A few colleagues asked me about case reports recently. The most common question is “Is this case worth reporting?”
Case report is the oldest form of medical literature. Clinicians described in details the patients they had saw, the treatment and subsequent outcome. When enough cases have been reported, generalizations can be made about the disease.
Fast forward to 21st century. With the explosion of information, it is rare to encounter diseases that few people have seen before (except new infectious diseases). Young colleagues often choose rare diseases with typical presentation. Though uncommon, these are usually diseases we meet once every few years. With a click on the keyboard, it is easy to find dozens of similar case reports already published. Saying “I have seen this too” is not very interesting.
Apart from describing new and rare diseases, case reports used to be platforms to discuss new medical treatments. However, without enough cases and controls, the outcome of a patient can hardly be attributed to the reported treatment. You can never prove or disprove if the patient would have the same or even better outcome if that treatment was not given. In the era of evidence-based medicine, the evidence on treatment efficacy provided by case reports is no better than expert opinion.
Does this mean that we should abandon case reports? No, writing case reports is excellent training. You learn not only writing skills, but also the ability to communicate medical information effectively with others.
Instead of describing rare conditions or novel treatments, I often encourage young people to watch out for uncommon presentations of common diseases. It can be as trivial as herpes zoster, or as dangerous as aortic dissection. Each encounter is an important lesson that everybody can learn.
P.S. Of course, whether a disease is rare depends on where you live. At one meeting, one colleague presented a case of intestinal tuberculosis. JL, a visitor from the Philippines, found that hilarious. She had a dozen of such cases in her ward at any time. To her, that presentation was no different from describing a typical case of COPD exacerbation.
20 Aug 2009
13 Aug 2009
Expensive
My mentor gave a nice discussion on cost-effectiveness at the medical grand round last week.
I was first introduced to this topic by Professor JW at the same meeting a decade ago, when I was a first-year resident. She presented three possible strategies to prevent osteoporotic fractures – starting bisphosphonates in all patients reaching a certain age, starting the drug in patients with confirmed osteoporosis but no fracture, and starting the drug after the first fracture. She illustrated clearly why the second strategy was the most cost-effective.
While we were all impressed by the presentation, the walking Harrison next to me whispered, “It is cheapest to withhold the drug in all patients even after fractures.”
I have no doubt that Harrison knows much more about health economics than me, but his remark demonstrates why it is so difficult to find common grounds with administrators when you discuss health expenditure. For frontline doctors, our priority regarding treatment is safety, effectiveness and cost-effectiveness. For administrators, the issue is reduced to costs.
Let’s take a hypothetical example. Suppose Drug X can reduce the risk of osteoporotic fractures and the overall cost of Drug X in a defined population is lower than that required for the management of fractures (e.g. surgery and rehabilitation). In that case, providing Drug X to all patients with the defined characteristics would be cost-effective and can save money for the whole healthcare system. However, if you are only concerned about the drug expenditure of a department, withholding the drug would be a quick way to reduce the budget. To complicate matters further, when surgery is required, the expenditure will go to another department and the relationship between the drug and surgery is difficult to measure. Therefore, administrators at the department or hospital level would be inclined to consider only costs but not cost-effectiveness. Theoretically, the government should be most interested in cost-effectiveness because of the effect on overall expenditure. In reality, insurance companies pay more attention to these aspects.
Life is not simple. More often than not, a new treatment is more effective but also more costly. Unlike the first example, the overall healthcare expenditure would increase, though you also get better outcomes. How should we choose then?
Let’s have another hypothetical example. Suppose there is a deadly condition in which all patients would die. At present, there is an old drug (Drug A) that can save 20 lives out of 100 treated patients at a cost of $100 in total (cost per patient is $1). If a new drug (Drug B) is used in the same 100 patients, 40 lives can be saved but the total cost is $10000 (cost per patient is $100). While the effect of Drug B is impressive, one may argue that you only spend $5 to save one life with Drug A ($100/20 lives) but $250 to save one life with Drug B ($10000/40 lives). Does this mean we should only use Drug A?
The trouble with this interpretation is that if there is a very cheap drug with some efficacy in the market, the medical field can never make any progress because any new treatment can never be cheaper. Instead of calculating the cost per life saved, health economists usually calculate the incremental cost-effectiveness ratio (ICER). It is the ratio of the change in the costs of an intervention to the change in the effectiveness. In other words, we are more interested in the cost required to save one extra life using the new treatment. In the above example, the ICER would be ($10000-$100)/(40-20), or $495 per extra life saved.
