In the last two months, no doubt the most important news is the influenza A(H1N1) epidemic. A few friends were concerned about me as a frontline worker in the hospital. When they learned that I was perfectly fine, the discussion drifted to why the virus had become less deadly over the weeks. As of 12 May 2009, over 5000 patients were confirmed to be infected. Fifty-eight Mexicans died, compared to 5 in the rest of the world.
The cause for concern is understandable and has been discussed extensively elsewhere (http://ccszeto.blogspot.com/2009/05/show.html, http://drkmchow.blogspot.com/2009/05/contagion.html). I will concentrate my discussion on why the mortality rate of influenza A(H1N1) appears to drop outside Mexico.
When the outcome of a viral infection changes, there are only four possibilities: (1) The virus has changed; (2) The host has changed; (3) The treatment has changed; and (4) The observation is an artifact.
The most successful microorganisms do not kill people. Viruses spread by droplets would transmit more efficiently if the hosts survive and walk around. The only microorganisms that benefit from debilitating the hosts are those transmitted by vectors. If you cannot move around, mosquitoes and ticks can bite you easily and transmit the microorganisms around. Therefore, we often see that viruses causing respiratory infections become less virulent with time. Comparison of earlier and later strains of the virus would answer this question.
Mortality from influenza A(H1N1) appears to be more common among adults and diabetics in Mexico. It remains to be seen if high-risk individuals are over-represented in the Mexican cohort. It is unlikely that the mortality rate can be explained by ethnicity since the mortality rate in Mexico is also declining.
Early use of antiviral drug (e.g. oseltamivir) and advanced organ support have also been proposed to be the cause of lower mortality in developed countries. While this may be true, I have not yet seen reports showing such a dramatic efficacy of oseltamivir. The point on organ support can only hold if a significant percentage of infected US citizens required intensive care. Another potential explanation is that the pattern of coinfection may be different in different countries. Again, further investigations are required.
Finally, I think the most probable explanation is that the observation is an artifact. We now know that the majority of infected individuals have mild symptoms. It is very likely that many infected people were never detected and reported, especially in the early stage of the epidemic.
As a young journal reviewer, I often reverse the sequence. I check if a study has major methodological flaws before learning what it is trying to say. More experienced academics, however, tend to see if a study asks an important question before reading on. After all, anything worth doing is worth doing well. The converse is also true.
14 May 2009
7 May 2009
Wrong Train
We just attended a medical conference in the lovely city of Copenhagen. No wonder it was the home of Hans Christian Andersen, the great author of numerous fairy tales.
On the fourth day, YL was surprised that I attended all sessions of the conference. “Do you mean that you have not visited anywhere?”
“No,” I answered defensively, “I had a boat ride on the first day, and I dined out every evening.”
It is however really not my cup of tea to tour around during overseas conferences. Above all, I enjoyed the conference very much. Even though my mentor said he could not find any reason to attend the lecture on ubiquitin, I managed to convince him that was also wonderful. Secondly, the mood is different when I travel with my family back home.
When my daughter was three months old, I had to leave my family and receive overseas training for several months. Understandably, my wife was stressful and sad at that time. Crying over phone calls was the rule rather than the exception. Of course, I could do little other than calling her frequently. Partly as a defensive mechanism, I stayed in the lab most of the time and convinced myself that at least I was doing something meaningful. As Eileen Chang wrote in her last novel Small Reunion (小團圓), “You think you are not so bad if you know you are bad.” I know this is silly, but silly I am.
On my last day in Copenhagen, I took the wrong train. Instead of going to the conference center, I travelled to some rural areas. It actually took me merely thirty extra minutes to go back. But there I was, alone in a small station. Since the next train would only come in five minutes, I had the privilege to enjoy the scene. Below the heavenly blue sky were vast green fields where cozy cottages were sparsely built. Everything was quiet and peaceful. The only sound was the whisper of the warm breeze.
When the train arrived, I could not help thanking God and thinking, “Wouldn’t that be good enough?”
