27 Dec 2012

Christmas

We attended the midnight mass on Christmas Eve. I used to go every year as organist until I became an intern. It was simply not possible to play for the church when I had duties every Sunday.

This year, however, IK was on vacation, and the choir conductor remembered me. So I happily took up the job again.

Angela kindly went with me. When we arrived at 9:30 pm, she was taken aback that we were having a rehearsal first and the mass would only begin two and a half hours later. “This is the definition of midnight,” I explained.

To my pleasant surprise, despite the passage of over a decade, I still found quite a few familiar faces at the choir. My friends still regarded me highly. They expected me to play half of the songs without prior practice, including one that required transposition. Brahms was said to have done this before, but it was truly God’s grace that an amateur could manage it.

As I greeted my friends, I could not help noticing the trace of time. The same must have occurred to me as well. In fact, after I had given a talk on clinical research to a group of young Korean doctors earlier this year, they sincerely asked me about career development. It was then I suddenly realized that I was no longer considered as their peer.

There is always a time to move on.

20 Dec 2012

Freedom

Earlier this month, I had the pleasure of meeting a few young Chinese doctors at a regional symposium. I learned quite a lot about my mother country. Above all, every student is actually a member of the Communist Youth League. Previously, I thought the League was open to just a selected few who were destined to become Communists. Furthermore, all Chinese doctors I met thought us Hong Kong people overreacted during the national education scandal. “Of course it is nothing but lies,” one of them said. “The thing is we have no trouble realizing this.”

As the dinner was served, a lady cardiologist raised the issue of training and career development in China. “In some centers, the boss controls everything. If you do not get along well with him, he can easily destroy your career. One of my colleagues has very good hands and has published a few papers. But as the boss does not like him, he can now only work at the out-patient clinic and has no chance to do procedures. Surely these things don’t happen in Hong Kong, do they?” she said.

I wanted to say that I grew up lucky, but decided to switch the topic. “It is freedom,” I replied. “In Hong Kong, we at least have the freedom to choose our job. Those who deny freedom to others deserve it not for themselves.”

13 Dec 2012

Fittest

During a recent trip, I read The Beginning of Infinity by David Deutsch. In one chapter, I was reminded of a principle of evolution that was commonly overlooked.

To many people, evolution is a process of survival of the fittest. Intuitively, this means selecting the best organisms. The species would only become stronger and stronger through natural selection. However, Deutsch pointed out that a successful animal does not necessarily fit best with the environment. Instead, the only aim is to win the better chance of reproduction, even if it means sacrifice.

He illustrated the point with an example. Say in a particular island, April is the best month for birds to build nests because of the climate and food availability. Now, although the majority of birds build their nests in April, some birds begin their work in March. The condition is not optimal in March, but the birds soon find that they can choose the best spots in March and can more easily find a mate. After a few generations, birds that build nests in March will be selected. The selection will continue to push the time of nest building forward until the disadvantage of working in cold weather balances out the benefit of having a head start. At this point, the species no longer fit best with the condition of the island, but they are nevertheless selected.

With this, I cannot help thinking how local toddlers are brought to attend seven extracurricular activities in a week.

6 Dec 2012

Progress

For some reasons, AL became unpopular among students.

Twice a week, we hold the gastroenterology teaching round in the morning. Medical students have to present all the cases. We emphasize the development of clinical sense and insist that the students should know not only the cause of hospitalization but also the treatment and progress afterwards. This is to equip students to become competent doctors.

One morning, a student repeatedly opened and closed the case record of a patient. As the starting time of the round approached, he looked increasingly agitated and began to wander around the ward like a headless chicken. When there were just five minutes left, he pointed at AL and angrily told his classmates, “She still hasn’t seen my patient!” It turned out that AL had not had time to write in the case notes yet, and the student did not know how to present the latest progress of the patient. His classmates nodded in sympathy.

It never occurred to him that he himself could assess the patient.

29 Nov 2012

QB

Unlike many of my friends, I do not have a favorite hairdresser. Some shops are too far away. The queue is too long in others. The whole process also takes too much time. Once I asked a hairdresser if I could skip washing and go straight to hair-cutting. He looked at me in disgust (I swear I was clean then). As a result, I keep going from one place to another. Besides, I attend the hairdresser’s infrequently to save time. My hair is always either too short or too long.

Last month, I came across the QB House in Kowloon. They do away hair washing and promise to complete the haircut in 10 minutes. I tried and they really did the job on time. They also did not talk. Exactly what I wanted!

Hairdressers may hate me for not enjoying their service but I guess there are loads of people like me. We just want a simple and quick haircut. If we wanted something else, we would have gone to a beauty salon. Going to work the next morning with a fresh haircut, I could not help but wonder if my patients really want public hospitals to have lobbies fit for a five-star hotel.

22 Nov 2012

Weather

Last Saturday, I attended an investigator meeting in Beijing. I did online check-in before the trip and printed the air ticket in my office. To my delight, at the bottom of the ticket was the weather forecast for the next five days. The temperature would be 17 to 20 degrees Celsius. Although I was pleasantly surprised to encounter such warm weather at this time of the year, I duly brought a light jacket only.

As I arrived in Beijing and stepped out of the plane, a chill went down my spine. In fact, a chill went down my entire body. It suddenly dawned on me that 20 degrees Celsius was the temperature of Hong Kong.

15 Nov 2012

Marshmallow Challenge

You may have played a similar version of this game before. Your group is given a bag of uncooked spaghetti, some tapes and strings, and a marshmallow. Your job is to build a tower with spaghetti to support the marshmallow. The group that builds the tallest tower wins.

When Peter Skillman analyzed the results, he noticed something interesting. Somehow, business school graduates consistently performed worse than fresh kindergarten graduates. On average, their towers were 10 inches shorter than those built by children.

What happened? It turns out that business school graduates did what we are all so familiar with – they held meetings. They formulated the best plan. When there were just a few minutes left, they started building their best design. At the last second, the chairman of the group put the marshmallow at the top, and the tower collapsed.

What about the children? They have never heard about meetings, agenda and brainstorming. All kindergarten groups started building right away. Although their towers collapsed time and again, they had plenty of time to try another structure. In the end, more groups would at least have a standing piece.

So, is it at odds with my previous advocation that we should spend much time planning a study? In my opinion, it really depends on whether you have enough information to make decisions. If you do not know anything, pretending you can develop the best plan would not bring you anywhere. This should be time for trial and error and gathering information. Empty talks without execution is, after all, empty talks.

8 Nov 2012

Predict

In the face of life and death, the decision on the duration of resuscitation is of secondary importance. In fact, we more often go one step earlier – to decide whether to go for resuscitation in the first place. This decision is closely linked to our ability to predict the prognosis of our patients.

Unfortunately, numerous studies have shown that doctors are poor in prediction. In general, doctors tend to overestimate the survival of their patients.

How about the perception of the patients themselves? In a recent article, Jane Weeks and coworkers studied 1193 patients who received palliative chemotherapy for metastatic lung or colorectal cancer and remained alive 4 months since the diagnosis [N Engl J Med 2012;367:1616-25]. Despite their advanced disease, only 31% of patients with lung cancer and 19% of those with colorectal cancer reported their disease would unlikely be cured by chemotherapy. In contrast, 25% of patients with lung cancer and 36% of those with colorectal cancer thought cure was very likely.

