30 Dec 2010

Hug

Earlier this month, I met KK on the way to the clinic. The retired cardiologist seemed very happy. He heartily came over and gave me a big hug. I was slightly surprised by the warm act, and thought I should be the one hugging my teacher.

In 2003, our Boss took his sabbatical and visited the Johns Hopkins University School of Medicine. Among all things, he was most impressed by the way clinicians there greeted their patients. Those patients might have AIDS or other rare infections, but the clinicians hugged them all the same. With our cultural background, it is unlikely that we could practice the same act here. Nevertheless, after listening to our Boss’s story, I found myself touching my patients’ hands more often.

That night, I was filled with joy and warmth. The moment I went back home, I opened my arms wide to hug my daughter.

"Yikes!" the girl ducked and ran back to the living room.

23 Dec 2010

Mask

Ever since we started wearing masks, my mentor complained he could not recognize any student.

We adopted the policy of wearing masks in all clinical area after the SARS outbreak. While many colleagues were infected, DH was miraculously unaffected despite having seen the index patient. “We have to see a lot of patients with respiratory infections including tuberculosis everyday,” recalled the Professor of Respiratory Medicine. “It is our custom to wear masks during consultations.”

Now that we are so used to masks, it is easy to forget we do not even know what our colleagues look like.

Last week, a young lady called me at the hospital corridor. I looked at her and tried to hide my hesitation. Was she my patient? After a while, I finally realized she was the nurse who worked in my consultation room in the last two years. “Humph, I could not recognize you with the mask off,” I remarked rather awkwardly.

One day, a patient asked at the end of a consultation, “Doctor Wong, I have known you for years but have never seen your face. May you take off your mask?” I duly complied. Secretly, I was quite happy and recalled a scene from The Return of the Condor Heroes.

After a brief encounter, Yang Guo (楊過) granted Guo Xiang (郭襄) three wishes. Guo Xiang immediately made the first wish and requested Yang Guo to take off his mask. Yang Guo was not pleased. He thought Guo Xiang did not understand the value of his gift. As one of the greatest heroes at that time, he could perform the most difficult tasks and solve whatever problems she might have in the future. Guo Xiang disagreed, “How can I say I know you if I haven’t even seen your face? This is not trivial.”

May the piece of paper mask my face but not my heart.

16 Dec 2010

Examiner

In my trainee days, many colleagues feared a senior consultant across the harbor. Rumor has it that she would take a week off before the membership examination for private study. During examination, she enjoyed asking difficult questions and failed a lot of candidates.

Partly because of her influence, I never read any books before serving as an examiner. The main reason, obviously, is because I am lazy. However, I feel the behavior does not make sense.

If I ask a candidate something that I only know after referring to a book recently, there are two possibilities. First, this may be something a practicing doctor does not need to know. That makes me an unfair examiner. Second, this may be something a practicing doctor should know. In that case, I should have been keeping up with the knowledge and not just look it up before examination. Otherwise, by failing a candidate I fail myself too. I should thus not continue to be a practicing doctor.

I should become an administrator.

9 Dec 2010

Standard

Last week, we held the licentiate examination for the Medical Council. This was an examination for medical graduates from other countries who wished to practise in Hong Kong. In the practical session, candidates were required to obtain history from and perform physical examination on patients. New examiners were often surprised to find how different the candidates could be. British-trained graduates performed examination in a systematic way. Others might jump from one step to another, picking up clues on the way and deciding what to do next as the case unfolded.

Many of us would allow a less systematic approach so far if important signs were not missed. Some examiners were less flexible and would already frown when a candidate pulled out the stethoscope before carefully inspecting a patient. The chief examiner repeatedly complained that Americans relied too much on investigations and did not examine patients properly.

A few examiners asked how we should mark the candidates. Since this was not a specialist examination, we could not expect candidates to get every diagnosis right. But how far should we tolerate?

“Shall we adopt the same standard as our own graduate examination?” suggested one examiner.

“Nope,” another examiner disagreed, “we pass 99% of our students every year. There isn’t a clear-cut standard.”

As usual, Szeto came up with the most useful advice. “Think if you are happy to be treated by the candidate in the future.”

But the room went silent.

What a terrible thought!

2 Dec 2010

Hunger

Last weekend, our team visited Guangxi Medical University and gave a few talks. To our surprise, the whole lecture hall was jammed with students. All seats were filled. Latecomers sat on the floor and stood at the back for the whole three hours. On the second day, even more people came. Although many could not enter the hall, they were willing just to stand outside and listen. The questions and answers session would never end if the chairman had not called the event to a close.

How does our own faculty in Hong Kong run a similar event? The organizers usually inform the students that their attendance would be recorded. Some students would sign their names and leave immediately.

On this, JW shared his recent experience.

His college invited a CEO of a big company to give a talk at a dinner symposium. While the students from mainland China listened attentively, the local ones chatted and played with their iPhones. After the talk, only the mainland students asked questions. The last question was how the CEO chose employees.

The CEO described a few qualities and concluded, “For example, I would choose those who asked questions just now.”

25 Nov 2010

Extra

After seeing GY, the same group of students approached me for an extra tutorial. (See http://ccszeto.blogspot.com/2010/10/absent.html for details.) I could not help mentioning that they had skipped several clinic sessions during their rotation.

“We know we were irresponsible,” the student was most apologetic. “This will never happen again.”

Irresponsible? They had totally missed the point. Learning from patients is not a responsibility. It is a privilege. Seeing that they still did not understand, I asked them to join our ward rounds and promised some teaching.

They never came.

I refused to be disappointed last time but now I do. They probably considered me unkind not to offer the extra tutorial right away. But I really can't just sell point-form notes and exam skills like the local tuition classes.

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all. –William Osler

18 Nov 2010

Checklist

How many people does it take to perform a gastroscopy?

As an on-call endoscopist, I often settle with the assistance of one student nurse. With luck, I may have a house officer too. So the answer is – two or three.

“How wrong you are,” sneered AJ.

That was a trick question. We cannot perform endoscopy without a patient. The answer should be four.

Seeing I was hopeless, LL enlightened me on this subject.

As part of the hospital accreditation exercise (I didn’t know this term either but was too ashamed to ask), every team had to prepare checklists for different procedures to improve safety. Since I was too dumb to be involved, I had never seen this kind of things. Anyway, according to LL, before a staff took blood from a patient, he or she was expected to fill in a form like this:

Blood taking checklist (Version 27.3, last updated at 16:17, 17 Nov 2010)
This checklist is the latest version. (Y/N)
I have completed training in blood taking. (Y/N)
I have brought a tourniquet. (Y/N)
The name and ID on the request form match those of the patient. (Y/N)
The scanner is in good function. (Y/N)
The label printer is in good function. (Y/N)
Scan the barcode on the request form. (Y/N)
Scan the barcode on the wrist band of the patient. (Y/N)
Print the labels. (Y/N)
The name and ID on the labels match those of the patient. (Y/N)
Check the expiry date of the needle. (Y/N)
Check the expiry dates of the specimen tubes. (Y/N)
Check the name and ID on the labels again. (Y/N)
Stick the labels on the specimen tubes. (Y/N)
Put on the tourniquet. (Y/N)
Draw blood. (Y/N)
Release the tourniquet. (Y/N)
Pull the needle out. (Y/N)
Cover the puncture site with a piece of gauze. (Y/N)
Discard the needle in the sharp box. (Y/N)
Put the request form in a designated box for proper disposal. (Y/N)
Put the specimen tubes in a designated specimen box. (Y/N)
Check for leftover needles and tourniquets at the bedside. (Y/N)
Put this checklist in the patient’s folder. (Y/N)
Fax a copy of this checklist to Room XXX. (Y/N)

“Very well,” said LL, “this is just a simple form for a simple procedure. Our job, however, is to develop a checklist for endoscopic procedures. We have to prepare for all expected and unexpected circumstances that may happen to an endoscopist and the team.”

I was wondering how they might foresee unexpected circumstances, but was interrupted by AJ.

“After the first meeting, we have not even gone beyond step three. The trouble was one of the committee members immediately smelled danger in the item ‘The endoscope is in good function’”.

“I don’t get it,” I was puzzled. “We always check our instruments. The item is quite reasonable.”

