29 Dec 2011

Composition

Angelina had her first examination before the Christmas holidays. One section in the Chinese paper was sentence composition. In the last few tests, Angelina had already learned that the marks did not depend on how interesting the sentences were but on whether she made any mistakes. Therefore, the simpler the sentence, the more likely she would get full marks.

So she wrote this:

Crawl: I crawl.

Probably because many girls did the same thing, the teacher added one more instruction during the examination – The sentence must include at least one comma. The next version became like this:

Crawl: Today, I crawled.

Not everything that counts can be counted and not everything that can be counted counts. But does counting breed evil at such a young age?

22 Dec 2011

Election

Recently, we had to elect representatives for the medical profession. They would in turn elect the next Chief Executive of Hong Kong. This time, a surprisingly large number of candidates joined the election.

Some candidates were kind enough to visit our hospital and shake hands with us. “Who will you vote for as the Chief Executive?” I asked one candidate on my way to the wards.

The wealthy dermatologist gave a diplomatic answer, “I haven’t decided yet. I will meet each candidate and learn their view on medical care before making the decision.”

I was just making fun of him. Actually, none of the candidates from our sector declared their choice openly. What intrigues me, however, is why they did that. If they clearly indicate their choice, voters with similar inclination can pick them without guessing. It is difficult to imagine they can attract more votes by hiding their choice.

But no, they were not hiding their choice from us. They were hiding it from the future winner.

I should say no more, so let’s get back to science.

In most elections, minority groups would try to push their agenda. These groups often more actively promote their views and persuade others to vote in favor of them. At the same time, many voters know little about the candidates and can be easily persuaded. In a research paper this month, Couzin and colleagues asked an interesting question: What is the role of these ignorant voters during an election? (Science 2011;334:1578)

Contrary to the prediction, the ignorant voters do not fall prey to the manipulation of minority groups. In contrast, according to three different models, the presence of these voters is essential in upholding the preference of the majority. They are more likely to follow the choice of their neighbors, resulting in amplification of the majority vote.

After reading this article, however, I do not know how the findings can be applied to our own election, when nearly all voters were ignorant.

P.S. “X lost,” W announced at lunch. V felt a chill over his spine. He quickly googled the election results on W’s iPhone and gave a sigh of relief. “Good Lord, he lost by more than one vote.”

15 Dec 2011

Invitation

During a local scientific meeting, a friend from a pharmaceutical company grabbed me aside. “Hi, Vincent! We sent you an invitation earlier regarding our upcoming advisory board meeting. Are you coming?”

“I am thinking about it,” I was being polite.

Sensing my hesitation, he continued, “I don’t know how to put it, but listen. I know you are good, but my bosses don’t. If you do not join our activities and meet them, I cannot arrange you to speak for our company in future symposia.”

I know people who would not pause a second but eagerly accept such invitations. Universities nowadays only count the countables, and overseas talks of whatever nature happens to be one. While I do not mind giving such talks, having fewer invitations is not a problem either. After all, I have jobs to do and cannot spend all the time flying around.

Whenever I face issues of academic integrity, I cannot help thinking what Professor AL would do.

Once, AL was invited by a company to give a talk in a regional meeting. Despite some disagreements, the company insisted that she used every slide prepared by them. She finally agreed.

On the day of the talk, AL pointed at the slide and began, “Let me explain why the message of this slide is misleading.” Her comments on each and every slide went on and on for the next twenty minutes.

8 Dec 2011

Title

On my way to work, I met F. He was my roommate during my final year of medical studies. When I told him my present title, he exclaimed, “You hold such a high position now!”

I was so embarrassed. Then I decided to tell him something else. “In some restaurants, waiters are waiters; captains are captains. In other restaurants, all waiters are called captains, if not managers.”

The most impressive remark on my title, however, came from my younger colleague.

After the morning round one day, our house officer asked me to write a reference letter for her. “My pleasure,” I said, “but why don’t you ask someone higher up? My recommendation is unlikely to be of much help.”

“You may be short, but your position is high,” she did not even hesitate.

1 Dec 2011

Age

Szeto told the story of his age recently. (See http://ccszeto.blogspot.com/2011/11/age.html) Let me share mine.

At the dinner after an advisory board meeting, the organizers could not resist the temptation to ask my age. I was so sorry. Evidently, they had expected to invite a more senior person. But then I decided to give a more evasive answer.

I referred to a professor from Beijing and said, “Professor J has known me for years. I can’t be that young.”

The professor of infectious diseases gave an even quicker answer, “I can prove that he is at least twenty.”

24 Nov 2011

Question

The next day, I met Little Red at the bedside tutorial. I had actually seen her during ward round already, just that I was not as observant as HC in regard to the hairstyles of girls.

We saw a patient with excellent physical signs of left homonymous upper quadranopia and hemineglect. After a student had checked the eyes, I asked whether he had completed the examination of the optic nerves. He said yes, and I explained that the examination of the eyes should include visual acuity, visual field, light reflex, accommodation reflex and ophthalmoscopy.

“The accommodation reflex is eye convergence and pupillary constriction, isn’t it?” Little Red raised her hand and asked.

“Yes, it is,” I answered.

“So it isn’t a test of the optic nerve, is it?”

“Um,” I hesitated, and then continued, “but the afferent pathway is through the optic nerve. A good point, though.”

Later that day, I met PC at lunch. The pathologist complained that his daughter’s Chinese teacher was totally inflexible. “She insists that the students must follow her way of writing Chinese characters, though there are actually more than one ways to write the same word.” I listened in silence and was quite happy that I was never offended by the questions and challenges from students. Over years, I had been wrong on many occasions. But if my students can ask questions and find the answers themselves, who say this is not a job well done?

17 Nov 2011

The Girl with Red Hair

“That girl was most impressive,” HC was referring to a year 3 student with impeccable knowledge. Seeing that we were not sure who he was talking about, he further described her as “the girl with red hair”.

“Not again,” moaned K. “I am sick of medical students with hair coloring.”

HC reassured him that the girl was not like that, “It was just a faint shade of dark red.”

Not long ago, a male student without a tie would already face the wrath of the professor. Now hardly anyone utters a word even when a student wears a Real Madrid shirt in the ward. Rules and tradition are shaky before a generation who only considers their teachers as ‘friends’ on Facebook.

“If you criticize their dress code, they won’t listen and will just think you are old fashioned,” HC explained.

K was still unconvinced and shared his experience of meeting students in shorts and scandals. “What would our patients think?”

That is more to the point. It should not be what we want. How the appearance may affect the work is much more important.

For me, I just need my students to be professional. If they aren’t, dressing like one hardly helps.

10 Nov 2011

Jubilee

Last week, Sir Alex Ferguson celebrated his 25th anniversary as the Manager of Manchester United. Many superstars thanked him for the teaching and inspiration. While success of the Club is taken for granted nowadays, it is difficult to imagine that Sir Ferguson spent his first three years struggling without a single trophy. During an interview, the Director revealed that the board of directors actually considered sacking him on at least three occasions for unsatisfactory club performance. Looking back, keeping the manager was one of the wisest decisions in the history of football club management.

On the other hand, I could not help thinking how many people were less fortunate and had their careers cut short before their effort paid off. This is not unique to football fields. The academic arena is no less fierce.

“How should leaders decide then?” I asked my mentor one day. “People should be given opportunities to develop. However, when a person is not productive, it is quite possible that he really does not have potential.”

“You should look at what the person is doing,” he answered. “In contrast, bad leaders only look at results. If you cannot distinguish between the two, you will always pay for results and can never attract talents.”

3 Nov 2011

Grief

As usual, the issue of student discipline was brought up at this year’s curriculum retreat. JC and others mentioned examples such as students skipping classes and coming to the wards in track suits or slippers. Some interns slept through the night without answering a call. The list could go on and on.

This year, however, JW tried to cool down the discussion. “We have to understand that this is grief reaction to loss. It is a loss of childhood. We have to be sympathetic and help the students go through this stage,” said the winner of Vice-Chancellor’s Exemplary Teaching Award.

