31 Dec 2009


I can hardly believe that I really wrote on this blog throughout the year. This is something I have never tried before.

It would be a lie to say that my writing is not influenced by Szeto. In fact, one of the major reasons for me to start writing is because Szeto’s Blog is so much fun. On the other hand, although I started my blog shortly after his article 'Anniversary', that particular piece made me hesitate. He explained that after reading hundreds of blogs of all kinds, he thought he could write better things. [http://ccszeto.blogspot.com/2008/12/anniversary.html]

I do not have the privilege to write such a statement. As Brahms said, who would dare write another symphony after Beethoven? The fortunate thing was he did, and it was not bad at all. One cannot do anything if he has to compare with others all the time.

Friends reading this blog would realize that I am not as knowledgeable as others may think. My repertoire is actually very narrow. This creates problems in my social life. In Hong Kong, one cannot join a conversation if you know nothing about stocks and the local media. When you talk, you are out of context.

A couple of months ago, I tried to tell a joke on brown fat when I was having lunch with my colleagues. As you may imagine, the response was a concerted "Huh?". After a while, DS finally asked what brown fat was. I briefly explained its role in newborns, and the conversation went dead. It was not fair. The identification of brown fat in adults was one of the big news in medical science this year!

With this background, I kept writing. Deep down I also agree that it is quite silly to tell jokes about brown fat, but it is comforting to think that there must be somebody out there who shares the interest.

Happy New Year, my friends.

24 Dec 2009


One hot topic in global warming is its effect on the sea level. Skeptics have questioned the validity of the predictions and the underlying mechanisms. For example, my friend refuted the enormous contribution from melting ice using Aristotle’s principle (See http://ccszeto.blogspot.com/2008/05/melt.html).

At present, the prevailing view still supports the notion that temperature change affects the sea level. Firstly, there are large ice sheets in Greenland and Antarctica. Since these ice sheets are on land, Aristotle’s principle does not apply and any melted ice adds water to the sea, a phenomenon known as eustatic change.

Secondly, materials expand in volume when heated up in most situations. The same holds true for water. Although we are just talking about changes in several degrees Celsius at most, the effect can be considerable since the net volume of the sea is so huge. This is known as thermosteric change.

In last week’s issue of Nature, Robert Kopp and colleagues estimated the sea level 125,000 years ago. That was the last interglacial stage when polar temperature was 3-5 degrees Celsius warmer than today.[Kopp RE et al. Nature 2009;462:863-7] Compared to previous reports, this work used integrated analysis of the most comprehensive data sets from different geographical locations and stringent mathematical modeling. Surprisingly, their conclusion was also one of the most alarming. According to their model, there is 95% probability that the global sea level at that time was at least 6.6 m higher than today. There is also 67% chance that the level was at least 8.0 m higher. In addition, the rate of sea level rise was very likely to be greater than 5.6 m per 1000 years.

In layman terms, if global temperature increases at the present rate, it is unlikely that the sea level can have a major impact during our life time but it is very likely that many predictions by scientists can come true in 1000 years. If the suggestions are sensible, we should support the measures to combat global warming. On the other hand, we must never forget that humans have many other silly methods to destroy the world before the passage of 1000 years.

17 Dec 2009


One of the hottest news now is the United Nations Climate Change Conference in Copenhagen. Although the countries still dispute much with each other in terms of financial input and policy enforcement, let’s wish that Hopenhagen does deliver hope. Having lived under the gray sky of Beijing for six months, I support campaigns to reduce pollution.

On the other hand, as I read more about the topic, I must say that we really know little about each environmental factor and its effects. For example, increasing nitrogen deposition and atmospheric carbon dioxide concentration has occurred over the last few decades. Each factor alone is known to reduce biodiversity through promoting the growth of above ground plants. As a result, above ground resources such as light become less available to plants below, resulting in a decrease in species. Biodiversity is important for community stability and resistance to diseases and invasive species.

With this background, the logical prediction is that when both nitrogen and carbon dioxide increase, there should be an additive or synergistic effect, resulting in further reduction in biodiversity. However, in a recent report by Peter Reich, the effect of both factors on biodiversity appears to cancel out each other.[Reich P. Science 2009;326:1399-402] In a 10-year project, 16 plant species were grown under different combinations of carbon dioxide and nitrogen levels. Although elevated carbon dioxide and nitrogen reduced biodiversity by 2% and 16%, respectively, both factors in combination only reduced biodiversity by 8%. Though the cause of the observation is unclear, it is possible that nitrogen and carbon dioxide may affect plant growth and changes in resources in different layers and thus have differential effects.

This is just a simple example to remind me to be humble and not to draw quick conclusions. Readers of this blog, however, may laugh and point out that the article caught my eyes mostly because of the amazing study duration.

10 Dec 2009


My father sent me a story.

During a talk for executives, the speaker performed a simple demonstration. He took out a big glass cylinder and filled it up with big spheres right to the top. “Is it full?” he asked after putting in the last sphere.

The audience was silent at first, and then a man hesitantly said yes.

The speaker smiled. He took out a bag of marbles. Sure enough, the marbles filled the gaps between the big spheres easily. “Is it full?” he asked again.

This time, the audience gave a concerted “no”. The speaker took out a bag of sand and filled the remaining space.

“What do you learn?” he asked after the demonstration.

“No matter how busy we may seem,” one manager replied, “we can still fit things in our schedule if we try hard enough.”

“No,” the speaker shook his head, “if you fill your time with marbles and sand first, there is no way you can get the big spheres in.”

What are the big spheres in your life?

Luckily, I am surrounded by people with great success. I have no problem searching for answers.

Three years ago, Boss and I were attending a conference. On the plane, he was reading Halftime by Bob Buford. When I looked interested, he explained that this was a book about mid-life. At that point, a man’s career was usually quite established. It should be time to reflect. Instead of striking for further success, one should start doing things with lasting significance.

Naturally, I asked what was significant to him. You can probably imagine he would not want another New England paper or NIH grant.

“I want my daughters to see me as a good father,” he answered, “and I want to be remembered for building a great team.”

Would I be too greedy to pick these big spheres first?

3 Dec 2009

Sleeping Beauty

Although I could not remember the source, someone wrote that daughters believed in every word from their fathers before they reached ten years old. It does not seem to apply to my girl. One of her favorite questions is “Daddy, are you lying?”

I regard myself an honest person. It must be because I made up too many bedtime stories.

Angelina is lately thrilled with ballet. Apart from practicing, she also watches DVDs about ballet.

Last week, we watched Sleeping Beauty together. This is the longest ballet by Pyotr Tchaikovsky. It contains a prologue and three acts. My wife left before the fairies came to the party. In contrast, knowing the story very well from books and the Disney movie, Angelina and I continued to watch happily.

Later, it came to the scene where the Lilac Fairy persuaded the Prince to save Princess Aurora, who was put to sleep by a magical curse one hundred years ago. Only the true love’s kiss could wake her.

After around twenty minutes, the Lilac Fairy was still dancing around the Prince. “Why doesn’t he go inside the castle?” Angelina finally asked.

Like most fathers, I provide an answer for her every question.

“He is worried. Aurora fell into sleep on her sixteenth birthday. Now one hundred years have passed. The Prince does not want to marry a woman one hundred and sixteen years old.”

“Daddy, are you lying?”

26 Nov 2009


Don’t mistake me. When I said I changed my view last week, I meant whether Boss would be a merry VC, not my view on administrators. For the latter point, I still fully support Fuller Albright, who provided practical tips for clinical investigators:

"The first time you are asked to serve on a committee, be anything but efficient."
"Never make the mistake of proposing some new reform."
"The desk of the good executive should be clear; that of an investigator should be littered."

Following this line, I am glad that my academic career had a wonderful start.

After joining the Department, my first task was to pick up external examiners with VM. While we were waiting at the parking area, the neurologist mentioned that he never succeeded in receiving the examiners. Somehow they always arrived at a different spot.

Luck seemed to be on our side. When I was about to suggest splitting up to wait at another spot, a mini-bus arrived. Five smart and powerful figures came out. We greeted them, said it must be tough serving at the College examination, and brought them to our conference room. I smiled at VM. It was a piece of cake, wasn’t it?

After we had gone up to the ninth floor, one examiner spoke up, "The examination took place at the out-patient clinic yesterday." I was puzzled. "But this is the first day of the examination here. Do you mean the clinic of the other hospital?" "No, the surgical clinic was on the second floor, right?" he said. At this point, we finally realized that we picked up the surgical examiners.

I can still remember the loud squeak that VM made.

19 Nov 2009


I learned about the nomination of our Boss several weeks ago. My first reaction was “Would he be happy?”

I have no doubt that Boss will be a good VC. But whether he can be a happy VC is another question. Under Szeto’s influence, I could not see any fun administrating others. Moreover, the academic world will soon face the loss of a brilliant researcher. At the Annual Meeting of the American Society for Clinical Investigation in 1944, Fuller Albright, President of the Society, laid the rules for clinical investigators. One important rule was “Do not show too much administrative ability”. [J Clin Invest 1944;23:921-52]

A recent incident changed my view.

As a VC candidate, Boss attended meetings to answer questions from different parties. At one session, a group of undergraduate students gave him a present to ridicule the current VC and asked him to open it. Fearless, he declared, “Even if you disagree with the VC’s policies and opinions, as educated persons, we should respect others. I will not open this present.” The audience applauded.

Important values are never taught in classrooms. Boss has demonstrated how a teacher may make bigger impacts by setting up role models. We wish you happiness at the job.

