New Year's Eve

At the end of a year - at least according to the Chinese lunar calendar - we are supposed to toss away the used items. Time to clean up.

Before the advent of such smart gadgets as personal digital assistant, I used to copy my friends' address and phone number in my diary anew each year. I had never learned to love this painstaking ritual of renewing my friends yearly.

As for me, friends are never meant to be used items for cleaning up.

Why is there such a need to delete an old friend who passed away from our telephone directory? Actually, I could understand it, but I just couldn't stand it. Thanks to the handheld electronic gadget, I don't have to copy the friends' list every year, and simply enjoy adding new names to my directory.

Ugly

When a friend of mine recently heard the radio news story about the failure to rescue a dying heart attack patient on the doorstep of a public hospital, he almost drove off the road.

Over the last two days, much has been written about the moral of this tragedy in the newspaper editorials and by the bloggers. I believe, however, that this is one of those evergreen bits of wisdom that we can never quite get enough of it.

Still, I dare not tell my friend another story because he would be stupefied to learn that my story occurred exactly at the same hospital. The drama began when a patient, who had undergone an outpatient gynaecology procedure at a day surgery centre, developed bleeding after the minor operation. The doctor, with the help of another nurse, rushed the patient on a stretcher to the acute hospital ward, just within a stone's throw.

Picture the doctor and nurse, both relieved to get the bleeding under control after hospitalization, only to find themselves being bombarded with a barrage of questions from the head nurse.

"For heaven's sake, why? Why don't you dial 999 and call the ambulance?"

The doctor's face fell, and she groaned, "Oh, dear, it would have taken the ambulancemen nearly half an hour to get our patient to the ward."

"And that wasn't exactly the point. You guys knew it, transport of patient on your own is forbidden. And silly! Who is to bear the liability if our patient had problem on the way, say, inside the elevator?"

The doctor wasn't sure she'd heard her correctly and looked slightly flummoxed. "Um… I don't quite understand… well, let me put it this way." She hesitated for a moment, considering her choice of words carefully in front of a head nurse. "What if, I mean, the patient had problem inside the elevator, even in the presence of ambulancemen?"

"That would be the problem of the ambulancemen, then. Not mine!"

Are we letting our ugly side define us more and more as a bureaucratized hospital? Surely, there are many more examples, but I must stop here. To say more would either get me in trouble or falsify my argument.

Hewlett

After reading a story of Hewlett-Packard recently, I learn that we may lose our trust without even noticing it. Trust is the easiest to lose and the hardest to survive without.

The story goes that its cofounder William Bill Hewlett stopped off one weekend at a company storeroom to pick up a tool, only to find that there was a lock on the tool bin. This was, as a matter of fact, contrary to the explicit practice the Hewlett-Packard company had established from the very beginning to keep all parts bins and storerooms open so that HP employees would have free access to any tools they might need.

Much to his chagrin, Hewlett broke the lock open and threw it away, and put up a sign where the lock had been. The sign read: HP TRUSTS IT'S EMPLOYEES.

At the same time, I had a real-life story nagging at me, one that I get frustrated for the umpteenth time.

Can you imagine the very first thing I need to do before starting my specialist outpatient clinic session in my own institution? To help you set the scene in your mind's eye, I should tell you that doctors can't enter the clinic through the front door because it is simply locked. Utter the word "lock" and the mind envisages a stoic and nitpicky boss who keeps everything locked up. Each morning we doctors need to fetch the key and unlock the drawer keeping all the ophthalmoscope, tuning fork and tendon hammer – all locked up! The more the things are being locked up, the madder I got. Normally, I hate using exclamation marks, but boy, am I mad!

Years ago, the name and title of the doctors were being displayed outside the clinic door. If you come to see us at the clinic, the name of the doctor whom you're going to see will be missing. Where is it?

Locked up. Again.

If you ask me who would be the one keen on hiding one's name and maintaining the highest standard of anonymity, that guy should be the least trustworthy. Whether our clinic nurse-in-charge knew it or not – and apparently she did not – her real job was to make the best lock.

While we laugh at the lock itself, we need to remember that the idea of such lock is not new. Our department policy of displaying the doctor's name next to the bed of our patients was banned just a month ago. You'll still find such matters difficult to understand. And – I will just say it – untrustworthy.

Doctoring

It took forever for medical doctors to reckon that we should avoid doctoring our loved ones or family members. It has taken even longer for me to learn to toe the line by not acting as the doctor of myself. I suppose that most of doctors want the privacy when they get sick. By treating my own illness, I am further tempted to expedite the care by pulling strings within the health care system.