This study is striking in that the majority of the patients had unrealistic expectation about their prognosis. Since Weeks did not study the doctors or the consultation process, it is difficult to determine if the observation resulted from vague explanations by the doctors or patient denial. However, it is noteworthy that all patients in this study chose to receive chemotherapy and survived for at least 4 months. Perhaps it always takes a little optimism to go on in life.

1 Nov 2012

Resuscitation

Years ago, a local TV drama pictured a surgeon performing cardiopulmonary resuscitation on a patient who developed cardiac arrest in the middle of an operation. After eight hours of effort, the surgeon refused to let go. “She is already dead,” his colleagues tried to pull him away. “This is human life. We cannot give up,” he yelled back.

Of course, this does not happen in real life. Other than rare occasions such as hypothermia, prolonged resuscitation is futile and does not do the patient any good. However, how long a resuscitation attempt is too long?

In a recent paper, Zachary Goldberger and coworkers reported the findings from an American registry of 64339 patients with cardiac arrests at 435 hospitals [Lancet 2012;380:1473-81]. Overall, 15% of this cohort survived to discharge after successful resuscitation. The average duration of resuscitation was 12 minutes among patients with return of spontaneous circulation, compared to 20 minutes among non-survivors. When centers were classified according to the duration of resuscitation attempts among non-survivors, hospitals in the lowest quartile tried on average 16 minutes and hospitals in the highest quartile tried 25 minutes. The effort was translated into improved outcomes. Patients receiving resuscitation in hospitals in the highest quartile of attempt duration were 12% more likely to survive to discharge.

Thus, it is reassuring to learn that attempting more does help. This, however, still does not answer the original question – How long should we try then?

25 Oct 2012

Chocolate

During the laboratory meeting this week, I showed my friends an article from New England Journal of Medicine (2012;367:1562-4). Flavanols are present in cocoa, green tea, red wine and some fruits, and have been shown to slow down cognitive decline in the elderly. Therefore, Franz Messerli hypothesized that chocolate consumption is proportional to the population density of Nobel laureates in different countries.

The author obtained the list of Nobel laureates from Wikipedia and chocolate consumption from convenient websites. Among 23 countries studied, chocolate consumption per capita and the number of Nobel laureates per 10 million persons have significant positive correlation (r=0.791, P<0.0001). Switzerland ranks first in chocolate consumption and the density of Nobel laureates, and China unfortunately ranks last in both.

Of course, this type of articles is mainly for fun. Numerous confounders such as economic status of a country and lifestyle of local citizens have not been taken into account. At the population level, Nobel Prize is a rare event and correlates poorly with the average cognitive function. Besides, preventing dementia is not the same as enhancing intelligence.

As I explained the points to my friends, I found my hands reaching for a box of Godiva. “Who ate them all?” The box was empty.

“It must be JY,” others said.

“At least we will know a Nobel laureate in the future,” my mentor concluded.

18 Oct 2012

Pop

A friend sent me a CD recently and asked me to have a look at the booklet.

The CD was a remix of Paula Tsui’s songs. In the booklet, Chet Lam described Paula as a respectable singer who insisted to do her own music with little regard to the trend.

The analogy I immediately recalled was Franz Schubert. A prolific composer who wrote almost a thousand pieces before he died at 32, Schubert was unfortunately not very much treasured during his days. The audience then favored ‘grand’ pieces, and his romantic style was too soft for their taste. Several decades after his death, his works became increasingly popular. Of course, similar stories are just all too common among artists. When people become history, we can finally filter out the influence of trend and see their true worth.

To sidetrack a bit, Schubert’s works were also mentioned in Kafka On The Shore by Haruki Murakami. In one scene, Oshima talked about Schubert’s Piano Sonata in D.

“It’s a tough piece to master. Some pianists can play one or maybe two of the movements perfectly, but if you listen to all four movements as a unified whole, no one has ever nailed it. A lot of famous pianists have tried to rise to the challenge, but it’s like there’s always something missing. There’s never one where you can say, ‘Yes! He’s got it!’ Do you know why?”

“No,” I reply.

“Because the sonata itself is imperfect. Robert Schumann understood Schubert’s sonatas well, and he labeled this one ‘Heavenly Tedious’.”

“If the composition’s imperfect, why would so many pianists try to master it?”

“Good question,” Oshima says, and pauses as music fills in the silence. “I have no great explanation for it, but one thing I can say. Works that have a certain imperfection to them have an appeal for that very reason – or at least they appeal to certain types of people. Just like you’re attracted to Soseki’s The Miner. There’s something in it that draws you in, more than more fully realized novels like Kokoro or Sanshiro. You discover something about that work that tugs at your heart – or maybe we should say the work discovers you. Schubert’s Sonata in D Major is sort of the same thing.”

I knew Schubert’s sonata was not popular but did not know it was imperfect. I knew what I was doing was imperfect but did not know it was not popular. In any case, I will continue to do what I think is right. And thanks for the CD.

11 Oct 2012

Trick or Treat

Last week, some Dr Chau demonstrated a novel way of tackling medicolegal issues. “The aim of the procedure is to enhance health. So it is not a medical procedure. All our clients have signed documents and agreed that this is not a medical procedure.” According to his definition, anything from hernia repair to kidney transplantation can be regarded as not a medical procedure.

Doctors can be the worst kind of cheaters. Other cheaters only want money. When doctors cheat for money, they do unindicated and potentially harmful procedures. I can just pray that would not happen to my students.

4 Oct 2012

Protocol

I learned almost everything about clinical trials from KL during my trainee days.

On average, he spent half a year to write a study protocol. The protocols were down to the finest details. For example, he would obsessively describe where the randomization codes would be kept and who could read the codes. It always amazes me that we are still in the middle of the NSAID No. 8 Study (KL had already been promoted to Chairprofessor after No. 7). To him, a clinical trial is a symphony, not a piece of homework to the Research Grant Council.

Completion of a protocol is just the beginning. Every day, he stayed at the Endoscopy Centre to see trial patients and perform endoscopies. In addition, he would find out every case that should be entered into his trial and remind us not to miss it next time. Remind is a soft word.

At one time, I became his roommate during an American meeting. The No. 7 study had just been completed, and KL was preparing the manuscript. For three days, he sat in front of his laptop without typing a word. I asked what was going on and he said he was thinking how to write the first paragraph of the discussion section. Interested readers may find the final version of this paragraph at Lancet 2007;369:1612-6.

27 Sep 2012

Change

When I was a house officer, the department implemented a new policy – All intravenous catheters were to be replaced every 3 days to prevent phlebitis and bloodstream infections. Our group read aghast the memo. That meant a lot of extra work.

That evening, I wrote an e-mail to Angela (I was trying to date her back then), explaining why the new policy was not evidence-based and detailing the study design required to answer this question.

Imagine how I felt when I read Lancet last Saturday. Claire Rickard and colleagues from 3 Australian hospitals randomly assigned 3283 patients who required intravenous catheters for several days to change catheters every 3 days or only when clinically indicated (Lancet 2012;380:1066-74). Phlebitis occurred in 7% of patients in both groups. Nine patients in the routine replacement group and 4 in the clinically indicated group developed bloodstream infection. The authors concluded that both groups were equivalent and the practice of routine catheter replacement should be abandoned.