12 Nov 2009


I have a dream. I always have a mental picture of me performing with Angelina. Franck’s Violin Sonata or the Spring Sonata by Beethoven would be my cup of tea. I did not expect the day came so soon.

Last Saturday, my girl sang in a kindergarten competition. We thought that was a good thing. She had to learn the importance of practice and the experience of facing an audience. To support her, I volunteered to play electric piano.

Of course, it could not be Schubert’s Lieder. We chose “The Wheels on the Bus Go Round and Round” instead.

At the competition, Angelina started twice but was interrupted by the adjudicators because they had not finished writing comments on the last contestant. She complained that the audience laughed at her, but I reassured her that we would just wait. Luckily, her performance was little affected. She sang beautifully.

P.S. As we were looking for the competition venue, my girl asked, “Have we got lost?” This is a trivial thing, but pretty much reflects what kind of impression I have made in her early years.

5 Nov 2009


After I stepped down from stage, the audience congratulated me on my Putonghua.

That was funny. I was almost the only speaker not using Putonghua as the mother tongue. You know what it means. No one has ever praised my Cantonese before. It is like watching a toddler throw a basketball. You say “good boy”, but actually mean it is kind of cute.

Putonghua is getting more and more important. I would keep practicing. Indeed, a taxi driver in Beijing asked if I came from Guangzhou. My Putonghua improved by 174 km to the north!

At least I did not suffer from serious misunderstanding.

A decade ago, YT participated in a project in northern China. This is his conversation in a restaurant:

Waiter: Do you want something to drink?

YT: White wine, please (喝白酒). (He meant beer - 喝啤酒.)

Soon the waiter returned with a big bottle of colorless liquid that could support combustion.

Waiter: How much do you want?

YT (waving his hand ferociously): Eight taels (喝八兩). (Though he meant he could not drink that - 喝不了.)

The rest is history.

29 Oct 2009


I gave a talk at a Chinese national meeting in October. The meeting was very well organized, and we are indeed experiencing tremendous progress in the quality of research in China. On the spot, I was also invited to chair a free paper session.

In a free paper session of scientific meetings, investigators present their work concisely followed by some discussion. In most meetings, the job of a chairman is very light. One only needs to read the title of the talk, and ask whether the audience has any questions or comments after the presentation. If no one speaks up, you just call for the next presenter (though most responsible chairmen would make up some questions themselves, i.e. pretend to be interested).

In China, the situation is different. I learned that a chairman had to summarize the presentation and comment on the quality of the work. This created some difficulties for me. Since I learned most of my medicine and basic science in English and the presentations were in Chinese, I had to guess if they were talking about stuffs like 'endoplasmic reticulum stress' and 'tumor necrosis factor'.

I was initially quite puzzled by this practice. What is the point of summarizing the presentation when the presenter has just done so? On second thoughts, this may not be a bad idea.

First, if a talk is lousy, at least one person has to remain awake and listen intently. Otherwise, how can he summarize the work?

Second, the summary by a chairman represents things that even an outsider can understand. These should be more important and noteworthy. In fact, I often discourage students from copying notes during my tutorials so that they may retain what is really important.

Finally, it is reassuring to see that the chairman does know something about a topic. This reflects the quality of the whole meeting.

As for the comments, I conveniently used terms like 'impressive', 'important', 'innovative' and 'intriguing'. Sometimes I mean it, but sometimes I was playing Sir Humphrey Appleby.

22 Oct 2009


Last month, we attended a scientific meeting in Taipei. My mentor was delighted when the work of our research assistant was chosen for oral presentation.

Since she was not a doctor by training and had never presented in such kind of meetings, the little girl was understandably terrified. We had to persuade and reassure her again and again before she agreed to present – at a price. As promised, we gave her training and rehearsals, and ran through her presentation slides repeatedly. At one session, she made me do the presentation and videotaped my performance.

This reminded me of my first presentation in Madrid. It is indeed scary when you think most of the audience are more knowledgeable than you and may make unexpected criticisms. However, my mentor taught me much about presenting a scientific work which I still find useful now. Most of the essentials are covered by books on speeches. Let me just highlight the more practical ones.

1. Do not read the title of your talk. The chairman would have done this during the introduction.
2. Put fewer words in the slides. Do not put things that you are not going to say. Otherwise, the audience would be busy reading the slides and ignore what you say.
3. The title of a slide reminds you what to say. Choose the words carefully.
4. Present the aims of the study clearly and deliver the answer point-by-point in the last conclusion slide. This indicates a clear mind.
5. The ‘thank you’ slide is useless. Say 'thank you' instead and stop at the last conclusion slide. Then the audience can digest the message and ask relevant questions.

So what happened in the end? Before the chairman could introduce her, the little girl ran up the stage, said 'thank you, chairman' (for what?), and began the well prepared presentation. Afterwards, the chairman asked two questions we had already prepared. We saw a confident smile and knew she was safe.

15 Oct 2009


I spent the better half of last week updating my CV. The impressiveness and innovativeness of the computer input system have been elaborated extensively elsewhere (see http://ccszeto.blogspot.com/2009/10/obotchaman.html) and will not be the focus of this article. Instead, I want to talk about my CV.

I prepared my first CV when I applied for a resident post in my current department. KL was responsible for screening the applications then. Soon after I sent out my CV, I was summoned to his office.

“How can I recommend you for an interview if your CV only contains your name?” he asked.

“No, I thought I wrote many things. See, my employment record is here.”

“Where are your scholarships and subject prizes?”

“Oh, I did not keep any record and do not like to boast about those things.”

At this point, KL was completely fed up. He threw a document at me and said, “Copy it. Find whatever applies to you.” I turned the cover. My goodness! That was the CV of the Walking Harrison when he was an intern. Till now, my record of scholarships remains inaccurate. Luckily, this section is no longer important as I grow older, and I finally swiped it off from my CV.

Did I learn anything?

Last week, I was appalled when I found out that the University wanted the record of my conference abstracts, outside talks and services. Even if I remembered everything I did, how could I recall when I did it? I searched my pocket PC, only to find that old records in the calendar were automatically erased.

As usual, I mentioned my difficulty to my mentor. History repeats itself. That afternoon, I received his own CV.

8 Oct 2009


You may not be sympathetic for what I described last week. Can I not predict the severity of gastrointestinal bleeding based on the clinical data provided, and thus reject some cases of urgent endoscopy?

Yes and no. There is indeed no shortage of prediction scores (of anything) in the literature. How they may help depends on the setting and application.

In a study published earlier this year, the Glasgow-Blatchford bleeding score (GBS) was validated in 4 UK hospitals.[Stanley AJ et al. Lancet 2009;373:42-7] The overall accuracy of GBS to predict the need for endoscopic intervention and death among patients with symptoms of gastrointestinal bleeding was good, with an area under ROC curve of 0.90. The investigators also prospectively implemented the score in real clinical practice and demonstrated that the need for hospitalization decreased.

Can I apply it? When one looks at GBS carefully, the low risk criteria include normal serum urea, normal hemoglobin level, normal blood pressure and heart rate, and absence of melena, syncope, cardiac failure, or liver disease. If a patient has none of these, you really would wonder if he/she suffers from anything at all. In fact, in the validation study, 56% of the patients fulfilling the low risk criteria (GBS=0) had no lesion or just hiatus hernia on endoscopy. It looks as if the score is most useful in helping those who cannot clerk a proper history and make the diagnosis of upper gastrointestinal bleeding. Sadly, whenever I am consulted, the patients would have at least several of the risk factors. According to evidence-based medicine, I should have no choice but come back to the hospital every time.

Another factor we cannot ignore is that the negative predictive value of any test depends on the prevalence of disease. At the primary care clinic or emergency department where most patients with symptoms of gastrointestinal bleeding actually would not die or require endoscopic therapy, using GBS to rule out significant bleeding is safe and accurate. Managing old and frail in-patients is obviously another ball game.

1 Oct 2009


My colleagues often consider me unlucky on call days. As an on-call gastroenterologist, I have to get back to the hospital in the middle of the night if a patient requires urgent endoscopy. Suffice to say, my hit rate is consistently above 50%, while many colleagues hardly ever come back. The difference cannot be explained by chance alone.

On the last on-call day before my overseas training, I had so many cases at night that the patients and their accompanying nurses had to line up in the waiting area, much like what it would be in a busy morning session. I also used up all the endoscopes in the cupboard and had to cleanse (I confess – I did not know the proper disinfection procedures) and reuse them myself. Last week, I also entered the endoscopy unit after office hours for three consecutive days.

I do not strongly believe in the play of luck. There must be a reason.

First, I thought there was recall bias. My colleagues were underreporting and I was just whining. However, after over 50 person-years of prospective follow-up, there was indeed a pattern.

Second, I hypothesized that my colleagues actually received as many calls as I did, just that they would turn down the requests. In other words, the difference should be apparent by composite end point analysis. LL and DS disagreed and said they really slept through the night. Of course, I can never confirm this.

My latest view is the presence of confounding. For borderline cases, people are ready to call me because they know I would say yes. When I was young, I was too shy to refuse. Now that I am older, I have become so used to coming back that I no longer bother to refuse. To test this possibility, we can blind the hospital staff to the call list.

Last Sunday, my Boss gave an excellent lecture in Taiwan entitled “Is emergency endoscopy necessary?” To this, KL had a wonderful idea. We can conduct a prospective study. When physicians are on-call, the best supportive care will be provided. When surgeons are on-call, emergency endoscopy will be performed at every request. Yes, this would be ground breaking.

24 Sep 2009


To many endoscopists, the colon is like a racecourse.