Which means that, over the years, I have been confusing my professional and personal roles, for example, by acting as a medical student and fetching medication from the drug trolley to treat myself at the same time. There was the issue of bias, the fine details of which I will spare you, except to say that I had previously thrown away my blood-streaked sputum instead of sending the specimen to look for tuberculosis. Whoa. All these years, I've made – or, avoided making – numerous diagnoses and given treatments for myself. I simply feel like a gymnast who has got more and more self-confident after performing a few apparently fabulous and flawless somersaults (in an empty auditorium, I confess). For my part, I simply can't resist the idea that I am doing a reasonable job of treading the fine line between offering objective diagnoses and being a bit personal. Such claim is insightful, reassuring, and completely wrong. I know.

That is not to say that our medical student who committed suicide recently had been treating herself. It would have been wrong for me, I believe, to fabricate and surmise what might happen to someone else I don't even know. I can't. After all, I don't even get the license to diagnose myself.

Bump

I found out recently that, among all those characters in the Mr. Men series by Roger Hargreaves, my wife loves Mr. Bump the most, ever since her childhood.

It didn't take me long to realize the reason.

For those of you who haven't read the children's literature of Mr. Men, Mr. Bump fell out of his bedroom window and bumped his head, leaving him wrapped up in bandage and loss of his memory. He keeps his looks after the injury and just can't help having accidents, including being cleaned in a car wash.

People might rightly scratch their heads and wonder how on earth Mr. Bump can bump into so many silly blunders. But trust me, I am no better than Mr. Bump. Throughout these years, my habits of imprudence ensure that not a week goes by without having accidents like mixing up shampoo with bathing lotion, wearing my roommate's spectacles after getting up and nearly ending up like Humpty Dumpty.

Flannery O'Connor said that anyone who has survived childhood has enough material to write for the rest of his or her life. Now, come to think of it, someone like me who have survived as a Mr. Bump should have enough to write in the next life.

Being a Mr. Bump is not so difficult, but quitting it is nearly impossible. This is not to say that my wife made a mistake in marrying me. Far from it. It's me who made the mistake during our wedding ceremony. No, don't get me wrong; I am not saying that I put the wedding ring on the wrong person's finger (Bump!). I simply put the wrong ring (mine instead of hers) on my wife's finger in front of all my guest friends.

Vampire Bats

During a sharing session with the medical interns this afternoon, our consultant taught us to be generous in offering a helping hand in hard times.

It brings to mind the fascinating story of vampire bats who, like our medical interns with their pockets full of syringes, feed on blood. Besides, the fact that both vampire bats and medical interns seldom have sleep at night suggests that these two species share more than simply a common ancestor. They look enough alike that I could see they are related.

Time and again, vampire bats have been observed to drink more blood than they would require. Those bats would take the surplus to other hungry bats staying behind. Just in case you didn't know, their generosity seems to extend beyond kinship; they do not share their meals with their offspring only. Whenever a vampire bat fails to find adequate nourishment, it may simply contact another vampire bat to solicit food donation by licking the lips of the potential donor. After observing them over a period of five years, a zoologist professor found (and published in Nature) that bats were far more likely to share gift with those that had fed them in the past, but not with new bats added to the group he was studying.

Some will argue that helping each other with a willful view for a return of the favour in the future can’t be righteous giving. Okay. Let's be honest. The truth is I can tell you that I am no better than those vampire bats.

Science

My mentor speaks of medicine's interest in the similarity and difference between individual patients. With huge variation from person to person, it is never possible to consider medicine in the same scientific way as Newtonian physics. To paraphrase the old saying, medicine is knowledge, judgment, experience, and luck.

It is ironic that as we are getting a better picture of how epidemiology studies get closer to predicting illness (or recovery from an illness), we are learning at the same time to realize how irrelevant the scientific statistics can apply to a single individual patient who is sitting in front of a medical doctor. Despite evidence based medicine's miracles like the oft-quoted p values or gene-expression signatures of human diseases – and they are touted as the elixir to make you a crystal ball – clinical knowing for the individual patient in acute care is not certain, nor will it ever be.

In the midst of cudgeling your computer and googling the chance of having a heart attack, you will soon stumble on the illusion how precise the prediction rule can be. These prediction rules might fare well in a population, but seldom work wonder for an individual patient. In the past few decades, for example, medical journals have published a flurry of scientific papers on the link between tobacco and heart attacks. But in case your patient complains of sudden chest pain, dare you forget about doing a workup for myocardial infarction because he doesn't smoke?