On the fourth day, YL was surprised that I attended all sessions of the conference. “Do you mean that you have not visited anywhere?”
“No,” I answered defensively, “I had a boat ride on the first day, and I dined out every evening.”
It is however really not my cup of tea to tour around during overseas conferences. Above all, I enjoyed the conference very much. Even though my mentor said he could not find any reason to attend the lecture on ubiquitin, I managed to convince him that was also wonderful. Secondly, the mood is different when I travel with my family back home.
When my daughter was three months old, I had to leave my family and receive overseas training for several months. Understandably, my wife was stressful and sad at that time. Crying over phone calls was the rule rather than the exception. Of course, I could do little other than calling her frequently. Partly as a defensive mechanism, I stayed in the lab most of the time and convinced myself that at least I was doing something meaningful. As Eileen Chang wrote in her last novel Small Reunion (小團圓), “You think you are not so bad if you know you are bad.” I know this is silly, but silly I am.
On my last day in Copenhagen, I took the wrong train. Instead of going to the conference center, I travelled to some rural areas. It actually took me merely thirty extra minutes to go back. But there I was, alone in a small station. Since the next train would only come in five minutes, I had the privilege to enjoy the scene. Below the heavenly blue sky were vast green fields where cozy cottages were sparsely built. Everything was quiet and peaceful. The only sound was the whisper of the warm breeze.
When the train arrived, I could not help thanking God and thinking, “Wouldn’t that be good enough?”
30 Apr 2009
Conversation
You never know how kids think nowadays.
Like most parents, I asked my 3-year-old daughter one day. “What do you want to do when you grow up?”
“Nothing,” she answered.
I did not give up. “How about being a doctor?”
“No.”
“Then what are you going to do?”
“I will get married.”
“Mummy also got married,” I replied, “but she still goes to work.”
I was anticipating an in-depth discussion on the meaning of life, but our conversation was interrupted by Mummy’s laughter.
Like most parents, I asked my 3-year-old daughter one day. “What do you want to do when you grow up?”
“Nothing,” she answered.
I did not give up. “How about being a doctor?”
“No.”
“Then what are you going to do?”
“I will get married.”
“Mummy also got married,” I replied, “but she still goes to work.”
I was anticipating an in-depth discussion on the meaning of life, but our conversation was interrupted by Mummy’s laughter.
23 Apr 2009
Examination
As the final professional exam draws near, more and more students ask me for examination skills. Some years ago, I really believed that I knew a few tricks.
Rule number one is to understand why an examiner asks a certain question. It can be because your original answer is wrong, he wants to test you some general knowledge, or he has recently come across a research paper on this topic. When I explained this, a student was quick to point out, “How can we know?” The loophole is I never thought about this.
In the past, many examinations using multiple choice questions had a penalty system – marks would be deducted for wrong answers. Knowing when not to answer was as important as knowing the correct answers. To test my method, I asked some trainees to record their confidence in a question (in percentages) as well as the final outcome (correct or incorrect). In theory, if they learned not to answer when their confidence was below a certain threshold, they would get the highest marks. However, none of them thought this method was very useful.
After all these years, I understand that the so-called tricks are just the rule of 10,000 hours. This is nothing but experience. I kept talking in tutorials whenever my classmates were shy or unsure. With time, I could anticipate questions and give appropriate answers even when I was uncertain.
So, there are no secrets after all. If you still insist on some tricks, I find Sima Yi’s (司馬懿) military advice very useful:
“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！”
Rule number one is to understand why an examiner asks a certain question. It can be because your original answer is wrong, he wants to test you some general knowledge, or he has recently come across a research paper on this topic. When I explained this, a student was quick to point out, “How can we know?” The loophole is I never thought about this.
In the past, many examinations using multiple choice questions had a penalty system – marks would be deducted for wrong answers. Knowing when not to answer was as important as knowing the correct answers. To test my method, I asked some trainees to record their confidence in a question (in percentages) as well as the final outcome (correct or incorrect). In theory, if they learned not to answer when their confidence was below a certain threshold, they would get the highest marks. However, none of them thought this method was very useful.
