You may have played a similar version of this game before. Your group is given a bag of uncooked spaghetti, some tapes and strings, and a marshmallow. Your job is to build a tower with spaghetti to support the marshmallow. The group that builds the tallest tower wins.
When Peter Skillman analyzed the results, he noticed something interesting. Somehow, business school graduates consistently performed worse than fresh kindergarten graduates. On average, their towers were 10 inches shorter than those built by children.
What happened? It turns out that business school graduates did what we are all so familiar with – they held meetings. They formulated the best plan. When there were just a few minutes left, they started building their best design. At the last second, the chairman of the group put the marshmallow at the top, and the tower collapsed.
What about the children? They have never heard about meetings, agenda and brainstorming. All kindergarten groups started building right away. Although their towers collapsed time and again, they had plenty of time to try another structure. In the end, more groups would at least have a standing piece.
So, is it at odds with my previous advocation that we should spend much time planning a study? In my opinion, it really depends on whether you have enough information to make decisions. If you do not know anything, pretending you can develop the best plan would not bring you anywhere. This should be time for trial and error and gathering information. Empty talks without execution is, after all, empty talks.
15 Nov 2012
8 Nov 2012
Predict
In the face of life and death, the decision on the duration of resuscitation is of secondary importance. In fact, we more often go one step earlier – to decide whether to go for resuscitation in the first place. This decision is closely linked to our ability to predict the prognosis of our patients.
Unfortunately, numerous studies have shown that doctors are poor in prediction. In general, doctors tend to overestimate the survival of their patients.
How about the perception of the patients themselves? In a recent article, Jane Weeks and coworkers studied 1193 patients who received palliative chemotherapy for metastatic lung or colorectal cancer and remained alive 4 months since the diagnosis [N Engl J Med 2012;367:1616-25]. Despite their advanced disease, only 31% of patients with lung cancer and 19% of those with colorectal cancer reported their disease would unlikely be cured by chemotherapy. In contrast, 25% of patients with lung cancer and 36% of those with colorectal cancer thought cure was very likely.
This study is striking in that the majority of the patients had unrealistic expectation about their prognosis. Since Weeks did not study the doctors or the consultation process, it is difficult to determine if the observation resulted from vague explanations by the doctors or patient denial. However, it is noteworthy that all patients in this study chose to receive chemotherapy and survived for at least 4 months. Perhaps it always takes a little optimism to go on in life.
Unfortunately, numerous studies have shown that doctors are poor in prediction. In general, doctors tend to overestimate the survival of their patients.
How about the perception of the patients themselves? In a recent article, Jane Weeks and coworkers studied 1193 patients who received palliative chemotherapy for metastatic lung or colorectal cancer and remained alive 4 months since the diagnosis [N Engl J Med 2012;367:1616-25]. Despite their advanced disease, only 31% of patients with lung cancer and 19% of those with colorectal cancer reported their disease would unlikely be cured by chemotherapy. In contrast, 25% of patients with lung cancer and 36% of those with colorectal cancer thought cure was very likely.
This study is striking in that the majority of the patients had unrealistic expectation about their prognosis. Since Weeks did not study the doctors or the consultation process, it is difficult to determine if the observation resulted from vague explanations by the doctors or patient denial. However, it is noteworthy that all patients in this study chose to receive chemotherapy and survived for at least 4 months. Perhaps it always takes a little optimism to go on in life.
1 Nov 2012
Resuscitation
Years ago, a local TV drama pictured a surgeon performing cardiopulmonary resuscitation on a patient who developed cardiac arrest in the middle of an operation. After eight hours of effort, the surgeon refused to let go. “She is already dead,” his colleagues tried to pull him away. “This is human life. We cannot give up,” he yelled back.
Of course, this does not happen in real life. Other than rare occasions such as hypothermia, prolonged resuscitation is futile and does not do the patient any good. However, how long a resuscitation attempt is too long?
In a recent paper, Zachary Goldberger and coworkers reported the findings from an American registry of 64339 patients with cardiac arrests at 435 hospitals [Lancet 2012;380:1473-81]. Overall, 15% of this cohort survived to discharge after successful resuscitation. The average duration of resuscitation was 12 minutes among patients with return of spontaneous circulation, compared to 20 minutes among non-survivors. When centers were classified according to the duration of resuscitation attempts among non-survivors, hospitals in the lowest quartile tried on average 16 minutes and hospitals in the highest quartile tried 25 minutes. The effort was translated into improved outcomes. Patients receiving resuscitation in hospitals in the highest quartile of attempt duration were 12% more likely to survive to discharge.
Thus, it is reassuring to learn that attempting more does help. This, however, still does not answer the original question – How long should we try then?
Of course, this does not happen in real life. Other than rare occasions such as hypothermia, prolonged resuscitation is futile and does not do the patient any good. However, how long a resuscitation attempt is too long?
