Shortly before the interview, I was asked to give two talks for secondary school students. I was wondering why I was invited after what happened several years ago, but when I arrived at the venue, I realized that none of the people in the last event was present anymore (http://vwswong.blogspot.hk/2011/10/orientation.html).
Nonetheless, the administrators said I gave a terrific talk. At least I did not say anything to terrify them, I thought.
What did I learn? First, no matter how gloomy a situation is, there is always a second chance. Second, things change. The most important of all, however, is I changed, too.
22 Aug 2013
15 Aug 2013
Blame
The next candidate was a boy. At the end of the interview, we asked whether he tried to figure out a doctor’s life through various channels.
“Ah yes,” he replied. “I read doctors’ blogs from time to time. One entry was particularly impressive. The doctor encountered a man with newly diagnosed lung cancer. He scolded the patient for smoking, but later found that he was actually a non-smoker. He regretted scolding the patient and explained the need to avoid stereotyping.”
“I beg to disagree,” my co-interviewer AC said. “We do not blame our patients regardless of what they have done. The patient may be a smoker, a drug addict, or a thief. But when he comes to us, he is our patient and deserves our attention and care.”
“Ah yes,” he replied. “I read doctors’ blogs from time to time. One entry was particularly impressive. The doctor encountered a man with newly diagnosed lung cancer. He scolded the patient for smoking, but later found that he was actually a non-smoker. He regretted scolding the patient and explained the need to avoid stereotyping.”
“I beg to disagree,” my co-interviewer AC said. “We do not blame our patients regardless of what they have done. The patient may be a smoker, a drug addict, or a thief. But when he comes to us, he is our patient and deserves our attention and care.”
8 Aug 2013
Interview
Last month, we held the admission interview. The function was very smooth, and I expected to go back to the hospital early. Towards the end, a girl entered. As usual, we asked the candidate to introduce herself.
“I am a very shy person,” she began, “and I am interested in science.” She was honest. She stopped after that sentence.
After all these years, I found that perfectly acceptable. There are many jobs suitable for shy medical graduates. Just to explore gently, I returned to the topic after a few other general questions, “Medicine involves communication. Do you feel comfortable talking to all kinds of patients in the future?”
After thinking for a while, the girl replied, “I think I can do it.”
“I believe you can,” I continued, “but my question is: would you enjoy it?”
Then she began to explain that many of her family members were doctors and how much her patients wanted her to become a doctor too.
I must say I have never encountered this before. Most candidates are desperate to enter the medical school. Others would pretend to be interested in medicine, only to be found to have trouble after admission.
In the end, I explained to the girl that because of her excellent academic results, she would probably be selected. I also did not feel it right to mark her down because of her honesty. Nevertheless, we sincerely hoped that she would choose a subject she loved and enjoy university life.
“I am a very shy person,” she began, “and I am interested in science.” She was honest. She stopped after that sentence.
After all these years, I found that perfectly acceptable. There are many jobs suitable for shy medical graduates. Just to explore gently, I returned to the topic after a few other general questions, “Medicine involves communication. Do you feel comfortable talking to all kinds of patients in the future?”
After thinking for a while, the girl replied, “I think I can do it.”
“I believe you can,” I continued, “but my question is: would you enjoy it?”
Then she began to explain that many of her family members were doctors and how much her patients wanted her to become a doctor too.
I must say I have never encountered this before. Most candidates are desperate to enter the medical school. Others would pretend to be interested in medicine, only to be found to have trouble after admission.
In the end, I explained to the girl that because of her excellent academic results, she would probably be selected. I also did not feel it right to mark her down because of her honesty. Nevertheless, we sincerely hoped that she would choose a subject she loved and enjoy university life.
1 Aug 2013
Autonomy
If a woman is diagnosed breast cancer and decides not to undergo treatment, we would persuade her but would accept her final decision. This is respect of autonomy and is one of the cornerstones of modern medical ethics.
In January 2013, a premature baby was born at a hospital in Hong Kong. Because of a complication of brain infection, the doctors recommended surgery. The father refused. That night, the hospital applied for guardianship and performed the brain surgery against the family’s wish. In April, the team operated on the baby’s eye, again despite the father’s protest. Last month, the baby was finally stable enough to enjoy a weekend at home. This time, however, the father refused to bring his son back to the hospital. The hospital obtained another court order and took the baby back.
Was autonomy being violated in this case? The doctors would argue that the father was after all not the baby himself. In the consent process, healthcare professionals were not asking what the guardian wished but what the baby would want should he have the ability to choose. When the father’s decision did not appear to be in the best interest of the baby, the team overrode his choice based on beneficence (to do good).
This story drew my attention as our team was involved in the care of two old ladies with bile duct obstruction and infection recently. Both ladies were in their nineties and suffered from multiple illnesses. Without intervention, the infection could be lethal. On the other hand, to clear the obstruction, we had to perform endoscopy, which was also very risky given their background. In face of such dilemmas, we used the standard tactics – explain everything to the families and let them choose. Ironically, the family of the sicker lady, who even depended on mechanical ventilation at night, insisted on aggressive treatment. She underwent two endoscopic procedures. More is yet to come.
In difficult situations like this, letting family members make the decision is the safest approach if the primary aim is to avoid complaints. Come to think of it, however, seldom do we ask what the patient herself really wants.
In January 2013, a premature baby was born at a hospital in Hong Kong. Because of a complication of brain infection, the doctors recommended surgery. The father refused. That night, the hospital applied for guardianship and performed the brain surgery against the family’s wish. In April, the team operated on the baby’s eye, again despite the father’s protest. Last month, the baby was finally stable enough to enjoy a weekend at home. This time, however, the father refused to bring his son back to the hospital. The hospital obtained another court order and took the baby back.
Was autonomy being violated in this case? The doctors would argue that the father was after all not the baby himself. In the consent process, healthcare professionals were not asking what the guardian wished but what the baby would want should he have the ability to choose. When the father’s decision did not appear to be in the best interest of the baby, the team overrode his choice based on beneficence (to do good).
This story drew my attention as our team was involved in the care of two old ladies with bile duct obstruction and infection recently. Both ladies were in their nineties and suffered from multiple illnesses. Without intervention, the infection could be lethal. On the other hand, to clear the obstruction, we had to perform endoscopy, which was also very risky given their background. In face of such dilemmas, we used the standard tactics – explain everything to the families and let them choose. Ironically, the family of the sicker lady, who even depended on mechanical ventilation at night, insisted on aggressive treatment. She underwent two endoscopic procedures. More is yet to come.