Some years ago, YT conducted a clinical trial testing the performance of a new colonoscopic technique. As part of the study, the intubation time (from anus to cecum) and extubation time (the way out) were recorded. Soon, endoscopists kept breaking and boasting about their new records. “I reached cecum in less than three minutes!” Of course, people only remembered their triumph and would never mention how long it took to struggle through a difficult case.

At the end of the study, we got a report card. As a whole, all of us did well. If you compare various endoscopists, I was on the slow side. It is hard to uphold self esteem in a place full of virtuosos.

Finally, some sensible people came to my consolation. In an elegant study, Barclay and colleagues demonstrated that the extubation time was proportional to polyp detection rate (NEJM 2006;355:2533-41). In other words, endoscopists who pull out the endoscope quickly are likely to miss important findings. After all, no patient would really mind if the procedure takes five more minutes. Quality is more important than speed.

Just for fun, LL looked at our data again and showed us the extubation time and polyp detection rate of each teammate. This time, I could say that my polyp detection rate was not bad. YT was even slower than me but found more polyps. WK was an outlier. He was fast but also found many polyps. The One whom I dare not name was the fastest. I also dare not report his polyp detection rate.

My memories were brought up by funny stories I heard from endoscopy nurses recently. In a community screening project, we need to record intubation and extubation time again. You Know Who just broke the new record of withdrawing the endoscope in ninety seconds. On another occasion, JL did a rather difficult procedure. After reaching the cecum finally, a nurse said “11 minutes 40 seconds” loudly for recording purpose. The Professor of Surgery did not realize that was a study case and thought the nurse was teasing him. According to the nurse, “he stared at me angrily”.

17 Sep 2009


On more than one occasion, my patients were impressed by my typing speed.

I have never had any formal typing lesson. My training was from my first computer. I could not recall the model, which was earlier than 80286. Anyway, these early models did not support complicated games. One of my favorite was a typing game. Words fell from the top. If you typed the words correctly, they disappeared. If you were slow and the words touched the bottom of the screen, you lost. With time, I became really good. My mother had to force me to turn off the computer because the game could not kill me even when the words were dropping like thunderstorm.

Recently, my Boss was surprised when I mentioned that my daughter attended piano group lessons. Why did I not teach her myself? Of course I tried. None of the songs I knew attracted her. So we see if others can do a better job.

While Angelina behaved at the lessons, asking her to practise at home remained difficult. One day, I played the DVD provided by the music school. It featured cartoon characters playing music. In one episode, a man hit the low and high keys and showed what they sounded like. Angelina immediately got interested and asked to try on our piano. That marked the beginning of her “do-re-mi” journey.

10 Sep 2009


My substitution during my domestic helper’s holidays inevitably invited the following comments from my wife. “You did nothing other than playing with Angelina.” I shamelessly referred her to Luke 10:38.

One day, Jesus visited the home of Martha and Mary. Mary listened intently to Jesus, while Martha was busy preparing dinner for the distinguished guest. At last, Martha was fed up. “Bad girl,” she said, “aren’t you going to help me?”

“You are worried about earthly things,” the Lord answered. “Mary just chose what is important, and it will not be taken from her.”

3 Sep 2009


My domestic helper had holidays in the Philippines last month. My wife and I took turn to look after our daughter at home.

Not satisfied with watching Mickey Mouse Clubhouse for the whole day, I took Angelina to the country park, had a boat ride, and visited the Museum of History. She was thrilled.

After listening to our report, my wife commented, “You basically did everything I refused to do with you in the past.” Quite true.

One night, Angelina watched the music fountain at the CityOne Plaza with me. “It is like fireworks made of water,” she whispered.

27 Aug 2009


My choice last week was evidently biased, but my taste for simplicity stems from my childhood.

Once, a professor from a conservatory of music in China visited us. He mentioned that they had a whole batch of tests to assess the techniques of their students. One of the parameters was the number of notes they could play in one minute, i.e. the ability to play Presto phrases. In fact, many students who strived to become professionals tried to play faster, louder and more difficult works to impress others. To this, my teacher gave a dignified answer. “We do not know music can be assessed this way. To us, technique is the ability to express music.”

When I became an accompanist for the school choir and an organist for the church, I had the privilege to apply the teaching. Most of the songs were not technically demanding. For the benefit of the singers, I also need to play the same songs over and over. Partly because of the spiritual environment in the church, I could find beauty in simple tunes. No song was too simple to practise.

Years later, I followed a surgeon renowned for his superb skills when I was a final year student. Most people said he was a very fast surgeon. In the operating theater, however, I could not feel any haste. The operation was just mysteriously finished in a short time. When I asked for the secret, he simply answered, “There is no point to rush. If you do not make mistakes, you are already very fast.” I believe this statement is true both for a junior worker like me and for a huge organization like the government.

In my biased view, youngsters who become great clinicians invariably derive much pleasure from the management of simple cases. They find joy and responsibility in learning how to treat diseases they see everyday better. On the other hand, I often cannot cover my disappointment when young doctors report their ‘set menu’ management of COAD and heart failure.

20 Aug 2009

Case Reports

A few colleagues asked me about case reports recently. The most common question is “Is this case worth reporting?”

Case report is the oldest form of medical literature. Clinicians described in details the patients they had saw, the treatment and subsequent outcome. When enough cases have been reported, generalizations can be made about the disease.

Fast forward to 21st century. With the explosion of information, it is rare to encounter diseases that few people have seen before (except new infectious diseases). Young colleagues often choose rare diseases with typical presentation. Though uncommon, these are usually diseases we meet once every few years. With a click on the keyboard, it is easy to find dozens of similar case reports already published. Saying “I have seen this too” is not very interesting.

Apart from describing new and rare diseases, case reports used to be platforms to discuss new medical treatments. However, without enough cases and controls, the outcome of a patient can hardly be attributed to the reported treatment. You can never prove or disprove if the patient would have the same or even better outcome if that treatment was not given. In the era of evidence-based medicine, the evidence on treatment efficacy provided by case reports is no better than expert opinion.

Does this mean that we should abandon case reports? No, writing case reports is excellent training. You learn not only writing skills, but also the ability to communicate medical information effectively with others.

Instead of describing rare conditions or novel treatments, I often encourage young people to watch out for uncommon presentations of common diseases. It can be as trivial as herpes zoster, or as dangerous as aortic dissection. Each encounter is an important lesson that everybody can learn.

P.S. Of course, whether a disease is rare depends on where you live. At one meeting, one colleague presented a case of intestinal tuberculosis. JL, a visitor from the Philippines, found that hilarious. She had a dozen of such cases in her ward at any time. To her, that presentation was no different from describing a typical case of COPD exacerbation.

13 Aug 2009


My mentor gave a nice discussion on cost-effectiveness at the medical grand round last week.

I was first introduced to this topic by Professor JW at the same meeting a decade ago, when I was a first-year resident. She presented three possible strategies to prevent osteoporotic fractures – starting bisphosphonates in all patients reaching a certain age, starting the drug in patients with confirmed osteoporosis but no fracture, and starting the drug after the first fracture. She illustrated clearly why the second strategy was the most cost-effective.

While we were all impressed by the presentation, the walking Harrison next to me whispered, “It is cheapest to withhold the drug in all patients even after fractures.”

I have no doubt that Harrison knows much more about health economics than me, but his remark demonstrates why it is so difficult to find common grounds with administrators when you discuss health expenditure. For frontline doctors, our priority regarding treatment is safety, effectiveness and cost-effectiveness. For administrators, the issue is reduced to costs.

Let’s take a hypothetical example. Suppose Drug X can reduce the risk of osteoporotic fractures and the overall cost of Drug X in a defined population is lower than that required for the management of fractures (e.g. surgery and rehabilitation). In that case, providing Drug X to all patients with the defined characteristics would be cost-effective and can save money for the whole healthcare system. However, if you are only concerned about the drug expenditure of a department, withholding the drug would be a quick way to reduce the budget. To complicate matters further, when surgery is required, the expenditure will go to another department and the relationship between the drug and surgery is difficult to measure. Therefore, administrators at the department or hospital level would be inclined to consider only costs but not cost-effectiveness. Theoretically, the government should be most interested in cost-effectiveness because of the effect on overall expenditure. In reality, insurance companies pay more attention to these aspects.

Life is not simple. More often than not, a new treatment is more effective but also more costly. Unlike the first example, the overall healthcare expenditure would increase, though you also get better outcomes. How should we choose then?

Let’s have another hypothetical example. Suppose there is a deadly condition in which all patients would die. At present, there is an old drug (Drug A) that can save 20 lives out of 100 treated patients at a cost of $100 in total (cost per patient is $1). If a new drug (Drug B) is used in the same 100 patients, 40 lives can be saved but the total cost is $10000 (cost per patient is $100). While the effect of Drug B is impressive, one may argue that you only spend $5 to save one life with Drug A ($100/20 lives) but $250 to save one life with Drug B ($10000/40 lives). Does this mean we should only use Drug A?

The trouble with this interpretation is that if there is a very cheap drug with some efficacy in the market, the medical field can never make any progress because any new treatment can never be cheaper. Instead of calculating the cost per life saved, health economists usually calculate the incremental cost-effectiveness ratio (ICER). It is the ratio of the change in the costs of an intervention to the change in the effectiveness. In other words, we are more interested in the cost required to save one extra life using the new treatment. In the above example, the ICER would be ($10000-$100)/(40-20), or $495 per extra life saved.

Another practical question, of course, is what level of ICER is acceptable. In Western literature, people are happy to spend US$50000 for one quality-adjusted life year (QALY). In countries where dissidents are readily imprisoned and executed, I am afraid only government officials and millionaires are worth that much.

