30 Aug 2012


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


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


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


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?