“The colleague said none of us were engineers. We were not qualified to certify that the endoscope was in good order. If we signed the checklist and complications occurred because of mechanical failure, we would be held responsible.”

“Hearing this, the nursing officer immediately declared the nurses would not sign the checklist either,” added LL. “And so the meeting went on and on for three hours.”

KL always says the only way to avoid trouble is by not doing anything.

But if we do not do anything, what are we doing here?

“We will hold another meeting,” concluded AJ and LL.

11 Nov 2010

Manchester

In the last few months, I attended more farewell parties than I would wish.

Then came the news of Sir Ferguson and Wayne Rooney. Despite all scandals, the story ended with Wayne holding a new contract. He was smiling. Sir Ferguson was smiling. Everybody was happy.

The salaries at local public hospitals are strictly regulated by the point scale. Similarly, Manchester United capped the salaries of its players to ensure financial stability. Therefore, it is interesting to learn what others do to keep their brilliant players.

Above all, players want to win. Although the club may not be able to offer crazy salaries like its rivals, some players are willing to accept a lower pay to win trophies. It is also attractive to play in the first team.

Second, a good club helps its players to improve everyday. A friendly environment and comradeship are also important.

Finally, as in Rooney’s case, the club is ready to break existing rules to build a better team when it is necessary.

While the last point is debatable, have we created the environment for our youngsters to live up to their potential?

4 Nov 2010

Fire

夫戰勝攻取,而不修其功者凶,命曰費留。故曰:明主慮之,良將修之。非利不動,非得不用,非危不戰。主不可以怒而興師,將不可以慍而致戰。合於利而動,不合於利而止。怒可以復喜,慍可以復悅,亡國不可以復存,死者不可以復生。故明君慎之,良將警之。此安國全軍之道也。《孫子兵法火攻篇》

I have never been too interested in military news. I still remember how my secondary school classmates excitedly discussed the tactics at the Gulf War. I could not have cared less. What can be so interesting about a one-sided match?

The Art of War by Sun Tzu, however, is an exception. Often hailed as the first book on military strategies in China, The Art of War actually taught us that war should always be the last resort. One should never declare war out of anger. Having one hundred victories in one hundred battles is not the best. Seizing the enemy without fighting is the best.

In addition, Sun Tzu taught us not to depend on luck. Although history mostly described stories about people winning in extreme conditions, Sun Tzu did not think much of it. The duty of a commander is to protect his country and people, not to get his name recorded in history. One should always be prepared and in an undefeatable condition. As such, victory should seem logical and not come as a surprise to other people.

No wonder so many teams embrace defensive football.

28 Oct 2010

Controversy

The last few weeks marked a series of anti-Japan demonstrations. I was happy that the Chinese captain was released, but found it difficult to share the strong views of some of my countrymen.

By definition, territorial dispute is a kind of controversy. While I have no hesitation in rising if my people are under attack, the link between fighting for an uninhabited land and patriotism is somewhat fuzzy. Claiming a piece of land because it historically belonged to a country is particularly flawed. The very reason of dispute is because all competing parties can report a period in the past when the place belonged to them.

Some people may say we have no right to express such a weak view because we never went through the war. I agree, but a recent radio interview caught my interest.

That was an eighty-year old lady who served in the local guerrilla during World War II. She has fought with brigands, shot Japanese, but mostly, provided education to local villagers. To avoid being caught and causing trouble to villagers, she never spent the night in villages but instead slept in bushes. During the interview, she let us know much about the lives of different people during the war.

In the midst of the recent rivalry with Japan, the host asked about her view. You may expect she would ask the Chinese government to declare war or at least scold the Japanese.

“Most Japanese did not want to invade us,” she answered. “During the war, people in both countries suffered a lot. The precious thing is not our victory over Japan but peace that we gradually achieved over several decades. It is important to preserve peace.”

To me, acts of hatred between the two nations are simply an insult to all our predecessors who died to create a better world.

21 Oct 2010

Mockingbird

Our friend KM mentioned Harper Lee’s Pulitzer Prize winning novel To Kill a Mockingbird recently. (See http://drkmchow.blogspot.com/2010/10/mockingbird.html) In this month’s Reader’s Digest, an article also celebrated the book’s 50th anniversary.

The story took place in Alabama during the Great Depression. A young white girl accused a black man called Tom Robinson for raping her. The court assigned Atticus, a middle-aged lawyer, to represent Tom. During the course, Atticus was under immense pressure from his neighbors and friends. They could not understand why he would agree to represent a black man. His children were also teased by their classmates as ‘nigger-lovers’. At one occasion, other townsmen nearly assaulted Atticus and Tom before the trial.

During the trial, Atticus unequivocally demonstrated that there was no evidence the rape ever occurred. On further questioning, it was clear that the shy and friendless white girl tried to seduce Tom. However, the girl’s father entered the house right at that time. To uphold their own reputation, they decided to make false allegation against Tom.

Despite overwhelming evidence, it was a time when a white person’s testimony was sufficient to condemn the blacks. Tom was convicted, and was later killed when he tried to escape from prison.

Although the novel touches on many serious topics, Lee cleverly used Atticus’ six-year old daughter as the narrator. Viewed from the eyes of a girl, the story had a degree of livelihood and humor. It is touching to see how Atticus was worried about his children and at the same time hoped they would understand why he was doing this.

Much has been said about courage and compassion in this story. To me, Atticus was remarkable for standing up to what is right when he did not have support from his peers. Fighting against enemies without considering their point of view is one thing. Respecting others’ points and at the same time upholding one’s own faith is integrity.

14 Oct 2010

Time

To the student’s question, my simple answer was you need to have priority.

A few years ago, a first-month resident mentioned she could not see all emergency cases at night and had some left unattended for quite a long time. Half jokingly, I told her, “In such situations, you have two choices. You may clerk full history and provide flawless management to some patients and let the rest run their natural course including death. Alternatively, you may provide ‘basic life support’ to all patients and make sure they make it to the next day, when the parent team takes over the care.”

Of course, this deviates from what a sensible person should advise. The textbook answer should be “We work as a team. You should ask your second-call (or consultant, COS, HCE, etc. depending on whether you live in Pluto or outside the Solar System) for help when the case load is high (which literally means every night).” Nevertheless, I mean it. We should not play God. We do our best, but should at the same time understand our own limitations. For one thing, our time is limited. An extra hour spent on one patient means one less for other patients. We spend more time on a patient when necessary, but judicious planning on time and resource allocation is equally important.

This month, a new group of students joined our ward round. Suddenly, AL explained that we were having busy business rounds and sent them away. As a teaching staff, I should have stopped her and encourage students to join clinical activities. However, I was too surprised and became speechless.

Perhaps that was very Freudian.

The spirit indeed is willing, but the flesh is weak.

P.S. Students, ignore the above. Of course you are welcome to join.

7 Oct 2010

Bad News

Most of my close friends know that I am responsible for a tutorial called “When the doctor becomes the patient”. When I was first assigned this topic three years ago, I was horrified. My only experience as an in-patient was when I was five years old, and I mistakenly swallowed a crayon. How can this silly story last for an hour?

After receiving the instructions from the Faculty, I realized I was much mistaken. My job was to play a video clip and lead some discussions. The video was about a consultant surgeon who stressed the importance of surgical skills and despised talks of caring attitude. One day, he attended an ENT checkup for sore throat, and was bluntly told, “Doctor, you have a growth.” He began to view doctor-patient relationship from the other side and was startled by his doctor’s cold attitude and paternal approach. At one point, his doctor offered radiotherapy for the throat cancer and did not allow discussion of alternative treatments. When he asked whether he could have surgery instead, the doctor simply replied, “You will lose your voice.”

Since I took up this tutorial, I have noticed that local students were very shy and felt uneasy about discussing care and emotions. Thus, I took the opportunity to teach both ethics and communication skills. The skill of breaking bad news was discussed and practiced. Instead of spending an hour discussing what one should do, I asked students to convey the same messages themselves in role plays. Through the exercise, they were able to learn the same things.

This year, a student approached me after the tutorial and asked, “It takes much time to explain things to patients. Will we really have time in the future?”

