25 Aug 2011


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


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


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


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.