During a chat the following Monday, JW further remarked that I had been too harsh to the students. “All right, I will be more sympathetic in the future,” I promised.

What JW said was true, and many graduates are indeed responsible and competent. Alas, we are sometimes putting our patients in the hands of children with grief reaction.

27 Oct 2011

Pay

“If I put bandages on my dolls,” Angelina asked one day, “will you give me more pocket money?”

Following the advice of some educationists, I have been giving Angelina pocket money since she was five. The idea sounds great. Children learn to save money and do simple arithmetic. They also become more confident by talking to grownups at the cashier. The interval of giving money is important. If you give every day, children tend to spend the sum at hand and have no incentive to save.

“Why would you want more money?” I asked.

“So that I can buy toys for my brother.”

Hmm, a legitimate reason. “But I don’t need bandages on the dolls. How about tidying up your toys instead?”

Angelina hesitated. She did not want to earn money by doing things she did not like. After some negotiation, she proposed to have the amount linked to her test or dictation results instead.

The next day, I started to feel very guilty. Paying for test results is against all education principles I have learned so far. Coincidentally, my friends at the hospital shared the stories of their children at lunch time.

“But shouldn’t we reward the learning process but not the results?” I asked them tactfully.

“Can you cite one paper to show that it works?” Szeto replied. I was much relieved. Even Szeto said so. Yet, I was still too embarrassed to mention that the reward was money.

Imagine how surprised I was when I read this article from Science last week.[2011;334:300] The National Math and Science Initiative in the United States has been paying students for satisfactory results at the Advanced Placement tests since 2007. The results were remarkable. Under this scheme, the number of students passing the tests increased by 124%, and even by 216% among African Americans and Hispanics. The rate of increase was over four times greater than schools not covered by this scheme.

Of course, the morality behind the scheme is highly debatable. Nonetheless, finding incentives to encourage learning remains the responsibility of teachers.

20 Oct 2011

Composition

Angelina brought her composition back. It began proudly with ‘I am clever and lazy’. Her mother fainted.

“How could you write that?” I said. “Even if you think so, you don’t need to tell your teacher.”

“She even used ‘and’, not ‘but’!” Angela said as she regained her consciousness.

Angelina was consistent with her statement. Later, we opened her handbook and found it full of codes we could not decipher.

“What is N.D.N.W.?” I asked.

“No dictation next week,” she answered.

“How about R.M.B.?”

“Read I can ride my bike.”

“This is ridiculous. You will forget what they mean soon.”

“But I remember.”

I paused. This was an argument I could not win. I tried to figure out why I was so upset. Perhaps it was because our administrators were also creating lots of short forms I could not comprehend. If my daughter wishes to become one of them, what can I say?

13 Oct 2011

Orientation

Last week, GW, HC and SW were discussing what to say on the university orientation day. They were quite surprised when they learned that I did not have to speak at the sharing sessions. After all, the Faculty even invited colleagues who graduated from other medical schools.

I explained that I talked at one of those occasions four years ago. My speech could be summarized as follows:

“Dear students and parents, thank you for coming to our university today. When you go through different exhibitions, you would be wondering what career to pursue and which university to enter. What a question. If you come twenty years ago, many people would tell you that doctors could make a fortune. Not anymore. Although doctors are still whining about manpower shortage, it is clear that many new doctors are produced every year. It does not take a deep knowledge in economics to understand that the income of doctors will decline significantly in the years to come. Take the private market for example; newcomers are already earning less than half of their predecessors.

“This to me is a good thing. High achievers who wish to earn as much as possible are better off doing businesses primarily about money. This is better than trying to get the same amount out of our patients’ pockets. At the end of the day, I hope that those of you who choose to enter our medical school will instead focus on serving the public and improving medical care. Thank you very much.”

After these years, I can elaborate much more on this topic. For some uncertain reasons, however, no one invites me to talk again.

6 Oct 2011

Vote

Last month, our dear colleague asked us to vote him as a representative in the Faculty. I could not be more surprised. Clearly not every researcher, including brilliant ones, dreads meetings. Summer bugs cannot talk about ice.

Every year there are at least several entries at the Freakonomics blog on voting. One of the earlier stories goes like this:

An economist met another economist at a polling station. After an embarrassing moment of silence, one of them said sheepishly, “My wife made me come.” The other responded, “Me too.” The first economist came up with an idea, “If you promise not to tell anybody I came here, neither would I.” The colleague eagerly shook his hand and said, “Deal.”

As Steven Levitt explained, the chance of a single vote to change the outcome of an election is infinitesimal. Therefore, at the individual level, voting is almost always a waste of time.

This view is a taboo according to the current general education curriculum. Voting is our civil responsibility. You may also argue that if everybody holds the same pragmatic view and does not show up at elections, the society would be at stake.

Let me ask you a question: Have you helped at an elderly home last weekend? Okay, some of you have. Have you helped in Fukushima then? There are many things ought to be done in this world, but it does not mean we have to do every one of those ourselves. For example, I regularly do volunteer work in some areas, and can feel at ease when I cannot help on other occasions. Of course, it could be problematic if nobody shows up at elections. But would it really happen?

So, did I vote in the end?

What a question! First, I promised to vote. Second, our colleague would make a great representative. Third, unlike a usual election, I need to lower my own chance of being elected.

Congratulations, R!

29 Sep 2011

Confidence

Throughout our school years, our teachers keep asking us to be humble. In medical school, we are taught not to jump to conclusions. We should always consider differential diagnoses and perform more confirmatory tests.

Have we followed their advice? Is the advice sound?

Let’s consider the second question first. In the last issue of Nature, Dominic Johnson and James Fowler used an evolutionary model to show that overconfidence confers survival advantage. [Nature 2011;477:317-20] When more than one person competes for resources, the decision to fight depends on the chance of winning as well as the cost of losing. If each person has perfect knowledge on the strength of oneself and the other competitors, the decision is straightforward. You only claim the resources when you are stronger than others, and should not fight at all in face of a stronger opponent.

In reality, however, perfect knowledge is rare. The decision is therefore based on an estimation of one’s strength in relation to others. As a result, a person who overestimates his strength would fight more often than average, while one who underestimates oneself would more likely give up. According to Johnson’s and Fowler’s model, overconfident populations would claim more resources in most situations and gradually grow in strength. The only exception is when the cost of losing is particularly harsh. For example, when KL was a senior medical officer, you would be a fool to argue with him about call duties. First, you still lose the argument. Second, he gives you an extra call next month.

No wonder we see so many arrogant people around. Now that we understand how they evolved, we should no longer hate them but congratulate them for improving our species. In an accompanying commentary, van Veelen and Nowak named a number of real life examples. [Nature 2011;477:282-3]

"Most people report their driving abilities to be above average. 70 percent of high school students think their academic performance is above average. 94 percent of professors rate their teaching abilities as above average."

I can easily add more items to the list. 100 percent of endoscopists underestimate their average cecal intubation time. 95 percent also overestimate the size of peptic ulcers they treated and polyps they removed. Don’t be surprised if you read an endoscopy report saying there was a 5 cm ulcer in the narrow first part of duodenum.

That is why we are so competitive.

22 Sep 2011

July

A recent meta-analysis confirmed the “July effect”. [Young et al. Ann Intern Med 2011;155-309-15] During changeover to a new group of interns, mortality of in-patients increases by 4-12%. This is accompanied by an increase in medical errors and prolongation of hospital stay.

It is often a relief to note that terrible things do not occur only locally. On the other hand, the fact that “July effect” is genuine and widespread is disconcerting. If a disease is causing deaths of this magnitude, it would have drawn a lot of attention. New treatments would be developed and introduced every year. The same does not apply to human errors. Professionals tend to accept that it is natural and inevitable that newcomers would commit errors.

While I was pondering this question, KM joined us for lunch. “I have a new proposal,” he announced. “Let’s ask interns to take care of all emergency cases. To ensure compliance, we can assign whole day clinics to on-call medical officers. The cases would then be reviewed only by the physicians in the evening.”