The study was strikingly simple and could be designed by a house officer like me. Why then, you may ask, was the study not published by me 10 years ago instead?

During a casual discussion on study planning, I mentioned a friend with my Mentor and remarked that he had loads of brilliant ideas but surprisingly few publications. He agreed with my observation and thought for a while. Then he said, “We do not know how he does things. I suspect he lacks the ability to complete a project. You can have a wonderful idea every day, but nothing will happen if you do not do anything.”

P.S. The dating request in the same e-mail was, as you can guess, successful. The intravenous catheter policy, on the other hand, was surprisingly short-lived.

20 Sep 2012

Fight

Last weekend, we watched a powerful demonstration of national education by our countrymen in the news. We could not help but wonder if our country would be dragged into war again.

At the turn of the last century, the prevailing view among academics was that large-scale warfare would not happen in Europe anymore because of the high level of economic development. The cost of war would be too great for any country. Unfortunately, shortly after the proclamation, two biggest wars in history broke out one after another.

If economic reasons are not strong enough to stop people from making stupid decisions, can globalization help? For two groups of people to kill each other, the distinction between ‘them’ and ‘us’ has to be clear cut. Soldiers are even trained to see enemies as animals. To do so, however, one has to be sufficiently unfamiliar to people in the opposing party. Even during relatively modern combats such as the Gulf War, the average soldier knew close to nothing about the culture, religion and life of his enemies. Now, we know our neighbors so well. We visit their cities, watch their movies and eat their noodles. Some of them are nasty, but so are we and the rest are good people. Is this knowledge good enough? I am not sure.

That said, a country should be defined by its people but not the number of uninhabited islands it claims. Sacrificing precious lives for sacred and oil-soaked soil? My answer is no.

13 Sep 2012

Hugga Wugga

Jonathan’s favorite video clip on Youtube is Hugga Wugga. It features an alien chanting ‘Hugga Wugga’. When it encountered another creature singing another song, the alien bullied it by blowing steam at it. Frightened, the poor creature followed the alien and sang ‘Hugga Wugga’.

Then came a new yellow creature that sang ‘You are my sunshine’. Hugga Wugga tried to silence it by blowing steam again. This time, however, the yellow creature outwitted Hugga, blew steam in its face and subdued it.

Yes, if hunger strike is radical, the yellow creature must be a terrorist.

6 Sep 2012

Brainwash

During a case presentation at the grand round, a student kept saying Drug N was the treatment of choice for peptic ulcer. After he had mentioned the drug the fourth time, I could not help but interrupt, “N is a brand name. There are also similar drugs in the same class. You have been brainwashed by the drug company!”

People say that art and humor are the best defense against brainwashing.

At the time of Soviet rule, a government official invited a famous artist to draw a painting to celebrate Soviet-Polish friendship. Seeing his reluctance, the official promised that he would have the freedom of expression, so far if he used the title ‘Lenin in Poland’.

When the painting was unveiled a few months later, the official almost fainted. It showed an ugly peasant woman in the arms of a man in front of Kremlin.

“Who is this ugly woman?” he asked.

“She is Nadezhda Krupskaya (Lenin’s wife).”

“And the man?”

“He is Leon Trotsky.”

Catching his breath, the official asked the final question, “Then where on earth is Lenin?”

“Lenin is in Poland.”

30 Aug 2012

Pororo

Last week, I watched Pororo with Jonathan at home.

One day, Poby the Bear sneezed a few times after spilling some pepper. “You’ve got a cold!” cried his concerned hummingbird friend Harry. Harry insisted Poby to rest in bed. After some persuasion, Poby agreed that he probably needed a rest. To comfort his friend, he reassured Harry that he felt fine.

Soon, Pororo the Penguin and Eddy the Fox visited them. They were surprised to find Poby in bed. “Poby has got a cold,” explained Harry, “but he keeps saying he is OK.”

“Oh,” said Eddy. “Let’s give him an injection.” He pulled out a big needle. At this point, Poby jumped up and ran out of the house.

Patients often look for doctors who are skillful in performing various procedures. What they do not know is how many more patients died because the correct diagnosis was never made.

23 Aug 2012

Prioritization

Along the same line, I can ask a series of questions that do not beg textbook answers. Students who have gone through liberal studies in secondary school must find these very easy.

“Now that we adopt the Model for End-stage Liver Disease (MELD) score instead of Child-Pugh score for prioritizing transplantation listing, what types of patients are most likely to be affected?”

“Do you think patients with liver cancer and cirrhosis instead of cirrhosis alone should jump the queue?”

“Should an organ be given to the sickest person or a person with the biggest survival gain after liver transplantation?”

The rationale behind the last question may not be immediately obvious. Unlike kidney failure, we cannot maintain life of a liver failure patient by dialysis. Therefore, the waiting time does not count. If a patient has mild disease, he will not get an organ even if he has been listed for 20 years (In reality this is not possible because he would have been delisted). Instead, the organ will be given to the sickest patient based on the MELD score.

Now is the more difficult part. For obvious reasons, the sickest person also has higher operative risk and is more likely to develop complications. His survival after liver transplantation is not the same as that of a person with milder disease. To complicate matters further, a patient with liver cancer is also at risk of cancer recurrence.

Suppose we have two patients. The first has liver failure, locally advanced liver cancer and multiple other medical diseases. His chance of survival without transplantation is zero while that after transplantation is around 20%. The second patient has advanced cirrhosis but is otherwise young and free of other diseases. His chance of survival without transplantation is 30% but is up to 70% 5 years after transplantation. Which one should receive the organ? If you choose the latter because the first patient is too ill, what is the difference in survival gain that you would accept?

16 Aug 2012

Child

HC was on sick leave last week. AL kindly took over the disappointed group of medical students and taught them during ward round.

One day, AL asked them, “Can you tell me the components of the Child-Pugh score?” With some help, the group managed to recall the five components.

Suddenly, a boy wailed, “Do we really have to know this? Is it in the syllabus?”

When AL told us the story later that week, she was not upset. “What I felt was the huge generation gap. I cannot imagine saying something like that in front of my seniors if I were him.”

I am not an expert in generation gap. Let me answer his questions more directly.

No, you may be assured that I will not ask about the components of the Child-Pugh score. Our syllabus discourages reciting hard facts. That is not good education.

Instead, if I were to ask you about Child-Pugh score in the examination, I would ask something like this, “Why do we no longer use the Child-Pugh score to prioritize transplantation listing in Hong Kong?”

9 Aug 2012

Books

Finally, I attended the admission interview last week. Szeto said one could learn a lot about another person by the books he reads. So I asked the candidates what books they had read in the last two months.

The results were revealing. It was clear that some students did not read anything other than their textbooks. Two boys said they read a lot of novels when they were young, but now they only read non-fictions. Another boy talked about Metamorphosis by Franz Kafka. I asked him why Kafka portrayed Gregor Samsa as a man transforming into a large insect. He said he was describing loneliness.

Soon, I realized that I forgot to ask Szeto a question – then what? While I understood the candidates more after this question, this in itself would not help me determine if they should be admitted to the medical school.