I dare not.

Sorry

My recent leisure reading on apology brought back my memory of a long-run Blondie comic strip, in which Mr. Dithers decides to apologize to Dagwood for calling him a "dimwitted noodle brain." Dithers then apologizes by saying, "Dagwood, I'm sorry you're a dimwitted noodle brain" and declares that his conscience is clear because of his "heartfelt apology." (And no prizes for guessing that Mr. Dithers uses the words "I'm sorry" in the sense to express compassion for Dagwood's being a dimwitted noodle brain.)

While I chuckle at the humour, I must confess that it takes time for me to learn how to apologize. It takes forever.

More often than not, people sling accusations at us offhandedly, we snarl back, they yell, we growl, and our voices clashing. There is hardly any place for apology, not to mention sincere apology. On reflection, I simply cannot let go of blame. Blame, by itself, has more claw marks than most of the things I try to let go of. Always the truth, from the alpha to the omega.

Well, blame has always been my knee-jerk response: figure out whose faults things are, and then try to manipulate that person into correcting his or her behaviour so that I can be more comfortable. And oh, yes, our natural human response is simply to look for someone to blame. I did it again and again, only to find out that our overwhelming need to lay blame is never an effective way to apologize.

Cripple

It was another routine morning. I went back to office, and started the computer before doing anything else. After fumbling through the keyboard, I found an Internet connection problem, and thereafter my work ground to a halt.

I couldn't open the tax computation message from the Inland Revenue Department. Interim report form for my research project could not be completed. I had no way to send out the reference letter for my intern. It was impossible for me to read the new issue of the New England Journal of Medicine.

Gone are the days when we survived perfectly well without computer and the Internet. In the event of computer crash nowadays, we doctors can't even read our old notes or figure out what drugs our patients have been taking, not to mention prescribe new ones.

If our computers do contribute to the flattening of the world, we are the guys who really cannot walk without falling whenever the field becomes less flat after a computer crash.

Thick and thin

After sharing an article about medical student burnout and misery in Facebook, quite a number of friends wrote to me.

Talk to any of the medical students, and it's hard not to notice that their bumpy path is littered with failures. I like listening to their collection of stories, told in their pain and occasionally joy, their passion and rage, their yearning and, more often, their cry.

I can sit and make sounds of empathy, but I am not able to come up with any good solution. Heart-breaking stories, I whispered.

And all the while I was listening, going over their stories, feeling somewhat connected and nostalgic, until finally, at some point, I remembered the physiology of our human heart, which is capable of remodeling in response to environmental demands and stress. That is what I was being told, at least, during the lectures about mechanisms by which the heart tries its best to reduce the stress on the wall of its pumping chamber, through thick and thin. Against the odds, human heart muscles grow tremendously and re-organise themselves after diverse insults (like high blood pressure or heart attack), instead of being dragged in a downward spiral, all the way to a dark alley.

To describe such compensatory response to injury or demand, cardiologists have coined numerous names including hypertrophy, athlete's heart or effort syndrome. Yet, I love the term "plasticity" the most. To be realistic, we will never be able to get rid of all the insults, but we can train or help ourselves to be more plastic in the face of pressure stress. Whew! If our hearts are capable of growing by at least 100% within just a few days of new stress, can we do something similar?

Cure

Medical students or doctors must have been asked for about the gazillionth time why they choose to practice medicine, and if that’s because they want to save life.

This is one of those questions where my first impulse is to say "Of course!" and "Impossible!" at the same time (which is of course impossible).

While I wish I could have answered something inspirational, the truth is that whenever students ask me for such advice, I would quote, without hesitation, Voltaire who once said that "the art of medicine consists in amusing the patient while nature cures the disease."

So it goes. To anyone labouring under the impression that doctors heal their patients who catch the flu or common cold, reality can be sobering. Can we hold anyone responsible for a patient who gets better after a bout of flu?

More often than not, medical doctors offer advice rather than heroic treatment. Add in the number of diseases for which there is no cure, ailments that are self-limiting, and all the treatments that turn out to be harmful rather than doing patients their favour, and my heart sinks to my boots.

Now don't get me wrong; I love my work as doctor. In any case, the bottom line is that if we want to love the work, we should remind ourselves that a lot of our patients get cured by nature, not us.

Conference

The very first thing I learn from the conference at Philadelphia this year is that I, being a doctor with training and special interest in diseases of the kidney, knew very little about renal pathology (which literally means medical sleuthing by peering through a microscope at the kidney tissue samples).