P.S. You think the second example is too extreme? Think about aspirin!

6 Aug 2009


We attended a hepatitis workshop in June. In one interesting session, speakers from Taiwan and Hong Kong presented the local guidelines, actual clinical practice and reimbursement system. After the presentation, it was clear that the prescription practice in Taiwan largely followed the guidelines of the expert committee. On the other hand, the management guidelines issued by hepatologists in Hong Kong and the actual criteria for initiating treatment issued by the Hospital Authority showed little concordance. As a result, many patients in need were either untreated or had to buy the drugs themselves.

“You have to talk to the government and fight for your patients,” our friends from Taiwan remarked.

My mentor was frustrated. “I attended a few of those meetings. My conclusion is that those administrators measure productivity by the number of meetings they hold but not by the things achieved.”

The Taiwanese disagreed. “Our professor always mentions that he spent twenty years talking to the government before we have this reimbursement scheme.”

Our friends might be right. However, their officials were not British trained. I could immediately recall the standard procedure by Sir Humphrey Appleby to denounce the significance of any expert report:

Step One: Public interest. Point out the report could be used to put unwelcome pressure on government because it might be misinterpreted. We need to wait for the results of a wider and more detailed survey over a longer time-scale. If such a survey is not being conducted, it is even better.

Step Two: Challenge the evidence. The report leaves important questions unanswered. Much of the evidence is inconclusive. The figures are open to other interpretations. Some findings are contradictory. (These criticisms can be made on any report even without reading it.)

Step Three: Undermine the recommendations. The report cannot be used for long-term decisions. There is insufficient information to support the conclusions. Broadly speaking, the report supports the current practice. (Mind you, most people do not really read full reports and are easily swayed.)

Step Four: Discredit the expert. He is harboring a grudge against the government. He is just attracting publicity. He used to be a consultant of a commercial company. If not, he wants to be a consultant of a commercial company!

30 Jul 2009


As usual, LS complained bitterly about the difficulty in getting her son in a decent primary school. Since both of our children were born at the end of the calendar year, our discussion shifted to Malcolm Gladwell’s new ideas in Outliers. JN, an expectant mother, said she had not heard about this and asked us to elaborate.

Gladwell’s book started with the observation that most top hockey players in Canada are born in January, February and March. The difference is too great to be explained by chance alone. He pointed out that the official cutoff line of admitting children players is January. In other words, among junior players in the same class, those born in January are the oldest while those born in December would be the youngest. In young children, a one-year difference in age means a significant difference in physique and skills. Even though they might not really be cleverer or more talented, this difference is enough to convince the coaches. These older children would be selected for more intensive training and given more encouragement. Because of this, the original spurious difference becomes a real and tremendous difference – that is, a self-fulfilling prophesy comes true.

Reflecting upon my childhood, I cannot help thinking how true the theory is and how lucky I am. I entered primary school at the age of five as the youngest student. In fact, my mother wrote a fake birthday in the application form to get me in school. I could hardly follow my classmates to do any arts and crafts, and I always finished last in races. I still vividly remembered how my arts teacher tore and threw away my drawing. This killed my remaining interest in arts.

Fortunately, I was granted other chances. When I entered secondary school, there was an entrance exam. The test selected the best and worst students and put them into different classes. I did fairly and was assigned to a so-so class. In most other schools, this would be the end of the story. Amazingly, in my school the whole purpose of the selection system was to provide more resources to students in need. The top students did not get more teaching. If anything, they had more free time to read books, play bridge, or do anything they liked. Looking back, I am always grateful that our school allowed us to develop our talents to the fullest.

P.S. My mother always supports the response of my arts teacher because I basically painted the whole picture in black (sometimes dark blue). Years later, I learned about Adolph Reinhardt's black paintings. This is unfair! I was just doing abstract expressionism precociously.

23 Jul 2009


While waiting to go out, my daughter and I played the piano. I chose a waltz by Chopin. To me, this was a lively and lovely piece which children might like.

“Daddy,” Angelina commented after I finished, “you are very noisy.”

My immediate association was the legendary piano accompanist Gerald Moore. The title of his autobiography was exactly Am I too loud?

Many friends know that I can play a few musical instruments, but my classmates in secondary school would know that I spent most of my lunch and after hours working as an accompanist. I played for the choirs, violinists, cellists, rehearsed for musical play singers, you name it. Sometimes, I accompanied others at Royal College exams, which to a young boy really earned me a fortune.

At one memorable occasion, our school organized a variety show and invited students from other schools (mostly girls, of course!) to perform. While I was hanging around at the backstage, a young lady who was going to sing was upset because our system could not play her sound track. After asking about the song, I said I could do it. The performance went well. Years later, I found out that she was IK the psychiatrist. It is a small world after all.

Interestingly, despite of the title of Moore’s book, he is well known to raise the status of an accompanist to an equal partner of the soloist. This certainly has never been my ambition. As an accompanist, I learned to listen to and assist others. The skills very much shaped my future behavior.

16 Jul 2009


During a meeting, our Boss asked us to evaluate the refresher course.

“Despite numerous limitations, I do not think the course can be improved further,” said the student representative.

A lot of limitations but no room for improvement? What kind of youngster are you? I hope this does not reflect your view on clinical skills.

Seeing that no teacher was going to speak, our Boss pointed at my friend. “Szeto, you seem to be not very happy about the course.”

“If the students like it, what else can I say?” the walking Harrison replied dryly.

Just when we all thought that the case was closed, KC spoke up and complained that many students were late for his lecture. After he scolded them, only one third of the class attended his lesson on the next day.

Our Boss gave him a gentle answer. “Do not take this personal. Young people are like this nowadays. KC, you are lucky for not being a parent. The rest of us get this kind of insults everyday when we go home.”

This is truly inspirational. If we hold this view, who can possibly insult us again? In no time, my emotional intelligence soared by another five points.

9 Jul 2009


Last month, our Departments of Surgery and Medicine provided the final year medical students with the “refresher course”. The original intention was wonderful. The students may have forgotten some clinical skills learned two years ago and would have difficulties catching up with the teaching in the final year. We should help.

When the final program was announced, however, the frontline teachers were amazed. The students were asked to attend six to seven one-hour lectures per day for four weeks. Instead of refreshing the clinical skills as originally stated, each lecture was didactic and covered broad topics like “common diseases in hepatology”. (Yes, I dare not comment on other topics.) In effect, we were asking the students to download the whole year’s curriculum within four weeks. How effective could it be?

When it came to my turn, I could not help but start my lecture with a short story.

“In Heaven Sword and Dragon Sabre (倚天屠龍記), Xie Xun (謝遜) wanted to teach his godson Zhang Wuji (張無忌) his superb martial arts. Instead of showing him how to fight, Xie Xun forced Wuji to recite all the martial arts scrolls. As expected, Wuji had a hard time memorizing the words because he did not have the slightest idea what they meant. Wuji’s parents also thought it was a silly way to teach martial arts.

As the story unfolded, Xie Xun did not actually plan to stay with the Zhang’s family for a long time. He just hoped that Wuji could learn martial arts by himself when he grew up. Some of the teachings were indeed useful during Wuji’s future adventures.”

Dear students, unless I die after the refresher course, I would not want to be Xie Xun. I am more than happy to show you martial arts in the coming year and long after your graduation.

P.S. I learned Eighteen Dragon Subduing Palms from my Boss, Heaven and Earth Great Shift from my mentor, and Nine Swords of Dugu from Szeto. In the end, all I could master was the three simple moves that Sha Gu (傻姑) learned from Huang Yaoshi (黃藥師).

2 Jul 2009


From the incident I described last week, the message from our administrators is loud and clear.

1. If the frontline staff does not follow our policy and things go wrong, he is responsible.
2. If the frontline staff follows our policy and things go wrong, he is inflexible and is still responsible.
3. We only take the responsibility (or credit) when things go smoothly.

It appears that “with greater powers comes great responsibility” only holds true in the Spiderman movie.

25 Jun 2009


AJ and I attended an investigator meeting last Saturday. During coffee break, he mentioned how the recent NovoSeven incident might affect their department policy in the future.

The story goes like this. Two weeks ago, there was a road traffic accident. A young lady suffered from pelvic trauma and was sent to a major hospital in town. Because of severe internal bleeding, the attending doctor suggested to use a drug called NovoSeven. However, this drug was not provided by public hospitals for this indication, and the family members had to pay for it. The family members paid but were unhappy with the arrangement. On second thought, they filed a complaint to the Hospital Authority.

At this time, the news has already been spread by the media. The Hospital Authority did not support the doctor either. The administrators quickly refunded the family members. According to the news, his behavior was commented as inflexible and inappropriate.

In the following days, politicians and columnists were quick to demonize the attending doctor. He was portrayed as apathetic and unkind. In addition, he was compared to physicians in Mainland China who refused to save patients if they had no money.

I can understand the reaction of the public. After all, it is scary if healthcare providers may not do their best during life-saving situations because of monetary reasons. However, fundamental questions were largely ignored. Did the emergency doctors withhold life-saving procedures at the time of discussion? Does NovoSeven work?

To my horror, whether the drug works was never the focus of discussion. Even politicians with medical background thought drugs with potential benefit (but not supported by evidence) should be given liberally during emergencies. In the era of evidence-based medicine, all medical treatment should be based on the best available evidence. The medical literature is full of examples of therapies with theoretical benefits that turn out to do more harm than good.

So, does NovoSeven work?

