Freedom

I must say in spite of my disapproving attitude, I didn't really stop that woman to talk about her alternative regimen. My logical mind says that I shouldn't do that - for freedom of speech is a human right, and, as Voltaire said, although I do not agree with what she says, I shall defend to death her right to say so.

But, am I doing my duty (of protecting other patients' welfare) if I allow that woman to disseminate wrong information on a potentially harmful treatment?

If you become slightly uncertain, let's go one step forward: What if this woman is the owner of a large company involved in the trading of free-range chicken and pumpkin from organic farms?

PS. As a believer of David Hume (that's a self-contradicting term, I know), I also doubt my own ground: Am I all certain that I know the best treatment and what that woman said is a total rubbish?

I always worry I may have unknowingly taken the apple from the Tree of Justice in Eden.

Remedy

This very woman obviously did not sense my tone of disagreement and went on with her speech.

"You know, it is an old traditional Chinese remedy - but a very simple one too. All you need is 1 tael of fresh red pepper seed, 2 taels of chicken oil, 3 taels of meshed pumpkin, and 4 taels of steamed gelatinous rice, thoroughly mixed and to be taken twice a day. Other than that, you can take whatever you like. No dietary restriction what-so-ever, and it cures 90% of all kidney diseases. Isn't it fantastic?"

I tried my best not to laugh aloud, wondering what appetite is left for the patient after taking such a splendid feast of medicine. However, I would like to pretend to be nice, "Em... madam, isn't this remedy too simple?"

"Doctor, you are pulling my leg. But I am serious. First, not every chicken is suitable for making the oil. It must be free range ones (走地雞) that never receive artificial feed, antibiotics, and hormones. Similarly, we can only use pumpkins from organic farms. Any trace of chemical fertilizer or insecticide is not acceptable."

"That seems more complicated. Although an easy remedy it first seems, there is a quota of live chicken for the Hong Kong market, and pumpkin from an organic farm is not easily available. How many patients could actually be treated with this remedy?" I continued with a polite smile.

***************************
On my way home after the seminar, I was confused.

No, it's not about traditional and alternative medicine. My mind was absorbed in a more profound question:

Should I shut her up?

Cure

As a rule, I do not describe in this site my clinical encounters. Nonetheless, a recent incident really caught my attention.

(No, it's nothing exciting. I am only interested in trivial and unimportant matters.)

The story goes like this: My unit conducts a bi-monthly patient education class for patients with kidney disease, and we doctors take turn to sit in and give some occasional comments in case an audience put up some difficult medical questions in the Q&A session.

It was my turn last month. Towards the end of the two-hour session, an elegantly dressed middle-age woman, who was sitting at the front row, put up her hand and said, "Excuse me. I have something to share."

"Yes...?" My mental alarm rang. That sentence is no ordinary statement that a common-place patient would begin with.

"You know, I have here with me a secret remedy that can cure all kidney diseases."

"Really!? What's that all about?" I felt light beaming from my eyes.

Pride

I could sense the hue of irony in L's reply.

"What happened in reality?" I asked.

"Nothing," my friend continued with his wicked smile, "Or I should say the business of the two shops remain very much the same. If anything, the real big spenders tend to go to H a trifle more."

"Why should that be the case?"

"That's quite natural. First, many potential customers pick a brand of handbag rather than the other by the brand per se; customer service has very little to do on the decision. If the craft and material of one brand is better than the other - or, if, in reality, one brand is the market leader because of a longer tradition - customers from a strong nation will follow their tradition and vote by their legs."

"I can understand that. But I suppose many of the customers do not have any pre-determined idea on which shop to go?"

"Very true. But, you know, handbag is something that they carry along with them, probably for many many years. The bag is a symbol of the owner's pride and something to show off. A shop run by cool and mask-face shopkeepers would be interpreted as elegant and high class, while an excessively friendly and obedient team of servant may appear to be grovelling - the honor of getting into the shop would be, ironically, depreciated."

Greet

(L went on to tell his story.)