LS was speechless. After a while, the intern coordinator finally said, “But our patients will die!”

“Interns are supposed to see emergency cases now,” reminded my mentor. “Why do we have to change?”

“I was approached by an intern,” KM explained. “She wished to see emergency cases, but said she could only do so if we put it as a policy.”

“Why?” all of us asked. “If she is eager to see the cases, who would stop her?”

15 Sep 2011

Rumors

趙孝成王七年,秦與趙兵相距長平,時趙奢已死,而藺相如病篤,趙使廉頗將攻秦,秦數敗趙軍,趙軍固壁不戰。秦數挑戰,廉頗不肯。趙王信秦之間。秦之間言曰:「秦之所惡,獨畏馬服君趙奢之子趙括為將耳。」趙王因以括為將,代廉頗。趙括既代廉頗,悉更約束,易置軍吏。秦將白起聞之,縱奇兵,詳敗走,而絕其糧道,分斷其軍為二,士卒離心。四十餘日,軍餓,趙括出銳卒自博戰,秦軍射殺趙括。括軍敗,數十萬之眾遂降秦,秦悉阬之。【史記•廉頗藺相如列傳】

“As a leader, one hears rumors about his staff from time to time. If you were the King of Zhao, how would you handle the situation?” asked my mentor one day.

My mentor rarely talks about Chinese history, so I knew it must be important. “With hindsight,” I answered, “sacking the general would of course be the worst option. I suppose I would not do anything.”

“If you have known your staff for years, you should understand his temperament and not be affected by rumors easily. Having said that, keeping silent is not good enough. Your staff is not stupid. He must have heard the rumor, too. If you do nothing, he would think you are plotting something. In this situation, I would tell the general that I heard some rumors but I believe in him.”

8 Sep 2011

Alpha

Angelina began her life as a primary school student last Friday. To celebrate this important event, parents prepare all sorts of gifts for their children. Some may choose books, others toys, or even stocks. We did something different. The answer can be found at www.ahwwong.blogspot.com.

1 Sep 2011

Citations

“You have been on Szeto’s blog for 5 consecutive days!” exclaimed LL and HC.

They were talking about my post 3 weeks ago (http://vwswong.blogspot.com/2011/08/unlucky.html). That piece was written for fun, but the subsequent elaboration by my friend was a masterpiece. As a result, there was also a modest increase in the number of views on my blog.

If that was a scientific article, it would have become a highly-cited paper. After impact factor, universities worldwide are now obsessed about citations. This is a fairer way to evaluate scientific works. After all, impact factor was designed to measure the performance of journals but not individual papers (see http://vwswong.blogspot.com/2011/01/impact.html for details). Individual papers are better judged by how often they get cited by others and whether they stimulate further works in related fields.

Nevertheless, my example illustrates that this system is imperfect. True, landmark studies and major breakthroughs are highly cited. But so are controversial and flawed works. Others cannot help refuting a shaky article. At the same time, however, they are forced to cite the original work.

P.S. Yes, I do look at my blog statistics because it is so interesting. At one time, I could not understand why so many Russians were reading my scribbles. LL enlightened me. That happened because similar blogs were blocked by the Chinese government. The ‘Russians’ were actually friends from mainland China (I forgot the technical term describing this phenomenon). Anyhow, I cannot be more grateful.

25 Aug 2011

Lasting

In a classical study, Philip Brickman and colleagues investigated the level of happiness of 22 major lottery winners, 29 paralyzed accident victims and 22 controls. [Journal of Personalaity and Social Psychology 1978;36:917-27] As expected, the winners rated winning the lottery as a highly positive event and the victims rated the accident as a highly negative event. Surprisingly, the effect was brief. Winners were not happier than controls and took less pleasure from daily life events. Victims were not significantly more melancholy either.

If one cannot have long-lasting happiness even after these extreme events, how can we expect otherwise with less dramatic stimuli? When I was a house officer, daily work became easier with the introduction of the computer investigation request system. We no longer needed to waste time filling in complicated blood taking forms. Now, our house officers do not even need to perform blood taking – that would be the job of phlebotomists. However, if you ask house officers in different eras, I doubt if anyone would report their work as less stressful and cumbersome than that of their predecessors.

According to the adaptation level theory, people can only derive short-term pleasure from favorable events. After a while, they would take that level of life for granted.

With this background, shall we still ponder so much about getting a transplant or not? True, living with uremia or ascites is frustrating. Brickman’s study, however, clearly indicates that true happiness can only occur if you can do what you love to do with the blessing of a transplant. Nevertheless, should life only start after transplantation?

18 Aug 2011

Cheese

At the department retreat 10 years ago, our Boss gave a talk titled “Who moved my cheese?”. The readers are probably familiar with this parable by Spencer Johnson. In brief, two mice and two men used to live in a maze and feed on a big chunk of cheese. One day, they woke up and found the cheese was missing. The two mice quickly left and searched for new cheese. Afraid of change, the two men stayed at the original spot and debated about what to do. After some time, one of them took the brave step, found new and better cheese, and through the process learned how to adapt to changes.

Like most parables, “Who moved my cheese?” is open for interpretation. When our Boss told the story, his focus was on the changing paradigms in medical research. The talk was inspirational and sincere. The message is of course totally different if a manager fires his workers and at the same time gives them this book. In fact, the most common criticism against this book is that workers are asked to unconditionally sacrifice for changes posed by the administration.

Back to the letter we shared last week. What should we do when the institution we work for does not take responsibilities and has no interest in our developments?

The most important thing I learned from my mentor is the power of autonomy. Who says I must feed on cheese? Can’t I choose rice or meat? Even if I fancy cheese, can’t I make my own cheese?

In essence, don’t let others define what success is. Success can be defined by a variety of ways. Choose the way you yourself believe in. If you are truly interested in research, don’t compare your income with your classmates in investment banks. If you are talented in some medical procedures, why must you bother about the number of publications? Once you understand what you really want, think outside the box. You do not need to follow others’ footsteps to attain the same goal.

To illustrate the last point, let me share with you a story about my mentor. In many universities, the promotion to a senior academic post requires international reputation. This is a vague concept, but is generally assessed by how often a faculty gets invited to talk in prestigious conferences and serves in professional bodies or biomedical journals. In Asia, however, age counts. Often the department head instead of the junior faculty who is more active in research gets the invitation. When my mentor first joined the university, he had the same problem. Big professors from other countries hardly talked to him, not to mention inviting him to conferences. Many people in this situation would just become more and more frustrated and even give up. Others may bid their time and wait until they have enough gray hair. How about my mentor? Again and again, he introduced himself to different big professors. When he was not invited, he organized his own meetings.

Dear friends, the discussion has been fragmented but I hope you find it comforting. Above all, find your dreams, and don’t succumb to the judgment of others.

11 Aug 2011

Letter

During a recent farewell party, L mentioned a letter we received in 2003. Frankly speaking, the prediction in that letter was not entirely accurate, and the author turned out to be one of the most successful transplant recipients. However, it is part of our history and should be of general interest.

"Dear friends,

"When I was on-call today and having yet another dreadful canteen dinner (which would have been unbearable except for the pleasant company of LK and CM), I came up with an interesting analogy of our current predicament as contract MO.

"The moment you become a contract MO would be equivalent to having been diagnosed with liver cirrhosis which in our locality has a life expectancy of 7 years. This can be broadly divided into 3 years (Child’s A) + 3 years (Child’s B) + 1 year (Child’s C). For example, I would be a late Child’s B cirrhosis. Of course, if you develop complications such as failing your MRCP exam or getting complained for negligence your life span may be dramatically shortened, but I believe that most of us can reasonably expect to reach year 7. Knowing that you only have 7 years to live is often a source of great stress to many of us and our important lifetime decisions such as marriage and buying an apartment are affected by this.