2 Aug 2012

Eat, Pray, Love

Last month, I had the honor to attend the farewell dinner of my teacher EL. As usual, the professor of rheumatology did not speak too much, but we enjoyed the recollections of events in the past 30 years through slide shows and speeches.

Most colleagues praised EL as a generous person. KL still vividly recalled how excited he was when his group of medical students followed EL to have lunch at the Jockey Club. As a teacher, he allowed students to follow him everywhere and observe what he exactly did at the clinic and wards.

Towards to end, his wife let us see him as we never did before.

“It is rather funny. At home, he would suddenly say, ‘Oh, how much I love my team! It is like a family.’

“And he has a list. It is a list of his patients. Every night, he asks God to look after them. Once in a while, he would come home excitedly and say something like, ‘Y has come out of ICU. God has listened to my prayer!’”

There was a moment of silence. I do not know what others were thinking at that time. I have prayed for my patients before, but certainly not every night. As a doctor, EL could eat, pray and love. What else can one ask for?

26 Jul 2012

Deletion

“Have you read L’s article in Fruit Daily?” PL asked us last Monday.

Seeing that none of us did, he told us the story. L has been writing for Fruit Daily for some time. Recently, the great surgeon wrote a provocative article saying that local people should not protest on 1 July. It should instead be a time to celebrate the return of Hong Kong to China.

The newspaper has a blog and claims to allow everyone to express their views. As expected, L’s article was met with numerous angry responses. A few days later, however, L received a letter from a reader. The gentleman said he actually supported L’s view and left a message at the blog. To his surprise, despite two attempts, his supporting message was soon deleted.

I have not verified his claims yet. But when I glanced through the response at the blog, there was indeed not a single message supporting him.

Voltaire once said, “I disapprove of what you say, but I will defend to the death your right to say it.”

To this end, I respect L’s freedom to express his view, although I see no reason why people cannot protest whenever they like.

As for Fruit, I sincerely hope that the allegation was untrue. The newspaper has already demonstrated its power to falsify facts and mislead readers on a number of occasions. Can it go even lower by upholding the freedom of speech on one hand and doing something more horrible than Communists on the other?

In any case, neither party understands the freedom of speech on this occasion.

19 Jul 2012

Cardiac Catheterization

In 1929, a 25-year old German surgical resident Werner Forssmann wanted to solve a clinical problem: How to improve the delivery of resuscitating medications to the heart? At that time, direct injection through the chest wall into the heart was an accepted practice, though it was largely ineffective and dangerous. On the other hand, cardiac catheterization was met with much skepticism. Dogma had it that touching the inside of the heart would lead to arrhythmia and death.

At that time, several groups had tried cardiac catheterization in animals, but no one was brave enough to test it in humans. Forssmann approached his boss with the idea of a human study and was immediately rejected. The senior surgeon knew he would not listen and even went at length to forbid everyone in his department to let Forssmann touch the surgical instruments.

Forssmann was not easily deterred. With much perseverance, he managed to persuade a surgical nurse named Gerda Ditzen to unlock the surgical instruments and offer herself as the first study subject. Forssmann tied her on a table and left the room. Ditzen waited and waited and wondered what was happening. Eventually, Forssmann reappeared with a catheter up his basilic vein and blood all over his body. The nurse angrily scolded him for betraying her. Yes, Forssmann only tricked her for the instruments and never intended to risk his colleague. He untied the screaming Ditzen and ordered her to take several x-ray pictures. That made history.

Looking at the bright and enthusiastic youngsters who were applying for the medical school, I could not help but wonder: Should we recruit people who would abide to the rule, or should we choose those who would challenge the rule? Can we afford to have doctors running around the hospital trying to tie up nurses?

P.S. Although Forssmann did not hesitate to risk his life, he never did the same thing on others. Serving in the German army during World War II, he was offered the opportunity to do experiments on prisoners. He promptly refused. “To use defenseless patients as guinea pigs was a price I would never pay for the realization of my dreams,” he wrote later. Unfortunately, his pioneering work was ridiculed by his colleagues as circus work. He was denied academic posts year after year and had to do urology instead. When he finally received the Nobel Prize in 1956 and was offered professorship in cardiology, he found himself cut off from the field for too long and could only serve as a “living fossil”.

12 Jul 2012

Outside the Box

Talking about thinking outside the box, I like this story from Fooled by Randomness.

“If you flip an unbiased coin 99 times and you get 99 heads, what is the chance that the next toll is a head again?” the author asked.

“The chance remains the same at 50 percent,” a PhD in statistics answered.

“Nah,” an investor disagreed, “I bet everything that this coin was biased. This next toll will still be head.”

Yes, the question was based on the assumption that the coin was unbiased. But why can’t assumptions be challenged? If our thinking is confined by dogma, how can we hope to make any progress?

5 Jul 2012

Light Bulb

This summer, we have to interview students applying for our medical school. GW suggested that I should ask the light bulb question. HC and RL were very curious and urged me to share it.

Here it goes.

There are 50 prisoners on life sentence at a remote island. Each of them occupies a separate cell in jail and cannot see or talk to each other. One day, the jail officer decides to play a game with them.

“From tomorrow onwards,” he explains, “I will reshuffle the cells you live in randomly every day. All but one cell are identical. In the special cell, which I would call Cell X, you are free to turn the light on and off at your will. You can only communicate with your fellow prisoners by switching the light bulb on or off, and are not allowed to leave other signals. If one day one of you can confidently claim that all 50 fellow prisoners have already been in Cell X at least once, I will set you all free. If, however, you make this claim but one or more prisoner has yet to enter Cell X, I will execute you all. Now, discuss the plan among yourselves. Good luck, gentlemen!”

Can you devise a plan to win this game?

After I had finished, HC and RL became very silent.

“We can draw lines on the wall,” RL finally muttered.

“Or we can leave our clothes in Cell X,” HC said.

“We’d better kill the officer while we are still together,” RL added.

And then they suggested 5 to 6 more possibilities.

“Hey,” I said, “neither of you are going to touch the light switch at all?”

“Can’t figure that out,” RL protested, “but shouldn’t the university encourage thinking outside the box?”

28 Jun 2012

Slavery

During a conference in Liverpool last week, we had dinner with Dr PC. PC is a consultant who grew up in Hong Kong and worked in Liverpool in the last three decades. He is a very kind person and has given several lectures in Hong Kong previously.

When he learned that I was leaving on the next day, he asked what my plan was.

“I want to attend the appetite control symposium. Afterwards, I will catch the train to London and then go home,” I answered.

“Listen,” he said, “you must visit the International Slavery Museum before you leave.”

Thus, I sneaked away in the middle of a talk and said goodbye to the conference. By the way, a psychologist was explaining why liking food and wanting food were different. It sounded interesting.

The Museum had but one theme. For around 400 years, Europeans sent tens of millions of Africans to America to work as slaves, mostly at cotton plantations. Through networking and business skills, merchants in Liverpool quickly led the field and made the city capital of human trafficking. The Museum also illustrated at length how the slavery business destroyed the economy and development of Africa. In essence, the illustrators believed that Liverpool should take full responsibility of the damage.

A nation cannot be great until it can face its history.