30 Sep 2010

Rejection

Recently, my mentor asked us to speak to some colleagues in China. I was assigned the easy topic of how to present scientific works in international meetings. Rightfully, GW had to talk about how to lead a successful academic career as a young doctor in Asia.

I was secretly happy that I did not have to do the other task. Above all, if I claim myself successful, I would blush for the entire talk. More importantly, Angelina keeps reminding me that I am no longer young.

Nevertheless, if I have to share my experience, have I learned a thing or two in my career?

Most youngsters would probably be surprised if I say the first thing that came through my mind was rejection. Teachers in medical schools often graduate with flying colors, pass all professional exams with ease, and are respectable clinicians. How can they be associated with failures?

The truth is I cannot count how many times my scientific papers and grant proposals were rejected. I had a paper which had been rejected by five different journals in a row. Some editors were nice and gave constructive comments. Others said the work was crap and should not be done in the first place. Each and every time, I wondered if this was the life I wanted to lead. To the least, if I just do clinical work, most of my patients have been satisfied with my service.

At one point, I asked my mentor what else I needed to improve before I could get my work published in leading medical journals. My hidden message was actually “I have done everything I can but the works all ended up in mediocre journals. I cannot take this any longer.”

He simply answered, “You have already got all the qualities to generate significant works. You have ideas, writing skills and also the patience to wait for the data. As for publications, luck plays a major part. In the current system, your paper will be rejected if just one of the reviewers dislikes your work. Just give it time.”

Looking back, of course I know I did not have the qualities my mentor described. But I did continue and the work was getting better. For those who wish to quit, I must say that rejection is a unique experience to improve oneself and it is worth it.

23 Sep 2010

Offices

At a recent advancement interview, a professor asked a candidate what he had learned in the last two years.

“I learned about the running of huge institutions by the hard way,” the candidate answered. “When I worked in private companies, the important thing was to get things done and procedures could be ignored. In a huge institution like the university, procedures are everything. People do not really care whether things really get done. If I want to do something, I have to stick to steps 1 to 5. If I somehow miss step 4, people would ask me to start from step 1 again. Of course, through the process, I also learned whom to approach.”

You think he failed? Not quite. First, the other potential candidates did not come to the interview. Second, all three interviewers liked his answer. In fact, I must say that after all these years, I still do not understand the administration of the university as well as this young man does. Whenever I look through the directory wondering who is responsible for what, I feel like Barnabas in The Castle.

“Is it even Castle work that Barnabas is doing, we then ask; he certainly does go into the offices, but are the offices actually the Castle? And even if the Castle does have offices, are they the offices Barnabas is permitted to enter? He enters offices, but those are only a portion of the total, then there are barriers and behind them still more offices.”

16 Sep 2010

The Castle

During this summer holiday, Angelina has read literally hundreds of books.

One day, I was astonished to see her reading The Castle by Franz Kafka. Of course, she was still working on chapter 1, Arrival, then. Thanks to training in phonics, she pronounced most words correctly and understood K. was trying to get a room at an inn.

After talking for a while, I realized that Angelina expected K. to rescue a princess in the castle or do something similar. She found the book too long and urged me to tell her the ending. “You have to find the answer yourself,” I said. But the book was nothing like that and would probably soon spoil her fun.

On second thoughts, I could modify the story a bit. Angelina would feel the conversations similar to those in Alice’s Adventures in Wonderland.

9 Sep 2010

Universal Studios

The next day, our family traveled to Singapore. As expected, we visited the Universal Studios.

We found many similarities between the Universal Studios and Hong Kong Disneyland. Both are small and not too well attended – compared to the same theme parks in other countries; you still need to wait around 10 minutes for each attraction. If you buy Universal Express (48 Singaporean dollars for each person) on top of the admission tickets, you do not need to wait at all. On the day of our visit, we could not see a single soul paying for fast pass.

If you think this means the Studios is no good, you are mistaken. When one travels with a four-year old girl, short waiting time is the most important. Few attractions are not our concern at all. We would not be able to hang around for the whole day anyway. Thus, despite of what many Hong Kong people have remarked, I think the Hong Kong Disney is a nice place. Nevertheless, I would not recommend the Treasure Hunters. This is a motor car ride in the Ancient Egypt area. There is little to see and the ride ends shortly.

The nicest attraction was Lights, Camera, Action! This illustrates how an empty soundstage can become the setting of a Category 5 hurricane in New York. The stormy scene ends with the destruction and collapse of the boathouse where you are standing.

Although technology must have progressed a lot, I felt the King Kong and Backdraft scenes that I saw 20 years ago at Universal Studios Hollywood were much better. Well, no canvas absorbs color like memory.

2 Sep 2010

Metro

I promised some of my colleagues to report on my recent trips to Shenzhen and Singapore.

The trip to Shenzhen was to deliver a talk at a meeting organized by an international cancer organization. I took the opportunity to try the Shenzhen Metro. The Metro was jointly run by the Hong Kong MTR Corporation and China. It was indeed convenient. The Metro station was connected to the Lok Ma Chau MTR station. Both the station and the trains were clean and tidy.

As I came out from the conference center station, I thought the venue would be easy to find. I was wrong. I looked around and found that all the giant complexes looked like conference centers. In the end, I still need to ask a policeman.

That was the first time the international cancer organization held a meeting in China. As most people are aware, China has the money and patients. Where else would pharmaceutical sponsors want the meeting to be? Nevertheless, the organizer somehow overestimated the situation and arranged seven concurrent sessions at the same time. Each room ended up hosting around twenty people, including chairmen and speakers. It is alright. My university promotes small group teaching anyway.

26 Aug 2010

Guidelines

But people who draft management guidelines are conscientious and world-renowned experts. They would not allow their potential conflicts of interest interfere with their judgment and recommendations, right?

Yes and no. I tend to trust that most guidelines reflect what the authors believe and are not for financial and political gains. Nevertheless, the recommendations can still be biased. In our field, colonoscopy surveillance for colorectal cancer prevention is a big business. In some countries, there are clinicians who would call themselves colonoscopists, more or less telling you that they would not do much else. However, one cannot ignore the fact that the effect of colonoscopy surveillance on overall and cancer-related mortality has not been tested by randomized controlled trials. In addition, there is accumulating evidence to show that colonoscopy does not save more lives than flexible sigmoidoscopy, a simpler procedure that does not require thorough bowel cleansing and sedation, not to mention the lower complication rate.

With this background, you probably would expect that experts should support the simpler procedure. Nevertheless, searching through the literature, many experts (notably gastroenterologists) still state colonoscopy as the preferred surveillance method.[N Engl J Med 2009;361:1179-87] The rationales such as more thorough examination and the inclusion of proximal colon are more theoretical than evidence-based. Again, in this particular case I do not doubt the experts recommend colonoscopy for their own benefits. They are so senior that I cannot imagine they are still making a living by doing endoscopies. The biased view merely stems from their background and thus health beliefs.

Therefore, the medical committee is suggesting a revisit of the guideline drafting process. In essence, experts in one particular field should mainly provide relevant evidence but not have overwhelming influence on the final recommendation statements.

P.S. If you search PubMed for articles on CT colonography, it would be funny to note that around half of the articles said that this new radiological technique is extremely good and half said its performance is suboptimal and not ready for routine clinical use. If you note the affiliations of the first authors, the former articles were all written by radiologists and the latter were by, you got it, gastroenterologists. This time, we are talking about real business.

19 Aug 2010

Conflict

Recently, our managers are striving to control the drug budget. Every team is requested to submit an innovative idea to reduce expenditure.

At lunch, AT complained that even an inexpensive drug was tightly controlled although current guidelines had already recommended the most expensive agent as first-line treatment.

“Mind you,” S replied, “most guidelines are written by international experts with much conflict of interest. Not surprisingly, companies selling the newest and most expensive drugs have a lot of influence.”

“You don’t have conflict of interest. You should sit in those panels,” EW suggested.

“Oh, it doesn’t work this way,” said S. “In their eyes, the very fact that I do not have conflict of interest is good enough proof that I am not an expert.”

12 Aug 2010

Puzzles

In one chapter, Gladwell described how the US security expert Gregory Treverton distinguished between puzzles and mysteries. Puzzles are there when we lack some essential information to a factual answer. If we obtain that information, we get the answer. For example, Osama bin Laden’s whereabouts are a puzzle. If you hunt down high ranking people in Al Qaeda who knows his hiding place, you find the answer.

