And, the annual cost of treatment is HK$1.6 million. In other words, the total cost of treating all patients in Hong Kong is HK$320 million - close to 1% of the entire budget of the Hospital Authority, and over 60% of all money allocated for medical equipment upgrade of all public hospital.

I hear you ask the question: Is it worthwhile?

No, I would ask a more fundamental question: Is it affordable?

Orphan

Shortly after L and I discussed the incident related to the Duke of cosmetic industry, I had the rare opportunity of visiting Aberdeen thrice in two days.

(No, not a enjoyable experience - at least not for someone with autistic personality disorder who works in the New Territory and lives in Kowloon east.)

I shall not explain why I had to go there that frequently, or what happened on those two days. Nonetheless, the oration during the College dinner in the second evening really intrigued me.

************************
The idea of the talk was simple: There are many rare diseases - what we call orphan diseases - that do not attract much attention and medical research is badly needed in these areas. Although the incidence is low and drug companies often do not have much incentive to develop treatment, effective drugs could prove highly profitable.

The example cited in the talk was Gaucher's disease. (For visitors without a medical background, don't be disappointed if you know nothing about this disease - we physicians are hardly any better.) Although the disease is rare, the first effective drug for this problem - imiglucerase - made a revenue of US$1800 million in 2009.

Rosy future for medical research, eh?

Late

While updating my blog entries in the evening, I suddenly realize the post on 18 October was not put up as scheduled - it was supposed to appear automatically at 6:30 AM, but, in reality, it comes up 12 hours later.

The reason is simple: I clicked the wrong button when selecting the time of posting.

No big deal of course. In fact, I'm not going to say to err is human and medical incidents are unavoidable.

But, rather, a little story of JC, our previous professor of clinical pharmacology, comes through my mind.

Here you go:

**********************
One day, after the morning round, JC told his two medical officers (yes, one was me) that he would be very busy the next day, and need to start the round at 9 AM sharp.

The two of us nodded. In the next morning, we finished with our first round early, and waited eagerly in the ward at 9 AM.

But JC did not turn up. We waited and waited; my colleague tried calling him but there was no response either. After an hour or so, the two of us smiled to each other and decided to get on with other duties.

The day passed quickly. By 4 PM, we received a call from the ward - it was JC, and he was asking us to start the consultant round!

"What's going on?" We asked the professor.

"Em... nothing," he smiled, "I think I meant London time yesterday."

Help

Although I tended to agree with my cynical friend, after considered for another while, I became slightly uneasy, "My friend, those advocates of alternative therapy or funny remedies may mean no harm. They have no personal gain, and all they want to do - as far as I could see - is helping people."

My friend laughed, "That comes back to our original principle: We can never determine the real purpose of anyone; all we could judge by objective means is what actually is being done. Although their aim might be noble, these amateur practitioners of alternative medicine may do more damage than our Duke of cosmetic stem cell biology - not only because the remedies they publicize could have adverse effects, but, more commonly, ill advised patients may give up valuable orthodox treatment and cost their life!"

"Well, yes. The road to hell is paved with good intentions." I was forced to agree, "After all, very few people deliberately do evil. Almost all disasters in human history had majestic objectives to start with - but they are led by persons with a crooked mind!"

Advocate

"No because I actually have much respect to most professional practitioners of traditional medicine," L explained, "I have more worry about those unprofessional advocates of alternative medical treatment."

"Who are they?" I asked.

"They are... em...," my friend hesitated and considered for a moment, "Let me tell you a little story I encountered this morning in the clinic. A young woman came for regular follow up - what disease she has is quite immaterial - asked if her disease could be benefited by a remedy of assorted vegetable oils that is highly praised by a famous columnist."

"Alas!" I knew what L was referring to. By coincidence I read the same newspaper and all mystical effects of flaxseed oil. "Well, what did you tell your patient?" I asked with a smile - trying to imagine how my cynical friend looked like when he was talking to that woman.

"I just said if a remedy is effective for treating a certain disease - cancer or allergy or what not - I shall remain humble and ask for the evidence; and, if there is none, I can only conclude further studies are needed," L recalled, "But, if that remedy is claimed to be effective for treatment of cancers and allergy and insomnia and hepatitis and thyroid problems and many others, I shall be very skeptical."