"From personal experience, I find that with the advancement of my liver cirrhosis, I become more lethargic with reduced energy levels. I find it increasingly hard to maintain my activity of daily living such as being on-call. Although I do not have flapping tremor, my memory of my medical knowledge is not what it used to be. I have noticed many of my colleagues have progression distension of their abdomens, their waistline increasing in proportion with their liver cirrhosis.

"Like all patients, we visit our doctors in hope of finding a cure. Often we are recommended to produce case reports, be punctual for our clinics and attend academic meetings regularly which I believe to be equivalent to taking “Essentiale” capsules. Many cirrhotic patients take them but I often wonder about their efficacy. However, one should never underestimate the placebo effect especially when it is coupled with unrealistic expectations regarding our own prognosis. As our disease advances, we often harbour anger at our doctors for somehow cheating us or depriving us of therapy. However this is merely the natural progression of having liver cirrhosis and they are not to blame. They are withholding life-prolonging therapy rather than actively cutting short your life. Doctor often will withhold active resuscitation because it only prolongs the suffering of the patient. Better to die with dignity.

"Then we come to the complicated topic of liver transplantation. There is a central list that the patients are not aware of. Often political considerations affect which patient actually gets a liver. However, there are currently so few cadaveric livers available that I expect most of us will expire before one becomes available. Usually it is only a matter of being at the right place at the right time. Liver transplantation consumes many resources and doctors will often choose very carefully. Only the “fittest” patients will be considered for transplantation. There is a MELD score which is used to determine the priority of liver transplantation. In case you don’t know, MELD is short for Model of End-Stage Lackluster Doctors and is derived from a complicated mathematical formula which requires 3 variables. The variables needed for calculation of your MELD score are first, the number of papers you have published, two, the “Prof S recognition factor” and finally the inverse of your salary. For example, if you have published no papers, Prof S thinks you are a house officer and you have a high salary, you might as well start planning your funeral.

"Dear friends, keep the faith and don’t lose hope! As a Christian, I believe that death is not the end, but the beginning. I believe God has prepared a path for me that will lead me to the fullness of my life. I cannot see past my own death but I know God can and he will take care of me because of his everlasting love for each and every one of us. He has inscribed our names on the palms of his hands. As I move past this life to a newer better one, I shall look back and know how short and transitory this current life was and how narrow was my perspective. Fellow cirrhotic patients, this is merely my perspective but I hope you may find it useful."

4 Aug 2011

Unlucky

Learning that I went back to the hospital 5 times for emergency endoscopies on a call day, my mentor said, “You have to see S the fortune teller.”

I frowned. Above all, I dislike that man. Besides, my religious and scientific background forbids me to seek such advice.

Let’s for the time being keep our cool. Was I really unlucky? To keep it simple, we will call me unlucky if my fate during the last call day could not be explained by chance alone.

According to figures from our center, endoscopists have to provide emergency service outside office hours around once every 3 days. By secondary school mathematics, the probability of having to do 2 emergency cases in 1 call day should equal 1/3 x 1/3, or 1/9. Similarly, the probability of going back 5 times is equal to 1/3 x 1/3 x 1/3 x 1/3 x 1/3, or 1/243. Since I am on call 4 times per month, I should expect to get 5 calls in a day once every 61 months (243 divided by 4). Instead of seeing this once every 5 years, this is the first time I encounter this since I started endoscopy training in 2003. I should consider myself lucky.

P.S. Lord, while I have nothing more to say about my call duties, would you keep an eye on my mother country? Those once-in-50-year disasters are happening every year there.

28 Jul 2011

Marry

While we were playing board games one night, Angelina suddenly said, “There is something I cannot get out of my mind.”

“What is it?” Angela asked.

“At the kindergarten today,” said Angelina, “N said it would be wonderful if we got married in the future.”

“But this is silly!” exclaimed Angela. “You haven’t even finished school.” She went on and explained why one needed to be mature enough before getting married.

The next Saturday, I was caught up with many emergency endoscopies and could not pick Angelina up from school. N’s mother offered her a ride. Sitting at the back, Angelina was delighted to find a mini-TV showing Disney programs. That afternoon, she muttered, “Maybe it is not a bad idea marrying him after all.” We were petrified.

Lai Yeh, I absolutely cannot take weekend duties anymore!

21 Jul 2011

Jonathan

Sooner than I realize, Jonathan is three months old. There is much to learn.

After big sister’s example, I never thought a baby could drink milk that fast.

I wish you would not sleep from seven to eleven every night. When you wake up at eleven, you look as if you have never seen me before. But your comfort is my wish.

My mother-in-law keeps urging me not to pick you up whenever you stir in bed. I cannot agree. If she has learned about JW’s experiments, she would know how miserable the rats were after he separated

them from their parents.

You babble so much. What a sight it would be when you chat all day long with your sister!

14 Jul 2011

Quantum Mechanics

After the remedial attachment, our Chairman sent us feedback comments from year 1 and year 2 students. That was eye-opening.

"Can the lectures be more specific on what we actually need to know?"

"Too many drugs in Pharmacology."

"The test contents are highly unrelated to the lecture's."

"Do we need to know embryology?"

With increasing specialization, I agree that most doctors only need knowledge in a small area. Szeto loves to stun colleagues by asking them the names of wrist bones. But why would you need to know them unless you become a surgeon specialized in hand surgery?

On the other hand, there are lots of things I wish I spent more time on during my undergraduate studies. I regretted my wishy-washy knowledge on embryology when I worked on stem cells. When I began doing research, I also hoped I had learned more molecular biology.

Surely you are not convinced, but I have heard a better answer.

Years ago, medical students need to study physics in year 1. One lecture was on quantum mechanics.

Overwhelmed by the complicated formulas, a frustrated student yelled, "Why do we have to learn this?"

The professor of physics paused for a second and continued with the lecture. After a while, the student interrupted again. "Why do we have to learn this?"

"Because," replied the professor calmly, "we have to prevent idiots from studying medicine."

7 Jul 2011

Report

In the second week, I frankly explained to the students that I did not feel comfortable training doctors who never talked to patients. They made an appropriately frightened look and rushed to the bedside immediately.

While I never intended to fail them, LS further consolidated my decision. The students had to hand in a written case report everyday. One of her students wrote a masterpiece.

"An 80-year old lady was admitted because of decreased general condition. She was not communicable." The end.

Learning this, I hesitated no more and wrote an e-mail to the Chairman recommending all students from my group to be promoted to the next year.

On the last day of week two, a girl from my group called me as I was leaving after ward round.

"May I ask a question?"

"Sure."

"Do we still have to come next week?"

How wonderful. And they disappeared.

30 Jun 2011

Remedial

Shortly after the examination, I was asked to take care of several students who had failed. The remedial attachment provided an opportunity for them to learn more clinical medicine. Tutors had to decide whether the students need to repeat the year of study afterwards. I personally did not have any negative feelings against those young people, but Warren and a few colleagues kept urging me to fail them.

Following their feedback, I observed the students more closely. The time they spent in the ward was reasonable. But one thing was weird. The only place they stayed at was the nursing station. They opened the case records, flipped through the pages and jotted notes here and there. They looked more like the girl with the dragon tattoo than doctors.

That reminded me of a story that many from my generation knew.

Boss was a hard-working person. He conducted ward round every day at 08:30, sometimes earlier. When Y was his trainee, he went to work at 08:25 and had to finish seeing 10 to 15 patients before Boss arrived. To his credit, he managed to write one full page of medical notes for each patient.

But when the old ladies tried to describe their symptoms, Y always made his famous reply, “Don’t disturb. The doctor is conducting ward round.”

23 Jun 2011

Harrison

Shortly before the final professional examination, our Chairman asked us for questions to be used in the viva voce examination. (See http://ccszeto.blogspot.com/2011/05/viva.html for details.)

Being the most junior teaching staff, I was not in the original communication list. Soon, however, I received copies of e-mail answers from two of my friends.

“Please ask VW.”

“I recommend VW. He is our walking Harrison.”

