CV

I spent the better half of last week updating my CV. The impressiveness and innovativeness of the computer input system have been elaborated extensively elsewhere (see http://ccszeto.blogspot.com/2009/10/obotchaman.html) and will not be the focus of this article. Instead, I want to talk about my CV.

I prepared my first CV when I applied for a resident post in my current department. KL was responsible for screening the applications then. Soon after I sent out my CV, I was summoned to his office.

“How can I recommend you for an interview if your CV only contains your name?” he asked.

“No, I thought I wrote many things. See, my employment record is here.”

“Where are your scholarships and subject prizes?”

“Oh, I did not keep any record and do not like to boast about those things.”

At this point, KL was completely fed up. He threw a document at me and said, “Copy it. Find whatever applies to you.” I turned the cover. My goodness! That was the CV of the Walking Harrison when he was an intern. Till now, my record of scholarships remains inaccurate. Luckily, this section is no longer important as I grow older, and I finally swiped it off from my CV.

Did I learn anything?

Last week, I was appalled when I found out that the University wanted the record of my conference abstracts, outside talks and services. Even if I remembered everything I did, how could I recall when I did it? I searched my pocket PC, only to find that old records in the calendar were automatically erased.

As usual, I mentioned my difficulty to my mentor. History repeats itself. That afternoon, I received his own CV.

Prophesy

You may not be sympathetic for what I described last week. Can I not predict the severity of gastrointestinal bleeding based on the clinical data provided, and thus reject some cases of urgent endoscopy?

Yes and no. There is indeed no shortage of prediction scores (of anything) in the literature. How they may help depends on the setting and application.

In a study published earlier this year, the Glasgow-Blatchford bleeding score (GBS) was validated in 4 UK hospitals.[Stanley AJ et al. Lancet 2009;373:42-7] The overall accuracy of GBS to predict the need for endoscopic intervention and death among patients with symptoms of gastrointestinal bleeding was good, with an area under ROC curve of 0.90. The investigators also prospectively implemented the score in real clinical practice and demonstrated that the need for hospitalization decreased.

Can I apply it? When one looks at GBS carefully, the low risk criteria include normal serum urea, normal hemoglobin level, normal blood pressure and heart rate, and absence of melena, syncope, cardiac failure, or liver disease. If a patient has none of these, you really would wonder if he/she suffers from anything at all. In fact, in the validation study, 56% of the patients fulfilling the low risk criteria (GBS=0) had no lesion or just hiatus hernia on endoscopy. It looks as if the score is most useful in helping those who cannot clerk a proper history and make the diagnosis of upper gastrointestinal bleeding. Sadly, whenever I am consulted, the patients would have at least several of the risk factors. According to evidence-based medicine, I should have no choice but come back to the hospital every time.

Another factor we cannot ignore is that the negative predictive value of any test depends on the prevalence of disease. At the primary care clinic or emergency department where most patients with symptoms of gastrointestinal bleeding actually would not die or require endoscopic therapy, using GBS to rule out significant bleeding is safe and accurate. Managing old and frail in-patients is obviously another ball game.

Luck

My colleagues often consider me unlucky on call days. As an on-call gastroenterologist, I have to get back to the hospital in the middle of the night if a patient requires urgent endoscopy. Suffice to say, my hit rate is consistently above 50%, while many colleagues hardly ever come back. The difference cannot be explained by chance alone.

On the last on-call day before my overseas training, I had so many cases at night that the patients and their accompanying nurses had to line up in the waiting area, much like what it would be in a busy morning session. I also used up all the endoscopes in the cupboard and had to cleanse (I confess – I did not know the proper disinfection procedures) and reuse them myself. Last week, I also entered the endoscopy unit after office hours for three consecutive days.

I do not strongly believe in the play of luck. There must be a reason.

First, I thought there was recall bias. My colleagues were underreporting and I was just whining. However, after over 50 person-years of prospective follow-up, there was indeed a pattern.

Second, I hypothesized that my colleagues actually received as many calls as I did, just that they would turn down the requests. In other words, the difference should be apparent by composite end point analysis. LL and DS disagreed and said they really slept through the night. Of course, I can never confirm this.