In contrast, mysteries require judgments and the assessments of uncertainty. For example, what would happen to Iraq after overthrowing Saddam Hussein was a mystery. You cannot get the answer even if his officials and sons honestly reply to your every question. The major difference between puzzles and mysteries is that in the latter condition, you are not having insufficient information. You just cannot make use of the information at hand.

Of course, not every one would agree to the definitions. However, when you are trying to solve a problem, it is useful to think why you have not got the answer yet and how the answer can be obtained. Without the insight, wrong moves will get you nowhere.

Many medical students spend countless hours reading textbooks and lecture notes without realizing that their future job demands mostly the ability to solve mysteries. If I ask you the tests for diagnosing pulmonary embolism, it is a simple puzzle one can solve by reading a textbook. The trouble is patients never ask you what the diagnostic tests are. They just tell you a symptom and show abnormalities here and there. If you cannot make the diagnosis, it is unlikely because you have not heard of pulmonary embolism before. Instead, you are probably overwhelmed by the information you cannot fully interpret and organize. Simply said, the answer is not in a textbook.

5 Aug 2010

Interesting

My recent bedtime reading is What the Dog Saw and Other Adventures by Malcolm Gladwell. This is a collection of his writing from The New Yorker. I seldom read this kind of recycled publications, but the temptation is too great after enjoying his famous books previously – The Tipping Point, Blink and Outliers.

While flipping through the pages and wondering whether to buy the book, a few lines in the preface touched me. Gladwell mentioned he was often asked where his ideas came from. If you have read his books, you would probably agree that he is a wizard in suggesting interesting answers to explain everyday phenomena. So how did he do it? He explained that most people considered most things uninteresting. What he did was to convince himself everyone has a story to tell.

This is no different from scientific research. At the end of the nineteenth century, scientists have studied thoroughly many areas of the physical world – electricity, optics, kinetics, to name a few. Many wise men held the belief that there was not much left to study in science. Looking back, we of course know how wrong they were. Relativity, quarks and DNA are just some examples of major breakthroughs that they have never imagined.

In clinical medicine, I have repeatedly heard youngsters complaining the ‘big’ questions have all been answered. Their view is certainly shared by many people in history, but so far all of them were proved to be wrong. If you are not satisfied with current beliefs and keep asking questions, well, the world is an interesting place after all.

29 Jul 2010

Coordination

Last week, Angelina had a performance at the Hong Kong Book Fair. After she had told a story, a group of six-year-olds performed a play - Jack and the Beanstalk. The children were cute and spoke excellent English. Unfortunately, one of them forgot a line and the performance became chaotic. Some classmates tried to be helpful and reminded each other what they should say. After a while, they realized none of them really knew where they were and could not go on. They made a bold decision, said ‘thank you very much’ together suddenly, and ended the show.

Once, I was a member of the hand bell team of my primary school. Hand bells sound nice, but each person is only responsible for two bells. Excellent players may be able to control four to five bells if they can change quickly. Thus, each member is like a single finger of a pianist. No matter how musical you are, you have little control over the whole song and rely heavily on your teammates. This is good training of team work.

I remember little about what we really did and the songs we practiced. Nevertheless, we once performed the bridal march at the wedding ceremony of our teacher. A wrong note appeared in the fifth bar. A couple of bars later, everyone played on their own and lost the melody. To her credit, the conductor tried her best to stop the disaster. Instead of keeping the beat with her baton, she repeatedly pointed at each of us like crazy, as if we were giant keys on the piano. We tried to cooperate, but we were so small! How could we know whether we were supposed to strike the bell in our right or left hand? In the end, she closed her fists tightly to end the song. All of us struck both bells together. The ultimate crash chord.

Our conductor was very angry and did not speak to us. On the other hand, the bride was kind enough to offer us cake. We were ashamed and sorry. Now that I have become an adult, I believe the audience really did not mind. At least we were funny.

22 Jul 2010

I listened to a radio interview of a famous investigator in Hong Kong recently. It was enlightening.

The details of the project have been described by my friend earlier. [see http://ccszeto.blogspot.com/2010/03/study.html] In brief, the investigator obtained one of the biggest research grants from our Government to study the prevalence of a disease among youngsters that was believed to be both common and important. After screening hundreds of subjects, the investigator failed to find any positive case.

Like many epidemiological studies, this study claimed to select potential subjects randomly. However, the selected subjects had the right to choose whether to proceed to the test. In such a situation, it is of vital importance to compare subjects who agreed to be tested and those who refused. If the two groups had major differences, the data obtained would be inaccurate or even misleading.

If I received a big grant from the Government and got such results, I probably would not be able to sleep. However, that investigator was obviously better than me. “The project is a huge success,” he explained to the host. “If the collaborating parties agree, we would definitely extend the project for another year.”

Somehow my mind drifted to a short story.

One day, Emperor Kangxi (康熙) disguised himself as a commoner and walked around Beijing. He met a crowd and found that a murderer was about to be executed. To his surprise, the poor prisoner looked very young and certainly did not match the description of the middle-age murderer. He put the execution to a halt and confirmed that the rich murderer paid a government official to exchange a young boy for him. Furious, he ordered a thorough investigation of the event and other death sentences in the past.

The Prince who took charge of the investigation was the most likely successor of the Emperor. After discussing with his advisors, he concluded that the investigation would reveal uncountable cases of corruption and mishaps. This would create much trouble among senior officials and he might lose their support. Therefore, he just pretended to do something and held a series of investigations and interrogations.

A few months later, the Prince submitted the final report to the Emperor. “In conclusion,” he described, “no other cases of inappropriate judgments or executions were identified. The judges and officials have done an excellent job and should be commended.”

At this, Emperor Kangxi hit the table and scolded, “What a coincidence! There was just one case of corruption in the whole of China and it happened to be seen by the Emperor!”

Well, our Government is not Kangxi after all. Perhaps the disease really does not exist in Hong Kong.

15 Jul 2010

World Cup

Another year of exciting World Cup games.

To be honest, I am interested in the games but seldom enthusiastic enough to stay up to watch in the middle of the night. The only exception is four years ago, when I worked in a lab in Beijing. When you stay with a group of postgraduate students most of the time, you have to pretend to be a youngster. Nevertheless, that was an interesting experience. I just cannot figure out how the Chinese football team can be so lousy when the whole nation is crazy about the game.

Since the time of Jürgen Klinsmann, I have been a supporter of the German team. Although the team does not have real stars and fails to obtain the trophy again after 1990, their performance and results are always respectable. It certainly reminds me of the importance of team work.

8 Jul 2010

Farewell

In the end, we attended three farewell parties for our Boss. Two parties were for the whole department and our team, and the speeches were very formal. The last one, however, was for his own trainees. Each attendee was asked to say something.

Most of us simply recalled funny occasions in the past. Many talked about how they shared a room with the Boss during overseas conferences and why they could not sleep. Discussing research in a swimming pool was also a collective memory. On the other hand, hardly anyone mentioned anything about success and achievements.

When it was JW’s turn, he boldly discussed built to last. He said few people could remember or cite our finest research papers in 1990s. Although those were great achievements, their importance faded with time. JW concluded that the achievement with really lasting effect was the establishment of a team of people who could continue to serve in different areas.

I cannot totally agree. Each generation has its own problems to solve. A low citation rate of papers on smallpox does not mean the original works were unimportant. Nevertheless, I suppose the point is nothing can substitute for the time you spend with your trainees and children.

P.S. The book we gave Boss contained a poem by Su Shi (蘇軾), <和子由澠池懷舊>. "人生到處知何似?應似飛鴻踏雪泥。泥上偶然留指爪,鴻飛那復計東西。" I am not interested in leaving a name in history. However, leaving a small footprint that may benefit others in the future is always a beautiful thing.

1 Jul 2010

Quotes

The other day, my mentor and I discussed about the speeches made by eminent guests at our Boss’ farewell party. He mentioned some people made good use of quotes, and Szeto probably knew best. (see http://ccszeto.blogspot.com/2010/06/blog-post.html)

Well, I am ashamed to report “The mystery is history” that appeared in my blog last week was from Winnie the Pooh.