Another practical question, of course, is what level of ICER is acceptable. In Western literature, people are happy to spend US$50000 for one quality-adjusted life year (QALY). In countries where dissidents are readily imprisoned and executed, I am afraid only government officials and millionaires are worth that much.
P.S. You think the second example is too extreme? Think about aspirin!
I was first introduced to this topic by Professor JW at the same meeting a decade ago, when I was a first-year resident. She presented three possible strategies to prevent osteoporotic fractures – starting bisphosphonates in all patients reaching a certain age, starting the drug in patients with confirmed osteoporosis but no fracture, and starting the drug after the first fracture. She illustrated clearly why the second strategy was the most cost-effective.
While we were all impressed by the presentation, the walking Harrison next to me whispered, “It is cheapest to withhold the drug in all patients even after fractures.”
I have no doubt that Harrison knows much more about health economics than me, but his remark demonstrates why it is so difficult to find common grounds with administrators when you discuss health expenditure. For frontline doctors, our priority regarding treatment is safety, effectiveness and cost-effectiveness. For administrators, the issue is reduced to costs.
Let’s take a hypothetical example. Suppose Drug X can reduce the risk of osteoporotic fractures and the overall cost of Drug X in a defined population is lower than that required for the management of fractures (e.g. surgery and rehabilitation). In that case, providing Drug X to all patients with the defined characteristics would be cost-effective and can save money for the whole healthcare system. However, if you are only concerned about the drug expenditure of a department, withholding the drug would be a quick way to reduce the budget. To complicate matters further, when surgery is required, the expenditure will go to another department and the relationship between the drug and surgery is difficult to measure. Therefore, administrators at the department or hospital level would be inclined to consider only costs but not cost-effectiveness. Theoretically, the government should be most interested in cost-effectiveness because of the effect on overall expenditure. In reality, insurance companies pay more attention to these aspects.
Life is not simple. More often than not, a new treatment is more effective but also more costly. Unlike the first example, the overall healthcare expenditure would increase, though you also get better outcomes. How should we choose then?
Let’s have another hypothetical example. Suppose there is a deadly condition in which all patients would die. At present, there is an old drug (Drug A) that can save 20 lives out of 100 treated patients at a cost of $100 in total (cost per patient is $1). If a new drug (Drug B) is used in the same 100 patients, 40 lives can be saved but the total cost is $10000 (cost per patient is $100). While the effect of Drug B is impressive, one may argue that you only spend $5 to save one life with Drug A ($100/20 lives) but $250 to save one life with Drug B ($10000/40 lives). Does this mean we should only use Drug A?
The trouble with this interpretation is that if there is a very cheap drug with some efficacy in the market, the medical field can never make any progress because any new treatment can never be cheaper. Instead of calculating the cost per life saved, health economists usually calculate the incremental cost-effectiveness ratio (ICER). It is the ratio of the change in the costs of an intervention to the change in the effectiveness. In other words, we are more interested in the cost required to save one extra life using the new treatment. In the above example, the ICER would be ($10000-$100)/(40-20), or $495 per extra life saved.
Another practical question, of course, is what level of ICER is acceptable. In Western literature, people are happy to spend US$50000 for one quality-adjusted life year (QALY). In countries where dissidents are readily imprisoned and executed, I am afraid only government officials and millionaires are worth that much.
P.S. You think the second example is too extreme? Think about aspirin!
6 Aug 2009
Expert
We attended a hepatitis workshop in June. In one interesting session, speakers from Taiwan and Hong Kong presented the local guidelines, actual clinical practice and reimbursement system. After the presentation, it was clear that the prescription practice in Taiwan largely followed the guidelines of the expert committee. On the other hand, the management guidelines issued by hepatologists in Hong Kong and the actual criteria for initiating treatment issued by the Hospital Authority showed little concordance. As a result, many patients in need were either untreated or had to buy the drugs themselves.
“You have to talk to the government and fight for your patients,” our friends from Taiwan remarked.
My mentor was frustrated. “I attended a few of those meetings. My conclusion is that those administrators measure productivity by the number of meetings they hold but not by the things achieved.”
The Taiwanese disagreed. “Our professor always mentions that he spent twenty years talking to the government before we have this reimbursement scheme.”