21 Jun 2012

Time

If I am a caveman or a hunter-gatherer, I would prefer immediate gain. Even if you promise to crown me king a month later, I cannot tell if I would still survive by then. With the strong force of evolution, no wonder it is so difficult for us to accept delayed gratification.

Steve Jobs asked us to consider, “If today were the last day of my life, would I want to do what I am about to do today?”

To be sure, this is a good way to distill earthly thoughts and focus on important matters. However, while the important should stay important regardless of the context, the reverse is not true. For one thing, if I am to die tomorrow, who cares about the retirement fund? On the other hand, a person retiring at the age of 60 can hardly say that.

Therefore, it really worries me that I laughed out loud at my MPF report.

14 Jun 2012

Wait

Suppose you can not only tell that the street musician is superb but also recognize he is Joshua Bell, will you stop and listen?

If we ignore the fact that one may listen for a while and can still go to work on time, the scenario reminds me of the famous marshmallow experiment. In 1972, Walter Mischel of Stanford University conducted a study on delayed gratification. In this experiment, preschoolers were offered the choices of taking one marshmallow immediately or getting two if they agreed to wait until the investigators came back. What the children did not know was that the investigators had no plan to come back. Instead, their behavior was videotaped and the time until they took the marshmallow was recorded.

Remarkably, when the investigators followed these children up, those who could resist the temptation and choose the later but bigger reward had better school performance and higher Scholastic Aptitude Test (SAT) scores (Science 1989;244:933-8). Last year, follow-up data of these children, now in their 40s, were presented. When they came back for further psychological tests, those who took the marshmallow quickly at the age of four continued to be distracted more easily by emotion and make mistakes four decades later (PNAS 2011;108:14998-5003).

For obvious reasons, I tried the same experiment on Angelina.

To my dismay, she gobbled the candy up before I finished my instructions.

I spent more time to explain and asked, "Don’t you prefer two candies?"

"No, one is enough," she grinned.

7 Jun 2012

Ignore

What can we learn from Joshua Bell’s story?

The simplistic view is how often we dwell on trivialities and miss beautiful moments.

What interests me, however, is how Bell described his experience. Before he played the first D minor chord of Chaconne, he suddenly felt nervous. “It wasn’t exactly stage fright, but there were butterflies.”

But Mr Bell, you played at ease before royalties and statesmen, didn’t you?

After a while, he stole a glance at the passersby. “It was a strange feeling, that people were actually, ah … ignoring me.”

The difference between a street performance and a show at Carnegie Hall is that in the latter case, people who come choose to do so and have already acknowledged his worth. When he disguised as a nobody, he had to gain respect by music alone, and it turned out to be very difficult.

If you are a budding musician struggling to become successful, this can also be a bitter story. So it is not how well you perform, but how good other people believe you are. Most people unfortunately cannot really distinguish good from great. Their appreciation is largely based on what others say, who in turn gain their views from yet other people. Worse still, in the current winners-take-all society, people would rather listen to a CD by a famous musician than a live (perhaps even free) performance of somebody unknown.

What can we do then? Simply, we can only do our best and accept that success may be a matter of luck. Do not let others define your worth, though this is often easier said than done. Above all, we do not need to be loved by everybody. When there is someone who loves you despite your imperfection, is it not good enough?

31 May 2012

Appreciate

Last week, my father sent me a story about Joshua Bell.

Bell is one of the best violinists worldwide. In 2007, Washington Post invited him to play at the L’Enfant Plaza Station during the morning rush hours and see how people react to excellent music.

On that day, Bell disguised himself as an ordinary street musician in jeans and cap. He opened his violin case, threw in a few coins as seed money, and began to play. The first piece was Chaconne by J. S. Bach.

Before this project, the journalists asked some professionals to estimate the result. Provided that no one recognized Bell as the famous violinist, they thought, only 75 to 100 people out of 1000 passersby could appreciate the quality of the performance and would stop and watch. But a small crowd would gather nevertheless.

The result? From 07:51 to 08:34 that Friday morning, 1097 people passed by. Only seven people stopped to listen for at least one minute. Bell earned $32 in total.

24 May 2012

Distinction

This year, our Chairman asked us to set questions for the viva examination again. I prepared something simple.

‘What is genome-wide association study?’

‘Can you name me an example of how genome-wide association studies have contributed to medical care?’

17 May 2012

Examination

We just had the final professional examination this week. While this was a very exciting time for students, the reciprocal was not true. Repeating the same questions over and over, examiners could be bored to death. Luckily, a few kind-hearted people entertained us.

At a history taking station, a student courteously greeted the patient and asked why he came back to the clinic. Before the patient replied, she suddenly screamed, "My God! I forgot to ask your age. How old are you?" Astonishingly, the next student did the same thing.

At another station, a foreign examiner asked a student to treat him as the patient and obtain consent for a medical procedure from him. The student asked sincerely, "May I speak in Chinese?"

On the second day, a student spotted me in the corridor and asked, "Will you be our examiner this morning?" I said no. Then she wailed, "Oh, you are our only hope!" Without a word, I waved my hand and walked away. She was insulting me!

10 May 2012

Beginner's luck

“I am afraid I will have to do emergency endoscopy tonight,” AL said on the day of her first gastroenterology call day. She just noticed that I would also be on-call that day.

The other teammates were very kind and tried to soothe her. “Most people have beginner’s luck,” they said.

I smiled and said something else instead, “If we have to do an emergency case, we will do it happily.” And we did. (I mean we did an emergency case. I am not sure if she did that happily.)

Beginner’s luck is widely accepted among gamblers. If you ask experienced gamblers, many would recall they won quite a bit during the first few games. On the other hand, the Chinese have a more logical saying – “People lose because they won before.”

Beginner’s luck is one manifestation of survivorship bias. People who lost bitterly in the beginning will less likely become habitual gamblers. So if you only survey current gamblers, chances are that the majority are early winners.

The same holds true among academics. I love to read the Masters’ Perspective in the Hepatology journal. Successful researchers take turn to describe their training and research and share wisdom. As I glance through the reference list of each article, I cannot help noticing that all the masters had their first few publications in top biomedical journals.

There are numerous possible explanations. Above all, their early success may reflect their brilliance and how good their training centers are. Survivorship bias is also at play. Young researchers who fail repeatedly may lose heart and decide to do something else, or they may just not be given another chance.

How about me? My first project during my internship was so lousy that it remains unpublished today (to be exact – not even submitted). I wonder if my first few publications were ever read at all.

Nevertheless, my mentor kept telling me that I could do it and urged me to keep trying. This, I believe, is the true beginner’s luck.

3 May 2012

General Studies

One evening, while Angela and I were discussing Mr T, Angelina suddenly got excited.

“I know who Mr T is. Mrs S talked about him during the General Studies class. He is our CE. Mrs S said he used his power to do bad things and should be put to jail,” she said.

I was dumbfounded. I was about to say that I agreed with everything Mrs S said except that I did not think he would end up in jail, but found that I could not address this issue any better. I thought teachers with independent thinking had been wiped out by the government’s brilliant education reform. Luckily I was wrong.

When I was in primary school, my teachers were free to teach anything they liked. One of my Chinese teachers was a graduate from Taiwan. Her main theme was that communism did not make sense and would collapse very soon. I am not sure what she thinks now as the Chinese government still stands strong, but in my mind she is perfectly correct. Communism does not make sense. It has collapsed everywhere. The biggest communist country no longer practices communism. That is the biggest collapse of all.

