When I was a house officer, the department implemented a new policy – All intravenous catheters were to be replaced every 3 days to prevent phlebitis and bloodstream infections. Our group read aghast the memo. That meant a lot of extra work.
That evening, I wrote an e-mail to Angela (I was trying to date her back then), explaining why the new policy was not evidence-based and detailing the study design required to answer this question.
Imagine how I felt when I read Lancet last Saturday. Claire Rickard and colleagues from 3 Australian hospitals randomly assigned 3283 patients who required intravenous catheters for several days to change catheters every 3 days or only when clinically indicated (Lancet 2012;380:1066-74). Phlebitis occurred in 7% of patients in both groups. Nine patients in the routine replacement group and 4 in the clinically indicated group developed bloodstream infection. The authors concluded that both groups were equivalent and the practice of routine catheter replacement should be abandoned.
The study was strikingly simple and could be designed by a house officer like me. Why then, you may ask, was the study not published by me 10 years ago instead?
During a casual discussion on study planning, I mentioned a friend with my Mentor and remarked that he had loads of brilliant ideas but surprisingly few publications. He agreed with my observation and thought for a while. Then he said, “We do not know how he does things. I suspect he lacks the ability to complete a project. You can have a wonderful idea every day, but nothing will happen if you do not do anything.”
P.S. The dating request in the same e-mail was, as you can guess, successful. The intravenous catheter policy, on the other hand, was surprisingly short-lived.
27 Sept 2012
20 Sept 2012
Fight
Last weekend, we watched a powerful demonstration of national education by our countrymen in the news. We could not help but wonder if our country would be dragged into war again.
At the turn of the last century, the prevailing view among academics was that large-scale warfare would not happen in Europe anymore because of the high level of economic development. The cost of war would be too great for any country. Unfortunately, shortly after the proclamation, two biggest wars in history broke out one after another.
If economic reasons are not strong enough to stop people from making stupid decisions, can globalization help? For two groups of people to kill each other, the distinction between ‘them’ and ‘us’ has to be clear cut. Soldiers are even trained to see enemies as animals. To do so, however, one has to be sufficiently unfamiliar to people in the opposing party. Even during relatively modern combats such as the Gulf War, the average soldier knew close to nothing about the culture, religion and life of his enemies. Now, we know our neighbors so well. We visit their cities, watch their movies and eat their noodles. Some of them are nasty, but so are we and the rest are good people. Is this knowledge good enough? I am not sure.
That said, a country should be defined by its people but not the number of uninhabited islands it claims. Sacrificing precious lives for sacred and oil-soaked soil? My answer is no.
At the turn of the last century, the prevailing view among academics was that large-scale warfare would not happen in Europe anymore because of the high level of economic development. The cost of war would be too great for any country. Unfortunately, shortly after the proclamation, two biggest wars in history broke out one after another.
If economic reasons are not strong enough to stop people from making stupid decisions, can globalization help? For two groups of people to kill each other, the distinction between ‘them’ and ‘us’ has to be clear cut. Soldiers are even trained to see enemies as animals. To do so, however, one has to be sufficiently unfamiliar to people in the opposing party. Even during relatively modern combats such as the Gulf War, the average soldier knew close to nothing about the culture, religion and life of his enemies. Now, we know our neighbors so well. We visit their cities, watch their movies and eat their noodles. Some of them are nasty, but so are we and the rest are good people. Is this knowledge good enough? I am not sure.
That said, a country should be defined by its people but not the number of uninhabited islands it claims. Sacrificing precious lives for sacred and oil-soaked soil? My answer is no.
13 Sept 2012
Hugga Wugga
Jonathan’s favorite video clip on Youtube is Hugga Wugga. It features an alien chanting ‘Hugga Wugga’. When it encountered another creature singing another song, the alien bullied it by blowing steam at it. Frightened, the poor creature followed the alien and sang ‘Hugga Wugga’.
Then came a new yellow creature that sang ‘You are my sunshine’. Hugga Wugga tried to silence it by blowing steam again. This time, however, the yellow creature outwitted Hugga, blew steam in its face and subdued it.