Our friends might be right. However, their officials were not British trained. I could immediately recall the standard procedure by Sir Humphrey Appleby to denounce the significance of any expert report:
Step One: Public interest. Point out the report could be used to put unwelcome pressure on government because it might be misinterpreted. We need to wait for the results of a wider and more detailed survey over a longer time-scale. If such a survey is not being conducted, it is even better.
Step Two: Challenge the evidence. The report leaves important questions unanswered. Much of the evidence is inconclusive. The figures are open to other interpretations. Some findings are contradictory. (These criticisms can be made on any report even without reading it.)
Step Three: Undermine the recommendations. The report cannot be used for long-term decisions. There is insufficient information to support the conclusions. Broadly speaking, the report supports the current practice. (Mind you, most people do not really read full reports and are easily swayed.)
Step Four: Discredit the expert. He is harboring a grudge against the government. He is just attracting publicity. He used to be a consultant of a commercial company. If not, he wants to be a consultant of a commercial company!
“You have to talk to the government and fight for your patients,” our friends from Taiwan remarked.
My mentor was frustrated. “I attended a few of those meetings. My conclusion is that those administrators measure productivity by the number of meetings they hold but not by the things achieved.”
The Taiwanese disagreed. “Our professor always mentions that he spent twenty years talking to the government before we have this reimbursement scheme.”
Our friends might be right. However, their officials were not British trained. I could immediately recall the standard procedure by Sir Humphrey Appleby to denounce the significance of any expert report:
Step One: Public interest. Point out the report could be used to put unwelcome pressure on government because it might be misinterpreted. We need to wait for the results of a wider and more detailed survey over a longer time-scale. If such a survey is not being conducted, it is even better.
Step Two: Challenge the evidence. The report leaves important questions unanswered. Much of the evidence is inconclusive. The figures are open to other interpretations. Some findings are contradictory. (These criticisms can be made on any report even without reading it.)
Step Three: Undermine the recommendations. The report cannot be used for long-term decisions. There is insufficient information to support the conclusions. Broadly speaking, the report supports the current practice. (Mind you, most people do not really read full reports and are easily swayed.)
Step Four: Discredit the expert. He is harboring a grudge against the government. He is just attracting publicity. He used to be a consultant of a commercial company. If not, he wants to be a consultant of a commercial company!
30 Jul 2009
Outliers
As usual, LS complained bitterly about the difficulty in getting her son in a decent primary school. Since both of our children were born at the end of the calendar year, our discussion shifted to Malcolm Gladwell’s new ideas in Outliers. JN, an expectant mother, said she had not heard about this and asked us to elaborate.
Gladwell’s book started with the observation that most top hockey players in Canada are born in January, February and March. The difference is too great to be explained by chance alone. He pointed out that the official cutoff line of admitting children players is January. In other words, among junior players in the same class, those born in January are the oldest while those born in December would be the youngest. In young children, a one-year difference in age means a significant difference in physique and skills. Even though they might not really be cleverer or more talented, this difference is enough to convince the coaches. These older children would be selected for more intensive training and given more encouragement. Because of this, the original spurious difference becomes a real and tremendous difference – that is, a self-fulfilling prophesy comes true.
Reflecting upon my childhood, I cannot help thinking how true the theory is and how lucky I am. I entered primary school at the age of five as the youngest student. In fact, my mother wrote a fake birthday in the application form to get me in school. I could hardly follow my classmates to do any arts and crafts, and I always finished last in races. I still vividly remembered how my arts teacher tore and threw away my drawing. This killed my remaining interest in arts.
Fortunately, I was granted other chances. When I entered secondary school, there was an entrance exam. The test selected the best and worst students and put them into different classes. I did fairly and was assigned to a so-so class. In most other schools, this would be the end of the story. Amazingly, in my school the whole purpose of the selection system was to provide more resources to students in need. The top students did not get more teaching. If anything, they had more free time to read books, play bridge, or do anything they liked. Looking back, I am always grateful that our school allowed us to develop our talents to the fullest.
P.S. My mother always supports the response of my arts teacher because I basically painted the whole picture in black (sometimes dark blue). Years later, I learned about Adolph Reinhardt's black paintings. This is unfair! I was just doing abstract expressionism precociously.