You may find this popular quote better: “The clock is running. Make the most of today. Time waits for no man. Yesterday is history. Tomorrow is a mystery. Today is a gift. That’s why it is called the present.” – Alice Morse Earle.

Along the same line, I like the Serenity Prayer by Reinhold Niebuhr.

“God, grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference.”

24 Jun 2010

Mystery

Last week, Angelina attended a Trinity College examination. Grades are not important, but it proves difficult not to be curious about what happened inside the room.

“What did the lady ask you?” I could not wait to ask.

“Well,” Angelina replied lightly, “she asked me a lot of questions. I cannot remember them now.”

Oh, one more mystery that would never be solved.

One day later, it was my postgraduate student’s turn. This time, I had to stay in the examination room. Inevitably, I heard questions that I could answer easily. It was trying to watch your own student hesitate and give obviously unconfident replies while you could not do anything. I could see why Ruud Gullit stepped in the football pitch as the player-manager of Chelsea FC, although that was not all too successful.

Maybe it is not unkind to keep parents out of examination rooms after all.

The mystery is history.

17 Jun 2010

Biscuits

After serving as a guest examiner, S had to organize an examination at his own school. To avoid leaking examination questions, candidates were required to report early and stay in a room so that they would not meet others who had completed their examination. Every year, candidates complained about the arrangement. The most common complaint was the school did not provide them with food and beverages.

S still remembered vividly what ST taught him last year. At the same examination, a girl said she was hungry and going to faint. S followed ST to see her.

“What is the matter?” the Discipline Master asked.

The girl looked at him, hesitated for a few seconds, and stammered, “N…Nothing.”

ST turned and brought S out of the room. He was content. What a piece of cake.

This year, another girl said she was hungry and had stomachache. S was sent to handle the matter. He did not really like it but thought it could not be too difficult. He stepped in the room and asked sternly, “What is the matter?”

The rest is history. Suffice it to say, S was caught by the Discipline Master and a few others for smuggling biscuits back to the waiting room.

10 Jun 2010

Core

JW further complained, “How would teachers be motivated to teach? The university does not reward good teaching at all.”

“Good teachers are actually punished,” I echoed. “Not directly, of course. However, when a teacher puts much emphasis on education, he will have less time for research.”

On the surface, universities must state they consider teaching important. In reality, teaching performance can hardly be measured and does not help the ranking of universities. Thus, the decision to promote an academic lies almost solely on measurable success in research output, such as the number of articles published, impact factor, citations, h-index and research grants. Some universities also attempt to assess an academic’s international reputation. How do they do that? Again, they can only use measurable parameters such as the number of times a teacher is invited to another country to give talks. As such, teachers who stay with their local students all the time are considered losers who lack international reputation.

These points are nothing new and have been elaborated by our friend Szeto many times before. Instead, the discussion brought my thoughts back to the topic of core value.

A few years ago, JW introduced the book Built to Last to me. Jim Collins and Jerry Porras described one of the consistent characteristics of successful companies was the preservation of core values. It appears that the content of core values is irrelevant. So far as a company sincerely upholds its core value, the staff can be motivated and the institution will have the drive to progress.

What interests me is the way they define core values: “Core values are the organization’s essential and enduring tenets, not to be compromised for financial gain or short-term expediency.” As Jesus said, even a tax collector loves his friends. But how many can uphold their core values when the very act results in severe punishment?

While I think I know what my core value is, I must say that I have never been really tested. I will just have to see.

3 Jun 2010

Acute

“Do you realize that the first time most of our graduates manage an emergency admission is when they become medical officers?” JW asked me last week.

I felt that was a scary idea. But after thinking for a few seconds, I had to agree.

“And therefore I shall resume on-call teaching round next year,” JW concluded happily.

When we were medical students, attending on-call rounds was bread and butter. We had to see every case emergently admitted to the hospital that day. When the professor came, we presented the cases and discussed the acute management. We never talked about hypothetical treatments such as “we would prescribe broad-spectrum antibiotics”. Instead, we were facing real patients. We said exactly the antibiotics we should choose because of the type of infection, the background medical history, and perhaps even drug allergy. This was a learning opportunity that could hardly be provided elsewhere. For example, if you just wait one more day and see the patient after he is stabilized, the situation is already totally different. And I certainly do not mind what you prescribe to manikins.

Like many good things, the on-call teaching round disappeared out of the blue. The change probably occurred during my junior training years and I could not recall what happened. JW also did not appear to know the details but just said physicians were becoming lazy.

No, it can’t be. Think about the superstars. They are anything but lazy.

27 May 2010

Great Expectations

By this time of the year, year 3 students have usually finished their exams and would assist in biomedical research as part of the training. This year, our original topic was to study the incidence of a disease and factors associated with its development. As we completed the project, it was evident that the number of patients developing the disease was smaller than expected. In effect, it would be difficult to identify the associated factors as planned.

After presenting the results, the boy in my group was obviously disappointed and felt they failed. I disagreed. First, this was a student project that lasted several weeks only. Inevitably, the data would be premature and could not be compared to international publications that represented years of hard work. Second, this is what research is about. Why do we still have to do a project if all the results must be as expected? In fact, I was glad that we had unexpected results. What better learning opportunity could one ask for?

In the end, we decided to report the unexpected results and work on a softer endpoint that the sample size could support. Honesty and problem-solving skills are the fundamental requirements in research. If the students have learned this, this module is successful.

20 May 2010

Test

S was invited to be an examiner of a vocational education school. He was honored.

The examination was simple. The students were instructed to examine a wheel of a car. They were expected to perform Test A, Test B and Test C.

The examination was fool-proof. The headmaster excitedly explained that the students had already undergone a rehearsal of the examination the week before. Besides, to ensure they would not say something silly, the students were informed that the wheel at the examination must be normal. They only needed to report Test A, Test B and Test C were negative. As a note of caution, the headmaster also advised the examiners to remind the students should they miss any tests.

S glanced at the marking sheet and was taken aback. There was one mark allocated to each of the following five steps: Entering the room, Test A, Test B, Test C, and leaving the room.

“Are we not supposed to mark the skills of performing Test A, Test B and Test C?” asked S.

“No,” the headmaster answered, “please just give full marks if a student has performed all three tests. But remember, some students may be nervous and forget one of the tests. In that case, give them a gentle reminder.”

“How then can we assess their skills? It is impossible not to get full marks.”

“This is not the purpose of this examination,” the headmaster replied. S felt he suddenly understood the purpose and decided not to ask anymore.

The examination was extremely smooth and efficient. Students confidently reported that Test A, Test B and Test C were negative, some even before finishing the tests. S was bored and tried to entertain himself by asking the students what could be wrong if only Test C was positive. Though none of them could answer, S understood they were not trained to read positive results and did not want to violate the marking instructions. He gave all of them five marks anyway.

Soon, the last student came in. S gave him one mark for entering the room and instructed him to start. To his surprise, he performed Test A and Test C swiftly and stopped.

“Have you completed the examination?” S dutifully reminded him.

“Yes,” the boy answered, “Test A and Test C were negative.”

“Would you like to perform Test B?” S asked explicitly. It really did not matter. He had given full marks to all students that day anyway.

“No, for this type of wheel, Test A and Test B always give the same results.”

S was sad. Although he could name a special situation in which Test A and Test B would have different results, the boy knew what he was doing but might end up at the bottom of the class.

In the end, S was determined. “You are right. Please just perform Test B for the sake of checking your skills.”

13 May 2010

Joy


Last month, Angela and I were trapped in Vienna because of the Icelandic volcano eruption the subsequent airport closure. One Tuesday, most museums were closed. In the end, we visited the Secession.

As soon as we entered the Secession Building, we realized that it was under renovation. The only work on display was the Beethoven Frieze by Gustav Klimt. The painting was created in 1902 for the celebration of Beethoven at the 14th Vienna Secessionist Exhibition. Though we have heard the Symphony No. 9 for countless times, reflecting on the work through a painting was a new and interesting experience.

Without doubt, the most famous part of the Symphony is the adoption of Friedrich Schiller’s An die Freude (Ode to Joy) in the fourth movement. But let’s first follow the painting on the three walls of the building. On the first wall were Floating Genii which were female figures representing the longing for happiness. Next came a kneeling couple, Suffering Humanity, who urged a Knight to fight for happiness.