"Szeto, I suppose you know the usual happenings. Everyday, early in the morning, there are a hundred people or so lining up outside the shops of C and H - they are all wealthy potential customers waiting to get admittance to the stores!"

I nodded.

"And, you know, both brands are eager to attract all big spenders. For that purpose, C comes up with a new tactics recently."

"What's that?"

"Alas, before the business hour every morning, shopkeepers of C will go out of the store and greet - in the most hearty way - all those people who are lining up and waiting. The idea is simple. People should choose the shop that has a better customer service and whose staff is more friendly."

"It sounds a good move." I remarked.

"Yes... or so we should imagine," L put up a mysterious smile.

Shop

As you may expect, as soon as I conclude that patients may not be in the best position to assess their doctors (especially physicians) because emphasis would be put inadvertently on skin-deep manner and short term symptom relief rather than genuine long term benefit, I come to realize students (not only medical students) may not assess their teachers properly.

But I could not dwell on this topic very long. I met L that evening and was about to tell him what I learnt in the specialty board examination. But, my friend was not in the mood.

His mind was obviously engaged in something else.

"You know, I went pass TST several times in the recent weeks," he explained, "To put it simply, I am intrigued by how those shoppes compete for business."

I nodded, because I knew what L meant. TST is the mecca of shopping and there are several dozens of famous stores, all selling exquisite and expensive shoes, handbags, jewels, and what not.

"So, have you heard of the recent story of C and H - the two most prestigious brands of handbag?"

Of course I had no idea.

Delayed

After the examination, when I reflected what FK said, however, I was not that sure.

My concern is simple: Could patients judge which doctor is good and which not?

Don't gasp. Yes, for treatment with short term immediate effects (for example, surgery), it would be obvious to the patient whether the doctor has done a good job. However, for physicians who take care of the long term medical problems (notably prevention and risk reduction in various aspects), good and lousy ones are usually not immediately discernible. In this situation, patients generally become clients or customers and judge their doctors by their manner and attitude, as well as their capability of providing short term symptom relief.

Oh, I'm not saying these latter aspects are not important in the overall medical care. Nonetheless, over-emphasis on immediate result may compromise the long term benefit, and a nice doctor may well pave his patient's road to hell.

PS. Do you know the difference between how Alex Ferguson and José Mourinho run their football teams?

Reputation

(For visitors not familiar with our local medical news, let me explain briefly: It has recently come to the attention of our public media that a few famous Hong Kong doctors in private practice continue to quote outdated qualifications in their name cards. Most of these qualifications are members of American specialty boards and the Hong Kong doctors in question do not take the trouble to sit for the re-certificate examination.)

"Hey! What do you mean with that curious smile?" We were surprised with FK's wordless response.

"Alas, the concern is quite beyond the point," our friend in private practice explained, "You know, when you come out and practice, it doesn't matter very much what titles you add to your name card. MB or MD, MRCP or FRCP, DCH or MPH or whatever - they don't make a dime's worth of difference. Patients will line up outside your office if you could solve their problem - your qualification, or the lack of it, is none of their business. On the other hand, if you muddle along or keep having all sorts of complications with your treatment, what good is there to have all the fellowships and doctoral degrees? In the real world, the reputation of a doctor is written by words of mouth, not what we put down on the name card."

I cannot agree more.

Title

Shortly after the Father's Day, we were holding the specialty board examination for our College.

It's a viva voce but the process is both dull and time consuming. This time, there're only three candidates - one for exit examination and two for interim assessment - but there are six examiners, all consultant grade, and one observer. All of us had to meet two hours before the examination actually started, so that we could, during lunch, go through all questions that each of us put up.

As you expect, soon after lunch and all paper work, we became engaged in more casual discussion.

"FK, what do our friends in private practice think about the problem of outdated qualification mentioned in the morning paper recently?" One of us asked. FK is another examiner - a nephrologist in private practice.

And, listening to the question, he just smiled.

Gift

Shortly after we paid a visit to the duck, it became the Father's Day.

Alas, here is my gift prepared by the two princesses of mine:

PS. Eutpere fried the eggs - with me holding her hands. Adler added the soy sauce.