Gladwell’s book started with the observation that most top hockey players in Canada are born in January, February and March. The difference is too great to be explained by chance alone. He pointed out that the official cutoff line of admitting children players is January. In other words, among junior players in the same class, those born in January are the oldest while those born in December would be the youngest. In young children, a one-year difference in age means a significant difference in physique and skills. Even though they might not really be cleverer or more talented, this difference is enough to convince the coaches. These older children would be selected for more intensive training and given more encouragement. Because of this, the original spurious difference becomes a real and tremendous difference – that is, a self-fulfilling prophesy comes true.
Reflecting upon my childhood, I cannot help thinking how true the theory is and how lucky I am. I entered primary school at the age of five as the youngest student. In fact, my mother wrote a fake birthday in the application form to get me in school. I could hardly follow my classmates to do any arts and crafts, and I always finished last in races. I still vividly remembered how my arts teacher tore and threw away my drawing. This killed my remaining interest in arts.
Fortunately, I was granted other chances. When I entered secondary school, there was an entrance exam. The test selected the best and worst students and put them into different classes. I did fairly and was assigned to a so-so class. In most other schools, this would be the end of the story. Amazingly, in my school the whole purpose of the selection system was to provide more resources to students in need. The top students did not get more teaching. If anything, they had more free time to read books, play bridge, or do anything they liked. Looking back, I am always grateful that our school allowed us to develop our talents to the fullest.
P.S. My mother always supports the response of my arts teacher because I basically painted the whole picture in black (sometimes dark blue). Years later, I learned about Adolph Reinhardt's black paintings. This is unfair! I was just doing abstract expressionism precociously.
23 Jul 2009
Loud
While waiting to go out, my daughter and I played the piano. I chose a waltz by Chopin. To me, this was a lively and lovely piece which children might like.
“Daddy,” Angelina commented after I finished, “you are very noisy.”
My immediate association was the legendary piano accompanist Gerald Moore. The title of his autobiography was exactly Am I too loud?
Many friends know that I can play a few musical instruments, but my classmates in secondary school would know that I spent most of my lunch and after hours working as an accompanist. I played for the choirs, violinists, cellists, rehearsed for musical play singers, you name it. Sometimes, I accompanied others at Royal College exams, which to a young boy really earned me a fortune.
At one memorable occasion, our school organized a variety show and invited students from other schools (mostly girls, of course!) to perform. While I was hanging around at the backstage, a young lady who was going to sing was upset because our system could not play her sound track. After asking about the song, I said I could do it. The performance went well. Years later, I found out that she was IK the psychiatrist. It is a small world after all.
Interestingly, despite of the title of Moore’s book, he is well known to raise the status of an accompanist to an equal partner of the soloist. This certainly has never been my ambition. As an accompanist, I learned to listen to and assist others. The skills very much shaped my future behavior.
“Daddy,” Angelina commented after I finished, “you are very noisy.”
My immediate association was the legendary piano accompanist Gerald Moore. The title of his autobiography was exactly Am I too loud?
Many friends know that I can play a few musical instruments, but my classmates in secondary school would know that I spent most of my lunch and after hours working as an accompanist. I played for the choirs, violinists, cellists, rehearsed for musical play singers, you name it. Sometimes, I accompanied others at Royal College exams, which to a young boy really earned me a fortune.
At one memorable occasion, our school organized a variety show and invited students from other schools (mostly girls, of course!) to perform. While I was hanging around at the backstage, a young lady who was going to sing was upset because our system could not play her sound track. After asking about the song, I said I could do it. The performance went well. Years later, I found out that she was IK the psychiatrist. It is a small world after all.
Interestingly, despite of the title of Moore’s book, he is well known to raise the status of an accompanist to an equal partner of the soloist. This certainly has never been my ambition. As an accompanist, I learned to listen to and assist others. The skills very much shaped my future behavior.
16 Jul 2009
Evaluation
During a meeting, our Boss asked us to evaluate the refresher course.
“Despite numerous limitations, I do not think the course can be improved further,” said the student representative.
A lot of limitations but no room for improvement? What kind of youngster are you? I hope this does not reflect your view on clinical skills.
Seeing that no teacher was going to speak, our Boss pointed at my friend. “Szeto, you seem to be not very happy about the course.”
“If the students like it, what else can I say?” the walking Harrison replied dryly.
Just when we all thought that the case was closed, KC spoke up and complained that many students were late for his lecture. After he scolded them, only one third of the class attended his lesson on the next day.
