Learning from Mother Nature, a creature or institution will thrive and survive environmental changes if it can do the followings:
1. Allow mutations or new ideas to occur.
2. Let mutants compete with wild types.
3. Accept the result of natural selection.
Unfortunately, most institutions overlook the latter two points. When a new policy comes up, it replaces the old one totally although there is no evidence that it is superior. Many people hate conservatives who reject all new policies – ward arrangement, teaching timetable, office renovation, you name it. Nevertheless, conservatives are very important. They preserve the good old days as far as possible and put the burden of proof on those who propose changes. Since bad ideas outnumber good ones in general, brutal replacement of old policies with new ones tends to result in disaster in the long run.
In the January issue of Proceedings of the National Academy of Sciences, Chris Darimont and colleagues described vividly the result of unnatural selection. Under normal selection pressure, the mortality rate of a species is usually limited, and immature and younger organisms die first. In contrast, in ecosystems affected by human predators such as hunters and fishermen, the mortality rate is higher, and the largest and mature organisms are the main targets. As a result, evolution under this unnatural selection is much faster. Interestingly, the size of organisms decreases by an average of 20%, and the life cycle shortens by nearly 25%. The poor preys just have to reproduce earlier to avoid extinction.
Sadly, the result of this report reminds us of ourselves. Good clinical research takes years or even decades of careful observation. Under the current method of research assessment, academics who only do big and long-term projects will die first because of insufficient research output. Next time when you read a me-too study or non-definitive study reporting dubious surrogate end points, don’t laugh. Those people are just shortening their reproductive cycle because of unnatural selection!
26 Feb 2009
19 Feb 2009
Competition
Between 1405 and 1433, Zheng He of the Ming Dynasty led a fleet of more than 20,000 men to explore the ocean west to China. The countries he visited included Indonesia, Yemen, Iran and Somalia in East Africa. The largest ship could carry 200 sailors and 1000 passengers. This took place before Christopher Columbus was born (1451-1506). The fleet was also much larger than the one led by Columbus. Although Zheng He’s mission was never meant to be colonization, we can still expect that the international influence of China would grow with time if similar voyages continued.
However, the policy of the Ming Dynasty changed suddenly afterwards. The country not only abandoned further sea adventures, but also cut off most international interactions. A number of hypotheses explained the change. Some said that the emperor used up all the finest lumber to build the Forbidden City. Others said that the main reason was the political rivalry between eunuchs and the royal family (Zheng He was a eunuch).
While we consider the abandonment as one of the foolish decisions in Chinese history, one may wonder why the same thing did not happen in Europe. New ideas are like mutations. If the idea of going out to search for unknown land (Columbus’ calculations and predictions before his voyage were almost completely incorrect) is a mutant, the wild-type would be minding your own business. In fact, when Columbus approached John II, King of Portugal, for funding, he hesitated. That is why Columbus had to turn to the Spanish Queen. The interests in sea adventures also fluctuated among different European countries.
What set Europe apart from China was the keen competition among countries. The great success of the Spanish campaign brought in gold and resources, building Spain into an empire in the 16th century. Other countries sensed the selection pressure and had to follow suit. This resulted in a long history of colonization. In contrast, China did not experience major economic and political competition from neighboring countries, and could live contently on her own until the European navies knocked her door.
However, the policy of the Ming Dynasty changed suddenly afterwards. The country not only abandoned further sea adventures, but also cut off most international interactions. A number of hypotheses explained the change. Some said that the emperor used up all the finest lumber to build the Forbidden City. Others said that the main reason was the political rivalry between eunuchs and the royal family (Zheng He was a eunuch).
While we consider the abandonment as one of the foolish decisions in Chinese history, one may wonder why the same thing did not happen in Europe. New ideas are like mutations. If the idea of going out to search for unknown land (Columbus’ calculations and predictions before his voyage were almost completely incorrect) is a mutant, the wild-type would be minding your own business. In fact, when Columbus approached John II, King of Portugal, for funding, he hesitated. That is why Columbus had to turn to the Spanish Queen. The interests in sea adventures also fluctuated among different European countries.