On the second wall were the Hostile Forces against happiness, including Sickness, Madness, Death, Lasciviousness, Wantonness, Intemperance and Nagging Care.

On the final wall the pursuit for happiness found fulfillment in Arts and Poetry. The Frieze ended with an angel chorus and a kissing couple. This was in agreement with the Finale of the Symphony.

“Be embraced, you millions!
This kiss for the whole world!
Brothers, beyond the star-canopy
Must a loving Father dwell.
Be embraced,
This kiss for the whole world!
Joy, beautiful spark of divinity,
Daughter of Elysium,
Joy, beautiful spark of divinity.”

The Symphony and the Frieze are certainly powerful. On the other hand, fighting for happiness is the hard way. I am glad I can just choose to be joyful.

6 May 2010

Pathétique

We met our neighbor in the lift last week. She praised Angelina for the magnificent piano performance. My daughter promptly thanked her.

Wait a second. I was the one who played Beethoven’s Sonata Pathétique just now. As I looked at Angelina, the thought was hilarious. Even if her hands were big enough for the numerous chords in the piece, how could her legs reach the pedals?

From another perspective, while a four-year-old playing this piece must be a child prodigy, mistaking my performance as a child’s reflects my interpretation was superficial. This I tend to agree. I never played Beethoven’s grander works really well. Strong emotion is something I admire but cannot fully grasp.

This brought me back to my memory of Chopin’s Valse de l’adieu (The Farewell Waltz). This piece was written to Maria Wodzińska, to whom Chopin was once engaged. Finding it one of the few easier pieces by Chopin, I mastered the work after practicing for several times. As I finished, my teacher said sadly, “Oh dear. Have you ever been in love?”

It took many more years before I learned what pain was.

29 Apr 2010

Diagnosis

Further to my eavesdropping, Ah Kap discussed whether we should rely on human memory or information technology in this era. He argued that doctors who looked up everything were more trustworthy than those who believed in their knowledge.

Frankly speaking, my textbook knowledge has decayed faster than uranium since I passed the membership exam. Apart from a few dozens of drugs that are commonly used, I always consult the British National Formulary before prescribing. Far from being ashamed, I believe treatment is the easy part. Anyone with average intelligence can copy from a drug book and determine anything from dosage to contraindications. With the help of computer programs, one can also easily check if there is dangerous interaction among the drugs being prescribed.

However, no matter how easy it is to obtain treatment information from various sources, the treatment cannot be applied if you do not know what is happening to your patient. You can easily find data showing that Drug A reduces mortality by 25% in a patient with Disease X, but what if you cannot diagnose Disease X?

For the latter point, people may have the romantic idea that new diagnostic tests and computer programs will one day help a doctor with little knowledge make the diagnosis of Disease X. To this, I refer to the discussion by my friend Szeto (see http://ccszeto.blogspot.com/2010/04/technology.html). If advanced technology takes over simple procedures, the inevitable result is junior doctors have few things for their practice, and, therefore, they would have more difficulty to master the difficult techniques. Similarly, if most of the bread-and-butter diagnoses are made by computers, future doctors will unlikely have medical sense. When a computer fails to make the diagnosis, what contribution can you expect from the doctor? Besides, even for bread-and-butter diseases, if a doctor has nothing in mind, he has no choice but to order numerous unnecessary tests before the diagnosis is made.

As Yuen Sir always says, 90% of the diagnosis should be made by history taking alone. I would add that the percentage depends on who and how the history is taken.

P.S. Is this discussion opposite to my original remarks described by Szeto? Yes, but people believe what they want to believe. My point is if robots cannot do not only simple procedures but also difficult ones, we are doomed by the time we retire.

P.P.S. Fine novels by Ah Kap can be found at http://wongsingk.blogspot.com/.

22 Apr 2010

Intelligence

In old days, elders were highly respectable because of their knowledge.

Not any more. Now is the age of information technology. Youngsters only need the skills of learning and problem solving. As for factual knowledge, it has long been outsourced to Google and Wikipedia. A click on the computer leads to much more information than any scholar can possibly memorize. Don’t you realize the intelligence has been rising over generations, a phenomenon known as the Flynn effect?

Yet I found a recent conversion among our pediatricians interesting.

“Who taught the students Turner syndrome?” asked a consultant.

“The Professor himself,” a resident answered, “Why?”

“During the examination today,” the consultant explained, “the students were asked to counsel a mother of a child with Turner syndrome. I am actually not too annoyed that many candidates knew little about the condition. However, quite a number of them told the mother that though they did not know the syndrome, she was welcomed to read more from the pamphlets outside.”

“How come they did not ask her to google it?” another colleague chuckled.

Although the importance of factual knowledge has been downplayed, I suppose I still prefer to see a doctor who can explain rather than refer me to a pamphlet.

On second thoughts, they were not so bad.

“I know that I am intelligent, because I know that I know nothing.” - Socrates

15 Apr 2010

Level 5

Be an anonymous leader and let the people feel they did the job themselves. It is easier said than done.

When my Boss was a junior doctor, he once wrote a case report for medical journals. Before he submitted the manuscript, he sought advice from his physician. The senior doctor did give an advice – He put himself as the first author in front of Boss’ name.

In comparison, I have always been the lucky one. To establish my career, my mentor and supervisors often let me take credit for studies that I only had minor contribution.

Are Level 5 leaders a rare species? Why do we not see them more often?

I suppose it is indeed difficult to attain level 5. Nevertheless, it is probably even more difficult for people to spot a diamond in the rough when they are dazzled by the brilliant performance of charismatic leaders.

8 Apr 2010

Leadership

My friend Szeto wrote about management lately, using Zhuge Liang as an example. (http://ccszeto.blogspot.com/2010/04/management.html). In fact, JW also loves referring to the five levels of leadership proposed by Jim Collins.

1. Highly capable individual
2. Contributing team member
3. Competent manager
4. Effective leader
5. Level 5 executive

Levels 1 to 3 are easy to comprehend. Level 4 leaders are charismatic leaders. They are often well-known to the public and peers, powerful and have strong visions. Companies usually have tremendous growth under their leadership. On the other hand, because a charismatic leader only needs a group of obedient staff who can effectively execute his/her brilliant ideas, little attention is paid to develop competent successors. Many companies suffer from significant decline after they leave.

In contrast, level 5 executive is a mixture of humility and will. Although they also have considerable will power to strive for the benefit of the company, they seldom draw attention to themselves and put emphasis on developing future leaders. From Collins’ study, companies under level 5 executives had more sustained and bigger growth.

When JW first discussed this with me, my first reaction was I had already learned this from Laozi.

「太上,不知有之;其次,親而譽之;其次,畏之;其次,侮之;信不足焉,有不信焉。悠兮其貴言。功成、事遂,百姓皆謂:我自然。」

1 Apr 2010

Orchestra

“I am the conductor of the medical association orchestra now,” JK told me recently. JK is a violinist with deep passion in music.

“Oh,” I replied, “congratulations!”

“I need time to learn more about the goals of the orchestra,” JK continued. “For example, do they want to expand? Shall we try more difficult works? By the way, we are in severe shortage of first violins. Would you like to join?”

I listened in horror (not for the last question because I knew how to reply politely). Although I have never attended any activities of this orchestra, as a medical professional I understand perfectly that expansion was the last thing they were thinking about. Orchestras and sports teams under professional bodies are mostly social gatherings. As for more difficult works, my violin teacher used to say that Mahler’s symphonies were the most fascinating. The structure was so complicated that everyone seemed to be playing different things at the same time. I think an amateur orchestra can at least achieve the latter effect.

At the end, I just answered, “If you are still there when I retire, I will certainly join.”

Somehow, the conversation reminded me of TW. When I was a junior trainee, one day TW and I were screening laboratory reports. “You know,” she spoke up suddenly, “resources are limited. One of the essential skills of a doctor is to determine when to make a big fuss and when not to. Somehow, it is curious to note that some doctors still make a big fuss over everything despite their seniority.”

Though TW was talking to me, I swear she was staring at the lady who crossed the harbor.