NovoSeven is recombinant factor VIIa. It serves the function of coagulation factor and makes the blood clot. It has been registered at the US Food and Drug Administration for the treatment and prevention of bleeding in patients with hemophilia (I left out the technical descriptions for simplicity). Apart from hemophilia, studies have shown improved functional outcomes among patients with intracranial hemorrhage treated with NovoSeven. In a randomized controlled trial of 301 patients with trauma and severe bleeding, the administration of NovoSeven, as compared to placebo, reduced the need for blood transfusion, but the difference in deaths and critical complications was not statistically significant.[J Trauma 2005;59:8-18] The absence of survival benefit was confirmed by a few other retrospective series. In other words, you probably can spare trauma patients from the drug by providing adequate blood transfusion and yet still achieve the same outcome.

At the end of the discussion, AJ was still worried that his patients with gastrointestinal bleeding would force him to provide the drug.

“Don’t worry,” I answered. “Level one evidence failed to show that the drug improves outcomes in patients with variceal bleeding.”[Gastroenterology 2004;127:1123-1130]

18 Jun 2009


I revisited 資治通鑑 during my holidays in early June. This time, I started from the preface. To be exact, this was the letter to the emperor explaining the background of the work (進書表).

As expected, a significant proportion of the preface was devoted to thanking the previous and present emperors for ordering him to accomplish the work and all the support. Interestingly, Sima Guang (司馬光) also thanked the emperor for not asking for staff development reports and research assessment exercises. (前後六任,仍聽以書局自隨,給之祿秩,不責職業。)

As a young academic in the 21th century, I was utterly amazed.

11 Jun 2009


Last Saturday, my wife and I watched Angels and Demons. Overall, the movie was entertaining. The scenery in Rome brought us happy memories of our previous trip.

Compared to The Da Vinci Code, the clues and mysteries in this work were a bit thin. Robert Langdon must be very lucky to get the secret path right.

In this story, terrorists disguised as members of the secret organization of Illuminati stole a canister containing some antimatter, which was supposed to be a dangerous substance that could produce huge explosion. To create fear, the terrorists hid the canister somewhere in Vatican City and transmitted its image to the police. The job of Robert Langdon and the police was to find the canister as well as the people behind the plot.

They soon thought of a good idea. By turning off lights at different parts of Vatican City one at a time, they could roughly locate the canister when the TV image became dark. The trouble was there were too many areas in the City and they only had four hours. The canister would probably explode before they could locate it. Nevertheless, the police decided to proceed, slowly but surely.

At this point, I could not help thinking, “Hey, this is a simple IQ test. Four hours is more than enough.”

Do you know how?

The correct approach is to turn off half of the lights in the whole City. If the canister is in the dark side, you have already excluded half of the City. Then you turn off half of the lights in the remaining part, so on and so forth. Repeating the exercise ten times is equivalent to testing 2 to the power 10, or 1024 spots. Repeating the exercise twenty times is equivalent to testing 1,048,576 spots. They should even have time to send the canister back to the physics lab.

This is the power of amplification. Solving a simple problem in a movie is of course nothing. Honor should go to Kary Mullis, who invented the polymerase chain reaction just by thinking about these numbers.

4 Jun 2009


This week is our fifth anniversary. It seems appropriate to write love stories.

One day, Plato asked Socrates what love was.

Socrates said, “Go across this field, and pick the biggest and best ear of wheat. Remember one thing. You cannot go back and have only one chance.”

After a long time, Plato came back with nothing. Socrates asked what happened.

“I once saw some big and nice wheat, but wondered if better ones were yet to come. So I just passed by, but the later ones were not better than before. Thus I had nothing at last.”

Socrates said this was love.

The other day, Plato asked Socrates what marriage was.

Socrates said, “Go across this forest, cut down and bring back the thickest and solidest tree. Remember, you cannot go back and have only one chance.”

This time, Plato brought back a tree that was good but not very tall or solid. Socrates asked him why.

“I saw many good trees on my way. This time, I learnt from the past and just chose a good one. Though this one was not the best, I was afraid I would get nothing again if I did not do so.”

Socrates said this was marriage.

Some days later, Plato asked Socrates what happiness was.

Socrates said, “Go across this field and pick the most beautiful flower. Remember, you cannot go back and have only one chance.”

Plato did so and came back with a fairly pretty flower.

Socrates asked him whether this was the most beautiful one.

Plato answered, “I saw this flower, thought this was the most beautiful one and picked it. Even though I saw many beautiful ones afterwards, I still believed this was the most beautiful one. So I brought it back.”

Socrates said this was happiness.

The story did not stop here.

My wife asked, “Do you dare say you agree with the story?”

“Yes,” I replied, “but I always have beginner’s luck, and have already found happiness.”

28 May 2009


We had lunch with WK after visiting a friend at his hospital. He mentioned how the administrators overreacted to the flu outbreak and frightened the patients away. Of course, this was nothing compared to the Metropark Hotel quarantine by our government. Somehow, these overreactions reminded me of a rather irrelevant story.

Some years ago, a professor of economics complained that university students only copied notes during lectures but did not listen to his message. To illustrate his point, he wrote ‘Mary has a little lamb’ on the whiteboard along with the other lecture notes. Sure enough, most students copied the meaningless sentence in their notebooks.

When the professor shared this experience, a colleague picked up the argument jokingly. “When you do not understand something in a lesson, shouldn’t you copy it down first?”

I would not be judgmental about doing something or pretending to be doing something when there is uncertainty, but I always find Szeto’s advice on clinical practice useful. “If what you do works, continue it. If what you do does not work, stop it. If you do not know anything, don’t do anything.”

21 May 2009


A byproduct of the flu outbreak is that we had to cancel the clinical exam.

Strictly speaking, we did not cancel the exam. Instead of asking students to examine real patients, we showed them photos, video clips and investigation results. This prevents patients from contracting infections during the exam. Realistically, patients would not come to the hospital anyway because of the risk.

JW was overjoyed. According to him, students who learned medicine in wards and medical grand rounds could get distinctions, while those who only read textbooks would have a tough time.

On second thought, this was indeed wonderful. Reward shapes behavior. While we grumble that many students are only interested in exam-related skills, can’t we modify the exam to encourage them to equip themselves as good and competent doctors?

We also grumble a lot about some academics who are only interested in publications. Theoretically, the reward system can be modified to encourage teaching and community service. The real question is – Are universities interested in these?

14 May 2009


In the last two months, no doubt the most important news is the influenza A(H1N1) epidemic. A few friends were concerned about me as a frontline worker in the hospital. When they learned that I was perfectly fine, the discussion drifted to why the virus had become less deadly over the weeks. As of 12 May 2009, over 5000 patients were confirmed to be infected. Fifty-eight Mexicans died, compared to 5 in the rest of the world.

The cause for concern is understandable and has been discussed extensively elsewhere (http://ccszeto.blogspot.com/2009/05/show.html, http://drkmchow.blogspot.com/2009/05/contagion.html). I will concentrate my discussion on why the mortality rate of influenza A(H1N1) appears to drop outside Mexico.

When the outcome of a viral infection changes, there are only four possibilities: (1) The virus has changed; (2) The host has changed; (3) The treatment has changed; and (4) The observation is an artifact.

The most successful microorganisms do not kill people. Viruses spread by droplets would transmit more efficiently if the hosts survive and walk around. The only microorganisms that benefit from debilitating the hosts are those transmitted by vectors. If you cannot move around, mosquitoes and ticks can bite you easily and transmit the microorganisms around. Therefore, we often see that viruses causing respiratory infections become less virulent with time. Comparison of earlier and later strains of the virus would answer this question.

Mortality from influenza A(H1N1) appears to be more common among adults and diabetics in Mexico. It remains to be seen if high-risk individuals are over-represented in the Mexican cohort. It is unlikely that the mortality rate can be explained by ethnicity since the mortality rate in Mexico is also declining.

Early use of antiviral drug (e.g. oseltamivir) and advanced organ support have also been proposed to be the cause of lower mortality in developed countries. While this may be true, I have not yet seen reports showing such a dramatic efficacy of oseltamivir. The point on organ support can only hold if a significant percentage of infected US citizens required intensive care. Another potential explanation is that the pattern of coinfection may be different in different countries. Again, further investigations are required.

Finally, I think the most probable explanation is that the observation is an artifact. We now know that the majority of infected individuals have mild symptoms. It is very likely that many infected people were never detected and reported, especially in the early stage of the epidemic.

As a young journal reviewer, I often reverse the sequence. I check if a study has major methodological flaws before learning what it is trying to say. More experienced academics, however, tend to see if a study asks an important question before reading on. After all, anything worth doing is worth doing well. The converse is also true.

7 May 2009

Wrong Train

We just attended a medical conference in the lovely city of Copenhagen. No wonder it was the home of Hans Christian Andersen, the great author of numerous fairy tales.

On the fourth day, YL was surprised that I attended all sessions of the conference. “Do you mean that you have not visited anywhere?”

“No,” I answered defensively, “I had a boat ride on the first day, and I dined out every evening.”

It is however really not my cup of tea to tour around during overseas conferences. Above all, I enjoyed the conference very much. Even though my mentor said he could not find any reason to attend the lecture on ubiquitin, I managed to convince him that was also wonderful. Secondly, the mood is different when I travel with my family back home.

When my daughter was three months old, I had to leave my family and receive overseas training for several months. Understandably, my wife was stressful and sad at that time. Crying over phone calls was the rule rather than the exception. Of course, I could do little other than calling her frequently. Partly as a defensive mechanism, I stayed in the lab most of the time and convinced myself that at least I was doing something meaningful. As Eileen Chang wrote in her last novel Small Reunion (小團圓), “You think you are not so bad if you know you are bad.” I know this is silly, but silly I am.