What set Europe apart from China was the keen competition among countries. The great success of the Spanish campaign brought in gold and resources, building Spain into an empire in the 16th century. Other countries sensed the selection pressure and had to follow suit. This resulted in a long history of colonization. In contrast, China did not experience major economic and political competition from neighboring countries, and could live contently on her own until the European navies knocked her door.
12 Feb 2009
Mutation
New ideas are like mutations. In Built to Last, James Collins and Jerry Porras illustrated how companies that encouraged new ideas outperformed those that explicitly avoided changes. The mutations allow the companies to change over time and face up new challenges. In Chinese history, many dynasties upheld the belief that ancestral decrees should never be disobeyed, and headed towards ruin when the environment changed.
Therefore, I cannot fully support those who reject all new policies such as the education reform and ward admission system. Of course, this is not to say that the results of these new policies are gratifying. In fact they aren’t. Supporters of conservative approach may point out that though the dynasties collapsed, they had each lasted for several centuries. In contrast, Wang Mang (王莽) established the Xin Dynasty (新朝) and was well known as a creative politician and scholar. He was described as a ruler who announced a decree in the morning and changed it in the evening (朝令夕改). The empire only lasted from 9 to 23 AD. In Fooled by Randomness, Nassim Nicholas Taleb explained the cost of progress (or change):
‘People tend to infer that because some inventions have revolutionized our lives that inventions are good to endorse and we should favour the new over the old. I take the opposite view. The opportunity cost of missing a “new new thing” like the airplane and the automobile is minuscule compared to the toxicity of all the garbage one has to go through to get to these jewels (assuming these have brought some improvement to our lives, which I frequently doubt).’
This leads us to fundamental questions – Does the outcome depend on the quality of the mutations? Is there an optimal mutation rate?
If we turn to Nature for an answer, the first question is obsolete. Mutations are random processes. History tells us that bad ideas outnumber good ones. Great minds do not guarantee better ideas. We only know that bad ideas by great people usually result in worse disasters (think about Karl Marx). So we have to accept the co-existence of good and bad ideas.
Similarly, microorganisms with the highest mutation rate are the most robust. HIV, hepatitis B and hepatitis C viruses can all produce mutations at any point in the genome within one day. They are also very successful in developing drug resistant mutants.
Then what went wrong? Why do the government and some institutions do badly even though the officials bombard us with innovative ideas all the time?
Therefore, I cannot fully support those who reject all new policies such as the education reform and ward admission system. Of course, this is not to say that the results of these new policies are gratifying. In fact they aren’t. Supporters of conservative approach may point out that though the dynasties collapsed, they had each lasted for several centuries. In contrast, Wang Mang (王莽) established the Xin Dynasty (新朝) and was well known as a creative politician and scholar. He was described as a ruler who announced a decree in the morning and changed it in the evening (朝令夕改). The empire only lasted from 9 to 23 AD. In Fooled by Randomness, Nassim Nicholas Taleb explained the cost of progress (or change):
‘People tend to infer that because some inventions have revolutionized our lives that inventions are good to endorse and we should favour the new over the old. I take the opposite view. The opportunity cost of missing a “new new thing” like the airplane and the automobile is minuscule compared to the toxicity of all the garbage one has to go through to get to these jewels (assuming these have brought some improvement to our lives, which I frequently doubt).’
This leads us to fundamental questions – Does the outcome depend on the quality of the mutations? Is there an optimal mutation rate?
If we turn to Nature for an answer, the first question is obsolete. Mutations are random processes. History tells us that bad ideas outnumber good ones. Great minds do not guarantee better ideas. We only know that bad ideas by great people usually result in worse disasters (think about Karl Marx). So we have to accept the co-existence of good and bad ideas.
Similarly, microorganisms with the highest mutation rate are the most robust. HIV, hepatitis B and hepatitis C viruses can all produce mutations at any point in the genome within one day. They are also very successful in developing drug resistant mutants.