Culture

You may well guess what I am about to say about accepting different cultures.

First, there is a fine line between culture and civilization. The former refers to a system of behavioral pattern which is characteristic of the members of a society and is acquired through learning (i.e. not the result of biological inheritance). Civilization, on the other hand, has a more restricted meaning, referring to certain elite of human culture that has a wealth of art, science, and technology.

In other words, there is culture amongst savages, but we don't call these people civilized - and we should not accept their barbarian activities (or, as they call it, culture). If anyone wants to keep up with the habit of cannibalism or castrating their man-servants, please do so but stay in their own tribe - alas, I wish to say cage.

PS. Discerning visitors may notice I said civilization calls for a wealth of art, science, and technology. Money is not in the equation.

Art

I must say I am not sure.

I look up the Wikipedia. Here is what I get: Art is a diverse range of human activities and the products of those activities. It is created through imaginative or technical skill, serving as a channel for the expression and communication of emotion or other values. I would add the activity should trigger our neuron and bring along some pleasant and enjoyable feelings.

It is slightly beyond the point to discuss whether the gigantic yellow duck is a kind of art. (My biased view is it is, although not a very brilliant one.) But, one thing is obvious: Not all human activities are artistic. For example, yelling a series of four-letter words is different from rap music, and doing press-up in a shopping mall while wearing nothing but only the best underwear from god is not a kind of behavioral art. We don't like this kind of activities because they are not artistic - not because we are not receptive.

Sounds simple, eh?

How about we attitude to different cultures?

Duck

Early on a Sunday morning, we brought our two princesses to say sayonara to that huge yellow duck in the harbour.

The place was not as crowded as we expected. Euterpe was all excited on our way to Tsim Sha Tsui; she had a few miniature plastic toy ducklings as long as she could remember, and she urged Vivian and I several times to bring her to see the gigantic one - because many of her classmates were mentioning it in her class.

But there's actually not much to be seen. It took the four of us some 15 minutes to walk around, take some pictures, and, that's it. Euterpe was still able to go home on time and attend her gymnastic class at 10:15 AM.

******************
On our way home, a question kept flashing through my mind:

Is the duck a kind of art?

Change

I end up downloading journal articles that I want to read as PDF file to my Google Drive.

The advantage is obvious. I have all files synchronized between the desktop computer of my office (where I download the papers) and my mobile phone (where I read those papers on my way to work). I can also bring whatever I need to read at home to my laptop via a finger disk. True, reading PDF on a mobile phone could hardly be called comfortable, but I save the trouble of carrying another electronic device for reading and nothing else. After all, I am trying to move much of the journal reading back to my computers.

And, there are more on the positive side. Papers are now showing up with colour and figures are easy to follow. I can highlight important points and pick interesting parts - or the whole article if I prefer - to Evernote for permanent storage and easy reference.

But, of course, most of the things that I read, however, are moved to trash that and there.

Journal

Another aspect of self management that I am always looking for a better strategy is keeping myself update with latest journals.

I have tried half a dozen of methods because none could work well forever. For many years, I read hard copy of all journals that I subscribe on Sunday morning. It worked well until the birth of my two princesses, as my weekends were almost always occupied with one thing or another. To complicate the problem, I found more and more journals that I subscribe gone astray, and I was aware of the problem only a few weeks later when my friend KM mentioned some latest articles that I had absolutely no idea.

Since then, and, until very recently, I was using Kindle - the good old black-and-white version without a touch screen function. I check regularly on the table of content of all journals that I wish to keep an eye on. For articles that I find interesting, I use the Send to Kindle button on by Chrome browser, and then I could read on my way to work from that primitive tablet by Amazon.

It all goes well - except the very basic problem that many figures do not show up properly. This shortcoming becomes critical when I come to papers that talk about molecular mechanism or management algorithm.

In short, I need to find another way.

Calendar

I give up using Moleskine to manage my calendar recently.

Frequent visitors of this site may know I had been using Google calendar until some three years ago, when I began my relation with the artistic hand-written notebook. (See http://ccszeto.blogspot.hk/2010/06/planner.html) My decision at that time had a very simple reason: my iPhone was slow; typing and synchronizing became a pain in the neck.