Yes, if hunger strike is radical, the yellow creature must be a terrorist.
Then came a new yellow creature that sang ‘You are my sunshine’. Hugga Wugga tried to silence it by blowing steam again. This time, however, the yellow creature outwitted Hugga, blew steam in its face and subdued it.
Yes, if hunger strike is radical, the yellow creature must be a terrorist.
6 Sept 2012
Brainwash
During a case presentation at the grand round, a student kept saying Drug N was the treatment of choice for peptic ulcer. After he had mentioned the drug the fourth time, I could not help but interrupt, “N is a brand name. There are also similar drugs in the same class. You have been brainwashed by the drug company!”
People say that art and humor are the best defense against brainwashing.
At the time of Soviet rule, a government official invited a famous artist to draw a painting to celebrate Soviet-Polish friendship. Seeing his reluctance, the official promised that he would have the freedom of expression, so far if he used the title ‘Lenin in Poland’.
When the painting was unveiled a few months later, the official almost fainted. It showed an ugly peasant woman in the arms of a man in front of Kremlin.
“Who is this ugly woman?” he asked.
“She is Nadezhda Krupskaya (Lenin’s wife).”
“And the man?”
“He is Leon Trotsky.”
Catching his breath, the official asked the final question, “Then where on earth is Lenin?”
“Lenin is in Poland.”
People say that art and humor are the best defense against brainwashing.
At the time of Soviet rule, a government official invited a famous artist to draw a painting to celebrate Soviet-Polish friendship. Seeing his reluctance, the official promised that he would have the freedom of expression, so far if he used the title ‘Lenin in Poland’.
When the painting was unveiled a few months later, the official almost fainted. It showed an ugly peasant woman in the arms of a man in front of Kremlin.
“Who is this ugly woman?” he asked.
“She is Nadezhda Krupskaya (Lenin’s wife).”
“And the man?”
“He is Leon Trotsky.”
Catching his breath, the official asked the final question, “Then where on earth is Lenin?”
“Lenin is in Poland.”
30 Aug 2012
Pororo
Last week, I watched Pororo with Jonathan at home.
One day, Poby the Bear sneezed a few times after spilling some pepper. “You’ve got a cold!” cried his concerned hummingbird friend Harry. Harry insisted Poby to rest in bed. After some persuasion, Poby agreed that he probably needed a rest. To comfort his friend, he reassured Harry that he felt fine.
Soon, Pororo the Penguin and Eddy the Fox visited them. They were surprised to find Poby in bed. “Poby has got a cold,” explained Harry, “but he keeps saying he is OK.”
“Oh,” said Eddy. “Let’s give him an injection.” He pulled out a big needle. At this point, Poby jumped up and ran out of the house.
Patients often look for doctors who are skillful in performing various procedures. What they do not know is how many more patients died because the correct diagnosis was never made.
One day, Poby the Bear sneezed a few times after spilling some pepper. “You’ve got a cold!” cried his concerned hummingbird friend Harry. Harry insisted Poby to rest in bed. After some persuasion, Poby agreed that he probably needed a rest. To comfort his friend, he reassured Harry that he felt fine.
Soon, Pororo the Penguin and Eddy the Fox visited them. They were surprised to find Poby in bed. “Poby has got a cold,” explained Harry, “but he keeps saying he is OK.”
“Oh,” said Eddy. “Let’s give him an injection.” He pulled out a big needle. At this point, Poby jumped up and ran out of the house.
Patients often look for doctors who are skillful in performing various procedures. What they do not know is how many more patients died because the correct diagnosis was never made.
23 Aug 2012
Prioritization
Along the same line, I can ask a series of questions that do not beg textbook answers. Students who have gone through liberal studies in secondary school must find these very easy.
“Now that we adopt the Model for End-stage Liver Disease (MELD) score instead of Child-Pugh score for prioritizing transplantation listing, what types of patients are most likely to be affected?”
“Do you think patients with liver cancer and cirrhosis instead of cirrhosis alone should jump the queue?”