25 Mar 2010

Abstract

Our oncologist friends told us that because their field was advancing so rapidly, they seldom cited full papers. To provide updated information, oncologists mostly cited conference abstracts. They anticipated they would soon have to cite data from press conferences.

That made us look very backward. At the time when the development of therapies for chronic hepatitis B was at its height, we did cite some conference abstracts. This dampened a lot in the last one to two years after the data of the major drugs in this field had been published as full papers. After all, why should we cite the year six data of a drug presented in the latest conference when the year five data have been published in peer-reviewed journals? The early online publication of accepted papers by biomedical journals also facilitates rapid dissemination of data. Certainly, we are far from the stage of citing New York Times except for fun.

A comprehensive review of 29,729 conference abstracts found that only 53% of all abstracts were eventually published as full papers at 9 years.[Scherer RW et al. Cochrane Database Syst Rev 2007 Apr 18;(2):MR000005] The observation may have a number of reasons. There may be publication bias where negative studies are less likely to be published. Some studies may have major methodological flaws. While they look alright in abstract form, they cannot get through the scrutiny of peer reviewers when presented in full. Moreover, some conference abstracts are obviously put up by pharmaceutical companies for promotional purpose and never intended to be published as full papers.

While it is charming to cite a reference to support our view, we must remember that big message does not equal big evidence. We should scrutinize the reliability of data, whether they are from scientific papers, abstracts or New York Times.

18 Mar 2010

Supervision

Shortly after the meeting, I had lunch with SW who came to Hong Kong for a job interview. Having spent three years in the PhD program, he would like to pursue his career as a clinician-scientist.

“Actually,” he remarked, “I seldom see my supervisor. He is so busy that I may meet him only once every several months. I learned most of my laboratory techniques and bioinformatics from a new postdoctoral fellow.”

After talking to quite a number of postgraduate students around the world, I am afraid this is a common phenomenon. In some countries, big professors may have one to two dozens of postgraduate students at any time. There are occasions in which a supervisor does not know the existence of a student, not to mention what he/she is working on.

It is understandable that students only want to follow big names though they are most unlikely to be available to provide supervision. Choosing among less famous supervisors can be even riskier. As such, how can the students survive?

My usual advice is not to depend too much on the supervisor. Find a big center and try the best to learn from people around you. After all, postgraduate study is about self-learning and problem solving.

11 Mar 2010

Game

At a meeting last week, CM explained the rules of choosing postgraduate students in the department. I beamed at my mentor. “Game theory!”

It goes like this. First, each department chooses a number of postgraduate students according to the assigned quota. These students would certainly be recruited. After that, there will still be vacancies in the whole faculty. Each department would then select candidates from the remaining list for central bidding. The latter students would compete with candidates recommended by other departments. Those with the best academic results would get the remaining seats.

Let’s ignore the issue of fairness for the time being. The central bidding step is the most fascinating part of the whole process. If we place less impressive candidates in the guaranteed list and pose the best students for central bidding, we would have a higher chance of getting more students for the department but also risk losing the best candidates. Conversely, if we put the best candidates in the guaranteed list and recommend the rest for central bidding, we for sure will retain the candidates we want but would less likely get extra students.

In game theory jargons, since the total number of vacancies for central bidding is fixed each year, this is a multi-person, zero-sum game. The payoff is the number of extra students obtained. Assuming that the quality of applicants in each department is similar, we can presume that a department will have almost 100% chance of winning if it sends the best candidate for bidding while other departments send those on the waiting list. Similarly, a department will have nearly zero chance of winning if it sends a waiting list candidate for bidding while others send the best ones. When two departments send the best or the so-so candidates for bidding at the same time, we can assume that the chance of either winning would be 50-50. The probability will decrease by proportion as more departments decide to send the best candidates.

In this situation, because there are multiple players in the game, the probability of having none of them choose the best (or very good) candidates for bidding is too trivial to consider seriously. Therefore, the only chance to win is to send the best student for the competition.

Then there is no need to hesitate, right? Not quite. In the above argument, the only payoff considered was the total number of extra candidates a department obtains. In reality, the perceived value of getting an extra candidate and that of losing a superb candidate should be taken into consideration too. That weighting is subjective.

I cannot say for others, but what is the perceived value for me?

That would be better explained by Cheshire Cat.

Alice: I was just wondering if you could help me find my way.

Cheshire Cat: Well that depends on where you want to get to.

Alice: Oh, it really doesn’t matter, as long as …

Cheshire Cat: Then it really doesn’t matter which way you go.

4 Mar 2010

Repay

Last week, we received a peculiar e-mail proposing a change in our specialist on-call system. Instead of starting our call duties when we arrive at work in the morning, we are to hand over duties at midnight.

The news was received with mixed feelings. Most specialties had already anticipated the change and stopped providing on-call service. Team members who continued to provide emergency service were particularly anxious. If one is paged right after midnight and again before the next midnight, this means one may need to work through two consecutive nights. The dissociation between the specialist and general on-call system also results in lengthening of working hours to fulfill both duties.

Why all these troubles? Under the latest court verdict, doctors are entitled compensatory leave after non-residential call. If the call day spans across midnight, administrators are worried that doctors may take advantage of the system and request two days of compensatory leave.

Having never taken compensatory leave before, I felt somewhat humiliated for being considered as a professional who may take advantage of others. On second thoughts, who can you blame?

During the Zhou Dynasty, Yurang (豫讓) served Earl Zhi (智伯) in Jin (晉國). During a civil war, Earl Zhi was killed by his enemies. Viscount Xiang (趙襄子) hated Earl Zhi so much that he used his skull as a cup.

After this, Yurang repeatedly tried to assassinate Viscount Xiang for revenge. To avoid being recognized by the Viscount and his followers, he rubbed lacquer on his skin to produce ulcers and swallowed hot ashes to destroy his voice. Although all his plans failed in the end, even Viscount Xiang was moved and asked why he had to suffer all these.

“Others treated me as a commoner,” answered Yurang, “and I repaid them as a commoner. Earl Zhi treated me as a hero and I should repay him as a hero.” 《史記•刺客列傳》

Courageous as it might, Yurang’s answer reflects the natural response of most people. My only challenge is if you do not want to be treated as a commoner, do not act like one.

25 Feb 2010

Stockholm

One day, learning that an assistant of a rather demanding senior doctor left her job, GW wondered aloud, “Why doesn’t the remaining assistant quit, too?”

“Stockholm syndrome.” I replied slyly.

Stockholm syndrome was coined by criminologist Nils Bejerot after the famous Norrmalmstorg robbery in Stockholm in August 1973. During the event, bank robber Jan Erik Olsson took four people as hostages for six days. While the victims naturally persuaded the government to follow Olsson’s request when they were held captive, it was remarkable that they continued to defend the robber after he surrendered. With strong emotional bonding, the hostages still claim they feared the police more than Olsson.

At present, Stockholm syndrome refers to a psychological phenomenon in which hostages develop irrational positive feelings towards their captors. Although the pathogenesis of the syndrome is not completely understood, there are a few prerequisites. The captor is considered to have the power to kill and grant lives by not killing. The hostage is isolated from other people. Importantly, the captor shows some kindness towards the hostage. As a result, the hostage perceives that his/her survival is linked to the captor.

In real life, we seldom meet fully-armed villains. However, I cannot help but think that we are often similarly bound to old habits and stubborn decisions for the same reasons. Failing to think outside the box, we are isolated from alternatives and exaggerate the danger of change and the merit of the present state.

18 Feb 2010

Catcher

J. D. Salinger passed away last month. His best known novel was The Catcher in the Rye.

The main character, Holden Caulfield, was a boy expelled from a preparatory school. The story was about his observation and thoughts while he wandered in New York for three days, not wanting to return to his parents yet. Disgusted by the adult world, he was considered an icon of teenage rebellion and confusion.

At the end of the story, Holden had a long discussion with his younger sister Phoebe. He pictured a scenario where many children were playing some games in a huge rye field next to a cliff. His dream work would be a catcher in the rye, saving children from falling down the cliff. In essence, he wanted to stop children from becoming ugly and superficial adults.

When I was a medical student, a local doctor wrote a very popular book called I am an Intern. Overall, the book was informative. However, one chapter depressed me. The author thought that senior doctors talked about caring for patients only because they had passed all the examinations and had less workload. This can be a slippery slope phenomenon. If one can accept not treating patients by heart because he has to prepare for examinations, he will have even more excuses later. Administrative work, specialty duties, research, you name it.