But things have changed. To begin with, it is another nuisance to go around with a hand-written diary and a mobile phone. The new mobile phone, together with the 4G network, is much faster. And, since I change to the Android system, working with Google is seamless.

The only other thing that I am not happy with the Google calendar (I mean the Android apps) is the screen becomes very difficult to read when two appointments clash with each other. For this apparently unimportant reason, I end up using the Jorte calendar (a free apps from the Play Store), which simply ignore overlapping appointments and show them all in series.

Well, Jorte also has a whole lot of pretty icons and the layout is more eye-catching than the generic Google, but that's less of my concern.

Suggeritore

Besides the Masquerade Hotel, another recent leisure reading of mine is Il Suggeritore (惡魔呢喃而來) by Donato Carrisi.

I borrow it from my friend AL, and I must say it is not the usual kind of book that I read. The plot is a variant of, once again, Agatha Christie's Curtain, but the layout is kind of a quasi mosaic of thriller and detective fiction. The golden rules of S.S. van Dine are deliberately neglected. (For example, supra-natural power was called in to help tracing the murderer.) There is also slightly more blood-shedding than what you could call comfortable.

Nonetheless, the story is brilliantly told. The Italian author does get my full attention from cover to cover, and I am repeatedly amazed and excited as the events unfold.

My only suggestion is, the anonymous mastermind should not be called Frankie or Adolf.

It should have been Karl.

Masquerade

Although I spent some time trying my calligraphic skill at the airport, I managed to finished with the novel that I brought along with me.

It was Masquerade Hotel (假面飯店) of Keigo Higashino (東野圭吾).

Is it good?

Em... it is a pleasurable reading. The plot is a variant of Agatha Christie's ABC Murder, and the story is very suitable for a short TV series. Although many of the characters appear unreal and much of the detail artificial, one trick of the murderer is, in my opinion, exemplary and has the potential of wide application.

The idea is simple: The best way to hide a critical flaw is to make another small but obvious mistake. A common psychological trap of human being is one man one disease. We (for example, readers of detection fiction or reviewers of a journal) are often satisfied when we identify one mistake in a piece of work. We say to ourselve, "Good. We have found out what this guy is trying to hide from us." And we will spare any further effort to look for other more important problems.

The face under a masquerade could simply be another mask of human skin.

下泉人

I looked around. There was a young woman in uniform standing next to the counter. But, rather than observing her duty as a storekeeper, she was all practising calligraphy.

I tried and cleared my throat to catch her attention.

In no time, her business soul came back. She put up a polite smile and said, "Oh, pardon me. Yes, you pay here. Give the books to me. By the way, would you fancy writing something here?"

She pointed to the gigantic sheet of papyrus that she was working at.

"Oh, my," I returned an embarrassing smile, "My calligraphic skill is abysmal."

"Come on! No harm trying." Her voice was more inviting than ever while giving me the receipt.

It was 6th June and certainly a bit late. Nonetheless, I could not resist the temptation and took up the writing brush.

Here is what I wrote:
悟彼下泉人，喟然傷心肝。

Bookstore

Shortly after the international conference, I had an one-day trip to another part of the crooked universe to give a talk.

The flight was unexpectedly smooth, and the place was pleasant. I arrived late in the evening, had a good sleep after a quick shower, get up at six next morning and had a short walk (my room was close to a lake), gave a presentation at eight, had a meeting with a biotech company to discuss some collaborative work at ten, and left for the airport by eleven in the morning. And, I could even use the spare time in-between to make the slide for my next medical grand round.

My flight was scheduled at two in the afternoon, and there was one-and-a-half hour of spare time for me. Yes, I brought a novel with me, but I decided to pay a short visit to a small bookstore next to my departing gate.

There were no more than a handful of people inside. After touching here and there for some time, I picked two paperbacks to the cashier.

No one was there.

(To be continued.)

Leader

You may say it is important for a medical school, as well as the society, to identify potential leaders, both in research and health care administration, in their budding phase and provide appropriate nurture.