On my last day in Copenhagen, I took the wrong train. Instead of going to the conference center, I travelled to some rural areas. It actually took me merely thirty extra minutes to go back. But there I was, alone in a small station. Since the next train would only come in five minutes, I had the privilege to enjoy the scene. Below the heavenly blue sky were vast green fields where cozy cottages were sparsely built. Everything was quiet and peaceful. The only sound was the whisper of the warm breeze.

When the train arrived, I could not help thanking God and thinking, “Wouldn’t that be good enough?”

30 Apr 2009


You never know how kids think nowadays.

Like most parents, I asked my 3-year-old daughter one day. “What do you want to do when you grow up?”

“Nothing,” she answered.

I did not give up. “How about being a doctor?”


“Then what are you going to do?”

“I will get married.”

“Mummy also got married,” I replied, “but she still goes to work.”

I was anticipating an in-depth discussion on the meaning of life, but our conversation was interrupted by Mummy’s laughter.

23 Apr 2009


As the final professional exam draws near, more and more students ask me for examination skills. Some years ago, I really believed that I knew a few tricks.

Rule number one is to understand why an examiner asks a certain question. It can be because your original answer is wrong, he wants to test you some general knowledge, or he has recently come across a research paper on this topic. When I explained this, a student was quick to point out, “How can we know?” The loophole is I never thought about this.

In the past, many examinations using multiple choice questions had a penalty system – marks would be deducted for wrong answers. Knowing when not to answer was as important as knowing the correct answers. To test my method, I asked some trainees to record their confidence in a question (in percentages) as well as the final outcome (correct or incorrect). In theory, if they learned not to answer when their confidence was below a certain threshold, they would get the highest marks. However, none of them thought this method was very useful.

After all these years, I understand that the so-called tricks are just the rule of 10,000 hours. This is nothing but experience. I kept talking in tutorials whenever my classmates were shy or unsure. With time, I could anticipate questions and give appropriate answers even when I was uncertain.

So, there are no secrets after all. If you still insist on some tricks, I find Sima Yi’s (司馬懿) military advice very useful:


16 Apr 2009

High School Musical

Earlier this month, my mentor, GW and I attended a meeting in Phuket and gave some talks. After the session, the Associate Dean at the Thai university invited us to watch his rehearsal. Much to our surprise, he and his fellows were going to dance in the celebration dinner. They chose a few scenes from High School Musical.

If you have never heard of High School Musical, you do not have a kid in primary or secondary school. This is a popular TV show featuring American students going to school, playing sports, dating, etc.

While the Associate Dean was jumping up and down on stage and gasping for air, we joked about the possibility of having our Boss give such a show.

“We will all be asked to accompany him,” GW reminded us.

“I’d rather give three talks than dance on stage,” said my mentor.

“Thais can enjoy life,” our Singaporean friend in the audience concluded. “On the other hand, we are too complex and would be worried that others may laugh at us.”

Watching the Thai professor laughing wholeheartedly with his colleagues, we felt happy for them. After all, this is what life is all about.

9 Apr 2009


Without the voices of our trainees, the story would be incomplete. Some older people believe they have already known what the youngsters think. Some even believe that the youngsters do not know how to think and they know what is best for them. To a certain extent, I also agree that young people may not tell you the truth even if you ask, but I wished to ask.

In March 2009, two investigators (VW and KY) independently generated a list of basic trainees in our department who have taken or passed the MRCP exam and expressed interest in joining a specialty. A standard set of open questions was sent by e-mail. For confidentiality reasons, the identity of trainees and the exact specialties would not be revealed. Overall, eight of nine trainees responded (response rate 89%).

The median number of specialties the trainees had seriously considered was 3 (range 2 to 4). Six trainees made the final decision after the MRCP exam and one made the decision during internship. One notable exception was a trainee who determined to join a specialty even before entering the medical school. That trainee continued to pursue the dream despite failing to enter the medical school at the first attempt. He/she is now generally agreed to be one of the most responsible and competent colleagues in our department. Based on this touching story, I am ready to help all youngsters to develop their careers.

Factors affecting the decision
Not surprisingly, five trainees stated interest as their main reason of choosing a specialty. Five also considered the team spirit and the behavior of other team members important. Three respondents considered future prospects (one stated promotion, one stated the likelihood of staying in the team after the completion of training, and one reported the prospect in the private market). Three trainees also thought the leadership of team heads was important. On the other hand, only one trainee wished to join a team for research and challenge. One trainee said that the decision was affected by what the other trainees chose.

One interesting phenomenon recently is that specialties with more trainees and fellows continue to attract the biggest number of new recruits. Some people have questioned this behavior on the ground that the promotion and training opportunities may be adversely affected. When we asked the same questions, three trainees thought that the number of existing members in a specialty was unimportant in their decision process. Three other trainees believed that bigger teams were more attractive because they would get more support and have better exchange of ideas. Only two respondents were worried about the prospect and said that specialties with more existing trainees were less attractive.

Pro-choice or Pro-life?
Under the current system, most trainees can enter their first-choice specialties. When we asked about their view on the possibility of job assignment by the department according to service need, four trainees stated that they would seek training posts in other hospitals and one would negotiate with the department. Two trainees would accept the offer if they could join their other favorite specialties, but would still leave us if the team was not what they wanted. None of these seven trainees believed they could excel in specialties they did not like. Only one respondent agreed to accept any offer and try the work first.

2 Apr 2009


Recently, there has been some discussion on the recruitment of trainees into different specialties in our department. Understandably, some team heads are not too happy when all trainees are attracted to a few popular specialties, while their own teams suffer from insufficient manpower. With immense interest in human thinking and behavior, I asked some colleagues for their opinion.

Prof Szeto answered, "I have decided that I do not need to have any opinion." (For details, please visit http://ccszeto.blogspot.com/2009/03/opinion.html.)

When I asked the same question, my mentor wrote down four words: '寧缺莫濫'. According to him, teammates are not just manpower. They are brothers and sisters. When a leader recruits a new teammate, he should help him/her develop a career as well. Therefore, he would rather wait patiently for suitable candidates.

As usual, I learned a lot by asking.

26 Mar 2009


Our department held the research day last Saturday. Sadly, none of our trainees attended the meeting. I hope they were just skeptical about the quality of the meeting instead of having no interest in research at all.

This is not to say that research must be of prime importance. In fact, I am afraid some people put too much emphasis on research output in judging one’s worth. I am all too happy to see youngsters striving to become responsible and competent doctors. However, in the era of evidence-based medicine, even doctors not doing research should know how research is done and if the conclusion of a report does justice.

The event led me to reflect why I am doing research.

Hopefully, it is not for fame, prize and money. If I choose those, the temptations to do wrong are too great.

It is the sheer joy of finding things out. Not only do I want to learn the truth, I am also eager to see how people get the answer. Our nephrologists were probably fed up during my attachment when I asked silly questions like ‘Why does proteinuria lead to frothy urine? When is frothy urine pathological (I often see bubbles in urine)? Does the size or number of bubbles matter?’

Recently, I brought our youngest and talented trainee to a laboratory meeting. After the presentation, she summarized the whole work in one question – ‘What is the use?’ At that time, I nodded politely. (Friends familiar with both of us would understand that I had no other choice.) Deep in my heart, however, my answer was, ‘You never know.’

When Osamu Shimomura applied for a research post to investigate why jellyfish glowed in the early 1960s, many might also question the significance of his work. Who would have imagined that the discovery of the green fluorescent protein would transform biomedical research and earn him a Nobel Prize in Chemistry 40 years later?

19 Mar 2009

Coca Cola Classic

Have you noticed the word “Classic” beside the Coca Cola logo in some of its products? What is so classical about a can of coke?

In 1980s, Pepsi launched an aggressive advertising campaign to boost sales. People at my age would probably remember television advertisements featuring a boy or girl trying two cups of unlabelled coke and being asked to choose the better one. After he/she had made the decision, the better coke always turned out to be Pepsi. You may think this is rubbish. We can always hire an actor to do this, right?

The Coca Cola Company certainly did not trust it either. However, being a big company, it decided to be cautious and secretly performed similar tests on volunteers. Much to their distress, Pepsi really seemed to be winning. Over 60% of testers thought Pepsi tasted better. The company saw this as a potential disaster, and quickly changed the formula of the drink with “New Coke” on 23 April 1985.

The result? The company converted a potential disaster to a real one. Customers just hated the new products and protested. Sales dropped. The company quickly returned back to the original formula in less than 3 months. To be absolutely sure that the customers were pleased, it added the word “Classic” next to the logo.

What went wrong? In a sip test, a tester only takes a mouthful of soft drink. The sweeter product is more likely to win. In real life, people drink the whole can of coke, not a sip. In such settings, it may taste too sweet.

Therefore, you must understand what an investigation is measuring before you can use it. Misusing an investigation is not useless. It is worse than useless. It is misleading.

Some weeks ago, I noticed a young doctor checking blood for carcinoembryonic antigen in a patient with anemia. “This is not supposed to be a screening or diagnostic test,” I said.

“A positive test increases our suspicion of colorectal cancer,” the doctor protested. “Taking some blood causes no harm anyway.”

“No,” I disagreed, “you can still harm the patient. Imagine what would happen if you decide not to perform endoscopy to rule out cancer if the blood test is negative.”

12 Mar 2009

Air Pollution Index

Last month, a group of medical students from our sister university took to the streets in protest and urged the government to update the Air Pollution Index (API). Do I support the act? Of course. Do I support the proposition? I am afraid not.