Preparing the questions was a piece of cake. I got it done in fifteen minutes. I could also understand that the overstatement was just out of politeness. However, I still felt uneasy. Walking Harrison used to be the term to describe our Boss and Szeto. How could I share the title with the giants?

On second thought, it really depends on which edition of Harrison’s Principles of Internal Medicine one is referring to. The giants represent the 8th and 10th editions, while the one I read was the 14th edition. Surely they are not comparable.

Having said that, I was happier when the young neurologist called me walking wikipedia a few years ago. It felt just right – appears to know a lot of things but not really accurate.

16 Jun 2011

Library

Last Saturday was our Faculty's 30th anniversary. I had the pleasure to accompany Professor AL at the celebration dinner. She told me a short story alongside with many other interesting matters.

Years ago, she went for training in England. On the first day, her mentor asked, "What project do you plan to do here?"

Being very green, she frankly admitted that she had not had a plan yet and would like to seek his guidance.

To her surprise, the Godfather sent her away. "The library is on the second floor. Come back when you know something."

When I shared the story with my teammates, they all felt the mentor was very cool and encouraged me to tell the medical students the same thing. After all, our medical library was also on the second floor.

I shook the attractive idea off immediately. "These will probably be my last words in the university."

It goes without saying that Professor AL went on to become an independent researcher and one of the greatest leaders in the field. Can we build leaders from refresher courses and examination notes?

9 Jun 2011

Amah Rock

There is a storytelling competition at Angelina's kindergarten every year. On the last two occasions, she told the stories of Three Little Pigs and Mickey and the Beanstalk. This time, she announced that since she was already in the graduation class, she would tell a grown-up story. Her first choice was Romeo and Juliet, which was banned by Mummy at once. She offered another story from the Greek myths. Mummy disapproved as well. "This is horrible!" Reluctantly, she chose Twelve Dancing Princesses, and had to skip the part about the beheaded princes.

A week later, she had her consolation. She told her Mummy a new story.

Once upon a time, there was a family in Shatin. The father often went abroad to do business. When he was away, the mother would carry her baby on her back and go up a hill. Looking far, she wanted to see her husband as soon as he returned.

For some unknown reasons, the father never returned this time. The mother did not give up. She kept going up the hill everyday. She stood all day long, carrying her baby.

Many months later, the mother went up the hill as usual. To her surprise, another woman was standing there. When she came closer, she found that the woman was a monstrous beast. She had snakes instead of hair on her head. It was Medusa! The monster turned and looked straight at her eyes. Instantly, the mother and the baby were turned to stones.

And they became the Amah Rock.

2 Jun 2011

Meet

How would you express your admiration to somebody?

In 1877, Nadezhda von Meck sent Pyotr Tchaikovsky the first letter, addressing herself as a fervent admirer. Soon, she became Tchaikovsky's most important benefactor, providing him with 6000 rubles a year. However, she had one most peculiar request - they were never to meet in person. On two occasions, they accidentally met in public. They pretended not to know each other and did not talk. Tchaikovsky immediately sent a letter on the next day, apologizing for 'offending' her.

Their relationship, however, was anything but distant. Over 13 years, they exchanged over 1200 letters. Both frankly revealed their deepest emotional turmoil and provided encouragement to each other. The relationship ended sadly with Nadezhda going into bankruptcy in 1890 and the composer's death 3 years later.

We could only guess why they chose not to meet. Most likely, the lady wished to maintain a certain fantasy.

But love is not about fantasy. It is a process of understanding and acceptance. Eleven years ago, I sent my first e-mail as a fervent admirer. Instead of offering half of my salary (which would come later), I asked for a date. We never managed to reach the restaurant among unfamiliar streets and had to resort to a Pizza Hut on the road side. This is probably called adventure.

Happy Anniversary, meine liebe kleine Frau!

26 May 2011

M-shape Society

After the professional examination, JW remarked, "The graduate class has become an M-shape society."

The M-shape society was described by the Japanese economist Kenichi Ohmae. It refers to the decline of the middle class. In other words, the society is polarized towards extreme rich and poor. Due to globalization and the demand on information technology skills, few people in the middle class grasp the means to get rich. The majority, however, loses competitiveness and declines towards the poor.

What JW observed was that brilliant performers grew in number and did better than those in previous years. The same, unfortunately, also happened at the bottom end. A few candidates were almost unanimously failed by all examiners, indicating poor knowledge in a broad spectrum of topics being tested.

What caused the change?

Simply said, the teachers, students, examination and medicine itself all changed. The new examination system includes a number of simulated cases that demand practical knowledge. Instead of reciting textbook knowledge, candidates can only perform well if the answers are specific to the patient at hand.

The greatest challenge to students is the evolving field. Every year adds numerous new medical treatments. It has become more and more difficult for any student to cover everything before they graduate. I have seen quite many students who know the latest medical advances in one field but close to nothing in other areas.

Latest advances sound great, but are actually poisonous to students. By the time students graduate and become specialists, some of the advances would become standard treatment, while others would have been abandoned due to new evidence. Therefore, snapshot knowledge on medical advances is quite pointless. Instead, only people who continue to use the knowledge and follow the evolution of practice can fully utilize the information.

Similar to the M-shape society, the current situation is a test of whether medical students can distinguish between important general principles and trivial factual knowledge. Having said that, one should not just laugh at students who cannot adapt. After all, it is the responsibility of teachers to help students become competent doctors no matter how the field has evolved.

19 May 2011

HeLa

I am reading The Immortal Life of Henrietta Lacks by Rebecca Skloot recently.

Henrietta Lacks was an African-American lady who sought medical care at the Johns Hopkins Hospital for cervical cancer in 1951. She died of progressive disease eight months later. Nevertheless, her cancer specimen turned into the first successful human cell line - HeLa. With the ability to grow human cells on culture plates, scientists developed the polio vaccine and answered one question after another on genetics and cancer biology. Henrietta’s cells traveled to laboratories in all continents and even to the moon.

Apart from the history in scientific development, the author painstakingly interviewed Henrietta’s surviving family members and reconstructed her life in the book. I was deeply touched by this part. Although I knew some cell lines and specimens I used in research were from humans, the materials in plastic wares felt so cold and unreal. The book serves as a reminder that the patients behind the specimens are after all real people who have lived and loved. The author rightly quoted Elie Wiesel from The Nazi Doctors and the Nuremberg Code: "We must not see any person as an abstraction. Instead, we must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph."

On the dark side, it should be mentioned that Henrietta never learned of her contribution. In fact, she did not even know her specimen had been taken for research purpose. Back then was a time when research ethics and informed consent were not well developed. To the extreme, Southam from Sloan-Kettering Institute for Cancer Research injected prisoners and terminal patients with HeLa cells to see if cancer cells might be inoculated to humans. Luckily, medical ethics and patient protection have come a long way since then. We must never forget the lessons and should thank our patients for contributing so much in our understanding of diseases and treatment.

12 May 2011

Experiment

Last December, a new patient came to my private clinic. The first thing he did was to complain. “You charge too much,” he said.

I was so surprised that I was speechless. Above all, I had not even charged him anything. Besides, my consultation fee was anything but expensive.

After that, I chatted with our secretary at the Christmas party and found out what happened. To make it simple, doctors are not allowed to charge freely at the university private clinic. They can only follow a preset range. Having said that, the top of the range is more than three times the lowest charge.

“When new patients book appointments,” she explained, “they usually ask about the consultation fee. Most patients also know they can choose from several doctors in a specialty and would want to compare fees. If I tell them your charge is one-third of that of other doctors, they would think you are lousy.”

“I don’t mind to be despised by people I don’t know,” I said, “but I certainly don’t want to appear greedy.” (Of course, the two statements contradicted with each other. Just forgive me for being human.)

Wait a second. Suddenly I realized this could be interesting.

I instructed our secretary to tell new patients that my charge was two-third of that of others in the next two months, and then say that my charge was one-third of that of others after that. To control for confounding factors, I would decline all media interviews in the coming months.