In a recent paper, Zachary Goldberger and coworkers reported the findings from an American registry of 64339 patients with cardiac arrests at 435 hospitals [Lancet 2012;380:1473-81]. Overall, 15% of this cohort survived to discharge after successful resuscitation. The average duration of resuscitation was 12 minutes among patients with return of spontaneous circulation, compared to 20 minutes among non-survivors. When centers were classified according to the duration of resuscitation attempts among non-survivors, hospitals in the lowest quartile tried on average 16 minutes and hospitals in the highest quartile tried 25 minutes. The effort was translated into improved outcomes. Patients receiving resuscitation in hospitals in the highest quartile of attempt duration were 12% more likely to survive to discharge.
Thus, it is reassuring to learn that attempting more does help. This, however, still does not answer the original question – How long should we try then?
25 Oct 2012
Chocolate
During the laboratory meeting this week, I showed my friends an article from New England Journal of Medicine (2012;367:1562-4). Flavanols are present in cocoa, green tea, red wine and some fruits, and have been shown to slow down cognitive decline in the elderly. Therefore, Franz Messerli hypothesized that chocolate consumption is proportional to the population density of Nobel laureates in different countries.
The author obtained the list of Nobel laureates from Wikipedia and chocolate consumption from convenient websites. Among 23 countries studied, chocolate consumption per capita and the number of Nobel laureates per 10 million persons have significant positive correlation (r=0.791, P<0.0001). Switzerland ranks first in chocolate consumption and the density of Nobel laureates, and China unfortunately ranks last in both.
Of course, this type of articles is mainly for fun. Numerous confounders such as economic status of a country and lifestyle of local citizens have not been taken into account. At the population level, Nobel Prize is a rare event and correlates poorly with the average cognitive function. Besides, preventing dementia is not the same as enhancing intelligence.
As I explained the points to my friends, I found my hands reaching for a box of Godiva. “Who ate them all?” The box was empty.
“It must be JY,” others said.
“At least we will know a Nobel laureate in the future,” my mentor concluded.
The author obtained the list of Nobel laureates from Wikipedia and chocolate consumption from convenient websites. Among 23 countries studied, chocolate consumption per capita and the number of Nobel laureates per 10 million persons have significant positive correlation (r=0.791, P<0.0001). Switzerland ranks first in chocolate consumption and the density of Nobel laureates, and China unfortunately ranks last in both.
Of course, this type of articles is mainly for fun. Numerous confounders such as economic status of a country and lifestyle of local citizens have not been taken into account. At the population level, Nobel Prize is a rare event and correlates poorly with the average cognitive function. Besides, preventing dementia is not the same as enhancing intelligence.
As I explained the points to my friends, I found my hands reaching for a box of Godiva. “Who ate them all?” The box was empty.
“It must be JY,” others said.
“At least we will know a Nobel laureate in the future,” my mentor concluded.
18 Oct 2012
Pop
A friend sent me a CD recently and asked me to have a look at the booklet.
The CD was a remix of Paula Tsui’s songs. In the booklet, Chet Lam described Paula as a respectable singer who insisted to do her own music with little regard to the trend.
The analogy I immediately recalled was Franz Schubert. A prolific composer who wrote almost a thousand pieces before he died at 32, Schubert was unfortunately not very much treasured during his days. The audience then favored ‘grand’ pieces, and his romantic style was too soft for their taste. Several decades after his death, his works became increasingly popular. Of course, similar stories are just all too common among artists. When people become history, we can finally filter out the influence of trend and see their true worth.
To sidetrack a bit, Schubert’s works were also mentioned in Kafka On The Shore by Haruki Murakami. In one scene, Oshima talked about Schubert’s Piano Sonata in D.
“It’s a tough piece to master. Some pianists can play one or maybe two of the movements perfectly, but if you listen to all four movements as a unified whole, no one has ever nailed it. A lot of famous pianists have tried to rise to the challenge, but it’s like there’s always something missing. There’s never one where you can say, ‘Yes! He’s got it!’ Do you know why?”
“No,” I reply.
“Because the sonata itself is imperfect. Robert Schumann understood Schubert’s sonatas well, and he labeled this one ‘Heavenly Tedious’.”
“If the composition’s imperfect, why would so many pianists try to master it?”
“Good question,” Oshima says, and pauses as music fills in the silence. “I have no great explanation for it, but one thing I can say. Works that have a certain imperfection to them have an appeal for that very reason – or at least they appeal to certain types of people. Just like you’re attracted to Soseki’s The Miner. There’s something in it that draws you in, more than more fully realized novels like Kokoro or Sanshiro. You discover something about that work that tugs at your heart – or maybe we should say the work discovers you. Schubert’s Sonata in D Major is sort of the same thing.”