I cannot agree more.

TCM

“I mean, although the murderer and process of killing are relatively obvious in this case, far more people die of – or, to say the least, are affected by other subtle means,” L looked grim.

“Such as…?” I must say I did not quite understand what my friend was talking about.

“Such as pseudo-science and pseudo-medicine,” he replied with a twist on his lips.

“Alas, since I know you for such a long time and know your bias well, I understand exactly what you are getting at,” I smiled, “You mean herbs and other traditional remedies, right?”

“Yes and no,” my friend shook his head, “Yes in the sense that they are often an annoying lot – or I would say they are the bat of medicine in Aesop’s Fables. Depending on the audience and situation, the same remedy could be regarded as specific treatment of a disease, measures for the maintenance of general health, or simply a food supplement. No regulation of any form is possible because the remedy always belongs to a different category.”

“Quite true. In fact, once I learn the circular argument of these people, I come to realize why the Americans put food and drug under the same administration,” I nodded, "But what do you mean by No?"

Purpose

(Our discussion went on.)

“The real problem is, it is a fundamental error to distinguish a procedure that aims to maintain health and another that treats a disease,” L explained.

“How about procedures that merely aim to promote beauty?” I asked.

“Same. No procedure could be excused because the aim is neither of the above, but, rather, for cosmetic reasons,” my cynical friend continued, “The very principle is, we can never determine the real purpose of anyone; all we could judge by objective means is what actually is being done. In other words, the question is not whether health maintenance or cosmetic industry should be regulated, but what types of procedure need close scrutiny.”

“This idea sounds simple enough,” I nodded.

“Not as easy as you think, but I suppose you are not interested in knowing all the practical problems in this muddy water,” L shook his head, “Alas, although the tragedy is theatrical, my personal bias is the limelight is pointing at the wrong subject.”

“What do you mean?”

Health

(The conversation with my cynical friend continued.)

"You seem excited on this matter," L smiled, "I suppose for people practising in this field, it has been well known for a long time?"

"Yes, but I must say I was touched - may be in my ass - when the Duke in this case defends by saying that the injections were meant for health protection rather than the treatment of any specific disease."

“Well…?” my friend certainly knew I had not finished.

“I mean, what’s the difference between maintenance of health and treatment of disease – or, is there such a difference? If you are entirely well and have your stool tested for colon cancer as a screening, are we taking it as for health maintenance? In that case, if we replace the test by colonoscopy – an invasive but more reliable test to screen for cancer, wouldn’t it also be considered for health maintenance? In that case, can we be excused from any responsibility if the patient dies of the complication of the test, for example, rupture of the bowel? In fact, all prophylactic treatment – warfarin for the prevention of stroke, and anticonvulsant for epilepsy control – fall into the category of health maintenance because their responsible target problem has not yet surfaced!” I tried to catch my breath after finishing this mini-lecture.

“I know very well what you mean. Alas, just like the relation between theology and philosophy, maintenance of health and treatment of disease are the two poles of a magnet,” L nodded, “They seem to be exactly opposite, but do really attract each other. More importantly, you can’t cut the magnet and just take away one pole! But, maybe I can go one step further: Do you remember the motto of the Hong Kong Medical Association?"

"Why!?" I exclaimed, "It is To Safeguard the Health of the People (維護民康). Yes, medicine is all about health protection. How could one ever says that a procedure that aims to maintain health – however simple it is – is not a medical treatment?"

Murder

Met my friend L again on my way home. As usual, he was reading his favorite weekly magazine with a curious smile.

"Hey! What's up this time?" I tapped on his shoulder.

"Oh, I'm just thinking of the famous sayings of Hamlet," he said.

"Which?"

"For murder, though it have no tongue, will speak with most miraculous organ," L explained, "Nonetheless, it remains eye-opening to see a murderer comes out and speaks to the media that he is only responsible for collecting the money and has nothing to do with the killing!"

"Or, as Theodore Roosevelt said, a man who has never gone to school may steal from a freight car; but if he has a university education, he may steal the whole railroad," I remarked, "In this case, when I hear that our unfortunate colleague is banned from practice for two years due to a wrong injection, I cannot refrain from thinking of the old sayings of Zhuangzi (莊子) : We penalize someone who steals a hook; but for the one who steals a country, we make him a Duke (竊鉤者誅，竊國者侯)."