In difficult situations like this, letting family members make the decision is the safest approach if the primary aim is to avoid complaints. Come to think of it, however, seldom do we ask what the patient herself really wants.
25 Jul 2013
Deadline
Last week, my friend AC invited me to write a review with him. At the end, he sheepishly added, “We expect the work in two weeks. The deadline has already passed.”
I sighed. Although I know many people who miss deadlines all the time, I have never done it before and find it hard to understand.
When I mentioned this to GW, she was most understanding. “It is quite natural. After you have missed the first deadline, everything else is postponed and will not be finished on time.”
“But then at least you should turn down new requests when you know you can’t meet the deadline?”
“When that becomes a habit, it does not matter anymore.”
What really surprises me, however, is that punctuality has little correlation with success. One of the best clinical researchers I know is notorious for being late. He would not even start working until he has received the first reminder. Yet people continue to beg him for help the next time. In a way, being good is more important than being punctual.
I sighed. Although I know many people who miss deadlines all the time, I have never done it before and find it hard to understand.
When I mentioned this to GW, she was most understanding. “It is quite natural. After you have missed the first deadline, everything else is postponed and will not be finished on time.”
“But then at least you should turn down new requests when you know you can’t meet the deadline?”
“When that becomes a habit, it does not matter anymore.”
What really surprises me, however, is that punctuality has little correlation with success. One of the best clinical researchers I know is notorious for being late. He would not even start working until he has received the first reminder. Yet people continue to beg him for help the next time. In a way, being good is more important than being punctual.
18 Jul 2013
Monopoly
Last weekend, our team attended a research workshop. That evening, my teammates taught me to play Monopoly Deal. I must say I have not formulated any winning strategy yet. Everything I put on the table was snatched by the other players.
At one point, SW charged me 5 million. I protested, “But I have no money. Why don’t you collect money from richer people?”
“Because I want your land,” SW explained. After a while, he added, “This is what happens in real life.”
How very true.
At one point, SW charged me 5 million. I protested, “But I have no money. Why don’t you collect money from richer people?”
“Because I want your land,” SW explained. After a while, he added, “This is what happens in real life.”
How very true.
11 Jul 2013
Photos
On the next day, AL showed me a set of photos she took during our medical grand round. I was wondering why she took photos of us, but alas, it was not us.
That was a student bored to death by our talk. The gentleman first took off his sandals, and then rubbed his toes one by one with his fingers. He turned on his laptop and flipped between Facebook and Yahoo. Despite all these, we speakers seemed not aware of his annoyance. He finally gave up and slept with his mouth wide open.
After seeing the photos, I was first quite defensive. “But we didn’t initiate that. The external examiners made us run that talk.” On second thoughts, I owed that student an apology.
That said, while we were waiting for the grand round to start, Szeto and I actually discussed what we would rather talk about. I suggested detective stories.
“Nah,” Szeto sneered, “that is beyond your expertise. If you talk about Mozart, I would have to discuss Beethoven.”
That would be interesting. One of the theories is that Mozart died of poststreptococcal glomerulonephritis (Ann Intern Med 2009;151:274-8). Perfect for a renal grand round.
That was a student bored to death by our talk. The gentleman first took off his sandals, and then rubbed his toes one by one with his fingers. He turned on his laptop and flipped between Facebook and Yahoo. Despite all these, we speakers seemed not aware of his annoyance. He finally gave up and slept with his mouth wide open.
After seeing the photos, I was first quite defensive. “But we didn’t initiate that. The external examiners made us run that talk.” On second thoughts, I owed that student an apology.
That said, while we were waiting for the grand round to start, Szeto and I actually discussed what we would rather talk about. I suggested detective stories.
“Nah,” Szeto sneered, “that is beyond your expertise. If you talk about Mozart, I would have to discuss Beethoven.”
That would be interesting. One of the theories is that Mozart died of poststreptococcal glomerulonephritis (Ann Intern Med 2009;151:274-8). Perfect for a renal grand round.
4 Jul 2013
Strategy
Yesterday, I had the pleasure of conducting the first medical grand round of the academic year with Szeto. I have always dreamed of doing a grand round with the walking Harrison. The intellectual exchange must be profound. Unfortunately, we took up a rather dull topic – introduction of the practical examination system.
Incidentally, I came across a comment by our student shortly before our presentation (http://liralen.xanga.com/700427944/item/). She was referring to my old entry on examination tactics (http://vwswong.blogspot.hk/2009/04/examination.html). That was a quote from Sima Yi:
軍事大要有五：能戰當戰，不能戰當守，不能守當走，不能走當降，不能降當死耳
According to our student, it's a pity that there is no significant difference in terms of prognosis of the last 3 options. This cannot be farther from the truth.
Above all, the final year professional examination has the lowest failure rate compared to all other examinations our graduates will face in the future. History is full of examples of students talking nonsense throughout the examination and still becoming doctors. Just this year for example, I encountered a girl with impeccable English but undetectable knowledge. Almost every sentence she said was wrong, but she picked up our non-verbal cues and rephrased her statement immediately every time. Szeto also examined her and arrived at the same conclusion. To our utter astonishment, all ten examiners passed her.
Now, saying that the last three strategies make no difference would certainly disappoint Mr Sima. When you do not know the answer, you can try to talk about things you know first and work the way through, skillfully change the topic, or sincerely admit your deficiencies. All these tactics seldom lead to failure.
Sir Ferguson enjoys big wins, but also understands the importance of drawing a difficult game. Only the team that does not give up can win the league.
Incidentally, I came across a comment by our student shortly before our presentation (http://liralen.xanga.com/700427944/item/). She was referring to my old entry on examination tactics (http://vwswong.blogspot.hk/2009/04/examination.html). That was a quote from Sima Yi:
軍事大要有五：能戰當戰，不能戰當守，不能守當走，不能走當降，不能降當死耳
According to our student, it's a pity that there is no significant difference in terms of prognosis of the last 3 options. This cannot be farther from the truth.
Above all, the final year professional examination has the lowest failure rate compared to all other examinations our graduates will face in the future. History is full of examples of students talking nonsense throughout the examination and still becoming doctors. Just this year for example, I encountered a girl with impeccable English but undetectable knowledge. Almost every sentence she said was wrong, but she picked up our non-verbal cues and rephrased her statement immediately every time. Szeto also examined her and arrived at the same conclusion. To our utter astonishment, all ten examiners passed her.