“The patients are bound to ask why you charge less than others,” she protested. “They would ask if you are not good.”

“Just tell them you cannot comment on that,” I replied.

In January and February, only one new patient registered to see me. He did not come. That makes sense. If cost is a major issue, the patients would choose public clinics. If they decide to go private, why not choose the best?

With great expectations, I looked forward to seeing what would happen in March, when my marked price further dropped by half. To my horror, the booking increased to four times that before the experiment was launched. And all patients turned up punctually at my clinic.

I will leave the readers to interpret the results. To me, the question is whether our secretary should lie after all.

5 May 2011

ROAD

One day later, our medical school organized a dinner to celebrate the establishment of an honor society. Alumni with distinctions at professional examinations were invited. It was a wonderful evening where we met old friends and graduates from different years.

During the meeting, we could not help noticing a clear trend. While the popular specialties of the older generation were general surgery and medicine, graduates turned to the “ROAD of success” at the turn of the century. ROAD stands for four attractive specialties: Radiology, Ophthalmology, Anesthesia and Dermatology.

The advantage of getting on ROAD is obvious. The on-call duties are less demanding, most fellows get promoted soon after they have completed training, and the private market is blooming. When I asked friends practicing in those specialties, most claimed quality of life was the major reason behind their choice.

This I can understand. What intrigues me, however, is why the preference changed. Top graduates in the past were also free to choose the easier path, but they didn’t. Is it just a generation thing, as most people in the older generation love to say, or are there deeper reasons?

While the generation change is obvious, I am reluctant to take this as the sole explanation. If you ask 100 medical school applicants at the entrance interview, 100 of them will tell you they do not mind hard work and are not doing medicine for money, and I believe them. If they state otherwise, I would not hesitate to reject their application. No, this is not about moral judgment. This is about intelligence. If you want a big pay check and leisurely work, medicine is a dumb choice. So, if these enthusiastic youngsters suddenly consider the thing they despised important by the time they graduate, our education has been killing their dream.

To satisfy my curiosity, I reversed the question and asked senior clinicians why they chose general surgery and medicine. This time, the most common response was the satisfaction of managing a broad range of medical conditions.

This would make sense. ROAD was less well developed 2 to 3 decades ago and provided less job satisfaction then. Over the years, these newer specialties have advanced a lot. On the other hand, you like it or not, practitioners in general surgery and medicine are also focusing on a much narrower field nowadays. If the job satisfaction and breadth of practice do not differ much, it is not surprising that other factors come into play in career decisions.

28 Apr 2011

Fairy Tale

Following our friends’ advice, we bought Angelina a Barbie doll and said it was a present from her newborn brother. This was supposed to be a good method against sibling rivalry.

Angelina opened the present and was delighted. “Wow,” she exclaimed, “how did baby brother know what I like?” The plan worked!

The next day, Grandma asked, “How come your brother had money to buy you a present?”

“Oh,” Angelina answered, “I guess Mummy bought it and told me it was from brother.”

That marked the end of another fairy tale, after Santa Claus and Tooth Fairy.

21 Apr 2011

Birth

Five years ago, I was waiting outside the operating theater, preparing for the arrival of Angelina. My mind wandered, though I was unable to think about anything in particular. Then I spotted a computer in the waiting room. I checked my e-mail account but everybody was so kind as to stop sending me anything. Like most people in apprehension, I resorted to things I used to do. I visited the website of New England, only to find that I had already read the issue the week before (it was a Tuesday).

Fast forward five years. If technology had changed, I didn’t change much. This time there was no computer in the waiting room. Alas, I took out my wife’s iPhone and did just as fine. I dutifully deleted a dozen of e-mails on seminars, investment opportunities and how to grow tumors. It was possible to have an idle e-mail account in 2005, but it would be a miracle in 2011. When I turned to Lancet, I finally realized I could not take in anything.

Soon afterwards, the baby cried and kicked his legs. But he slept peacefully in our arms as soon as he was wrapped in a clean blanket. We know it would be another chance to learn. The Lord taught us to love and to serve. Is there a better way to learn this than to have a child?

14 Apr 2011

The Last Lecture

It is a tradition at Carnegie Mellon University that professors take turn to deliver ‘the last lecture’. The speakers are asked to imagine that they are going to talk to students for the last time, and may discuss any topic they like. We can only guess that most of those lectures must be enlightening.

On 18 September 2007, Dr Randy Pausch made the program world famous. His lecture was entitled ‘Really Achieving Your Childhood Dreams’. After a humorous introduction, he told the audience he was suffering from recurrent pancreatic cancer and only had a few more months to live. But no, there was no time for sorrow and self-pity. When the days were numbered, Randy trimmed down trivial things and only considered what was important. He demonstrated the vigor, passion and love of life.

Last week at the medical grand round, TL came close to that. Unlike others, the neurologist spent the first half of his talk discussing what quality a doctor should have. He wished future doctors to be responsible and knowledgeable. They should be patient, have empathy and work as a team.

At the back of the lecture theater, our colleagues were deeply moved by his effort. The qualities he mentioned were more important than the medical facts we taught. On the other hand, we felt it disconcerting that those had to be spelled out. What would you think if a bank manager has to tell the clerks it is wrong to steal?

7 Apr 2011

Logbook

One thing the student representative brought up was the logbook system. “It is often hard to find teachers to sign the logbooks because they are engaged in clinical duties,” she said. “Can we abandon it?”

A few years ago, the Faculty administrators informed us that we were the only department without a formal record of students’ attendance during clinical attachments. In response, we gave each student a logbook and asked them to obtain signatures from teachers after tutorials. Our secretaries, however, never kept any record. The logbook system was more to satisfy the administrators than to check attendance.

“It is unfair to introduce the logbook system without clear instructions,” commented KL. “We should state clearly what level of attendance is acceptable. For example, students may need to attend a certain number of tutorials before they are allowed to take the year exam.”

I startled. That reminded me of the Haifa experiment. At day care centers, some parents pick up their kids late from time to time. Teachers have to stay behind and this can be frustrating. In a study in Haifa, Israel, researchers tested the effect of charging parents for extra service if they came late. The result? The number of latecomers increased. Worse still, after the additional charge had been removed, the number never decreased back to baseline level. By paying for the service, the parents no longer felt guilty for burdening the teachers.

When I worked in Beijing, the medical school there introduced an interesting rule – All PhD students must publish one paper with an impact factor of 2.0 or above before they could obtain the degree. The policy was to ascertain a minimal quality of the research work. Before that, some students were able to publish papers in high-ranking medical journals, while over half actually did not have any publication by the time they graduated. What happened after the adoption of the policy? You bet. All students ended up publishing a paper with an impact factor of 2.0, not more.

If we state the required level of attendance at tutorials, will we be taking away the moral incentive?

In the end, while we decided to abandon the logbook system anyway, GC asked the student representative, “What is the reason for asking to abandon the logbook? Is it really because it is difficult to get a signature, or is it because your classmates want to skip tutorials and do not want to be recorded?”

Now, that is a more fundamental question. If the students do not want to come, why force them?

31 Mar 2011

Learning

One morning last month, Szeto was rather busy and conducted a quick ward round. In the middle of the session, he overheard a medical student whisper to his classmate, “I thought renal physicians teach!”

When Szeto told us this story, we all found it hilarious. It was like complaining Feng Qingyang for not teaching Huashan Swordplay when he could actually demonstrate the Nine Swords of Dugu.

A few days later, a student representative reported his classmates’ view on clinical teaching at our department meeting. This led to heated discussion on how clinical medicine should be taught. Most professors stressed that we should not spoon feed students by providing a lot of factual knowledge at ward rounds and tutorials. Rather, if the students knew the patients and their clinical progress, they should have already learned much by observing how clinicians made decisions on treatment.

Last year, after our Boss took up the post as the VC, JW arranged some media interviews to celebrate the event. Somehow, I was labeled as the last trainee of Boss. What an honor!