The protest was an excellent piece of civil education. I hope our students would join some of these activities, too. The real question is – does updating the API do any good?

Currently, the Environmental Protection Department provides the API based on the level of 6 atmospheric pollutants, including sulfur dioxide, nitrogen dioxide, suspended particulates, carbon monoxide, ozone and lead. The index and air quality objectives were set in 1987. Actually, the medical students were not the first to criticize that the index was not update. In October 2005, Task Force on Air Pollution has already stated that the current API is ‘meaningless’. First, some harmful components are not measured. Second, our cutoffs fall short of the World Health Organization Air Quality Guidelines.

I do not doubt that the experts know a lot more about the relationship between air pollution and disease. But what if we update the API? Can we shut down a few factories in Guangdong on bad days? Can we ask our drivers not to drive? Don’t be silly. You may argue – at least we can warn patients with lung diseases not to go outdoors, right?

People working in hospitals in Hong Kong may recall that we have an alert system for avian influenza. It is funny to use the word ‘recall’ for something in the present. The trouble is we are always on yellow alert. When you are always on alert, you have no choice but to ignore it. According to Prof Anthony Hedley of the Task Force, the air pollution of Hong Kong should be stated as ‘absolutely sky high’ most of the year. Can we ask the poor men to stay at home most of the year?

At the end of my hematology rotation as a medical student, I gathered my guts and asked. “Professor GC, our patients come in every few weeks for blood transfusion, but most of them do not have a diagnosis. Wouldn’t it be nice if we perform bone marrow exam and know what we are dealing with?”

“Investigations should only be done when they change the management,” the hematologist answered. “If these people suffer from myelodysplastic syndrome, I will provide supportive transfusion. If they turn out to have leukemia, I will still provide supportive transfusion.”

So forget about more investigations. The government certainly knows that the air pollution is bad. What we should push for is the means to combat pollution, not how to measure it.

5 Mar 2009


(The original version of ‘Sixteen Things About Vincent’ appeared in Facebook on 31 January 2009. Thanks to my friends’ feedback, the arrogant phrases were modified.)

My mentor tagged me. I guess I just have to follow suit.

1. I studied in three primary schools. My mother thought that was like Mengzi’s mother, who moved house three times to pave the way for the great scholar. Through the process, I did learn how to adjust to new environment. In essence, you have to make friends quickly, and respect that others may do things differently in different places.

2. I entered primary school at the age of 5 and have been the youngest in class ever since. While I was OK with language and mathematics, I could never manage craftworks.

3. Contrary to what child educationists may suggest, my mother constantly emphasized that I was not smart at all when I was in primary school. She believed this would make me more hard-working. Some of my friends would probably agree with her – that I am hard-working and not smart.

4. I am a Wah Yan boy. Although the Wah Yan spirit has never been formally defined, most Wah Yan boys think they get it. It is very much like the Dragon Scroll in Kungfu Panda.

5. I thought I was good at physics. I am humbler now. I am glad that Stephen Hawking deleted most mathematical formulas in A Brief History of Time.

6. I was made the producer of a joint-school musical play when I was in Form 6. While all my classmates were busy dating girls, I was worried sick about how to settle the budget everyday. This was meant to be a fund-raising project for the Hong Kong Cancer Fund, but the stage staff and actors spent almost every penny in the end. During the last rehearsal, the stage curtain was torn in half by a handrail at the edge of the set, costing another $5000 (I know. Similar things happened when Jesus died on the cross.). This was the only time when an opera moved me to tears. After the event, I was rather depressed and ashamed for letting the Cancer Fund down. In retrospect, this was no big deal, and we learned a lot through the project. But it took me years to forgive myself.

7. I can play piano, violin and pipa. If you only want ‘Twinkle, Twinkle, Little Star’, I can almost play any instruments.

8. I learned handball in the university. Two other medical students attended handball class with me, but I was the only one who had scored at all (only 3 goals in 10 games).

9. Prof Jean Woo was my Physician on my first day as a resident. I later learned that she did not want a first-year trainee, but Dr Michael Fu convinced her that I would be good enough. Of course I can never be good enough. I only strived to become better everyday.

10. After my MRCP exam, Prof Sung told me that I failed. I was glad he got it wrong this time.

11. I presented an abstract in a European meeting right after the MRCP exam. After I stepped down from the stage, Prof Anna Lok praised me. This was very important for my development. Before that, I had quite severe stage flight. Now I try to praise young doctors and students whenever I could. If you have read Henry’s notes, you will know that Prof Sung and Prof Lok are the grandparents of my career.

12. I wrote my first paper with Dr Nancy Leung and Henry. I could not find ‘chi-square test’ in the pull-down menu of SPSS, and Prof CC Szeto taught me right away. I did not mention his help in the acknowledgement section because it was quite embarrassing to thank people for teaching me chi-square test in a scientific paper. I would like to thank him now.

13. My wife and I prepared a presentation on osteoporosis in my final year. The presentation went badly, but I got my wife.

14. My favorite movie is The Pianist by Roman Polanski. My wife thought I was crazy when I repeatedly played Chopin’s Ballade No. 1 in the movie. Now that my daughter is 3 years old, we can only watch Strawberry Shortcake at home.

15. I tell my daughter bedtime stories every night. Since I am bored with her story books, I have started making up stories. The latest hits included Strawberry Shortcake meets Spiderman and Strawberry Shortcake meets Mr Incredible.

16. I know I seldom attend social gatherings now. But on the first day I went to work after the New Year holidays, my daughter complained to my wife. “My Daddy doesn’t miss me.” What else can I do?

Want to read the arrogant version in Facebook? Don’t be silly. I have already modified it.

26 Feb 2009

Unnatural Selection

Learning from Mother Nature, a creature or institution will thrive and survive environmental changes if it can do the followings:

1. Allow mutations or new ideas to occur.
2. Let mutants compete with wild types.
3. Accept the result of natural selection.

Unfortunately, most institutions overlook the latter two points. When a new policy comes up, it replaces the old one totally although there is no evidence that it is superior. Many people hate conservatives who reject all new policies – ward arrangement, teaching timetable, office renovation, you name it. Nevertheless, conservatives are very important. They preserve the good old days as far as possible and put the burden of proof on those who propose changes. Since bad ideas outnumber good ones in general, brutal replacement of old policies with new ones tends to result in disaster in the long run.

In the January issue of Proceedings of the National Academy of Sciences, Chris Darimont and colleagues described vividly the result of unnatural selection. Under normal selection pressure, the mortality rate of a species is usually limited, and immature and younger organisms die first. In contrast, in ecosystems affected by human predators such as hunters and fishermen, the mortality rate is higher, and the largest and mature organisms are the main targets. As a result, evolution under this unnatural selection is much faster. Interestingly, the size of organisms decreases by an average of 20%, and the life cycle shortens by nearly 25%. The poor preys just have to reproduce earlier to avoid extinction.

Sadly, the result of this report reminds us of ourselves. Good clinical research takes years or even decades of careful observation. Under the current method of research assessment, academics who only do big and long-term projects will die first because of insufficient research output. Next time when you read a me-too study or non-definitive study reporting dubious surrogate end points, don’t laugh. Those people are just shortening their reproductive cycle because of unnatural selection!

19 Feb 2009


Between 1405 and 1433, Zheng He of the Ming Dynasty led a fleet of more than 20,000 men to explore the ocean west to China. The countries he visited included Indonesia, Yemen, Iran and Somalia in East Africa. The largest ship could carry 200 sailors and 1000 passengers. This took place before Christopher Columbus was born (1451-1506). The fleet was also much larger than the one led by Columbus. Although Zheng He’s mission was never meant to be colonization, we can still expect that the international influence of China would grow with time if similar voyages continued.

However, the policy of the Ming Dynasty changed suddenly afterwards. The country not only abandoned further sea adventures, but also cut off most international interactions. A number of hypotheses explained the change. Some said that the emperor used up all the finest lumber to build the Forbidden City. Others said that the main reason was the political rivalry between eunuchs and the royal family (Zheng He was a eunuch).

While we consider the abandonment as one of the foolish decisions in Chinese history, one may wonder why the same thing did not happen in Europe. New ideas are like mutations. If the idea of going out to search for unknown land (Columbus’ calculations and predictions before his voyage were almost completely incorrect) is a mutant, the wild-type would be minding your own business. In fact, when Columbus approached John II, King of Portugal, for funding, he hesitated. That is why Columbus had to turn to the Spanish Queen. The interests in sea adventures also fluctuated among different European countries.

What set Europe apart from China was the keen competition among countries. The great success of the Spanish campaign brought in gold and resources, building Spain into an empire in the 16th century. Other countries sensed the selection pressure and had to follow suit. This resulted in a long history of colonization. In contrast, China did not experience major economic and political competition from neighboring countries, and could live contently on her own until the European navies knocked her door.

12 Feb 2009


New ideas are like mutations. In Built to Last, James Collins and Jerry Porras illustrated how companies that encouraged new ideas outperformed those that explicitly avoided changes. The mutations allow the companies to change over time and face up new challenges. In Chinese history, many dynasties upheld the belief that ancestral decrees should never be disobeyed, and headed towards ruin when the environment changed.