After all these years, I understand that the so-called tricks are just the rule of 10,000 hours. This is nothing but experience. I kept talking in tutorials whenever my classmates were shy or unsure. With time, I could anticipate questions and give appropriate answers even when I was uncertain.
So, there are no secrets after all. If you still insist on some tricks, I find Sima Yi’s (司馬懿) military advice very useful:
“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！”
16 Apr 2009
High School Musical
Earlier this month, my mentor, GW and I attended a meeting in Phuket and gave some talks. After the session, the Associate Dean at the Thai university invited us to watch his rehearsal. Much to our surprise, he and his fellows were going to dance in the celebration dinner. They chose a few scenes from High School Musical.
If you have never heard of High School Musical, you do not have a kid in primary or secondary school. This is a popular TV show featuring American students going to school, playing sports, dating, etc.
While the Associate Dean was jumping up and down on stage and gasping for air, we joked about the possibility of having our Boss give such a show.
“We will all be asked to accompany him,” GW reminded us.
“I’d rather give three talks than dance on stage,” said my mentor.
“Thais can enjoy life,” our Singaporean friend in the audience concluded. “On the other hand, we are too complex and would be worried that others may laugh at us.”
Watching the Thai professor laughing wholeheartedly with his colleagues, we felt happy for them. After all, this is what life is all about.
If you have never heard of High School Musical, you do not have a kid in primary or secondary school. This is a popular TV show featuring American students going to school, playing sports, dating, etc.
While the Associate Dean was jumping up and down on stage and gasping for air, we joked about the possibility of having our Boss give such a show.
“We will all be asked to accompany him,” GW reminded us.
“I’d rather give three talks than dance on stage,” said my mentor.
“Thais can enjoy life,” our Singaporean friend in the audience concluded. “On the other hand, we are too complex and would be worried that others may laugh at us.”
Watching the Thai professor laughing wholeheartedly with his colleagues, we felt happy for them. After all, this is what life is all about.
9 Apr 2009
Choice
Without the voices of our trainees, the story would be incomplete. Some older people believe they have already known what the youngsters think. Some even believe that the youngsters do not know how to think and they know what is best for them. To a certain extent, I also agree that young people may not tell you the truth even if you ask, but I wished to ask.
In March 2009, two investigators (VW and KY) independently generated a list of basic trainees in our department who have taken or passed the MRCP exam and expressed interest in joining a specialty. A standard set of open questions was sent by e-mail. For confidentiality reasons, the identity of trainees and the exact specialties would not be revealed. Overall, eight of nine trainees responded (response rate 89%).
Decision
The median number of specialties the trainees had seriously considered was 3 (range 2 to 4). Six trainees made the final decision after the MRCP exam and one made the decision during internship. One notable exception was a trainee who determined to join a specialty even before entering the medical school. That trainee continued to pursue the dream despite failing to enter the medical school at the first attempt. He/she is now generally agreed to be one of the most responsible and competent colleagues in our department. Based on this touching story, I am ready to help all youngsters to develop their careers.
Factors affecting the decision
Not surprisingly, five trainees stated interest as their main reason of choosing a specialty. Five also considered the team spirit and the behavior of other team members important. Three respondents considered future prospects (one stated promotion, one stated the likelihood of staying in the team after the completion of training, and one reported the prospect in the private market). Three trainees also thought the leadership of team heads was important. On the other hand, only one trainee wished to join a team for research and challenge. One trainee said that the decision was affected by what the other trainees chose.
One interesting phenomenon recently is that specialties with more trainees and fellows continue to attract the biggest number of new recruits. Some people have questioned this behavior on the ground that the promotion and training opportunities may be adversely affected. When we asked the same questions, three trainees thought that the number of existing members in a specialty was unimportant in their decision process. Three other trainees believed that bigger teams were more attractive because they would get more support and have better exchange of ideas. Only two respondents were worried about the prospect and said that specialties with more existing trainees were less attractive.