I knew Schubert’s sonata was not popular but did not know it was imperfect. I knew what I was doing was imperfect but did not know it was not popular. In any case, I will continue to do what I think is right. And thanks for the CD.
The CD was a remix of Paula Tsui’s songs. In the booklet, Chet Lam described Paula as a respectable singer who insisted to do her own music with little regard to the trend.
The analogy I immediately recalled was Franz Schubert. A prolific composer who wrote almost a thousand pieces before he died at 32, Schubert was unfortunately not very much treasured during his days. The audience then favored ‘grand’ pieces, and his romantic style was too soft for their taste. Several decades after his death, his works became increasingly popular. Of course, similar stories are just all too common among artists. When people become history, we can finally filter out the influence of trend and see their true worth.
To sidetrack a bit, Schubert’s works were also mentioned in Kafka On The Shore by Haruki Murakami. In one scene, Oshima talked about Schubert’s Piano Sonata in D.
“It’s a tough piece to master. Some pianists can play one or maybe two of the movements perfectly, but if you listen to all four movements as a unified whole, no one has ever nailed it. A lot of famous pianists have tried to rise to the challenge, but it’s like there’s always something missing. There’s never one where you can say, ‘Yes! He’s got it!’ Do you know why?”
“No,” I reply.
“Because the sonata itself is imperfect. Robert Schumann understood Schubert’s sonatas well, and he labeled this one ‘Heavenly Tedious’.”
“If the composition’s imperfect, why would so many pianists try to master it?”
“Good question,” Oshima says, and pauses as music fills in the silence. “I have no great explanation for it, but one thing I can say. Works that have a certain imperfection to them have an appeal for that very reason – or at least they appeal to certain types of people. Just like you’re attracted to Soseki’s The Miner. There’s something in it that draws you in, more than more fully realized novels like Kokoro or Sanshiro. You discover something about that work that tugs at your heart – or maybe we should say the work discovers you. Schubert’s Sonata in D Major is sort of the same thing.”
I knew Schubert’s sonata was not popular but did not know it was imperfect. I knew what I was doing was imperfect but did not know it was not popular. In any case, I will continue to do what I think is right. And thanks for the CD.
11 Oct 2012
Trick or Treat
Last week, some Dr Chau demonstrated a novel way of tackling medicolegal issues. “The aim of the procedure is to enhance health. So it is not a medical procedure. All our clients have signed documents and agreed that this is not a medical procedure.” According to his definition, anything from hernia repair to kidney transplantation can be regarded as not a medical procedure.
Doctors can be the worst kind of cheaters. Other cheaters only want money. When doctors cheat for money, they do unindicated and potentially harmful procedures. I can just pray that would not happen to my students.
Doctors can be the worst kind of cheaters. Other cheaters only want money. When doctors cheat for money, they do unindicated and potentially harmful procedures. I can just pray that would not happen to my students.
4 Oct 2012
Protocol
I learned almost everything about clinical trials from KL during my trainee days.
On average, he spent half a year to write a study protocol. The protocols were down to the finest details. For example, he would obsessively describe where the randomization codes would be kept and who could read the codes. It always amazes me that we are still in the middle of the NSAID No. 8 Study (KL had already been promoted to Chairprofessor after No. 7). To him, a clinical trial is a symphony, not a piece of homework to the Research Grant Council.
Completion of a protocol is just the beginning. Every day, he stayed at the Endoscopy Centre to see trial patients and perform endoscopies. In addition, he would find out every case that should be entered into his trial and remind us not to miss it next time. Remind is a soft word.
At one time, I became his roommate during an American meeting. The No. 7 study had just been completed, and KL was preparing the manuscript. For three days, he sat in front of his laptop without typing a word. I asked what was going on and he said he was thinking how to write the first paragraph of the discussion section. Interested readers may find the final version of this paragraph at Lancet 2007;369:1612-6.
On average, he spent half a year to write a study protocol. The protocols were down to the finest details. For example, he would obsessively describe where the randomization codes would be kept and who could read the codes. It always amazes me that we are still in the middle of the NSAID No. 8 Study (KL had already been promoted to Chairprofessor after No. 7). To him, a clinical trial is a symphony, not a piece of homework to the Research Grant Council.
Completion of a protocol is just the beginning. Every day, he stayed at the Endoscopy Centre to see trial patients and perform endoscopies. In addition, he would find out every case that should be entered into his trial and remind us not to miss it next time. Remind is a soft word.
At one time, I became his roommate during an American meeting. The No. 7 study had just been completed, and KL was preparing the manuscript. For three days, he sat in front of his laptop without typing a word. I asked what was going on and he said he was thinking how to write the first paragraph of the discussion section. Interested readers may find the final version of this paragraph at Lancet 2007;369:1612-6.
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