During the interview, I had to recall how Boss taught me. The reflection surprised me. During my entire training from medical student to specialist, I had one tutorial by him on inflammatory bowel disease. He also observed me do one gastroscopy and one ERCP. Both procedures failed. That’s all. According to today’s standard, I should file a complaint at the College for not receiving proper teaching.

But I learned much more than that. At ward rounds, he showed us how to care for patients and gain their trust. He showed us how to ask important questions. At casual talks, he shared his experience with a bad boss and a good boss, and how the past modeled his choices.

And for the rest, I cannot see why I cannot get the information from books and journals. I think this is more than enough. But how can I make our students believe this is really good enough?

24 Mar 2011

Music Lessons

It is often said that medicine is half science and half art. In Annals of Internal Medicine last week, Dr Frank Davidoff, Editor Emeritus of the journal, went as far as discussing what doctors might learn from musicians.

Reflecting on my own musical training in the past, I would say practice is one of the most important things that I have learned.

Practice is not mechanical repetition of the same movements. It is both a motional and mental process that involves the following steps in cycles: Trial, reflection and experimentation. Without the ability to reflect and the interest to experiment, one may do the same job for the whole life without any improvement. Before a student can do this on her own, it is the responsibility of the teacher to complete the cycle.

Practice takes time. Arthur Rubinstein was born to play Chopin – after years of practice. Similarly, good doctor-patient relationship and clinical sense cannot be developed in the library. You have to interact with patients. It hurts to see some doctors quarreling with patients all the time and never think how they may do it better.

“If I don’t practice for a day, I know it; if I don’t practice for two days, the critics know it; if I don’t practice for a week, everyone knows it.” Having said that, the time required to maintain a skill depends on the level of skill you want to have. Practicing 30 minutes per day (when Angelina is doing something else), I am quite comfortable with Mozart’s Sonatas. If I am to play Beethoven’s Appassionata for others, I would have to practice eight hours per day. By the same token, Szeto reads medical textbooks for 30 minutes everyday to maintain his medical knowledge. I am embarrassed to report when I last opened the Harrison Textbook of Medicine.

17 Mar 2011

Joint Decision

After so many brainwashing meetings – I mean brainstorming – I start to wonder how best decisions should be made. Is more people better? With more people, information may be shared and loopholes may be filled. But will this affect efficiency?

In the February issue of the Proceedings of the National Academy of Sciences, an interesting experiment by Ashley Ward and colleagues tested the effect of the number of members on decision making using mosquitofish, Gambusia holbrooki, from Australia. In the study, the fish was put to swim in a Y-shaped maze. In one of the arms hid a 12 cm replica predator. The mosquitofish were considered to have made the correct decision if they avoided the predator and swam to the other arm.

As predicted, the bigger the number of fish in the shoal, the more likely the fish would make correct decisions. Was that due to higher chance of including a clever fish in a bigger shoal? When each fish was tested in isolation, none of them performed significantly better than the others.

Now come the more interesting part. Contrary to our anticipation, bigger shoals always made quicker decisions than smaller ones. It turned out that the decision speed was determined by the first fish that made the decision, probably after it had caught sight of the predator. When there were more fish, the time for any one fish to spot the predator and start moving was shorter.

Can we learn a thing or two from mosquitofish?

I can see you shaking your head. Above all, Homo sapiens are not called the crown of creation for nothing. As advanced species, we always have experts who can see the whole picture when frontline workers can’t. Besides, we will never bump into a predator in ten seconds. With the new time-out exercise, it will take at least five minutes before we start swimming. Even if we bump into the predator despite all precautions, we still have the Advanced Incidents Reporting System (AIRS). In short, our system is fool-proof.

To me, the major drawback of following the mosquitofish model is that my voice will never be heard. The fastest fish, GW, will make all decisions at grand rounds before the rest of us can understand what is happening to the patients. Having said that, is it all that bad? Should I not benefit more by using the time to ask what stocks JW have bought recently?

The above discussion, as usual, is off the point. Brainstorming meetings are never meant for decision making, I know.

10 Mar 2011

Revolution

It all began in Tunisia. Soon the Year of Revolution swept through Middle East. At a smaller scale, our local young doctors also voiced out their need and aspirations. I am no fan of the butterfly effect, but the mood is indeed infectious.

Last week, our department administrators held a brainstorm meeting with the medical officers. I was secretly sorry for them as they had little to offer unless radical changes occurred at the head office level. Nevertheless, it is good to listen. At least it is better than saying “When I was a medical officer, I worked 90 hours a week and had ward rounds every weekend”.

There are a few problems that cannot be solved overnight. The lack of promotional prospect is not a unique phenomenon in hospitals but also occur in other areas as middle-grade posts are occupied by people of the generation X. The monopolization of professional training by the public institution also encourages it to disregard the benefits and morale of its staff until recently. That said, these problems are still easy to solve when the institution realizes the need to improve the pay and recognition to frontline doctors. The real difficulty stems from the insufficient supply of new doctors and the huge salary gap between the public and private sectors.

In the past, most politicians representing the medical field were from the private sector. Understandably, they did their best to stop the number of medical graduates from growing. With changing political paradigm, we are finally expecting 320 new graduates per year in Hong Kong several years later. Time will tell if the pendulum will over swing again this time.

Having visited many cities in mainland China, I could not help noticing that many medical schools produced huge numbers of doctors. A medical school serving a population similar to that of Hong Kong may have 5000 graduates per year. This makes our own number look ridiculous. True, the doctor-to-patient ratio in China remains low. However, at the present level of development, urban hospitals cannot absorb these graduates. As a result, most graduates have to find other kinds of jobs (e.g. sales representatives of pharmaceutical companies) or work in rural clinics with little prospect.

Of course, the increase in medical student quota in Hong Kong is trivial compared to what happens in China. Nonetheless, with increasing supply the salary will likely drop gradually. This is certainly good news to patients and the community. It is however intriguing to speculate what will happen when the medical profession becomes less profitable. Will we still be able to recruit the best students? When the dollar sign shrinks, will we actually get more passionate candidates?

3 Mar 2011

Learning

Szeto had some interesting discussions on eternity recently. (See http://ccszeto.blogspot.com/2011/02/eternal.html). As practising doctors, we need both learning skills and the desire to learn to keep up with the changing world. Without learning skills, the acquisition of knowledge is inefficient. Without the desire to learn, those skills are empty. Whenever young doctors or medical students say there is so much that they do not know, I reassure them medicine is after all for lifelong learning.

Some years ago, a postgraduate student asked his supervisor, “Professor, I really don’t know anything. What should I do?”

The professor answered, “When you think you know everything, they give you a bachelor degree. After you have learned that you don’t know anything, they give you a master degree. If you realize that not only do you not know anything but others are not better off, it is time you get your PhD.”

As such, we should not worry when so many final year students say they are not ready to be doctors. They have progressed to the stage of that postgraduate student and should join our master program. (http://www.idd.med.cuhk.edu.hk/msc-in-gastroenterology.html)

Conflict of interest statement: None declared.

24 Feb 2011

Equipoise

“Doctor, am I on active drug or placebo?” asked my patient one day. She was enrolled in a randomized controlled trial in liver disease.

“No, we deliberately make sure that neither you nor I know the treatment assignment so that we can assess the treatment effect fairly. Otherwise, I may treat you differently just because I know what treatment you are on,” I tried to explain.

“But if I am on placebo right now, are you delaying my treatment?”

Was I delaying treatment?

In this case, I was quite comfortable in explaining that although the mechanism of action of the new drug looked promising, there really was not any clinical data to show that it worked. That was precisely why the pilot study had to be performed. If she was not in that trial, the unproven drug would not be offered anyway. Meanwhile, she was receiving all other optimal treatments. This is the principle of equipoise. Some people hold the belief that clinical trials are only ethical when there is no existing evidence that one of the study arms is worse than others.