Pro-choice or Pro-life?
Under the current system, most trainees can enter their first-choice specialties. When we asked about their view on the possibility of job assignment by the department according to service need, four trainees stated that they would seek training posts in other hospitals and one would negotiate with the department. Two trainees would accept the offer if they could join their other favorite specialties, but would still leave us if the team was not what they wanted. None of these seven trainees believed they could excel in specialties they did not like. Only one respondent agreed to accept any offer and try the work first.
In March 2009, two investigators (VW and KY) independently generated a list of basic trainees in our department who have taken or passed the MRCP exam and expressed interest in joining a specialty. A standard set of open questions was sent by e-mail. For confidentiality reasons, the identity of trainees and the exact specialties would not be revealed. Overall, eight of nine trainees responded (response rate 89%).
Decision
The median number of specialties the trainees had seriously considered was 3 (range 2 to 4). Six trainees made the final decision after the MRCP exam and one made the decision during internship. One notable exception was a trainee who determined to join a specialty even before entering the medical school. That trainee continued to pursue the dream despite failing to enter the medical school at the first attempt. He/she is now generally agreed to be one of the most responsible and competent colleagues in our department. Based on this touching story, I am ready to help all youngsters to develop their careers.
Factors affecting the decision
Not surprisingly, five trainees stated interest as their main reason of choosing a specialty. Five also considered the team spirit and the behavior of other team members important. Three respondents considered future prospects (one stated promotion, one stated the likelihood of staying in the team after the completion of training, and one reported the prospect in the private market). Three trainees also thought the leadership of team heads was important. On the other hand, only one trainee wished to join a team for research and challenge. One trainee said that the decision was affected by what the other trainees chose.
One interesting phenomenon recently is that specialties with more trainees and fellows continue to attract the biggest number of new recruits. Some people have questioned this behavior on the ground that the promotion and training opportunities may be adversely affected. When we asked the same questions, three trainees thought that the number of existing members in a specialty was unimportant in their decision process. Three other trainees believed that bigger teams were more attractive because they would get more support and have better exchange of ideas. Only two respondents were worried about the prospect and said that specialties with more existing trainees were less attractive.
Pro-choice or Pro-life?
Under the current system, most trainees can enter their first-choice specialties. When we asked about their view on the possibility of job assignment by the department according to service need, four trainees stated that they would seek training posts in other hospitals and one would negotiate with the department. Two trainees would accept the offer if they could join their other favorite specialties, but would still leave us if the team was not what they wanted. None of these seven trainees believed they could excel in specialties they did not like. Only one respondent agreed to accept any offer and try the work first.
2 Apr 2009
Training
Recently, there has been some discussion on the recruitment of trainees into different specialties in our department. Understandably, some team heads are not too happy when all trainees are attracted to a few popular specialties, while their own teams suffer from insufficient manpower. With immense interest in human thinking and behavior, I asked some colleagues for their opinion.
Prof Szeto answered, "I have decided that I do not need to have any opinion." (For details, please visit http://ccszeto.blogspot.com/2009/03/opinion.html.)
When I asked the same question, my mentor wrote down four words: '寧缺莫濫'. According to him, teammates are not just manpower. They are brothers and sisters. When a leader recruits a new teammate, he should help him/her develop a career as well. Therefore, he would rather wait patiently for suitable candidates.
As usual, I learned a lot by asking.
Prof Szeto answered, "I have decided that I do not need to have any opinion." (For details, please visit http://ccszeto.blogspot.com/2009/03/opinion.html.)
When I asked the same question, my mentor wrote down four words: '寧缺莫濫'. According to him, teammates are not just manpower. They are brothers and sisters. When a leader recruits a new teammate, he should help him/her develop a career as well. Therefore, he would rather wait patiently for suitable candidates.
As usual, I learned a lot by asking.
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