Then what went wrong? Why do the government and some institutions do badly even though the officials bombard us with innovative ideas all the time?
5 Feb 2009
Darwin
My colleagues were surprised when I celebrated the 200th anniversary of the birth of Charles Darwin in a public talk on hepatitis B recently.
Explaining the evolutionary theory to non-specialists is a bit tricky, but people working on antiviral therapy use the theory all the time. The essence of the evolutionary theory is ‘survival of the fittest’. During reproduction, gene mutations sometimes result in phenotypic changes in an organism. Most of the mutations are hazardous, but a minority confers competitiveness. Organisms bearing more competitive mutations have a better chance of giving birth to offsprings, and eventually the new gene will dominate the population. People working with viruses are seeing a fast-forward version of evolution. Viruses replicate quickly and produce a lot of mutations because of their lack of proof-reading during gene transcription. When an antiviral drug is given to a patient, viral mutants that do not fear the drug will replicate more effectively and soon become the dominant strain.
Actually, before Darwin published his book On the Origin of Species, a few other scientists had already noticed the gradual phenotypic changes of animals and plants. However, most considered the changes a well-planned evolution by God. It was Darwin who spotted that the changes were random, and the evolution was driven by natural selection – ‘survival of the fittest’. For those with basic knowledge on genetics, the theory may seem pretty easy to understand. However, one must remember that genetics did not exist at Darwin’s time (although Gregor Mendel was actually humbly doing his cross-breeding experiments at roughly the same time). Imagine how difficult it would be for me to explain the last paragraph again without describing anything about genes and mutations.
Like all great theories, the implications extend well beyond the original territories. I will elaborate this further next week.
Explaining the evolutionary theory to non-specialists is a bit tricky, but people working on antiviral therapy use the theory all the time. The essence of the evolutionary theory is ‘survival of the fittest’. During reproduction, gene mutations sometimes result in phenotypic changes in an organism. Most of the mutations are hazardous, but a minority confers competitiveness. Organisms bearing more competitive mutations have a better chance of giving birth to offsprings, and eventually the new gene will dominate the population. People working with viruses are seeing a fast-forward version of evolution. Viruses replicate quickly and produce a lot of mutations because of their lack of proof-reading during gene transcription. When an antiviral drug is given to a patient, viral mutants that do not fear the drug will replicate more effectively and soon become the dominant strain.
Actually, before Darwin published his book On the Origin of Species, a few other scientists had already noticed the gradual phenotypic changes of animals and plants. However, most considered the changes a well-planned evolution by God. It was Darwin who spotted that the changes were random, and the evolution was driven by natural selection – ‘survival of the fittest’. For those with basic knowledge on genetics, the theory may seem pretty easy to understand. However, one must remember that genetics did not exist at Darwin’s time (although Gregor Mendel was actually humbly doing his cross-breeding experiments at roughly the same time). Imagine how difficult it would be for me to explain the last paragraph again without describing anything about genes and mutations.
Like all great theories, the implications extend well beyond the original territories. I will elaborate this further next week.
29 Jan 2009
Philosopher Ruler
When we saw some consultations last week, a few high-ranking officials were visiting the ward. “The Earth is invaded by extra-terrestrials!” I exclaimed. All my teammates laughed.
This stems from the language in Szeto’s blog, which almost all frontline staff in our department read regularly. In his blog, our Boss is called the man from Pluto, while other hospital administrators are extra-terrestrials outside the Solar System. Although they control everything on Earth, they do not understand how people on Earth think and do things. Clearly, Szeto has a strong distaste for administrators.
I admire Szeto in every aspect, but cannot share his feelings on this point. If administrators cease to exist, who are going to hold endless boring meetings, meet the press for hospital mishaps, and explain to the government why a hospital spent nearly twice its original budget? We probably all need to share some of these. One reason why we are writing blogs so happily now is because some people love administrative work.