I must say I am not that confident.

My concern is simple: Do we have reliable means, based on the academic performance in secondary school and the admission interview, to identify the few who would turn into good researchers or great leaders twenty years later? No, there is no such an evidence. And, if you look around, I don't think you could identify 90% of the chair professors and senior administrators when they were applying for their medical study. Many of us need to spend some time in the field in order to know where our interest lies and what we are good at.

A notable example that I love to quote is: One of the past presidents of our College of Physicians actually failed medicine in his final MB examination. He certainly learnt his lesson and put up exceptional effort later after and became an outstanding physician. But, I must take my hat off to the department chairman who had the vision and offered a training post to this detained student.

PS. If you talk about evidence-based practice, the only thing we could be reasonably sure is students who are late in submitting the necessary documents or photos to complete the admission procedure are likely to do badly in their final MB examination.

Global

Although I am surprised to learn that university professors are turning into salesman in the admission interview, it is, to say the least, a pragmatic step to improve the quality of our medical student.

And, our faculty seems determined to do so by whatever means that could be executed. For example, a recent gadget that we put up is the global medical degree.

For obvious reasons, I should not discuss what I think about this innovation. Nonetheless, I could not resist the temptation to imagine what would be the feeling of all other students of the ordinary medical degree. Yes, the halo on the head of those global students may stand for a group of elite, but they may just be, in a sense, a species born with a silver spoon in their mouths. A lion's share of opportunity (doing research, going to famous overseas centers, mentorship, and so forth) goes to them, not for any observable credit, but because they come with a different name.

Alas, I am keen to see what kind of people would be the applicants.

Salesman

Met LS and a few other friends of mine during lunch.

"Szeto, are you going to the salesman's briefing tomorrow?" The professor of rheumatology asked.

"What...?" My response showed clearly that I was not going - actually I had no idea what she was talking about.

"I mean the briefing session for interview board members. You know, we are about to interview the next round of applicants of our faculty."

"I see. After all, I am never involved in selecting new medical students." I smiled, "But I find your description remarkable. Why on earth do you call it a salesman's briefing?"

"Because it is! You know, the real task of the interview board nowadays is not to select creme de la creme from a group of excellent applicants but to show off how good we are, so that good secondary school students would make up their mind and be recruited into our faculty - rather than taking up offers from the business school or other side of the harbour!"

I must say I was not amused.

Allergy

One tradition of hosting an international conference is there is a faculty dinner to thank all speakers and organizers.

This time, we make it on a floating seafood restaurant. The expense is reasonable, and, at least we local organizers believe, there is a good touch of local flavor for all those gweilo.

But we had a hiccup. Shortly before the dinner was served, AF, an American professor of a Chinese descent, came to my table and spoke to my colleague BK, "Em... there's a problem. My friend CL, who is sitting next me, actually has very bad seafood allergy."

We were dumbfounded. The invitation letter we sent out did put up clearly that this event is on a seafood restaurant, and we expect most of the dishes to be coming from the sea.

Thank goodness our trouble did not last long. Our secretary quickly fetched some French fries and Indian naan for our unfortunate guest. Nonetheless, we continued to talk about this event the whole evening and kept watching to make sure he was OK.

*****************
Some time later, the dish of vegetable was served. (Visitors who understand the routine of a Chinese banquet would know what I mean.) One of us smiled and pointed at the lettuce and mushroom, "You know, our allergic friend couldn't even try this. It is cooked with oyster sauce!"

"Maybe not," I chuckled, "As it comes to light recently that our beef meatball does not have any beef, it seems equally possible that our oyster sauce contains no oyster!"

Waiting

In spite of my grumble, many of the talks in the conference were indeed very good.

TM, one of our trainees, was amazed to learn from the plenary lecture of the opening ceremony that the waiting time for heart ultrasound scan in Jamaica is one day. In Hong Kong, the average time that a patient has to wait is one week if the request is urgent - and easily over one year for a routine referral.

"That's easy," I said to myself, "We can always cut down the waiting time of any surgery, or X-ray or whatever, to one day - as long as you turn down or neglect most of the demand. Alternatively, we could easily achieve that short a waiting list by taking you a year or two to be put on that list of waiting."