家家酒

On the next Saturday, Euterpe had to attend interviews of two primary schools. Naturally Vivian and I went with our princess.

Thank goodness the interviews were a couple of hours apart, and we could actually take a short break in between the two. In fact, as a parent, I had nothing material to do for the interview other than waiting outside the room.

And, you know what, I read another detection fiction.

It was Akui (惡意) of Keigo Higashino (東野圭吾).

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

I must say the story was so so, and it appears to me nothing but a clumsy mimic of The Murder of Roger Ackroyd.

But, the confession of Osamu Nonoguchi (野野口修), the school teacher, does impress me:

“The relation between teachers and students is based on a misunderstanding. Teacher hallucinate they has something to teach the students, and students fancy they could learn something from their teachers. The irony is, it would be fortunate for both sides to maintan this mutual misunderstanding, and, it does them no good if they realize the truth. What we are doing is, after all, a playing house of education.”

Trees

I have been longing for a break and was most thankful to see the mid-autumn holiday. Shortly after our family gather at the Snow Garden, Vivian and I brought the two princesses of ours to the university campus.

It was probably the best time for hiking and picnic throughout the year. Seriously, there aren’t any exciting things to see as such. However, it was great fun for our girls to run after butterflies on the grass, say hello to dragonflies, and observe the fish and turtles in the lotus pond. I was also trying to take the opportunity and teach Euterpe some local botany: Chinese banyan (細葉榕), Taiwan acacia (台灣相思), caoutchuc (印度榕), paper-bark (白千層), horsetail (木麻黃), swamp mahogany (大葉桉), tree cotton (木棉), and so forth.

Alas, of course she was not interested.

PS. It was the same evening that the catastrophic shipwreck happened. Shortly after the holiday, Euterpe asked what simple phrase she should write on the card.

Here is what I suggested: 生者振作，死者安息。

單尾

樟茶鴨接上。看之平平無奇，聞之亦不大有煙燻香氣，然細啖之，肉質細嫩，不酥而鴨味足，卻是喜出望外。而伴碟蝴蝶餅微甜鬆軟，更極為小孩所喜。

素菜是黄崧豆腐，即野菌竹笙豆卜，以上湯煨之。較諸尋常蔬菜，色澤口味，多了一份豐頰，煞是不錯。

單尾是生煎飽和叉子燒餅併雞子米崧。前者煎得香脆，餡料汁液豐盈，只稍嫌肥肉略多，此亦滬菜傳統也。叉子燒餅烘得夠火，雞子米崧者，即醬炒雞肉末及松子，以此加入中空口袋，乘熱啖之，口感豐富複雜。平心而論，雞肉味淡，此品以老式榨菜肉末，當更為惹味，唯榨菜稍微辛辣，席上小孩便是不宜矣。

行席至此，驚覺前菜未至。問之侍者，即歉聲連連，菜亦旋踵而至，為素鵝和醉雞。前者為脆皮熱吃之法，香夠味足。後者酒味濃重，皮厚脂滑，竊以為不錯，內人卻謂不過爾爾矣。
甜品芝麻糊湯圓。糊未夠厚身，湯圓浸久後亦微有發漲。此亦無非應節慣例而已。

總的而論，此席菜式平凡卻吃得極為頰意，可見店家固守傳統而不妄自創作，可喜可佩。而此夜由把兄楊君請客，卻之不恭矣。

雪園

中秋前家庭聚會於雪園。此為老店，區區已十餘年不曾光顧。記得九四年初臨此處，乃同窗慶祝皇家學院試及格，其時初嚐火膧翅及蒸鰣魚，無不驚為天人。今，俱往矣。家慈近年戒絕魚翅，而自有新鮮三鯬，亦不曾於館子吃鰣魚。是以此夕菜單，無非尋常食際，可稱返璞歸真也。