My latest view is the presence of confounding. For borderline cases, people are ready to call me because they know I would say yes. When I was young, I was too shy to refuse. Now that I am older, I have become so used to coming back that I no longer bother to refuse. To test this possibility, we can blind the hospital staff to the call list.

Last Sunday, my Boss gave an excellent lecture in Taiwan entitled “Is emergency endoscopy necessary?” To this, KL had a wonderful idea. We can conduct a prospective study. When physicians are on-call, the best supportive care will be provided. When surgeons are on-call, emergency endoscopy will be performed at every request. Yes, this would be ground breaking.

Race

To many endoscopists, the colon is like a racecourse.

Some years ago, YT conducted a clinical trial testing the performance of a new colonoscopic technique. As part of the study, the intubation time (from anus to cecum) and extubation time (the way out) were recorded. Soon, endoscopists kept breaking and boasting about their new records. “I reached cecum in less than three minutes!” Of course, people only remembered their triumph and would never mention how long it took to struggle through a difficult case.

At the end of the study, we got a report card. As a whole, all of us did well. If you compare various endoscopists, I was on the slow side. It is hard to uphold self esteem in a place full of virtuosos.

Finally, some sensible people came to my consolation. In an elegant study, Barclay and colleagues demonstrated that the extubation time was proportional to polyp detection rate (NEJM 2006;355:2533-41). In other words, endoscopists who pull out the endoscope quickly are likely to miss important findings. After all, no patient would really mind if the procedure takes five more minutes. Quality is more important than speed.

Just for fun, LL looked at our data again and showed us the extubation time and polyp detection rate of each teammate. This time, I could say that my polyp detection rate was not bad. YT was even slower than me but found more polyps. WK was an outlier. He was fast but also found many polyps. The One whom I dare not name was the fastest. I also dare not report his polyp detection rate.

My memories were brought up by funny stories I heard from endoscopy nurses recently. In a community screening project, we need to record intubation and extubation time again. You Know Who just broke the new record of withdrawing the endoscope in ninety seconds. On another occasion, JL did a rather difficult procedure. After reaching the cecum finally, a nurse said “11 minutes 40 seconds” loudly for recording purpose. The Professor of Surgery did not realize that was a study case and thought the nurse was teasing him. According to the nurse, “he stared at me angrily”.

Typing

On more than one occasion, my patients were impressed by my typing speed.

I have never had any formal typing lesson. My training was from my first computer. I could not recall the model, which was earlier than 80286. Anyway, these early models did not support complicated games. One of my favorite was a typing game. Words fell from the top. If you typed the words correctly, they disappeared. If you were slow and the words touched the bottom of the screen, you lost. With time, I became really good. My mother had to force me to turn off the computer because the game could not kill me even when the words were dropping like thunderstorm.

Recently, my Boss was surprised when I mentioned that my daughter attended piano group lessons. Why did I not teach her myself? Of course I tried. None of the songs I knew attracted her. So we see if others can do a better job.

While Angelina behaved at the lessons, asking her to practise at home remained difficult. One day, I played the DVD provided by the music school. It featured cartoon characters playing music. In one episode, a man hit the low and high keys and showed what they sounded like. Angelina immediately got interested and asked to try on our piano. That marked the beginning of her “do-re-mi” journey.

Housework

My substitution during my domestic helper’s holidays inevitably invited the following comments from my wife. “You did nothing other than playing with Angelina.” I shamelessly referred her to Luke 10:38.

One day, Jesus visited the home of Martha and Mary. Mary listened intently to Jesus, while Martha was busy preparing dinner for the distinguished guest. At last, Martha was fed up. “Bad girl,” she said, “aren’t you going to help me?”

“You are worried about earthly things,” the Lord answered. “Mary just chose what is important, and it will not be taken from her.”

Holidays

My domestic helper had holidays in the Philippines last month. My wife and I took turn to look after our daughter at home.

Not satisfied with watching Mickey Mouse Clubhouse for the whole day, I took Angelina to the country park, had a boat ride, and visited the Museum of History. She was thrilled.

After listening to our report, my wife commented, “You basically did everything I refused to do with you in the past.” Quite true.

One night, Angelina watched the music fountain at the CityOne Plaza with me. “It is like fireworks made of water,” she whispered.