I feel warm whenever I see young doctors and students chatting with patients and really listening to them. I may not be a good catcher, but please, don’t fall down the cliff.

11 Feb 2010

Vaccine

Recently, our government officials were asked about incidents of Guillain-Barre syndrome and intrauterine deaths in people who received the new swine flu vaccine. Every time, their response was monotonous. “There is no evidence that the risk of Guillain-Barre syndrome (or intrauterine deaths or any complications, depending on the original question) is increased with the use of the vaccine.”

According to the tone of the media, their claim was hardly reassuring. Many still fear that the government is tricking them to use an unsafe product. (The effect was better illustrated at http://ccszeto.blogspot.com/2010/01/armor.html.) Although I do not really think the vaccine is dangerous, I have the uneasy feeling that the government may intentionally or unintentionally confuse the public.

In evidence-based medicine, the lack of evidence can never be used as evidence against a concept or hypothesis. For example, if no one has ever tested a drug in a certain disease, you can just say you do not know if it works but cannot state it does not work. The same also applies to harm. If you never look for the harm, how would there be evidence?

In the last two months, the efficacy data of the swine flu vaccine became available. [Greenberg et al. N Engl J Med 2009;361:2405-13, Zhu et al. N Engl J Med 2009;361:2414-23, Clark et al. N Engl J Med 2009;361:2424-35, Arguedas et al. N Engl J Med 2010;362:370-2, Nolan et al. JAMA 2010;303:37-46] Notably, all these studies excluded pregnant women. Similar to our government, WHO and CDC also encourage pregnant women to receive the new vaccine and reassure the public that studies on pregnant women are ongoing. If we search ClinicalTrial.gov, we can see that a handful of studies are recruiting pregnant women to try different brands of the swine flu vaccine. Each study recruits around 150 to 300 women. Thus, in the end we probably will have safety data of 1000 to 2000 women. It is reassuring, isn’t it?

This leads to the question of statistical power. In 2003, data from the US National Center for Health Statistics showed an average fetal mortality rate of 6.9 deaths per 1000 births. Using online calculators, we can estimate that a sample size of 2000 subjects can achieve a confidence level of approximately 0.5% at a 95% confidence interval. Although this confidence level is already respectable, it also means that we can conclude the new vaccine causes harm only if the rate of fetal death has doubled. Therefore, the importance of post-marketing surveillance cannot be overemphasized.

In the end, the vaccine probably will result in more benefit than harm at the community level by reducing the number of people infected with the virus. However, the risk-to-benefit ratio is less certain at the individual level. People who stress the mortality rate of swine flu is higher than the harm of the vaccine should consider the fact that people not receiving the vaccine may not contract the virus at all. While the motives of various health authorities are understandable, mixing up the above concepts can be misleading.

4 Feb 2010

Thanks

Thank you all for your greetings last week. In fact, I secretly removed my birthday from my Facebook profile earlier on and realized that my friends could still see it. This is probably a good example of my aging mind. Other examples may include:

- Silly enough to tell my wife that another woman was very beautiful. (She was Martha Argerich.)
- I thought Bach was boring when I learned piano. Now it has become my prayers.
- I can no longer recite any new music work.
- When I was a student, I once went to the medical clinic and requested to follow Szeto. He threw me out of the room. I was really angry then but can now see his point.
- I stopped wearing ties on Saturdays and thought that was quite sporty.
- I zoomed to 150% when I typed this.

28 Jan 2010

Generations

The post-eighty generation has become the focus of the recent political turmoil and is even considered as a social problem. This kind of crude classification often creates trouble. In Identity and Violence, Amartya Sen elegantly demonstrated that such narrow view was central to the current international conflicts. Think about Muslims. Commonly stereotyped, they can actually be viewed as members of other groups such as by citizenship, residence, gender, class, profession, employment, food habits, etc. Some of them may even be fans of FC Barcelona like me.

I will not talk more about politics, but it is interesting to share what my mentor taught me about generations. As usual, this is a brilliant utilitarian view.

The baby boomers (born roughly in 1946-1964) are hard working and hold key positions in many organizations at present. People from Generation X (roughly 1965-1980) generally receive better education and have high aims. On the other hand, people from Generation Y (roughly 1981-2000) are relatively egocentric and look for fun. Of course, this classification is crude and the years vary among societies depending on the pace of economic development. Anyway, this is not the main point of my mentor.

His point is since your supervisor is often one generation immediately before you, you will be recognized by him/her and be successful if you share the characteristics of that generation. For example, the most successful people from Generation X are hard working and good team players. In contrast, people who quarrel about workload all the time can hardly be appreciated and given chance.

Inevitably, our conversation turned to the future of our children. Generation Z is born in a wealthy and high-tech world. The children learn to use iPhone and Facebook faster than any of us, but they also lack face-to-face social interactions. To be recognized by Generation Y, these children must develop passion in some areas and be able to make friends with others.

21 Jan 2010

Move

We moved house earlier this month. The trick is not how to pack things, but to decide what to abandon.

Words of wisdom? Angela obviously did not think much of it. She thought my main contribution in the process was taking care of books. Of course, my simple response was the books were my only possessions.

When it comes to books, the selection is utterly simple. My rule of thumb was to bring only books that I would read again or I expected Angelina would read in the future. Most books did not fulfill these criteria. As an example, I only stared at the A Textbook of Medicine for five seconds. First, some contents were outdated. Second, it no longer represented the lousiest textbook of medicine. It should go.

In Noruwei no Mori (Norwegian Wood) by Haruki Murakami, Nagasawa said he only read books written more than fifty years ago. Life was short and one should not waste time on unworthy works that could not stand the test of time. On the other hand, for works that were worth reading, one could read them over and over again and never got bored. In fact, one could read any page at random and always be satisfied.

This view is obviously not welcomed. If everyone does so, how can authors earn a living? Nevertheless, when I looked at the bookshelves in our new home, most books were over ten years old. Not bad.

14 Jan 2010

Library

GW asked me what books I borrowed from the university library. I just answered novels but did not elaborate further. I was too embarrassed to explain my recent habit of crosschecking stories from Disney movies.

As a father of a four-year old girl, I watch countless cartoons. With time, I realize that I have mixed up most stories. For one thing, the Disney version of The Hunchback of Notre Dame cannot make sense without describing the lust of Claude Frollo toward Esmeralda. On the other hand, children probably would not accept the fact that the beautiful Gypsy was betrayed by her love, Captain Phoebus. As if this is not enough, in the latest version of A Midsummer Night’s Dream that we watched, Mickey Mouse, Minnie Mouse, Donald Duck and Daisy Duck were starring the four Athenian lovers. In The Three Musketeers, four Barbie dolls were shouting the famous motto “tous pour un, un pour tous”. Getting more and more confused, I have no choice but to read the original works.

When I was an undergraduate student, I often feared what I read from textbooks might be inaccurate or even misleading. My predecessors only suggested that I should make my life easier by sticking to and believing in one textbook. I could not take that and ended up reading multiple books on a similar subject. The obvious advantage was the development of critical thinking which built my interest in research. How can one find what is not right without viewing from different angles?

This is probably similar to the study of antiques. According to KL, all collectors have to go through three stages.

Stage 1: Being fooled by others
Stage 2: Knowing he has been fooled by others
Stage 3: Fooling others

7 Jan 2010

Thursday

Szeto and BM described the schedule of my blog as the publishing day of the New England Journal of Medicine on different occasions. I am always happy to meet regular readers of the Journal. I developed the habit since my first medical clerkship. Upon KL’s encouragement, I started reading Lancet as well since my last year as a medical student. To maintain the habit of reading every issue, I glance through the content on the day of publication every week.

For young readers, below is a list of weekly journals that I read regularly. I left out Nature Medicine and the journals of my specialty, which are monthly publications. But I think KL is right. One should be pretty fine just by sticking to the two general medicine journals.

Wednesdays: JAMA, Annals of Internal Medicine (twice per month)
Thursdays: New England Journal of Medicine, Nature
Fridays: Science
Saturdays: Lancet, BMJ