Therefore, I cannot fully support those who reject all new policies such as the education reform and ward admission system. Of course, this is not to say that the results of these new policies are gratifying. In fact they aren’t. Supporters of conservative approach may point out that though the dynasties collapsed, they had each lasted for several centuries. In contrast, Wang Mang (王莽) established the Xin Dynasty (新朝) and was well known as a creative politician and scholar. He was described as a ruler who announced a decree in the morning and changed it in the evening (朝令夕改). The empire only lasted from 9 to 23 AD. In Fooled by Randomness, Nassim Nicholas Taleb explained the cost of progress (or change):

‘People tend to infer that because some inventions have revolutionized our lives that inventions are good to endorse and we should favour the new over the old. I take the opposite view. The opportunity cost of missing a “new new thing” like the airplane and the automobile is minuscule compared to the toxicity of all the garbage one has to go through to get to these jewels (assuming these have brought some improvement to our lives, which I frequently doubt).’

This leads us to fundamental questions – Does the outcome depend on the quality of the mutations? Is there an optimal mutation rate?

If we turn to Nature for an answer, the first question is obsolete. Mutations are random processes. History tells us that bad ideas outnumber good ones. Great minds do not guarantee better ideas. We only know that bad ideas by great people usually result in worse disasters (think about Karl Marx). So we have to accept the co-existence of good and bad ideas.

Similarly, microorganisms with the highest mutation rate are the most robust. HIV, hepatitis B and hepatitis C viruses can all produce mutations at any point in the genome within one day. They are also very successful in developing drug resistant mutants.

Then what went wrong? Why do the government and some institutions do badly even though the officials bombard us with innovative ideas all the time?

5 Feb 2009


My colleagues were surprised when I celebrated the 200th anniversary of the birth of Charles Darwin in a public talk on hepatitis B recently.

Explaining the evolutionary theory to non-specialists is a bit tricky, but people working on antiviral therapy use the theory all the time. The essence of the evolutionary theory is ‘survival of the fittest’. During reproduction, gene mutations sometimes result in phenotypic changes in an organism. Most of the mutations are hazardous, but a minority confers competitiveness. Organisms bearing more competitive mutations have a better chance of giving birth to offsprings, and eventually the new gene will dominate the population. People working with viruses are seeing a fast-forward version of evolution. Viruses replicate quickly and produce a lot of mutations because of their lack of proof-reading during gene transcription. When an antiviral drug is given to a patient, viral mutants that do not fear the drug will replicate more effectively and soon become the dominant strain.

Actually, before Darwin published his book On the Origin of Species, a few other scientists had already noticed the gradual phenotypic changes of animals and plants. However, most considered the changes a well-planned evolution by God. It was Darwin who spotted that the changes were random, and the evolution was driven by natural selection – ‘survival of the fittest’. For those with basic knowledge on genetics, the theory may seem pretty easy to understand. However, one must remember that genetics did not exist at Darwin’s time (although Gregor Mendel was actually humbly doing his cross-breeding experiments at roughly the same time). Imagine how difficult it would be for me to explain the last paragraph again without describing anything about genes and mutations.

Like all great theories, the implications extend well beyond the original territories. I will elaborate this further next week.

29 Jan 2009

Philosopher Ruler

When we saw some consultations last week, a few high-ranking officials were visiting the ward. “The Earth is invaded by extra-terrestrials!” I exclaimed. All my teammates laughed.

This stems from the language in Szeto’s blog, which almost all frontline staff in our department read regularly. In his blog, our Boss is called the man from Pluto, while other hospital administrators are extra-terrestrials outside the Solar System. Although they control everything on Earth, they do not understand how people on Earth think and do things. Clearly, Szeto has a strong distaste for administrators.

I admire Szeto in every aspect, but cannot share his feelings on this point. If administrators cease to exist, who are going to hold endless boring meetings, meet the press for hospital mishaps, and explain to the government why a hospital spent nearly twice its original budget? We probably all need to share some of these. One reason why we are writing blogs so happily now is because some people love administrative work.

In an idealized society described by Plato in The Republic, the best ruler should be a philosopher. A philosopher is in love with the truth. When a man’s desire flows towards the acquisition of knowledge, his pleasure will be in things purely of the mind, and physical pleasures will pass him by. Money and fame would not be his concern. However, he fits the job as a ruler because of his good memory, readiness to learn, breadth of vision and grace, and that he is a friend of truth, justice, courage, and self-control. Interestingly, the best ruler should not want to be a ruler at all.

Of course, we are not in an ideal world, and I have to say our Boss is great after all. Just out of fantasy, LY will be an interesting candidate who can double our department’s value every year and turn our frontline staff into shareholders. Szeto is closest to the philosopher ruler described by Plato. Under his rule, I expect every senior staff can not only recite Harrison’s Textbook of Medicine, but also quote a New England paper with the correct page number during ward rounds.

22 Jan 2009


Szeto once commented that I appeared content and happy all the time. I take that as praise.

When I was 10 years old, I joined the recorder ensemble in my primary school. For some reason, my teacher did not ask me to play the recorder or other wind instruments, but assigned me to a humble percussion instrument - two pieces of wood you could hit with a stick. Anyway, I practised and tried to create different sounds out of it. I also concentrated on the rhythm. Our team eventually lost in a local competition. To my surprise, the adjudicator specifically discussed my percussion and spoke highly of me. This has been an important lesson over the years. It does not matter where God places me. If I work faithfully, the result is always fruitful.

Lately, Szeto recalled that he did not plan to do nephrology during his college days and basic training. In retrospect, I realize I did not have much planning at all. When I had the opportunity to apply for a scholarship at the Royal College of Music, my Dad felt that was a really bad idea and I entered the medical school instead (of course I would never reveal this in any interview). When I was wondering whether to do internal medicine or science, KL took me to his room exactly one week before the Professor of Chemical Pathology phoned me up. Since my first year of basic training, KL asked me not to consider other specialties.

Many would think this is a silly way of handling one's career, but I am thankful to God for letting me do these wonderful jobs all the same.

15 Jan 2009

Role Model

One day, AJ asked a question suddenly. "What does 'xxxxxxx' mean?"

We were all confused by the seemingly ancient language. AJ took us to the endoscopy center, and showed us a work of Chinese calligraphy. Alas, he not only read a few words incorrectly, but also started reading from the wrong side! It should be '但開風氣不為師'.

'We do not teach. We set examples.' No one in our team ever claimed that this was our motto or core value, as some enterprises love stating. However, this is exactly what our predecessors did.

When I became a medical student, I only wanted to become a good doctor. I believed that first-class research did not exist in Hong Kong, where government support was little. Later, I found out that many people in the medical school conducted cutting-edge research despite limited resources. Many studies even radically changed clinical practice worldwide. These dedicated clinician-scientists also keep their role as competent clinicians. They are great role models for students and young doctors. They open a window for youngsters so that they dare dream big.

In my tutorials, I used to teach short-case examination. In essence, a candidate has to perform physical examination on a patient and try to figure out what the underlying diagnosis is. These are vital techniques for passing any professional examination. Last year, when a medical student requested an extra tutorial from me, I half-jokingly asked. "Do you want to learn how to pass the examination, or how to become a good doctor?" Much to my surprise, the answer was firm. "We want to learn how to become good doctors."

I was so ashamed on hearing the response. What was I doing? Why should I waste time teaching students how to pass an examination with over 90 percent passing rate, when many patients may die because of foolish judgements, and many more could not receive the love and attention they deserve? Since then, all my tutorials have become teaching rounds. We see patients together, greet them, chat with them, and discuss the proper clinical decision and management.

For students wondering why I have a different mode of teaching, this is my answer.

8 Jan 2009

Black Hole

Our team head, KL, is well known for his black hole policy.

You may ask, "Isn't Stephen Hawking the leading expert in black holes instead?"

True, but Hawking is a theoretical physicist. As clinicians, we favor translational research.

According to KL, there are just too many junk mails and unreasonable requests everyday. These will just bar us from achieving our own goals. Instead of responding to the requests faithfully, he just gently presses the 'delete' button. In the last few months, he took a step further and stopped pressing the 'delete' button. He just leaves thousands of mails unopened, which, of course, resembles a black hole more.

This policy may not work every time. Once, a very famous professor requested him to write a chapter for his new textbook. This time, KL could not just press the 'delete' button. Instead, he pretended to be his secretary and answered the e-mail. "Dear Professor DG, I am Prof KL's secretary. Prof KL is on long leave and will not be back till August. I am afraid he might not be able to do it."

The big professor was undeterred. "August is fine. Please ask him to return his chapter in August." For once, KL had to comply.

The victims of the black hole policy will probably protest. "How can you do this to me?"

KL is not alone. Richard Feynman, who received the Nobel Prize in Physics for his work in quantum electrodynamics, was also famous for rejecting administrative work so that his research would not be interfered. He taught us how to respond to the Dean's request - "Let George do it."

1 Jan 2009


During a casual chat, GW mentioned how difficult it was to delegate job to young colleagues. This reminded me of an interesting story.

A few years ago, our Boss was working both as a Chairprofessor and a hospital administrator. Everyday, he need to see patients, teach students, do research, and attend numerous administrative meetings. In an international meeting, he met Prof AL in the United States and complained about his hard work.

Prof AL was not sympathetic. "Why don't you ask other people to do the jobs?"

"Who can I turn to?" our Boss answered.

Prof AL casually pointed at one of his younger colleagues. "He can do it," she continued. "You feel it difficult to delegate jobs to others because you think you do those things better. Doing everything yourself is not kindness. It is arrogance. Think about it. Probably any of these guys can do a better job than you because they have time and you don't."

I do not know how much influence this conversation had, but our Boss did quit his job as a hospital administrator several months later. Many local people were worried that this would be a great loss to our hospital. However, our Boss achieved much more than any of us could imagine afterwards. The one who took over the post as the department head also turned out to be a great leader.