26 Apr 2012

Sacrifice

Angela and Jonathan got baptized during Easter. The baby was unusually peaceful during the ceremony.

At that time, a few scriptures were read. One was on the testing of Abraham’s faith. God granted Abraham a son after decades of infertility. One day, God suddenly commanded him to sacrifice his son. Without a question, Abraham brought his son Isaac up a mountain, built an altar and tied him up. Just before he killed his son with a knife, God stopped him and acknowledged his faithfulness.

At the ceremony, it dawned on me that the whole story was a metaphor of what would happen to Jesus years later, except that Jesus really had to die on the cross. Without the narrative of a human, the description of God sacrificing His beloved son could sound distant.

It surprised me that I never made that association over the years. Now that I know it, this remains a test I cannot pass. Let me sacrifice something else.

19 Apr 2012

Golden Hair

One day while I was driving, Angelina said, “There is a golden hair on my seat.” She threw it to the back before I could have a look.

“Only two kinds of creatures can leave a golden hair here,” I said after a while.

“What, Daddy?”

“First, a beautiful lady.”

“And?” Angelina eyed at me.

“Or it may be a Pekingese.”

“Cookie!” she jumped.

12 Apr 2012

Resurrection

One day, Angelina looked at our old photos and asked, “Is this the father of Mummy?”

“Yes,” I answered.

“And he has died?”

“Yes, indeed.”

“After people die, they go to heaven,” she continued, “It must be lucky to come back to this world.”

“We Christians believe in life after death. We will all meet in heaven in the end.”

After a while, I suddenly added, “At that time, I will wait for you with a game of chess.”

“You mean when I am in hospital?”

“No, I mean I will wait for you in heaven.”

Angelina nodded. “And you will spare my Queen?”

“Yes, I will spare your Queen.”

5 Apr 2012

Colony

Next, our host turned to the history of Taiwan. “Taiwan was occupied by the Dutch and the Spanish. After that, we became a Japanese colony for fifty years,” he said.

Suddenly, the Japanese professor bowed and said, “I am very sorry.”

The host could not be more apologetic. “No, no, no, we didn’t mind at all.”

Friends from China would probably sneer in disgust if they were in the audience, and that would be polite. Sympathizing with invaders is no better than treason.

Nevertheless, born in another colony myself, I had no problem understanding their feelings. No doubt our cities were taken over for the wrong reasons. However, on both occasions the natives benefited much from the cultural influence and technological input. We also cannot help noticing how difficult it is to find a better local leader.

From another perspective, I was moved by the Japanese professor's response. But life really can be so simple. If Japanese leaders apologize, I am sure we will just say we do not mind anymore.

29 Mar 2012

Professor

Earlier this month, I had the honor to give a talk at a surgical conference in Taiwan. After the talk, we had lunch with the organizers.

One of the overseas speakers was a retired professor from Japan. The discussion somehow turned to the history of medical schools.

“When the first medical school was established in Japan, there was much debate on the system we should adopt. We were to choose from the British system and the German system. In the end, we decided to follow the Hannover model. In essence, the professor had supreme power in the department,” he explained.

The organizer nodded in agreement. Then he told me a story about his mentor, to whom my named lecture was dedicated.

“One day during ward round, Professor L was displeased with my case management. He threw the case notes out of the door of the room. Our ward was on the second floor, and the chart fell right down to the ground floor. Without a word, I ran down, picked up pieces of the notes and tied them with a string. When I returned, I bowed, apologized and handed the notes back to Professor with both hands. The next thing I knew, the notes flew out the door again.”

22 Mar 2012

Critique

“I shall not alter a single word. I shall publish the work exactly as it is!”

As I glanced through the four-page comments by my reviewers, how much I hoped I could just return these two sentences! But no. I first wrote a note of thanks to the reviewers, and then prepared a list of point-by-point response. Along the line, the manuscript was modified bit by bit, until it was no longer the same.

Unlike Tchaikovsky, I am not the one who decides to publish. Currently, scientific journals are run largely according to the peer-review system. Manuscripts are sent to other researchers with similar interests for review. Many reviewers are helpful and suggest ways to improve the presentation. Others, however, write comments only because it does not look good to admit that they have nothing to add. Do more experiments. Redo the whole work using another animal model. While it is an easy comment that can be applied to all research works, the time and resource it implies are tremendous. This also delays dissemination of scientific findings.

Only once in my life was my manuscript accepted directly without any revision. My mentor described that as a modern miracle.

Tchaikovsky also received much criticism when his Piano Concerto No. 1 and Violin Concerto were first played at concert. Vulgar, unmusical, showing off technique like in a circus, you name it. Nutcracker was too symphonic for ballet. Maybe they were correct. It goes without saying, however, that these masterpieces continued to be played 130 years later. On the other hand, hardly anyone remembers who the critics were.

For this reason, I am more interested in producing good works than publishing angry letters criticizing other people.

15 Mar 2012

Revision

Recently, a group of experts wrote a regional guideline and submitted it for publication at the official journal of their society. The handling editor sent it out for external review. One reviewer returned several dozens of recommendations and suggested a number of major modifications in the guideline.

The chairman of the guideline committee was furious. “This is humiliating! The guideline represents the results of thorough discussion and voting by the committee members. How can it be modified by a single outsider who did not join the discussion?” He went on to threaten to withdraw the manuscript and send it to another journal, which he was sure would eagerly accept it as it was. After all, a guideline on a major topic would guarantee several hundred citations.

This reminded me of another story. After Tchaikovsky had completed his Piano Concerto No. 1 in 1875, he showed it to the pianist Nikolai Rubinstein, hoping that he would perform the work at concert. Rubinstein listened as Tchaikovsky played the piano part. He remained silent throughout the performance. When Tchaikovsky finally finished and asked for his opinion, he stated that the work was vulgar, unplayable and should be largely rewritten. “I shall not alter a single note,” the angry Tchaikovsky answered. “I shall publish the work exactly as it is!” And he did. (Interestingly, Tchaikovsky actually revised the work in 1879 and again in 1888. This later also became Rubinstein’s favorite piece and one of the world’s most popular piano concerti.)

But medical science is different from art. I look forward to reading the final version of the guideline.

P.S. According to the Six Links Rule, any person can be linked to any other person on this planet through a chain of no more than six different people. Amazingly, as the story unfolds, I actually know the chairman, handling editor and both reviewers personally. It is a small world after all!

8 Mar 2012

A minor

More about Sonata No 8.

The Sonata in A minor was the first of Mozart’s only two piano sonatas in minor key. It was written at a time of great emotional turmoil. The composer left his comfortable job in Mannheim for the first time and took up unstable freelance work. That was compounded by the recent death of his mother and his affair with Aloysia Weber.

When you want to understand a person, you’d better watch what he does at difficult times.

Mozart was an expert in expressing a wide range of emotions in a single piece. Though the Sonata was deeply melancholy, one could hardly ignore the interception by passages of playfulness. Similarly, the second movement was expressive and romantic, only interrupted by a tense and dissonant passage in the middle. The swinging emotions make you feel that the composer was trying hard to pull away from the sadness and bitterness, as if it did not matter; as if it had not occurred.