In an idealized society described by Plato in The Republic, the best ruler should be a philosopher. A philosopher is in love with the truth. When a man’s desire flows towards the acquisition of knowledge, his pleasure will be in things purely of the mind, and physical pleasures will pass him by. Money and fame would not be his concern. However, he fits the job as a ruler because of his good memory, readiness to learn, breadth of vision and grace, and that he is a friend of truth, justice, courage, and self-control. Interestingly, the best ruler should not want to be a ruler at all.
Of course, we are not in an ideal world, and I have to say our Boss is great after all. Just out of fantasy, LY will be an interesting candidate who can double our department’s value every year and turn our frontline staff into shareholders. Szeto is closest to the philosopher ruler described by Plato. Under his rule, I expect every senior staff can not only recite Harrison’s Textbook of Medicine, but also quote a New England paper with the correct page number during ward rounds.
This stems from the language in Szeto’s blog, which almost all frontline staff in our department read regularly. In his blog, our Boss is called the man from Pluto, while other hospital administrators are extra-terrestrials outside the Solar System. Although they control everything on Earth, they do not understand how people on Earth think and do things. Clearly, Szeto has a strong distaste for administrators.
I admire Szeto in every aspect, but cannot share his feelings on this point. If administrators cease to exist, who are going to hold endless boring meetings, meet the press for hospital mishaps, and explain to the government why a hospital spent nearly twice its original budget? We probably all need to share some of these. One reason why we are writing blogs so happily now is because some people love administrative work.
In an idealized society described by Plato in The Republic, the best ruler should be a philosopher. A philosopher is in love with the truth. When a man’s desire flows towards the acquisition of knowledge, his pleasure will be in things purely of the mind, and physical pleasures will pass him by. Money and fame would not be his concern. However, he fits the job as a ruler because of his good memory, readiness to learn, breadth of vision and grace, and that he is a friend of truth, justice, courage, and self-control. Interestingly, the best ruler should not want to be a ruler at all.
Of course, we are not in an ideal world, and I have to say our Boss is great after all. Just out of fantasy, LY will be an interesting candidate who can double our department’s value every year and turn our frontline staff into shareholders. Szeto is closest to the philosopher ruler described by Plato. Under his rule, I expect every senior staff can not only recite Harrison’s Textbook of Medicine, but also quote a New England paper with the correct page number during ward rounds.
22 Jan 2009
Content
Szeto once commented that I appeared content and happy all the time. I take that as praise.
When I was 10 years old, I joined the recorder ensemble in my primary school. For some reason, my teacher did not ask me to play the recorder or other wind instruments, but assigned me to a humble percussion instrument - two pieces of wood you could hit with a stick. Anyway, I practised and tried to create different sounds out of it. I also concentrated on the rhythm. Our team eventually lost in a local competition. To my surprise, the adjudicator specifically discussed my percussion and spoke highly of me. This has been an important lesson over the years. It does not matter where God places me. If I work faithfully, the result is always fruitful.
Lately, Szeto recalled that he did not plan to do nephrology during his college days and basic training. In retrospect, I realize I did not have much planning at all. When I had the opportunity to apply for a scholarship at the Royal College of Music, my Dad felt that was a really bad idea and I entered the medical school instead (of course I would never reveal this in any interview). When I was wondering whether to do internal medicine or science, KL took me to his room exactly one week before the Professor of Chemical Pathology phoned me up. Since my first year of basic training, KL asked me not to consider other specialties.
Many would think this is a silly way of handling one's career, but I am thankful to God for letting me do these wonderful jobs all the same.
When I was 10 years old, I joined the recorder ensemble in my primary school. For some reason, my teacher did not ask me to play the recorder or other wind instruments, but assigned me to a humble percussion instrument - two pieces of wood you could hit with a stick. Anyway, I practised and tried to create different sounds out of it. I also concentrated on the rhythm. Our team eventually lost in a local competition. To my surprise, the adjudicator specifically discussed my percussion and spoke highly of me. This has been an important lesson over the years. It does not matter where God places me. If I work faithfully, the result is always fruitful.
