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!