Now, saying that the last three strategies make no difference would certainly disappoint Mr Sima. When you do not know the answer, you can try to talk about things you know first and work the way through, skillfully change the topic, or sincerely admit your deficiencies. All these tactics seldom lead to failure.
Sir Ferguson enjoys big wins, but also understands the importance of drawing a difficult game. Only the team that does not give up can win the league.
27 Jun 2013
Mock
Not surprisingly, AL and K passed the College examination with flying colors. Shortly before the examination, they asked GW and me to conduct a mock examination for them. Personally I think such kind of exercise is quite useless. But as Prof RK said, when many useless things add up together, they may turn out useful. To go along this line, I asked a useless question that would never appear in the examination.
“A 38-year old man learned from the news that a rich man in town is dying from liver failure. He offers to donate part of his liver to him, but demands a compensation of $500,000 in return, which the family for sure is willing to pay. He argues that he owns his body and should have autonomy over its use. Besides, he believes that his request is reasonable given the sacrifice he is going to make. As a doctor, do you agree with his points?”
After thinking for a while, the candidate replied, “This is certainly not acceptable. Above all, doing no harm is the fundamental standard of medicine. We cannot risk his life to save a richer person.”
“Wait a second,” I interrupted. “Do you mean you are against living donor organ transplantation?”
Seeing it could not be right, the candidate changed strategy, “Not really. We also need to see if the patient had problems with alcohol and the reason for liver failure.”
“He does not drink alcohol. He had decompensated hepatitis B-related cirrhosis.”
“We should see whether the patient really requires liver transplantation and is fit for the procedure. Besides, we shouldn’t let someone jump the queue just because he can pay.”
“All right,” I said. “In other words, if the patient is at the top of the waiting list but a cadaveric liver is not available yet, you would find the proposal acceptable. In fact, you may argue that such a move would even shorten the waiting list for other patients.”
“No, no, no. Organ trading is illegal in Hong Kong.”
“That is true,” I said, “but what is the ethical basis of the policy?”
“I give up.”
At least we learned one thing that afternoon. Principles are not subject to conditions. There is no if or when. You cannot say the government should not run students over with tanks if they are protesting peacefully. They just shouldn’t.
“A 38-year old man learned from the news that a rich man in town is dying from liver failure. He offers to donate part of his liver to him, but demands a compensation of $500,000 in return, which the family for sure is willing to pay. He argues that he owns his body and should have autonomy over its use. Besides, he believes that his request is reasonable given the sacrifice he is going to make. As a doctor, do you agree with his points?”
After thinking for a while, the candidate replied, “This is certainly not acceptable. Above all, doing no harm is the fundamental standard of medicine. We cannot risk his life to save a richer person.”
“Wait a second,” I interrupted. “Do you mean you are against living donor organ transplantation?”
Seeing it could not be right, the candidate changed strategy, “Not really. We also need to see if the patient had problems with alcohol and the reason for liver failure.”
“He does not drink alcohol. He had decompensated hepatitis B-related cirrhosis.”
“We should see whether the patient really requires liver transplantation and is fit for the procedure. Besides, we shouldn’t let someone jump the queue just because he can pay.”
“All right,” I said. “In other words, if the patient is at the top of the waiting list but a cadaveric liver is not available yet, you would find the proposal acceptable. In fact, you may argue that such a move would even shorten the waiting list for other patients.”
“No, no, no. Organ trading is illegal in Hong Kong.”
“That is true,” I said, “but what is the ethical basis of the policy?”
“I give up.”
At least we learned one thing that afternoon. Principles are not subject to conditions. There is no if or when. You cannot say the government should not run students over with tanks if they are protesting peacefully. They just shouldn’t.
20 Jun 2013
Comments
We held the professional examination last month. After examining the first five students, Professor RY remarked on the standard of the class at the coffee break. Many of us were astonished. It took us at least several months to arrive at the same conclusion. “Of course this may be sampling bias. I will examine the rest of the students first,” he said when the next batch of students entered.
When I told my friends the story, they were not impressed. “He doesn’t pay attention during examinations,” HC said. “He even dozed at the last college exam.” I did not argue. However, after so many years, I am sure he does not need ten minutes to decide who is a competent doctor.
Once, a famous director was invited to the rehearsal of a play. A moment later, he fell asleep. The cast was very embarrassed but had to continue. After the first act, the producer could not tolerate any longer and woke the director up. “We are sincerely asking for your comments, and you simply dozed off!”
The director rubbed his eyes and mumbled, “That was my comment.”
When I told my friends the story, they were not impressed. “He doesn’t pay attention during examinations,” HC said. “He even dozed at the last college exam.” I did not argue. However, after so many years, I am sure he does not need ten minutes to decide who is a competent doctor.
Once, a famous director was invited to the rehearsal of a play. A moment later, he fell asleep. The cast was very embarrassed but had to continue. After the first act, the producer could not tolerate any longer and woke the director up. “We are sincerely asking for your comments, and you simply dozed off!”
The director rubbed his eyes and mumbled, “That was my comment.”
13 Jun 2013
Cirrhosis
I gave a lecture at the refresher course last Monday. Two days later, I received a list of questions from a student. I have never answered questions in my blog before, but then I have never received so many questions from a student all at once either. The questions are practical and insightful and should be shared with other students.
1. I was told that in liver cirrhosis progression, it usually starts with deranged clotting profile, then albumin, then bilirubin, then ascites and finally encephalopathy. Is that true that when patient developed, let's say, ascites or encephalopathy, it indicates a more severe cirrhosis?
Answer: The sequence of laboratory changes is not absolute. However, it is true that clinical complications such as ascites and encephalopathy usually indicate more severe disease and are associated with poor prognosis.
2. In monitoring patients with cirrhosis, do we monitor by Child-Pugh grading + HCC surveillance + varices screening + hepatorenal syndrome screening? Do we need to repeat ultrasound for progression of features?
Answer: You have included different concepts here: assessment of the severity of cirrhosis and complications screening. Currently, most doctors use the Child-Pugh score or the model for end-stage liver disease (MELD) score to assess the severity of cirrhosis. The purpose is to predict the prognosis and prioritize patients for liver transplantation.
HCC surveillance is performed to detect early HCC so that patients may receive curative treatment. That said, this should only be done in patients who are candidates for curative treatment. For example, a patient with Child’s C cirrhosis and multiple comorbid illnesses cannot undergo liver resection or locoregional therapy even if a small HCC is detected. Surveillance would not be helpful.
Screening for varices is also recommended to reduce the risk of variceal bleeding.