Lately, Szeto recalled that he did not plan to do nephrology during his college days and basic training. In retrospect, I realize I did not have much planning at all. When I had the opportunity to apply for a scholarship at the Royal College of Music, my Dad felt that was a really bad idea and I entered the medical school instead (of course I would never reveal this in any interview). When I was wondering whether to do internal medicine or science, KL took me to his room exactly one week before the Professor of Chemical Pathology phoned me up. Since my first year of basic training, KL asked me not to consider other specialties.
Many would think this is a silly way of handling one's career, but I am thankful to God for letting me do these wonderful jobs all the same.
15 Jan 2009
Role Model
One day, AJ asked a question suddenly. "What does 'xxxxxxx' mean?"
We were all confused by the seemingly ancient language. AJ took us to the endoscopy center, and showed us a work of Chinese calligraphy. Alas, he not only read a few words incorrectly, but also started reading from the wrong side! It should be '但開風氣不為師'.
'We do not teach. We set examples.' No one in our team ever claimed that this was our motto or core value, as some enterprises love stating. However, this is exactly what our predecessors did.
When I became a medical student, I only wanted to become a good doctor. I believed that first-class research did not exist in Hong Kong, where government support was little. Later, I found out that many people in the medical school conducted cutting-edge research despite limited resources. Many studies even radically changed clinical practice worldwide. These dedicated clinician-scientists also keep their role as competent clinicians. They are great role models for students and young doctors. They open a window for youngsters so that they dare dream big.
In my tutorials, I used to teach short-case examination. In essence, a candidate has to perform physical examination on a patient and try to figure out what the underlying diagnosis is. These are vital techniques for passing any professional examination. Last year, when a medical student requested an extra tutorial from me, I half-jokingly asked. "Do you want to learn how to pass the examination, or how to become a good doctor?" Much to my surprise, the answer was firm. "We want to learn how to become good doctors."
I was so ashamed on hearing the response. What was I doing? Why should I waste time teaching students how to pass an examination with over 90 percent passing rate, when many patients may die because of foolish judgements, and many more could not receive the love and attention they deserve? Since then, all my tutorials have become teaching rounds. We see patients together, greet them, chat with them, and discuss the proper clinical decision and management.
For students wondering why I have a different mode of teaching, this is my answer.
We were all confused by the seemingly ancient language. AJ took us to the endoscopy center, and showed us a work of Chinese calligraphy. Alas, he not only read a few words incorrectly, but also started reading from the wrong side! It should be '但開風氣不為師'.
'We do not teach. We set examples.' No one in our team ever claimed that this was our motto or core value, as some enterprises love stating. However, this is exactly what our predecessors did.
When I became a medical student, I only wanted to become a good doctor. I believed that first-class research did not exist in Hong Kong, where government support was little. Later, I found out that many people in the medical school conducted cutting-edge research despite limited resources. Many studies even radically changed clinical practice worldwide. These dedicated clinician-scientists also keep their role as competent clinicians. They are great role models for students and young doctors. They open a window for youngsters so that they dare dream big.
In my tutorials, I used to teach short-case examination. In essence, a candidate has to perform physical examination on a patient and try to figure out what the underlying diagnosis is. These are vital techniques for passing any professional examination. Last year, when a medical student requested an extra tutorial from me, I half-jokingly asked. "Do you want to learn how to pass the examination, or how to become a good doctor?" Much to my surprise, the answer was firm. "We want to learn how to become good doctors."
I was so ashamed on hearing the response. What was I doing? Why should I waste time teaching students how to pass an examination with over 90 percent passing rate, when many patients may die because of foolish judgements, and many more could not receive the love and attention they deserve? Since then, all my tutorials have become teaching rounds. We see patients together, greet them, chat with them, and discuss the proper clinical decision and management.
For students wondering why I have a different mode of teaching, this is my answer.
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