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


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


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


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.