Finally, the main role of ultrasound is for HCC surveillance. We use other parameters to assess the severity of cirrhosis.
3. Once patient is diagnosed to have liver cirrhosis, when should we start screening for varices? and by what mean? Ultrasound or endoscopy?
Answer: Unless the patient is moribund, all cirrhotic patients should be screened for varices by OGD.
4. When we say ultrasound imaging to look for presence of varices, do we mean hepatic doppler ultrasound that the flow in different hepatic vasculature may suggest the presence of esophageal varices?
Answer: In good hands, splenic varices may be visualized by ultrasound. While this feature confirms the presence of portal hypertension, it cannot replace OGD. It is bleeding from esophageal or gastric varices that we want to prevent.
5. For HCC surveillance, do you mean serum AFP + LFT + CT (or USG?) scan regularly?
Answer: Good question. For some hepatologists, this means 6-monthly USG and AFP testing. Liver function test does not detect HCC. CT is more accurate but involves radiation and has not been tested in the screening setting. Triphasic CT is usually reserved for confirming the diagnosis of HCC when a liver nodule is identified by USG. Interestingly, the current American guidelines only suggest USG surveillance and discourage the use of AFP. This is highly debatable.
6. In bleeding esophageal varices, do we need to give both octreotide and terlipressin together? What is the usual dosage given and are they given as IV infusion or bolus?
Answer: Either somatostatin analog (e.g. octreotide) or vasopressin analog (e.g. terlipressin) would do. The dosage we are using is octreotide 50 mcg iv stat, followed by 50 mcg/h infusion; and terlipressin 2 mg Q4-6H iv. There have also been studies showing that terlipressin infusion may be better than bolus injections.
7. In variceal bleeding, do we need to correct the deranged clotting profile by transfusing fresh frozen plasma? and also correct any platelet derangement?
Answer: Many doctors do so, but this practice is not adequately tested.
8. Do we need to prophylactically give lactulose to all cirrhotic patients with variceal bleeding to prevent development of hepatic encephalopathy? or do we give only when patients develop symptoms and signs of HE?
Answer: Because patients with variceal bleeding are at high risk of developing hepatic encephalopathy and lactulose carries few side effects, we usually give it prophylactically.
9. In secondary prophylaxis of variceal bleeding, you mentioned an option of endoscopic variceal ligation, but I thought you have already banded all varices during last variceal bleeding? or do you mean those new varices developed? Also, do we need to start beta blocker +/- nitrate immediately after first episode of variceal bleeding?
Answer: It takes an average of 5 sessions to eradicate all esophageal varices. A clinical trial from Spain showed that pharmacological therapy is more effective than endoscopic variceal ligation for secondary prevention of variceal bleeding and result in less complications (N Engl J Med 2001;345:647-55). However, a subsequent meta-analysis showed that combining endoscopic variceal ligation and pharmacological therapy would further reduce the chance of rebleeding (Aliment Pharmacol Ther 2012;35:1155-65). At our center, we do both.
Immediately after variceal bleeding, the patient should still be on vasoactive drugs such as octreotide or terlipressin. You do not need to start beta-blockers yet. Besides, it is a bad idea to give a drug that would lower the blood pressure right after active bleeding. Instead, beta-blockers and/or nitrates may be started after the acute episode settles.
10. If we are to give lactulose to patient during variceal bleeding, since patients are kept NPO, can he still tolerate an oral lactulose? How about in the case when patient is drowsy and confused as in grade 2-3 encephalopathy or patient in hemorrhagic shock, is it still safe to give oral lactulose?
Answer: We can keep the patient nil by mouth except medications. If the patient has aspiration risk, medications should be delivered via nasogastric tube instead.
11. In patients with ascites with deranged renal function (creatinine >133), do we routinely stop diuretics or paracentesis for 2 days to assess hepatorenal syndrome?
And even with albumin infusion, ascites will still come back right? And is this because hypoalbuminemia is not related to pathophysiology of ascites? And in this case, do we just leave the ascites untreated and observe?
Answer: It is important to stop diuretics and paracentesis in cirrhotic patients with acute kidney injury. They may well be the culprit.
Albumin infusion is for the prevention of paracentesis-induced circulatory dysfunction, not ascites. Therapeutic paracentesis relieves ascites rapidly but does not alter the underlying pathophysiology of portal hypertension and salt retention. Therefore, ascites will recur after paracentesis unless the patient is well controlled with salt restriction and diuretics. However, some patients will still have refractory ascites and require either repeated paracentesis or TIPS.
12. I'm sorry to complicate the case further. What if the patient has co-morbid cardiovascular condition (eg. hypertension, heart failure) that requires the use of diuretics? Do we still stop it for assessment? If patient is on ACEI, do we need to stop it for HRS assessment?
Answer: You have to assess the fluid status. If the patient is having fluid overload, you do not have much choice. For your last question, cirrhotic patients are very sensitive to ACEI because renal perfusion is often suboptimal. In case of renal deterioration, we have low threshold to stop ACEI.
1. I was told that in liver cirrhosis progression, it usually starts with deranged clotting profile, then albumin, then bilirubin, then ascites and finally encephalopathy. Is that true that when patient developed, let's say, ascites or encephalopathy, it indicates a more severe cirrhosis?
Answer: The sequence of laboratory changes is not absolute. However, it is true that clinical complications such as ascites and encephalopathy usually indicate more severe disease and are associated with poor prognosis.
2. In monitoring patients with cirrhosis, do we monitor by Child-Pugh grading + HCC surveillance + varices screening + hepatorenal syndrome screening? Do we need to repeat ultrasound for progression of features?
Answer: You have included different concepts here: assessment of the severity of cirrhosis and complications screening. Currently, most doctors use the Child-Pugh score or the model for end-stage liver disease (MELD) score to assess the severity of cirrhosis. The purpose is to predict the prognosis and prioritize patients for liver transplantation.
HCC surveillance is performed to detect early HCC so that patients may receive curative treatment. That said, this should only be done in patients who are candidates for curative treatment. For example, a patient with Child’s C cirrhosis and multiple comorbid illnesses cannot undergo liver resection or locoregional therapy even if a small HCC is detected. Surveillance would not be helpful.
Screening for varices is also recommended to reduce the risk of variceal bleeding.
Finally, the main role of ultrasound is for HCC surveillance. We use other parameters to assess the severity of cirrhosis.
3. Once patient is diagnosed to have liver cirrhosis, when should we start screening for varices? and by what mean? Ultrasound or endoscopy?