This contrasts sharply from Beethoven. When Beethoven became increasingly deaf, he wrote the Symphony No 5 in C minor. The four-note motif at the beginning of the Symphony was one of the most well-known phrases in music. As the composer later revealed, “Thus Fate knocks at the door!” The four-note motif would appear in many different forms throughout the entire Symphony.

So, what was the Symphony about? Was it about the cruelty of Fate and the hardship of Life? Yes and no. To Beethoven, C minor was his special key. He always portrayed himself as the Hero whenever he wrote in C minor. The Symphony, for instance, finished with the triumphant fourth movement. The greatness of Man conquered Fate.

1 Mar 2012

K310/300d

若言琴上有琴聲,
放在匣中何不鳴?
若言聲在指頭上,
何不於君指上聽?
- 蘇軾〈題沉君琴〉


Lately, I have become a one-handed pianist.

When Jonathan is sleeping, I have to keep quiet. When he is awake, Angela would not let me play. “Aren’t you going to take care of your son?”

So, I decided to carry Jonathan to the piano. My main difficulty, however, was that he wiggled a lot on my laps. To keep him from falling down, I had to hold him with at least one arm.

Today, I played Mozart’s piano sonata No. 8 in A minor. During the most symphonic passage, I could only choose to play either the quick notes by left hand, like the flow of oil as Mozart loved to describe, or the majestic chords by right hand. In the end, it really did not matter. Though I could only play a fragment of the great piece, music was complete in my heart.

I am never too fond of expensive hi-fis. My sweetest memory was from the days when I only had a rather primitive cassette player. Though the sound was just discernable at best, I played and played the same recording on Tchaikovsky’s Swan Lake, overwhelmed by the elegance and harmony.

If Liszt could insist on performing on an old piano in a small church and Beethoven could conduct his Symphony No. 9 without hearing a single note, the most beautiful music exists in our mind rather than any equipment after all.

23 Feb 2012

Faces

“To survive in the academic world, you need to improve your networking,” my mentor told me.

This is of course very true. Nowadays, good research demands a whole range of expertise that a single team is unlikely to master. Clinical studies also require bigger and bigger sample sizes that can only be achieved by many centers working together. It is therefore important to know people.

But I have a problem – I cannot recognize faces. Recently, I looked at Whitney Houston’s photo and thought that was Jennifer Lopez, you see what I mean.

When I greet friends in overseas conferences, I try my best to hide the fact that I cannot recall where he is from and what his name is. Invariably, disaster soon strikes. Another friend comes and expects me to introduce them to each other. After a few polite remarks, both friends know I cannot recall a thing about either of them.

So, imagine how I felt when I learned that paper wasps (wasps!) were good at recognizing faces.

In a recent paper by Sheehan and Tibbetts, paper wasps were trained to recognize faces (Science 2011;334:1272). The investigators took pictures of the faces of different paper wasps and put them in a maze. When a wasp went in front of the picture of an incorrect wasp, it got an electric shock. It did not take much training before the wasps could choose the correct pictures. On average, they got it right 8 times out of 10.

I learned three important lessons from this study.

First, animal activists can accept insect studies.

Second, it takes only a few hundred neurons to form a neural network for recognizing faces. I am sure I have that.

Third, what I really need is just a few electric shocks.

14 Feb 2012

Angels

Years ago, I read this lovely piece by a writer from Taiwan.

Is there a mother who was not an angel? Every girl has lived by the stars. They paint the sky with rainbow and play hide-and-seek among the clouds. Did they ever have to worry? They are the youngest daughters of God. They look at their reflection in the river, amazed at their youth and beautiful wings.

One day, her wings were gone. She put on ordinary clothes and decided to become a mother. Someone says her wings were locked in a chest. She can no longer fly. Others even say her husband locked her wings and hid the key in a secret place. However, every mother understands that the angel actually knows where the key is. When nobody is around, she would even open the chest and touch the wings sadly. She knows once she puts the wings on, she can fly up to the sky again. But she touches and touches, and still closes the chest and hides the key. Yes, it was herself who locked the wings. She can no longer fly, because she no longer wants to.

Happy Valentine’s Day, my lovely angel!

9 Feb 2012

VIP

Last week, I received a call from BM. “Thank you for doing endoscopy for my patient. She is VIP’s friend.”

I was taken aback. That was a complicated procedure. Although it went smoothly, it could easily have gone wrong. “But you didn’t mention anything before,” I complained.

She chuckled, “That is a good way to prevent VIP syndrome.”

I thought for a second. She was right. I really did not want to know. So I thanked her and said we would keep an eye on the patient.

Coincidentally, my mentor talked about VIP syndrome recently. He retold a story from Andre Agassi’s autobiography.

During his brilliant career, Agassi had a funny observation. When he played against an obviously weaker opponent, the match often turned out to be tough. Big win seldom occurred as he had hoped.

After he made that observation, he started to investigate what went wrong. It dawned on him that whenever he had a weak opponent, he did unusual things. He would hit the ball harder, trying to finish the other player quickly. But since this was not what he usually did, it often became unforced error instead.

Then he devised a plan. The next time he faced a weak opponent, he had to answer a question first – Why did he think he was weak? If he could not find a reason, he concluded that the opponent might not be weak after all. If the weakness was truly apparent, he should calmly attack the weak point.

“VIP syndrome is the same,” my mentor concluded. “Disasters happen because people make unusual decisions in face of a VIP. The only solution is to have a clear mind and suppress the urge.”

2 Feb 2012

Production Cluster

Recently, somebody dropped some old letters at my desk. I could read every word but could not understand a single sentence. I would be much obliged if readers may enlighten me on what they are talking about.

Dear comrades,

We have extensive discussion among various involved parties concerning the situation in the factories and would like to propose the following action plan:

1. Trial run ‘production cluster’ instead of limiting to individual ‘factory’. Karl has listed out the potential benefits as follows:
- Workers can continue to work in their own factory first, instead of being re-allocated to other factories
- Balance production lines and finishing time among different factories
- Manpower management

2. Workers
- We are actively recruiting part-time workers to work in factories with large workload.

We understand this will create anxiety among workers, and will definitely continue to monitor the situation. On the other hand, we really need the help and contribution of everyone to have a trial on this.

Best wishes,
Mikhail


Dear comrades,

1. We all agree that the tin factory needs more staff. But we have difficulty in finding more workers from our pool. Siberia has stopped allocating workers to the tin factory in the previous months.

2. I am a bit disappointed at stopping the trial run of the ‘production cluster’ concept. While I fully agree that we should not always ask workers from one factory to help in another factory on a regular basis (but should try other ways), the main reason behind the concept is to act as a buffer to meet unexpected shortage of workers or surge in tin demand.

Karl


Dear Karl and Mikhail,

The major drawback of the proposed ‘production cluster’ system is that it is hard to implement the quota system at the same time. Quota system is the main incentive for efficient work and punctuality.

I am a believer of a fair system with incentive and punishment rather than a Utopia system that everybody is working hard for the benefit of the system and willingly offer their helping hands when others are in need (the whole reason why communism failed).

Friedrich

26 Jan 2012

The 100% perfect girl

Angelina asked me for a story to be used in the upcoming story-telling competition at school.