“Should an organ be given to the sickest person or a person with the biggest survival gain after liver transplantation?”
The rationale behind the last question may not be immediately obvious. Unlike kidney failure, we cannot maintain life of a liver failure patient by dialysis. Therefore, the waiting time does not count. If a patient has mild disease, he will not get an organ even if he has been listed for 20 years (In reality this is not possible because he would have been delisted). Instead, the organ will be given to the sickest patient based on the MELD score.
Now is the more difficult part. For obvious reasons, the sickest person also has higher operative risk and is more likely to develop complications. His survival after liver transplantation is not the same as that of a person with milder disease. To complicate matters further, a patient with liver cancer is also at risk of cancer recurrence.
Suppose we have two patients. The first has liver failure, locally advanced liver cancer and multiple other medical diseases. His chance of survival without transplantation is zero while that after transplantation is around 20%. The second patient has advanced cirrhosis but is otherwise young and free of other diseases. His chance of survival without transplantation is 30% but is up to 70% 5 years after transplantation. Which one should receive the organ? If you choose the latter because the first patient is too ill, what is the difference in survival gain that you would accept?
“Now that we adopt the Model for End-stage Liver Disease (MELD) score instead of Child-Pugh score for prioritizing transplantation listing, what types of patients are most likely to be affected?”
“Do you think patients with liver cancer and cirrhosis instead of cirrhosis alone should jump the queue?”
“Should an organ be given to the sickest person or a person with the biggest survival gain after liver transplantation?”
The rationale behind the last question may not be immediately obvious. Unlike kidney failure, we cannot maintain life of a liver failure patient by dialysis. Therefore, the waiting time does not count. If a patient has mild disease, he will not get an organ even if he has been listed for 20 years (In reality this is not possible because he would have been delisted). Instead, the organ will be given to the sickest patient based on the MELD score.
Now is the more difficult part. For obvious reasons, the sickest person also has higher operative risk and is more likely to develop complications. His survival after liver transplantation is not the same as that of a person with milder disease. To complicate matters further, a patient with liver cancer is also at risk of cancer recurrence.
Suppose we have two patients. The first has liver failure, locally advanced liver cancer and multiple other medical diseases. His chance of survival without transplantation is zero while that after transplantation is around 20%. The second patient has advanced cirrhosis but is otherwise young and free of other diseases. His chance of survival without transplantation is 30% but is up to 70% 5 years after transplantation. Which one should receive the organ? If you choose the latter because the first patient is too ill, what is the difference in survival gain that you would accept?
16 Aug 2012
Child
HC was on sick leave last week. AL kindly took over the disappointed group of medical students and taught them during ward round.
One day, AL asked them, “Can you tell me the components of the Child-Pugh score?” With some help, the group managed to recall the five components.
Suddenly, a boy wailed, “Do we really have to know this? Is it in the syllabus?”
When AL told us the story later that week, she was not upset. “What I felt was the huge generation gap. I cannot imagine saying something like that in front of my seniors if I were him.”
I am not an expert in generation gap. Let me answer his questions more directly.
No, you may be assured that I will not ask about the components of the Child-Pugh score. Our syllabus discourages reciting hard facts. That is not good education.
Instead, if I were to ask you about Child-Pugh score in the examination, I would ask something like this, “Why do we no longer use the Child-Pugh score to prioritize transplantation listing in Hong Kong?”
One day, AL asked them, “Can you tell me the components of the Child-Pugh score?” With some help, the group managed to recall the five components.
Suddenly, a boy wailed, “Do we really have to know this? Is it in the syllabus?”
When AL told us the story later that week, she was not upset. “What I felt was the huge generation gap. I cannot imagine saying something like that in front of my seniors if I were him.”
I am not an expert in generation gap. Let me answer his questions more directly.
No, you may be assured that I will not ask about the components of the Child-Pugh score. Our syllabus discourages reciting hard facts. That is not good education.
Instead, if I were to ask you about Child-Pugh score in the examination, I would ask something like this, “Why do we no longer use the Child-Pugh score to prioritize transplantation listing in Hong Kong?”
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