Answer: Unless the patient is moribund, all cirrhotic patients should be screened for varices by OGD.
4. When we say ultrasound imaging to look for presence of varices, do we mean hepatic doppler ultrasound that the flow in different hepatic vasculature may suggest the presence of esophageal varices?
Answer: In good hands, splenic varices may be visualized by ultrasound. While this feature confirms the presence of portal hypertension, it cannot replace OGD. It is bleeding from esophageal or gastric varices that we want to prevent.
5. For HCC surveillance, do you mean serum AFP + LFT + CT (or USG?) scan regularly?
Answer: Good question. For some hepatologists, this means 6-monthly USG and AFP testing. Liver function test does not detect HCC. CT is more accurate but involves radiation and has not been tested in the screening setting. Triphasic CT is usually reserved for confirming the diagnosis of HCC when a liver nodule is identified by USG. Interestingly, the current American guidelines only suggest USG surveillance and discourage the use of AFP. This is highly debatable.
6. In bleeding esophageal varices, do we need to give both octreotide and terlipressin together? What is the usual dosage given and are they given as IV infusion or bolus?
Answer: Either somatostatin analog (e.g. octreotide) or vasopressin analog (e.g. terlipressin) would do. The dosage we are using is octreotide 50 mcg iv stat, followed by 50 mcg/h infusion; and terlipressin 2 mg Q4-6H iv. There have also been studies showing that terlipressin infusion may be better than bolus injections.
7. In variceal bleeding, do we need to correct the deranged clotting profile by transfusing fresh frozen plasma? and also correct any platelet derangement?
Answer: Many doctors do so, but this practice is not adequately tested.
8. Do we need to prophylactically give lactulose to all cirrhotic patients with variceal bleeding to prevent development of hepatic encephalopathy? or do we give only when patients develop symptoms and signs of HE?
Answer: Because patients with variceal bleeding are at high risk of developing hepatic encephalopathy and lactulose carries few side effects, we usually give it prophylactically.
9. In secondary prophylaxis of variceal bleeding, you mentioned an option of endoscopic variceal ligation, but I thought you have already banded all varices during last variceal bleeding? or do you mean those new varices developed? Also, do we need to start beta blocker +/- nitrate immediately after first episode of variceal bleeding?
Answer: It takes an average of 5 sessions to eradicate all esophageal varices. A clinical trial from Spain showed that pharmacological therapy is more effective than endoscopic variceal ligation for secondary prevention of variceal bleeding and result in less complications (N Engl J Med 2001;345:647-55). However, a subsequent meta-analysis showed that combining endoscopic variceal ligation and pharmacological therapy would further reduce the chance of rebleeding (Aliment Pharmacol Ther 2012;35:1155-65). At our center, we do both.
Immediately after variceal bleeding, the patient should still be on vasoactive drugs such as octreotide or terlipressin. You do not need to start beta-blockers yet. Besides, it is a bad idea to give a drug that would lower the blood pressure right after active bleeding. Instead, beta-blockers and/or nitrates may be started after the acute episode settles.
10. If we are to give lactulose to patient during variceal bleeding, since patients are kept NPO, can he still tolerate an oral lactulose? How about in the case when patient is drowsy and confused as in grade 2-3 encephalopathy or patient in hemorrhagic shock, is it still safe to give oral lactulose?
Answer: We can keep the patient nil by mouth except medications. If the patient has aspiration risk, medications should be delivered via nasogastric tube instead.
11. In patients with ascites with deranged renal function (creatinine >133), do we routinely stop diuretics or paracentesis for 2 days to assess hepatorenal syndrome?
And even with albumin infusion, ascites will still come back right? And is this because hypoalbuminemia is not related to pathophysiology of ascites? And in this case, do we just leave the ascites untreated and observe?
Answer: It is important to stop diuretics and paracentesis in cirrhotic patients with acute kidney injury. They may well be the culprit.
Albumin infusion is for the prevention of paracentesis-induced circulatory dysfunction, not ascites. Therapeutic paracentesis relieves ascites rapidly but does not alter the underlying pathophysiology of portal hypertension and salt retention. Therefore, ascites will recur after paracentesis unless the patient is well controlled with salt restriction and diuretics. However, some patients will still have refractory ascites and require either repeated paracentesis or TIPS.
12. I'm sorry to complicate the case further. What if the patient has co-morbid cardiovascular condition (eg. hypertension, heart failure) that requires the use of diuretics? Do we still stop it for assessment? If patient is on ACEI, do we need to stop it for HRS assessment?
Answer: You have to assess the fluid status. If the patient is having fluid overload, you do not have much choice. For your last question, cirrhotic patients are very sensitive to ACEI because renal perfusion is often suboptimal. In case of renal deterioration, we have low threshold to stop ACEI.
6 Jun 2013
Present
Curiously, this is the first time I wrote on my blog on our anniversary. This year is also special in that my brother Roy is getting married later this month.
Roy reminds me much of Levin in Anna Karenina. He expressed how pointless the wedding preparation and ceremony were, but ended up doing everything others did. I wish he would enjoy it as much as Levin did in the end.
Every Christmas, our parish priest tells us a story about love. Every Christmas, he tells the same story.
Once there was a poor couple. The husband had a watch, but it had no straps. One Christmas, the wife gave him a pair of leather straps as present. The man was very surprised, “How did you get the money?” The wife replied that she sold her hair. The man then gave her a present. It was a beautiful comb. This time, it was the wife who was surprised. “I sold my watch,” the man explained.
At this point, Angelina commented, “You can still use the comb with short hair. Besides, the hair can grow back. The man was less lucky.” I replied, “I think he was very lucky. The present was love.”
Roy reminds me much of Levin in Anna Karenina. He expressed how pointless the wedding preparation and ceremony were, but ended up doing everything others did. I wish he would enjoy it as much as Levin did in the end.
Every Christmas, our parish priest tells us a story about love. Every Christmas, he tells the same story.
Once there was a poor couple. The husband had a watch, but it had no straps. One Christmas, the wife gave him a pair of leather straps as present. The man was very surprised, “How did you get the money?” The wife replied that she sold her hair. The man then gave her a present. It was a beautiful comb. This time, it was the wife who was surprised. “I sold my watch,” the man explained.
At this point, Angelina commented, “You can still use the comb with short hair. Besides, the hair can grow back. The man was less lucky.” I replied, “I think he was very lucky. The present was love.”
30 May 2013
Deserve
There are four potential theories of distribution justice.