“We have made up so many stories already, why do we need to write a new one?” I asked.

“Mrs S said the stories must teach us something,” Angelina answered.

That was a serious blow. Although there was much free association in my stories, I never realized they did not have any message. Anyway, we made up another story right away.

Linda is a primary one student. She loves going to school. She pays attention in class and does her homework well.

But something annoys her. No matter how hard she tries, she always forgets some answers or makes some silly mistakes during tests. Though her test results are quite good, she wonders what it would be like to have full marks in exams.

One day, Linda sees an old lamp on the ground on her way home. The lamp is gold in color but is all covered with rust. That reminds her of the magical lamp in Aladdin. Curious, Linda picks up the lamp and rubs it with her hand.

Suddenly, a puff of smoke shoots out from the lamp and a genie in black cloak appears. “What do you wish, little miss?” asks the genie.

It gets curiouser and curiouser. Nonetheless, Linda replies, “I wish to have one hundred marks in all my tests and exams.”

With another puff of smoke the genie disappears. Linda opens her eyes and finds herself in bed. “Oh, what a silly dream.” She cleans herself, eats breakfast, and goes to school.

The math test is held that day. Linda has prepared well but is a little nervous. As she glances through the paper, she feels calmer. The first few questions are on odd numbers and even numbers, which she knows well. She picks up a pencil and starts to answer. But her pencil stops in mid-air.

The paper has already been done. Each and every question has been answered. Mrs K must have made a mistake. She looks up. However, none of her classmates seems to have problems with their papers. They are all writing vigorously. Linda looks at her paper again. She reads the questions and answers carefully and is sure that the answers are all correct. Strangely, the answers remarkably resemble her handwriting and are written by pencil. Linda uses a rubber and finds that the answers can be erased. As she puts down the rubber, however, the answer appears on the paper again. While she is still wondering what has happened, Mrs K announces that the time is up.

The next day, Linda gets full mark the first time in her life. Mrs K says she has become more careful this time and wishes her to keep up the good work. Her friends cheer for her. Linda is uneasy but also enjoys the praise. She always knows she has worked hard, but being admired in front of the class is another thing.

In the Chinese and English tests later that week, the same thing happens. Linda gets one hundred marks without even raising her pencil. When she shows her parents the test results, Daddy says, “Well done, Linda. We are so proud of you. We hope you enjoy learning.”

Soon, Linda realizes that she can easily become first in class. The lessons do not seem so interesting now. She spends every minute at home playing with her toys and stops studying. Whenever Mummy asks her to revise her schoolwork, she replies, “I know everything already.”

A few months later, it comes to the final exam. The genie does not fail her. Once again, all the correct answers appear faithfully on the exam papers. Linda effortlessly gets all subject prizes in her class, as she has always wished.

After the exam, her class teacher Mrs S brings her to the headmistress. The headmistress is a kind lady. She says Linda has done very well this year. After a little chat, she asks, “What does eight plus seven equal to?”

Linda puts up her fingers and suddenly finds that she has not used them for math for ages. She clumsily counts her fingers and answers, “Thirteen?”

The headmistress and Mrs S are a bit surprised. “How do you spell kitchen?” the headmistress asks again.

“K…” Linda utters and cannot finish. She blushes and tries hard not to cry. On the way out, Mrs S puts her hand on Linda’s shoulder and says, “Never mind. I should have told you earlier. You are just too nervous.”

That evening, Linda keeps thinking about what happened. When has she become so bad? She has enjoyed the magic so much and stopped learning. Tears come out from her eyes and she begins to cry bitterly. Daddy and Mummy rush to her room and ask her what is wrong.

Linda decides to tell the truth. “Daddy and Mummy, I am sorry. I have been cheating.” And she tells them everything since the day she met the genie.

After she has told the story, Daddy and Mummy hug her. “The important thing is never how many marks you get or how many prizes you win,” Daddy says. “Being honest and enjoying learning are much more important.”

From that day on, Linda starts to pay attention in class again. She finds the subjects are very interesting after all and is surprised how she could have missed the fun. At the next test, she is relieved to see that the paper is no longer answered. Now, she sometimes gets one hundred marks and sometimes does not, but she knows in her heart what really is important.

19 Jan 2012

200

This year marks the 200th anniversary of the New England Journal of Medicine. Beginning as a small publication distributed on horsebacks around Boston, the Journal has emerged as one of the most influential platforms in modern medicine. As I glanced through the history of the Journal, I was fascinated by the tremendous progress over the years, but was also amazed to find that many ‘routine’ treatments we use nowadays were not developed until rather recently. To give you an idea of my awe, I have listed some examples below:

1810s: Invention of the stethoscope
1820s: Description of polyneuropathy
1830s: Description of rhinoplasty
1840s: First uses of inhaled ether for surgical anesthesia
1850s: Pasteur identified germs as a cause of disease
1860s: Florence Nightingale established a pioneering nursing school
1870s: Development of cholera vaccine
1880s: Koch isolated tuberculosis bacillus
1890s: First X-ray image
1900s: First electrocardiogram
1910s: Discovery of syphilis treatment by arsphenamine
1920s: Discovery of penicillin
1930s: Establishment of the first blood bank
1940s: First chemotherapy for cancer
1950s: First kidney transplantation
1960s: First liver transplantation and discovery of Australian antigen
1970s: Description of the pathogenesis of atherosclerosis
1980s: First description of AIDS
1990s: First hepatitis A vaccine
2000s: Development of imatinib as a targeted therapy for chronic myelogenous leukemia

As Bill Gates said, there’s a tendency to overestimate how much things will change in 2 years and underestimate how much change will occur over 10 years. Those who say there won’t be much more development in their fields will continue to eat their hats, I am afraid.

12 Jan 2012

Scan

During the last two trips, I surprisingly finished reading all journal articles at hand before I returned to Hong Kong. You may also be surprised if you have a look at my reading list (see http://vwswong.blogspot.com/2010/01/thursday.html). I usually keep around two dozens of articles in my cell phone and read them with Adobe during my free time. I have considered using iPad instead but realized that my reading time was unpredictable and I didn’t want to carry a bigger device all day long.

On close scrutiny, I found that the number of articles in my cell phone had been decreasing gradually. The reasons were actually pretty obvious.

First, my interest has become narrower and narrower.

Second, technological advance has facilitated my screening process. In the past, I scanned article titles and downloaded the ones of potential interest. Now, scanning is often performed in the matter of a few seconds. When the cursor goes near the title of an article, the abstract is shown on the same page. Some journals just provide a few lines summarizing the main results of the study instead. In essence, I can quickly grasp the main messages and decide not to read further if the topic is not related to my practice.

Neither sounds right.

5 Jan 2012

Zombies

We visited my mother-in-law in Macau during the New Year holidays. After a lunch, my sister-in-law said I was good at educating Angelina. I was flattered. That was even better than praising my awesomeness.

What exactly did she observe?

We played ‘Plants vs zombies’ at lunch. No, not the original computer game; I only borrowed the idea. Instead, I used my hands as zombies and moved them toward Angelina. To kill the zombies, she had to do mathematical sums in time. Otherwise, the zombies would enter the house and eat everybody.

The game invariably ended with the zombies breaking past all defense and Angelina screaming at the top of her voice.