However, equipoise often does not happen in clinical trials. In medical jargons, we move forward to large phase 3 trials because the results of early phase 2 trials look good. If equipoise is essential, most clinical trials should be abandoned and drugs would be registered with preliminary data. This is obviously problematic. If new drugs are not fully evaluated, the efficacy may be inaccurately determined and important side effects may be missed.

In this month’s New England Journal of Medicine (2011;364:476-80), Franklin Miller and Steven Joffe argued that the concept of equipoise was flawed. Especially because new drugs are often very expensive nowadays, it is important to confirm it works before its introduction to the market.

I would not bore readers with the arguments. Suffice it to say, we are not doing favor to our patients by enrolling them to clinical trials. The aim, however, is to develop better treatments to benefit future patients. Participants in clinical trials may potentially be receiving less effective treatment or treatment with more side effects. This should be explained clearly to our patients, and we should be grateful.

17 Feb 2011

Valentine

Two years ago, seeing a pair of secondary school students kissing each other at a mall, my wife sighed, “What should we do when this happens to our girl?”

“This is simple,” I did not need to think. “I will come up to the boy, break his leg, and say, ‘This will teach you a lesson!’”

Last month, however, the mother of Angelina’s classmate told us how much her son liked her. “Your daughter is really lovely,” the grandma added. Meanwhile, that boy buried his face in his mother’s dress, trying to hide himself.

Did I break his leg?

While the mothers were laughing heartily, I just told myself, “I can understand that.”

Oh, I was too soft. Let me practise on Ken later.

10 Feb 2011

Relativity

One day, Angela asked Angelina at a restaurant, “Do you want one of these kid’s meals?”

Angelina glanced through the menu and was not interested. “Mummy,” she said, “I am not a kid. I am a big girl.”

A few days later, Angela asked her to tidy up the toys. Seeing no response from her daughter, she said, “I thought you were a big girl already.”

“Mummy,” Angelina did not even raise her eyes from the book, “you call a five-year-old a big girl?”

3 Feb 2011

Fake

Football fans can easily recall a few faked falls during important matches. Quite often a faked fall is sufficient to change the result of a match.

At the recent meeting of the Society for Integrative and Comparative Biology, Robbie Wilson reported a study on faked falls at football matches.[Science 2011;331:280] Among 2800 falls, only 6% were definitely deceptive dives, i.e. no contact between the players. At first sight, this figure appears surprisingly small. However, it makes perfect sense. According to game theory, if faked falls occur more commonly, the general scrutiny of dives would change, making the cost-benefit ratio less attractive.

Secondly, the closer to the goal, the more likely a fall was deceptive. This is because of the high payoff of creating a scoring opportunity. Besides, when it was closer to the goal, the success rate of faked falls was high. Free kicks or penalty kicks were offered to the attacking side in 80% of the time.

The observation can be extrapolated to other situations such as scientific publications.

1. Although faked works do occur, thank God they should be rare events.
2. Faked works are stimulated by payoffs. Since the payoff from a single scientific publication is usually small and the result of being caught is devastating, young researchers are at highest risk of crossing the line.

What if there is a sudden increase in the number of less established researchers? This is the worrying bit.

27 Jan 2011

New Blood

If the escalating impact factors are due to increasing number of researchers, where do they come from?

Western politicians love to blame Chinese workers for everything. But this time they are not too far off. The last decade saw a rapid increase in research papers from developing countries. In fact, China is already second (after USA) in the number of biomedical papers produced last year. Although the quality of many papers still has room for improvement, more and more top scientific papers are coming from China.

There are many reasons behind the rise of developing countries. Many countries enjoyed substantial economic growth and could support scientific research. Globalization and easy access to scientific articles online also stimulate scientific development.

I found a new reason during our recent visit to China.

A medical professor told us that not only academics but also most doctors in China had to publish papers. It is almost impossible to get promoted to a consultant post in urban hospitals without publications. In the past, publications in Chinese journals were still acceptable. Nowadays, administrators are more ambitious and ask for papers in international journals. Worse still, many international journals do not accept case reports any more. So original research works are required.

While I believe all medical doctors should be trained in evidence-based medicine and be able to critique biomedical works, asking everyone to write papers appears to be pushing too far.

“Do you mean,” I found it difficult to understand, “that even doctors in small service hospitals have to do studies and publish papers?”

“Yes, indeed.”

“How do they get the time and funding for research?”

“Well, they don’t have any.”

“That is forcing them to …” I was forced to conclude. And we fell back in silence.

20 Jan 2011

Impact

What did I learn from that list?

To understand the list, we first need to know how scientific journals are ranked. Journals in different categories are ranked according to the impact factor. For example, the impact factor of a journal in 2009 is calculated as the number of times articles published in 2007 and 2008 were cited during 2009, divided by the total number of articles published by that journal in 2007 and 2008. Simply said, it reflects the average citations per article a journal receives.

There are many ways to boost the impact factor. Some journals reduce the number of original articles and increase the number of review articles, which are known to be cited more often. Journals affiliated to certain societies have particular advantage because they can publish guidelines. I have also encountered journals that would explicitly ask authors to cite their articles before the papers would be accepted.

Let’s for the time being ignore the differences among individual journals’ strategies. The list is enlightening.

Overall, the impact factors of most journals are on the rise. This does not necessarily mean that new papers are more important than old ones. Rather, the phenomenon can be explained by the rapid increase in the number of journals in each category and the number of researchers. In fact, journals whose impact factors did not increase significantly in the last decade almost invariably fell back in rank.

Secondly, there was little change in the ranking of top journals in each category. This is due to the submission pattern of researchers. It is natural for researchers to submit their best works to the top journals. The other journals could just receive less important works and even papers that have been rejected by top journals. Thus the difference between top journals and the other journals perpetuates.

Moreover, the increase in impact factor and number of citations did not distribute evenly among all journals. The increase was more in general journals than in highly specialized journals. Although specialized journals may enjoy good years when the field is rapidly advancing, the downturn can be equally harsh. On the other hand, general journals can easily turn to more promising fields when the environment changes. This, of course, should apply to other industries as well.

13 Jan 2011

Time Capsule

Last week, Szeto showed us the list of stocks he bought in 2001-2002. [See http://ccszeto.blogspot.com/2011/01/list.html.] I could only be jealous. Incidentally, I went through another electronic time capsule at the same time. It was the list of medical journals 10 years ago.


6 Jan 2011

Facebook

Mark Zuckerberg, the founder of Facebook, is TIME’s Person of the Year 2010.

When one uses the computer everyday, it is easy to take the way of work for granted. The change in the last decade, in fact, is astonishing.

When I was a medical student, people were still searching gigantic directories for reference articles. Just before I graduated, it became possible to do computer search. Even so, the database was not web-based. Instead, the library received a CD ROM containing the information of scientific articles every 3 months. One could only know the latest publications by reading many journals or attending medical conferences. Nowadays, with a click on my keyboard, I can find not only articles published this week but also those that will be published in the coming months. As for medical conferences, I can download the presentation slides, or even watch the video of the presentation online.

In the past, when people submitted papers to journals, they had to make several photocopies of the manuscript and send them by express mail. The famous DNA paper by Watson and Crick in Nature, for example, was prepared by James Watson’s sister with a typewriter under his constant encouragement: “You are participating in perhaps the most famous event in biology since Darwin’s book!” With mails to and fro, the review process usually took several months. You may think this kind of ancient communication must occur before the 1990s. In this you are wrong. My last paper published this way was in 2004.

I still remember vividly the moments when I received reply letters from medical journals. Is my paper accepted? The anticipation and apprehension were no less than those from love letters. Now all we get are e-mail notifications. Certainly time has changed. When young lovers break up nowadays, they just send each other text messages by phone. Worse still, some simply change their status on Facebook. I wonder when we will post scientific papers on Facebook and be evaluated by the number of ‘likes’ from readers.

Maybe we should not complain. Under the current research assessment exercise, academics should submit as many papers as the phone numbers a bachelor gets at dating parties. As such, we should settle with Facebook. Or perhaps Twitter?