Resign

Met L on my way home. In addition to many remarkable characters, he is also the lord of the grapevine.

“You know, WT just resigned.”

I know WT; he is a surgeon who was promoted from one hospital to another not too long ago.

“Alas, is he screwed up by his warrant trading, or is it because of a new exquisite apartment that he buys?” I smiled.

“Neither. He has a series of so-called unfortunate incidents in the past few months, and his boss is less than forgiving. In short, he is resigned – in an elegantly executed passive voice.”

“But, how could that happen? I mean, I don’t think I heard of any problem with his surgical technique in the past. Why on earth does he have so much trouble in the new hospital?” I was puzzled.

(To be continued.)

Trotter

A recent obituary that caught my attention is the death of Charlie Trotter.

For those who are not familiar with cookery, Trotter was an American Chef who owned the Michelin two-star restaurant Charlie Trotter’s in Chicago. He also appeared in the TV show The Kitchen Sessions with Charlie Trotter, which I first watched in 2005 and was immediately impressed by his orderly method and meticulous details.

“If there is reincarnation and Hercule Poirot turns into a cook, it must be him.” I said to myself.

Two years ago, I had the opportunity of staying in Chicago for a few days. I was almost courageous enough to book a table and dine alone at Charlie Trotter’s. In retrospect, that’s really a pity – the restaurant closed down last September.

Nonethless, to me, the famous chef survived by two cookbooks of his on my shelf: The Kitchen Sessions with Charlie Trotter and Charlie Trotter Cooks at Home.

RIP.

Balance

In a such question of life or death, why should we be affected by the wordings?

No, we should go back one step and ask: Is it merely the effect of framing?

The problem is, in the “peak-and-end” model, as well as the cold water immersion experiment, the parameter being assessed has only one dimension. A person suffers, and we assess how he values his suffering and makes decision – and same for enjoyment. But, in real life, we have both at the same time, and our decision on accepting a treatment depends on the balance of the two. As Daniel Kahneman points out, the factors are not put on the two sides of a balance and cross out each other.

Unfortunately, in the context of medical decision, Kahneman’s doctrine of loss-aversion does not hold either. (I must admit I am not aware of any experimental proof of my suggestion, but it seems consistent with what we observe everyday.) In general, people do not avoid loss (that is, suffering) even if the gain (pleasure or enjoyment) is minimal. The respiratory drive of many patients is not the degree of joy or excitement some time later, but an imprinted idea that could not be easily appreciated by an outsider (for example, graduation of one’s children, completion of a book, or conclusion of a lawsuit).

In Buddhism, we call that obsession (執念).

Frame

There is a critical flaw in my argument yesterday that may skip your eyes.

As Daniel Kahneman says, the decision really depends on how you phrase the question.

You see? Let’s imagine we ask a cancer patient the following question: Would you accept a treatment that would increase the maximal suffering for a while, have no effect on the terminal symptoms, and could slightly prolong your survival? If we use the “peak-and-end” model described yesterday to assess value, the expected answer would be NO.

But, we certainly agree that’s not the answer in real life.

Why? Because we are trapped in the wrong frame. If we begin by asking this: Would you accept a treatment that neither affects your maximal nor final pleasure, but could slightly prolong your survival? We could reply a logical YES.

Prolong

When I come to think of it, the ideas of Daniel Kahneman are not only applicable to economics and psychology; they challenge many of the common concepts that we hold for clinical medicine.

One notable example is the assessment of suffering. Kahneman's theory is simple: the subjectively experienced degree of suffering has nothing to do with the "area-under-the-curve" amount of pain or other unpleasant feelings, but is determined only by two factors: the maximum degree of suffering during that period, and the degree at the end of the period. In short, by and large, all that ends well feels well.

And, this phenomenon would make a whole lot of difference to the practice of palliative care. For example, the orthodoxical teaching is Do not prolong the suffering. But, if the duration is not a problem, a palliative treatment that prolongs a suffering life is, arguably, not undesirable as long as the finale is not that miserable. On the other hand, if, for example, a treatment of cancer can extend the survival by, say, 6 months, but, at the same time, induces a transient but intense adverse effect, then, assuming there is no change in the suffering before the eventual death, the treatment is valuable according to the traditional view, but it would not be welcome by the patient.

For obvious reasons this theory needs further testing in clinical setting. I must say the cold water immersion experiment presented by Daniel Kahneman is, from a physician's point of view, child's play. Patients may view suffering very differently when we talk about real diseases.

Think

My recent leisure reading is Daniel Kahneman’s Thining, Fast and Slow.

Daniel Kahneman is a winner of Nobel Prize in Economics, and, by and large, this book summarizes decades of his research.

Kahneman's general idea is simple: There are two systems – or, to be exact, two modes – of our thinking. One system is fast, instinctive and emotional, while the other is slow, logical, a laborious. I must say the idea is not new to me – it has been described in quite some detail in Daniel Goleman’s bestseller Emotional Intelligence – and, in fact, has a neuroanatomy basis (the archicortex of the hippocampus and limbic system versus the neocortex of the cerebral hemisphere). The brilliant contribution of Kahneman is, however, his work on how human beings make choices, especially on various aspects of cognitive bias and how we value benefit and risk.

My comment? Very simple. Before I finished with one-third of this book, I decided to read it again some time later - with a writing pad ready for taking notes.

Or, I dare say, it is not an honor of Daniel Kahneman to receive the Nobel Prize - it is the honor of the Prize to have such a recipient.

Everything

The meeting didn’t last forever, but what Mr. Greene said kept echoing in Franz’s mind. Later that evening, when the humble nerd was dragging his exhausted body home, he met Philo – a wise friend of his.

It goes without saying that Franz told his friend what he thought.

To the surprise of Franz, Philo was less than sympathetic, “Although the argument is bitter to the palate, it is, nevertheless, a logical conclusion.”

“How could that be?”

“My friend, it is a romantic idea to run a department store that sells everything. For example, if you think it is not good enough to have dedicated areas for women’s fashion and cosmetics, and a counter for electronic device – say, tablet – is necessary, is it good enough if it sells only iPad and leave out Samsung, Nexus, Kindle Fire, and so forth? You may have a specialty nominally, but you certainly could not cover every subspecialty.”

“That may be true,” Franz scratched his head. He couldn’t really tell whether his friend was speaking the truth or irony.