Our Boss gave him a gentle answer. “Do not take this personal. Young people are like this nowadays. KC, you are lucky for not being a parent. The rest of us get this kind of insults everyday when we go home.”
This is truly inspirational. If we hold this view, who can possibly insult us again? In no time, my emotional intelligence soared by another five points.
“Despite numerous limitations, I do not think the course can be improved further,” said the student representative.
A lot of limitations but no room for improvement? What kind of youngster are you? I hope this does not reflect your view on clinical skills.
Seeing that no teacher was going to speak, our Boss pointed at my friend. “Szeto, you seem to be not very happy about the course.”
“If the students like it, what else can I say?” the walking Harrison replied dryly.
Just when we all thought that the case was closed, KC spoke up and complained that many students were late for his lecture. After he scolded them, only one third of the class attended his lesson on the next day.
Our Boss gave him a gentle answer. “Do not take this personal. Young people are like this nowadays. KC, you are lucky for not being a parent. The rest of us get this kind of insults everyday when we go home.”
This is truly inspirational. If we hold this view, who can possibly insult us again? In no time, my emotional intelligence soared by another five points.
9 Jul 2009
Refresh
Last month, our Departments of Surgery and Medicine provided the final year medical students with the “refresher course”. The original intention was wonderful. The students may have forgotten some clinical skills learned two years ago and would have difficulties catching up with the teaching in the final year. We should help.
When the final program was announced, however, the frontline teachers were amazed. The students were asked to attend six to seven one-hour lectures per day for four weeks. Instead of refreshing the clinical skills as originally stated, each lecture was didactic and covered broad topics like “common diseases in hepatology”. (Yes, I dare not comment on other topics.) In effect, we were asking the students to download the whole year’s curriculum within four weeks. How effective could it be?
When it came to my turn, I could not help but start my lecture with a short story.
“In Heaven Sword and Dragon Sabre (倚天屠龍記), Xie Xun (謝遜) wanted to teach his godson Zhang Wuji (張無忌) his superb martial arts. Instead of showing him how to fight, Xie Xun forced Wuji to recite all the martial arts scrolls. As expected, Wuji had a hard time memorizing the words because he did not have the slightest idea what they meant. Wuji’s parents also thought it was a silly way to teach martial arts.
As the story unfolded, Xie Xun did not actually plan to stay with the Zhang’s family for a long time. He just hoped that Wuji could learn martial arts by himself when he grew up. Some of the teachings were indeed useful during Wuji’s future adventures.”
Dear students, unless I die after the refresher course, I would not want to be Xie Xun. I am more than happy to show you martial arts in the coming year and long after your graduation.
P.S. I learned Eighteen Dragon Subduing Palms from my Boss, Heaven and Earth Great Shift from my mentor, and Nine Swords of Dugu from Szeto. In the end, all I could master was the three simple moves that Sha Gu (傻姑) learned from Huang Yaoshi (黃藥師).
When the final program was announced, however, the frontline teachers were amazed. The students were asked to attend six to seven one-hour lectures per day for four weeks. Instead of refreshing the clinical skills as originally stated, each lecture was didactic and covered broad topics like “common diseases in hepatology”. (Yes, I dare not comment on other topics.) In effect, we were asking the students to download the whole year’s curriculum within four weeks. How effective could it be?
When it came to my turn, I could not help but start my lecture with a short story.
“In Heaven Sword and Dragon Sabre (倚天屠龍記), Xie Xun (謝遜) wanted to teach his godson Zhang Wuji (張無忌) his superb martial arts. Instead of showing him how to fight, Xie Xun forced Wuji to recite all the martial arts scrolls. As expected, Wuji had a hard time memorizing the words because he did not have the slightest idea what they meant. Wuji’s parents also thought it was a silly way to teach martial arts.
As the story unfolded, Xie Xun did not actually plan to stay with the Zhang’s family for a long time. He just hoped that Wuji could learn martial arts by himself when he grew up. Some of the teachings were indeed useful during Wuji’s future adventures.”
Dear students, unless I die after the refresher course, I would not want to be Xie Xun. I am more than happy to show you martial arts in the coming year and long after your graduation.
P.S. I learned Eighteen Dragon Subduing Palms from my Boss, Heaven and Earth Great Shift from my mentor, and Nine Swords of Dugu from Szeto. In the end, all I could master was the three simple moves that Sha Gu (傻姑) learned from Huang Yaoshi (黃藥師).
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