The feudal or caste system is the most unjust. Whether a person ends up being a prince or a slave depends solely on the luck at birth but not what he does.
The libertarian system or free market appears to offer equal opportunities, but this is not entirely so. If children from rich families are more likely to receive good education and job opportunities, they still have a huge advantage over poorer people.
In some countries, this potential flaw is tackled by the meritocratic approach. This attempts to offer fair equality of opportunity. For example, the government may provide equal educational opportunities for both the rich and the poor. In USA and China, children of ethnic minorities are even preferentially admitted to the college. (Of course, ethnic minorities are not necessarily poorer. That would be another topic.)
However, John Rawls (1921-2002) argued that even the meritocratic approach cannot totally eliminate inequality. You may provide opportunities to the disadvantaged, but you cannot prevent the fastest runners from winning a race and the cleverest students from entering college. To a certain degree, being fast or clever is also a matter of luck similar to being born in a rich family. The society still produces the retired professor who found no problem in charging his patient an outrageous sum.
Now, you may argue that your success is not the sole result of talent and upbringing; you have worked very hard to achieve what you have today. Rawls would counter by saying that even effort may be the product of a favorable upbringing. Besides, the society pays for your achievements, not your hard work. In this world, there must be soccer players who practise even harder than David Beckham and remain unheard of, but you probably would not advocate that they should be the richest soccer players instead.
Rawls is not saying that successful people should not earn more. This would take away the incentives to work hard and excel. Instead, he wants us to understand that while we are entitled to what we have, we should remain humble and not to think we deserve everything. Instead, earning more is justifiable only if we at the same time help less fortunate people.
The feudal or caste system is the most unjust. Whether a person ends up being a prince or a slave depends solely on the luck at birth but not what he does.
The libertarian system or free market appears to offer equal opportunities, but this is not entirely so. If children from rich families are more likely to receive good education and job opportunities, they still have a huge advantage over poorer people.
In some countries, this potential flaw is tackled by the meritocratic approach. This attempts to offer fair equality of opportunity. For example, the government may provide equal educational opportunities for both the rich and the poor. In USA and China, children of ethnic minorities are even preferentially admitted to the college. (Of course, ethnic minorities are not necessarily poorer. That would be another topic.)
However, John Rawls (1921-2002) argued that even the meritocratic approach cannot totally eliminate inequality. You may provide opportunities to the disadvantaged, but you cannot prevent the fastest runners from winning a race and the cleverest students from entering college. To a certain degree, being fast or clever is also a matter of luck similar to being born in a rich family. The society still produces the retired professor who found no problem in charging his patient an outrageous sum.
Now, you may argue that your success is not the sole result of talent and upbringing; you have worked very hard to achieve what you have today. Rawls would counter by saying that even effort may be the product of a favorable upbringing. Besides, the society pays for your achievements, not your hard work. In this world, there must be soccer players who practise even harder than David Beckham and remain unheard of, but you probably would not advocate that they should be the richest soccer players instead.
Rawls is not saying that successful people should not earn more. This would take away the incentives to work hard and excel. Instead, he wants us to understand that while we are entitled to what we have, we should remain humble and not to think we deserve everything. Instead, earning more is justifiable only if we at the same time help less fortunate people.
23 May 2013
Utility
For libertarians, the question is quite unworthy for discussion. So far as the patient is willing to pay and there is no coercion or deceit, charging dearly is not wrong. For instance, you would not object to Lionel Messi’s salary however high it may be. Libertarians favor free market. People should be free to decide what to do with their money. Taxation is unjust because it jeopardizes the ownership. To go one step further, libertarians also believe that people own their bodies and their lives, and therefore do not support moral laws such as those against prostitution.
In contrast, the utilitarian philosophy considers how we may maximize happiness and minimize pain. For example, Jeremy Bentham proposed building beggar workhouses in the 18th century. According to the scheme, beggars in the streets were to be locked up. They would then have to work to pay for the expenses of the workhouses. Bentham reasoned that other citizens would be happier with no beggars in the streets, at a small cost of a few beggars who might be forced to live in places they did not like. The overall happiness, or utility, of the society would nevertheless increase.
At first glance, we may think that utilitarians must support low doctor fees. Patients would be happier, or at least feel less pain, if they can pay less for the same service. However, utilitarians would point out that it depends on whether lowering doctor fees would result in fewer competent doctors joining the profession and deteriorating health care. In the latter case, the utility of the society would actually decrease.
Utilitarian principles are difficult to apply. Above all, happiness cannot be quantified but utilitarians try to measure everything in the same scale. Even if measurement is possible, a popular policy among the majority does not mean it is right. In the era of the Roman Empire, prisoners were forced to fight with tigers and die a brutal death for the entertainment of Roman citizens. Tens of thousands of people were enchanted at the expense of a few prisoners who would die from other punishments anyway, but yet we find the practice hard to accept. Surely overall or average happiness cannot be the sole yardstick we go after.
In contrast, the utilitarian philosophy considers how we may maximize happiness and minimize pain. For example, Jeremy Bentham proposed building beggar workhouses in the 18th century. According to the scheme, beggars in the streets were to be locked up. They would then have to work to pay for the expenses of the workhouses. Bentham reasoned that other citizens would be happier with no beggars in the streets, at a small cost of a few beggars who might be forced to live in places they did not like. The overall happiness, or utility, of the society would nevertheless increase.
At first glance, we may think that utilitarians must support low doctor fees. Patients would be happier, or at least feel less pain, if they can pay less for the same service. However, utilitarians would point out that it depends on whether lowering doctor fees would result in fewer competent doctors joining the profession and deteriorating health care. In the latter case, the utility of the society would actually decrease.
Utilitarian principles are difficult to apply. Above all, happiness cannot be quantified but utilitarians try to measure everything in the same scale. Even if measurement is possible, a popular policy among the majority does not mean it is right. In the era of the Roman Empire, prisoners were forced to fight with tigers and die a brutal death for the entertainment of Roman citizens. Tens of thousands of people were enchanted at the expense of a few prisoners who would die from other punishments anyway, but yet we find the practice hard to accept. Surely overall or average happiness cannot be the sole yardstick we go after.
16 May 2013
Bill
Most of us cannot accept what Chopper did. Doctors should not earn money by doing unnecessary and harmful procedures.
In that case, let me tell you another story.
A retired professor performed a 5-minute procedure for a rich man. The accounting clerk saw the bill and was astonished. That was the price of a brand new car. Summoning her courage, the clerk called the professor and asked if he might have added an extra zero by mistake. (She wanted to say two zeroes but thought better of it.)