先上是清炒蝦仁，大小適中，蛋白、走油、掛茨，俱恰到好處，實老幼咸宜一味。

再上是雲吞雞。此實為火膧走翅。雲吞不過不失，湯略鹹唯鮮味足，自忖放入粉絲素翅，便與真品無異矣。

之後是獅子魚兩吃。此魚與廣府獅頭魚相類而體形略大，起出背連尾兩片肉，以油泡之、吉列炸之，是為兩吃。因其無骨而肉嫩，素為不吃魚者所喜。獅子魚本為賤物，此味功夫仔細，卻不賣價錢，是以幾近失傳。

再上是一字骨。作法與東坡肉相近，不過以肋排代替五花腩，肉味較濃。此味功夫之處，在於把肥油逼出，而瘦肉要煮得酥軟入味，實為粗料細作另一示範。

Entertainment

On a lovely Saturday, I had the opportunity of waiting Vivian for lunch.

My wife was having an urgent meeting with the Strawberry bear and Rex. It just so happened that I had finished with all journal articles in my Kindle, but in my bag there was a book I borrowed from AL. The weather of an autumn afternoon was perfect, and I managed to find an armchair under a gigantic Chinese banyan tree to enjoy a rare moment of peacefulness.

The book was Dochira Kaga Kanojo Koroshita (誰殺了她) by Keigo Higashino (東野圭吾).

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

I finished with the entire book that night, and felt a gush of satisfaction that I missed for ages.

No, I’m not saying the book was superb. It is damn good – but that’s quite beyond the point. You know, during my final year of medical school study, I had the habit of reading a detection fiction every Saturday. (That’s actually the only entertainment I had all through that year.)

It just feels warm to enjoy the final year of medical school once again.

Exit

Like Vivian, you may also find it difficult to understand why I only consider stocks with a large sum of daily trading.

The principal reason of mine is simple: I have to make sure, in case my valuation is wrong (for example, there is a sudden change in the condition of the company), or if I need the money for urgent reasons, I have a secure way out and could cash back at least part of my money.

My opinion is simple: Before we could prepare for a victory, we should first consider what to do when our luck is tough. Contrary to the teaching of Xiang Yu (項羽) and Han Xin (韓信), we won't be more likely to win by shutting up the emergency exit.

Well, there is another reason why I prefer stocks with a high volume of trading: If you practice traditional value investment, what you are actually doing is to put money on a company that is under-valued by the market, and you expect the market would soon discover the true value of this company. The sobering truth is, an undervalued company could remained unnoticed for years and sometimes decades. On average, however, a high trading volume usually means that the true value of the company is more likely to be realized in the near future.

Criteria

While I was considering how to diversify an investment portfolio, a related topic that Vivian and I had some vigorous discussion recently was: What stocks should we pick?

Alas, I will not tell you what should be done – for there is probably no black-and-white answer as such. Nonetheless, let me tell you what I am doing.

In essence, I screen for potentially interesting target on the following three criteria:

1. The price is over HK$1.
2. The dividend rate is consistently over 2% in the past 3 years.
3. The average daily trade is over HK$10M.

When I showed this list to Vivian, she was rather surprised – to be specific, she was slightly incredulous with the third criteria.

Number

You may ask: In that case, how many types of stocks should we hold for optimal, but not excessive, diversification?

I have no cut-and-dry answer.

When I first study how to pick stocks and build a portfolio, I was told that the ability of diversification (i.e. spreading the risk of a portfolio) reaches a peak when you hold 7 stocks. Any further increase in the number does not help to reduce the risk because it is likely that some of the stocks would have the risk overlap with each other. The statistical jargon is there is internal correlation.

(Unfortunately, I cannot find the reference or origin of this very number.)

How about me? At this moment, I owned 13 different stocks. In general, I try to keep it below 15 but at least 5. There was a brief moment during the financial tsunami that I hold only 3 stocks (Hong Kong China Gas, Link, and Yip’s Chemical). I don’t think this situation will ever happen again.

Diworsify

Frequent visitors of this site would have sensed my tinge of disagreement yesterday. Many of my friends would also point out immediately that I am all against (over) diversification.

My concern is simple: Although you may have an astronomical sum of money in your account (unfortunately, that doesn’t include me), your portfolio is always 100% in total. The more types of stock you hold, the less likely each one of them would make an impact on the overall performance. In fact, if you consider expanding your portfolio from 50 to 100 stocks, it is much more likely to hit some landmines in the second 50 than the first. In other words, the risk is not reduced by further diversification, but quite the opposite.