PS. In real life, the latter strategy is more commonly applied in reverse: Patients are seen and put on list as quickly as possible, but it takes ages to stay on the list before it comes to your turn for whatever procedure you need.

Meeting

It was an exceptionally busy week because we were hosting an international conference.

Many of you would know I am no big fan of conference. Nonetheless I agree a good symposium does have educational value, and I certainly learn a lot in the past few days.

But, the phenomenon that I find impossible to understand is: Why should some 50 supposedly experts and important people sit at a round table, with an aim to come up with a so-called position statement?

Not to say the topic that they discuss is vague and the only conclusions that everyone could agree with are:

1. All mothers are women.
2. The contribution of men to human reproduction is trivial, except in the very early phase.
3. Further studies are needed to determine the value of a male lavatory in an obstetric ward.

Good. Let's call a press conference.

Love

It may be coincidental to talk about extracurricular activity today.

Many of you would know I am rather apathetic to local politics. Nonetheless, it is amazing to learn that a slogan as neutral as Love our country, love our people (愛國愛民) could become a target of debate - and it is really eye-opening to see this simple motto has to be put aside in order not to offend the others.

As the old English proverb says: If you do not stand for something, you will fall for anything.

And my opinion is naive: I love my country.

I believe the people whom we pay tribute to today were holding the same belief during that exceptionally long May.

Value

(The discussion between Vivian and I continued.)

"There are whole lot of things that you could learn," I explained while trying to do away with the consideration of opportunistic cost, "For example, rather than playing piano or violin, I began studying the stock market since Form 4."

"Oh, but I suppose that's certainly not a practical subject for you at that time?"

"Certainly not. I had neither the money nor the means to trade in the stock market. Remind you, that was the time before Internet and electronic banking."

"In that case, what's the use of studying all the financial news and stock prices?"

"The philosophical answer is, although men are political beings, all human activities are economic ones. Financial news tell us what's going on around this planet." I explained, "My personal view is, most of the things that we learn, being it from the school or elsewhere, are not needed for our usage. All we achieve is to have a vague idea on the subject, so that we will not be easily taken in by crooks - or experts!"

Class

You may think I was just nostalgic when I talked about my experience in extracurricular learning during secondary school.

But no. There's a earthly reason for my grumble: Vivian and I were discussing what summer courses should our two princesses take up this year. Since Euterpe is advancing to primary school this September, we are also thinking of taking away some of the private tutorial classes that she is now attending.

"The piano class is essential," Vivian concluded after considering each and every class that our elder daughter is undertaking, "Alas, everything seems important! Mandarin, English, arithmetic, gymnastics... my god."

"Yes and no. It may also mean that nothing is essential," I remarked, "For example, what's the value of learning piano?"

"My dear, it's all about music and the cultivation of a humanistic character."

"I agree that's important, but I'm not sure that's essential. As you know, I play no instrument and know close to nothing about music. Well, I may be deficient in humanistic quality, but I do not feel incomplete. Seriously, I have in mind another subject that one should learn but is not taught in traditional schools -  although Euterpe may be too young for it."

"What's that?"

不學無術

My recent leisure reading is Manabanai Tantei-Tachi No Gakuen (不學無術的偵探學園) by Tokuya Higashigawa (東川篤哉).

I must say I am not impressed by the story. Nonetheless, the underlying plot does bring me back to much sweet memory on my secondary school days. In short, this novel of Higashigawa is about three teenagers who form a crime-fiction club and try to act as detectives as their extra-curricular activity.

And, many of us just do the same! Did I pay any attention in my secondary school study? Yes, some - no more than two hours a day even before my school certificate examination. I spent much of the time playing chess, learning astrology, and reading absolutely irrelevant books.

Of course, none of the things that I learnt from my private study has any pragmatic use - but neither does any subject that I was taught in the school. Well, they may serve the purpose of training up our brain so that it could learn more serious and useful things in our later days.

Or, as a famous professor from the other side of the harbour says: No knowledge is useless.