The professor answered, “I am a famous doctor and he is a rich man. What is the problem with that?”
Now, is this acceptable? This time, the professor did a legitimate albeit simple procedure. Money did not bias his clinical decision. In fact, one may even argue that if he can charge whatever he likes for such minor tasks, the chance for him to offer unnecessary interventions would be lower.
In that case, let me tell you another story.
A retired professor performed a 5-minute procedure for a rich man. The accounting clerk saw the bill and was astonished. That was the price of a brand new car. Summoning her courage, the clerk called the professor and asked if he might have added an extra zero by mistake. (She wanted to say two zeroes but thought better of it.)
The professor answered, “I am a famous doctor and he is a rich man. What is the problem with that?”
Now, is this acceptable? This time, the professor did a legitimate albeit simple procedure. Money did not bias his clinical decision. In fact, one may even argue that if he can charge whatever he likes for such minor tasks, the chance for him to offer unnecessary interventions would be lower.
9 May 2013
Chopper
Recently, my friend told me a story about Chopper.
Chopper, as you may imagine, chops things. As far as the patient can pay, he can chop off anything. Over the years, he has chopped many cancers, but he has also chopped off countless normal body parts. Now, if you persuaded a patient to undergo surgery but the resection specimen turned out to be normal, you would probably blush and wonder how to explain. But not Chopper. He would just knock on the door with a radiant smile and trumpet with his baritone voice, “Congratulations, madam! There was nothing but normal tissue. It was not cancer. You don’t need to worry now.” Time and again, the patient would thank him wholeheartedly, eyes filled with tears.
Last year, a high-ranking official from the Whirlpool Galaxy travelled to Earth. He had cancers spread everywhere. No healer from his galaxy could offer any cure. Chopper was undeterred. “I can chop off your airbags and the oncologists can then take care of the smaller tumors,” he explained.
The official could not live without airbags and died shortly after the chopping procedure. Furious, a group of Whirlpoolers grabbed Chopper and planned to burn him in M51. As luck would have it, Charles Messier learned about the operation and rescued Chopper from the Whirlpoolers. That said, Chopper’s eyes were burnt by the scorching flame of the Sun. If you come across him, you may still see him wearing a pair of extra-large sunglasses.
Chopper, as you may imagine, chops things. As far as the patient can pay, he can chop off anything. Over the years, he has chopped many cancers, but he has also chopped off countless normal body parts. Now, if you persuaded a patient to undergo surgery but the resection specimen turned out to be normal, you would probably blush and wonder how to explain. But not Chopper. He would just knock on the door with a radiant smile and trumpet with his baritone voice, “Congratulations, madam! There was nothing but normal tissue. It was not cancer. You don’t need to worry now.” Time and again, the patient would thank him wholeheartedly, eyes filled with tears.
Last year, a high-ranking official from the Whirlpool Galaxy travelled to Earth. He had cancers spread everywhere. No healer from his galaxy could offer any cure. Chopper was undeterred. “I can chop off your airbags and the oncologists can then take care of the smaller tumors,” he explained.
The official could not live without airbags and died shortly after the chopping procedure. Furious, a group of Whirlpoolers grabbed Chopper and planned to burn him in M51. As luck would have it, Charles Messier learned about the operation and rescued Chopper from the Whirlpoolers. That said, Chopper’s eyes were burnt by the scorching flame of the Sun. If you come across him, you may still see him wearing a pair of extra-large sunglasses.
2 May 2013
Equality
What, then, is equality?
According to our young student, equality means rich and poor people should receive the same medical service. Allowing some patients to pay for earlier treatment is discrimination against the poor and jeopardizes their welfare. You may argue that the problem only exists when an institute practises private and public services at the same time. In a broader sense, however, unless the supply of healthcare workers is unlimited, the private market drags manpower away from the public system and affects the waiting time and service quality similarly.
Many people would object to the student’s idea of equality. It violates the freedom of choice. If people are not allowed to buy what they want, there will be limited incentives for working. As my co-interviewer said, this would be the path to communism.
Nevertheless, in the case of medical care, freedom of choice is not the only issue. Most of us would not mind the rich buying a Porsche while the sports cars are inaccessible to people less well-off. In contrast, it would be unacceptable if firefighters would only come after payment by victims. Therefore, the root of the problem is what we consider as essential care.
According to our young student, equality means rich and poor people should receive the same medical service. Allowing some patients to pay for earlier treatment is discrimination against the poor and jeopardizes their welfare. You may argue that the problem only exists when an institute practises private and public services at the same time. In a broader sense, however, unless the supply of healthcare workers is unlimited, the private market drags manpower away from the public system and affects the waiting time and service quality similarly.
Many people would object to the student’s idea of equality. It violates the freedom of choice. If people are not allowed to buy what they want, there will be limited incentives for working. As my co-interviewer said, this would be the path to communism.
Nevertheless, in the case of medical care, freedom of choice is not the only issue. Most of us would not mind the rich buying a Porsche while the sports cars are inaccessible to people less well-off. In contrast, it would be unacceptable if firefighters would only come after payment by victims. Therefore, the root of the problem is what we consider as essential care.
25 Apr 2013
Communism
One year ago, a girl described her aspiration to serve the poor at our admission interview. I asked, “In the current public hospital system, patients have to line up for investigations and treatment. For example, a cancer patient may have to wait several weeks before surgery can be performed. Now, if she agrees to pay for the service as a private case, the surgery can be done on the next day. Do you find this acceptable?”
“No,” the girl replied promptly, “all people should have equal access to medical care. Allowing rich people to jump the queue is unfair and is a discrimination against poor people.”
“Are you against private medical service in general? If the same patient enjoys immediate surgery at a luxurious private hospital, is it unfair?” I pursued. The girl appeared less confident. “I still feel it not right.”
After the interview, my co-interviewer exclaimed, “Communism!”
I did not have any standpoint when I asked the question. Some are proud to be the doctors of the richest men in town, while others take pride in serving the public. I thought it was just a matter of choice. It was not until the hospital raised the private consultation fees that I gave the matter another thought.
Our administrators would tell you that the private service at public hospitals serves a noble mission – to earn money to support other public services. Besides, the two systems are separate and would not interfere with each other. Both arguments are flawed. First, the purpose of public hospitals is to provide affordable medical service to the public, not earning money. If resource is at stake, we should seek support from the government and cut unnecessary wastages. At the same time, patients who can afford private service may be encouraged to do so. We do not need to provide private service ourselves.