Alas, why don’t you put up more effort to choose the first 50, and, when you have extra money, put them back of these carefully chosen ones?

Or, let me put it like this:

The traditional teaching is: Don’t put all eggs in one basket.

My interpretation is: It doesn’t mean that you have to put each egg in a different basket.

By the way, the advise of Warren Buffett is: Put all your eggs in a few baskets – and watch them closely.

Limiting

Once you realize time is the limiting factor, it is tempting to jump to the conclusion that there are situations where prolific in good ideas and a wealth of excellent output could come together.

For example, in the case of investment.

The consideration is obvious: Although we all have only 24 hours a day and cannot work out as many good ideas as we could generate, you can certainly invest on as many stocks (or options, warrants, bonds, ELIs, and what not) as you like - provided that you have sufficient money.

In fact, this idea is well utilized by many mutual funds. For example, Peter Lynch is probably blessed by the muse of investment and could make use of almost aspect of ordinary  daily life – the Fidelity Fund under his management used to hold close to 1500 different stocks. (See One Up On Wall Street.)

They call it diversification.

Materialize

Yes, I mean what I say: Having many brilliant ideas does not coexist with carrying out a lot of work.

Important. I'm not saying having brilliant ideas does not always result in a lot of work. If I could play Aristotle for a moment, the two phrases are not subject (主詞) and predicate (謂詞), and the relation not a proposition (命題) (specifically, A or I type). What I mean is: The two conditions are mutually exclusive and could not happen together.

Why? It is because time is the limiting factor. For every good idea, you need fresh and blood to make it materialize. If one spend most of their time generating ideas, it is actually unlikely that he could have the time to work them out.

PS. When LS and I were giving a talk to the research students in Shanghai, we were asked how often do we generate useful research idea from reading journals. My reply was I would feel fortunate if I could have one good idea each year - after scanning through some 3000 research papers.

Execution

My primitive idea was simple. You've got to be smart to have good ideas, but it involves an entirely different aspect of capability to execute an idea - determination, planning, and endurance.

By the way, it is a common misconception that Emotional Intelligence means the ability to identify and control ones own emotion. In fact, the famous Stanford Marshmallow Experiment - the result of which correlates with the score of high school examination - tests whether a child accepts deferred gratification, not the ability of handling emotion as outlined in the models of Stanley Greenspan and Daniel Goleman.

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But, let's go one step forward. We should not always blame extraterrestrials (for example, administrators of research grants). As mentioned above, it is often the problem of ourselves rather than any extrinsic force. However, many a time it is a mathematical problem.

In fact, other than medical research, many things in our life could be taken as an example. The paradox is: having many brilliant ideas does not coexist with carrying out a lot of work.

Ideomotor

It is obvious that my friend VW was thinking about a different problem when he talked about people who keep having good ideas but none could be worked out.

The reason that he puts up was simple: They do not have the ability to complete a project.

My opinion is: this statement is a level one explanation of the problem. (For those who are not familiar with the five levels of understanding a problem, please refer to the black cylinder experiment - go read Practical Thinking of Edward de Bono.)

You may ask: Do I have some explanation of a higher level?

Unfortunately, no - although I am sure I have encountered more people with this very form of ideomotor dysfunction than our professor of hepatology.

My vague idea of analogy is: Having a good idea requires IQ, while working an idea out involves EQ.

Priority

In his recent blog entry, my friend VW outlined his plan of conducting a randomized control trial back in the days when he was a house officer. He went on and discussed why some people continue to have excellent research idea but they hardly bear any fruit. (See http://vwswong.blogspot.hk/2012/09/change.html)

Simple, eh?

No. It involves much deeper a water and actually several unrelated problems that may skip your eyes.

To begin with, an excellent research idea to one (especially when it is viewed with some hindsight) may not be at all interesting to the funding bodies - or, in the jargon of our friends outside the solar system, not having sufficiently high priority.

The sobering truth is, how our funding bodies rank research priority is no different from how the lay public choose which stock to buy: When everyone sees a great opportunity in a particular item, it usually means that  this item has already passed its prime time.