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?”