Second, we are the same doctors. When we are seeing private patients, we cannot be seeing public patients at the same time. Whenever some of us perform endoscopies for private patients, we occupy the rooms and our colleagues can just stay idly in the waiting area. It is difficult to conceive how public service would not be affected.
Of course, our applicant did not know the inside story. Her argument therefore centered on equality. Is equality a sound argument against private medical practice?
“No,” the girl replied promptly, “all people should have equal access to medical care. Allowing rich people to jump the queue is unfair and is a discrimination against poor people.”
“Are you against private medical service in general? If the same patient enjoys immediate surgery at a luxurious private hospital, is it unfair?” I pursued. The girl appeared less confident. “I still feel it not right.”
After the interview, my co-interviewer exclaimed, “Communism!”
I did not have any standpoint when I asked the question. Some are proud to be the doctors of the richest men in town, while others take pride in serving the public. I thought it was just a matter of choice. It was not until the hospital raised the private consultation fees that I gave the matter another thought.
Our administrators would tell you that the private service at public hospitals serves a noble mission – to earn money to support other public services. Besides, the two systems are separate and would not interfere with each other. Both arguments are flawed. First, the purpose of public hospitals is to provide affordable medical service to the public, not earning money. If resource is at stake, we should seek support from the government and cut unnecessary wastages. At the same time, patients who can afford private service may be encouraged to do so. We do not need to provide private service ourselves.
Second, we are the same doctors. When we are seeing private patients, we cannot be seeing public patients at the same time. Whenever some of us perform endoscopies for private patients, we occupy the rooms and our colleagues can just stay idly in the waiting area. It is difficult to conceive how public service would not be affected.
Of course, our applicant did not know the inside story. Her argument therefore centered on equality. Is equality a sound argument against private medical practice?
18 Apr 2013
April Fools
“Do you know the hospital has raised the consultation fee for private patients substantially this month?” AC called me last week. “I told the new patients the old rates. Should I call them again?”
To be honest, I received an e-mail about this some time ago but chose to ignore it. The new rates were so ridiculous that I did not know what to do. The e-mail explained that the rates had not been adjusted for a decade but neglected the fact that the original fees were already several times higher than the market rate. I just did not realize All Fools’ Day came so soon.
My recent reading is Justice: What’s the Right Thing to Do? by Michael Sandel. The book began with the story of Hurricane Charley in 2004. In the wake of the disaster, there was widespread price gouging in Florida. A contractor charged $23,000 to remove trees from a rooftop. People had to pay a fortune to stay in motels. Oil and food were sold at unbelievable prices.
Florida has a law against gouging. Not surprisingly, the Florida people filed a number of lawsuits afterwards. Some people disagreed. Thomas Sowell explained that there is no such thing as a fair price. In a free market, price would naturally respond to market conditions. During a disaster, it is better to raise the price. First, this limits wasteful use of scarce resources. Second, suppliers would then be attracted to provide goods and services. It is not unjust but reflects the value buyers and sellers mutually agreed upon. To go one step further, Jeff Jacoby argued that suppressing the price in such a situation would actually slow down Florida’s recovery.
In response, Attorney General Crist stated that such arguments do not apply in times of emergency. Buyers under duress have no freedom. Their purchases of necessities like safe lodging are forced.
Of course, medical consultations are different from services during a natural disaster. They however still have a lot in common. Let’s apply the theories of justice and ponder on two questions first. Should public doctors provide private service? Should doctors be allowed to charge whatever they want?
To be honest, I received an e-mail about this some time ago but chose to ignore it. The new rates were so ridiculous that I did not know what to do. The e-mail explained that the rates had not been adjusted for a decade but neglected the fact that the original fees were already several times higher than the market rate. I just did not realize All Fools’ Day came so soon.
My recent reading is Justice: What’s the Right Thing to Do? by Michael Sandel. The book began with the story of Hurricane Charley in 2004. In the wake of the disaster, there was widespread price gouging in Florida. A contractor charged $23,000 to remove trees from a rooftop. People had to pay a fortune to stay in motels. Oil and food were sold at unbelievable prices.
Florida has a law against gouging. Not surprisingly, the Florida people filed a number of lawsuits afterwards. Some people disagreed. Thomas Sowell explained that there is no such thing as a fair price. In a free market, price would naturally respond to market conditions. During a disaster, it is better to raise the price. First, this limits wasteful use of scarce resources. Second, suppliers would then be attracted to provide goods and services. It is not unjust but reflects the value buyers and sellers mutually agreed upon. To go one step further, Jeff Jacoby argued that suppressing the price in such a situation would actually slow down Florida’s recovery.
In response, Attorney General Crist stated that such arguments do not apply in times of emergency. Buyers under duress have no freedom. Their purchases of necessities like safe lodging are forced.
Of course, medical consultations are different from services during a natural disaster. They however still have a lot in common. Let’s apply the theories of justice and ponder on two questions first. Should public doctors provide private service? Should doctors be allowed to charge whatever they want?
11 Apr 2013
Spell
Last Friday, LH helped us at the clinic as a volunteer. LH is three years more senior than me and was amongst the first in our team to join the private market. That is to say something. For a long time the first generation trainees never imagined life outside the team.
As LH described the life of a private gastroenterologist, I could not help thinking of a little story from Life of Pi.
‘We had a mouse that lived for several weeks with the vipers. While other mice dropped in the terrarium disappeared within two days, this little brown Methuselah built itself a nest, stored the grains we gave it in various hideaways and scampered about in plain sight of the snakes. We were amazed. We put up a sign to bring the mouse to the public’s attention. It finally met its end in a curious way: a young viper bit it. Was the viper unaware of the mouse’s special status? Unsocialized to it, perhaps? Whatever the case, the mouse was bitten by a young viper but devoured – and immediately – by an adult. If there was a spell, it was broken by the young one.’
As LH described the life of a private gastroenterologist, I could not help thinking of a little story from Life of Pi.
‘We had a mouse that lived for several weeks with the vipers. While other mice dropped in the terrarium disappeared within two days, this little brown Methuselah built itself a nest, stored the grains we gave it in various hideaways and scampered about in plain sight of the snakes. We were amazed. We put up a sign to bring the mouse to the public’s attention. It finally met its end in a curious way: a young viper bit it. Was the viper unaware of the mouse’s special status? Unsocialized to it, perhaps? Whatever the case, the mouse was bitten by a young viper but devoured – and immediately – by an adult. If there was a spell, it was broken by the young one.’
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