I wish I had attended this fascinating renal pathology course long ago. And that brings me to my story of flying to a top-notch renal pathology course in New York seven years ago. For heaven's sake, I was almost there if not because of my last-minute flight re-schedule to save money, and more importantly, the crashing of the World Trade Centre soon after my airplane took off (on the day of September 11). So, needless to say, my mum was glad that I returned home in one piece after my flight was forced to turn back.

The flip side of the story follows that I didn't get a good chance to learn renal pathology until seven years later. It was a tiny incident in itself, but it gave me a better glimpse than I had had before of attending international medical conference – the merits of which are getting more and more under attack amid the looming global warming, and hence the pressing need to cut our carbon footprint.

I still remember reading an article about foregoing international medical conferences in the British Medical Journal few months ago. And it was a lengthy discussion about the alternatives of videoconferences and assessing posters in virtual networks. Believe it or not, there is nowadays free online networking site for users doing a PhD or postdoctoral research, or the so-called Facebook website equivalent for scientists.

Sure, overseas conference travel might not always be the best for our money, time and the planet. None of this means that international conference never works wonder. The educational renal pathology course that I attended today makes a convincing case for this. Meeting, watching and listening to the real experts matter. Interaction counts. Getting hand-on experience on the microscope, or whatever practical skills, with great teachers around makes sense – which I suppose in many ways it does.

Trait

My sister went to a meeting at Vancouver. I am going to attend a nephrology conference at Philadelphia. My elder brother lives in Illinois. We ended up having a family get-together at my brother's home.

You don't have to be Hercule Poirot to see that the three of us would gossip about our parents. And you've probably heard the complaint that one's mum who doesn't really listen to her children because she thinks there's nothing they could say she doesn't already know; a mum who refuses to consider new ways of looking at things simply because she is your mum (traditional, misguided, nagging, old-fashioned, conservative, authoritative – pick your favorite descriptive word here).

And you know what? The three of us soon came to the same conclusion that we are never open-minded ourselves. Ever since my wife met me, she has thought that there were some magic spells that make me say no to every creative suggestion she would come up with. As for the inertia to new stuff, my brother's son hates it more bitterly than I can perhaps make clear. How much that has to do with genetics and how much with having grown up in a traditional family, I cannot say.

But really, secretly, when I look back at ourselves in my family, I find it an excellent way to relearn what we thought we had already known.

Hope

As a medical professional on the flight to Chicago this morning, I was called upon to see a gentleman who passed out twice after bouts of vomiting and diarrhoea.

It was not an exciting story. Instead, it reminds me the very first time when I, as a graduate medical student, was to help someone fallen sick aboard.

We were having the Outward Bound School sea diploma course then. The sea was rough, the majority of us miserable with throwing up. My teammates turned to me, who was supposed to be the best guy to treat their sea sickness. Medical doctor is surely the most appropriate one to be relied upon when you fall sick, except when it is not.

I dutifully reached across the bed in the cabin and fetched my stock of medicine. Nevertheless, I knew very well that my medical degree has never granted me a magic cure whatsoever for sea sickness. Worse, as I fumbled around the medication, I found not even a drug for motion sickness.

But I was not supposed to disappoint my teammates. "Friends, the good news is that I bring with me the best medication for sea sickness. The bad news is that I got one such marvellous tablet only." I announced. "Come on. Don't get mad with me. That being the case, we gotta help Jenny, who is the worst hit by the sea."

With that, I handed Jenny a "precious tablet", which was simply paracetamol (and has nothing to do with sea sickness).

She got far better after taking my remedy.

Work

After finishing my round on a Saturday morning, I was about to leave the hospital. I then heard someone calling my name, and it turned out to be an old friend of mine.

There followed a five-minute conversation starting with "What do you do?" on the corridor. This familiar conversation opener, whether you like it or not, is everywhere around us.

The way we ask or answer this question simply reflects how we identify ourselves in terms of the work we do. In virtually every society, people are defined by the work they perform. It is almost impossible nowadays to say that you "know" somebody without first knowing his or her job title. When we meet someone, the first question we ask is "What do you do?" In a wedding party, we often hear the question "What does the bridegroom (or bride) do?"

On the other hand, we seldom ask, "How do you spend most of your time?" So much so, in fact, that the latter is reserved as a tactful euphemism for asking the question "What do you do?"

Violence

Suppose you're going for dinner and the waitress forgets to place your order, keeping you hungry at the restaurant for thirty minutes without a good reason. What would you do? Never shall I forget the last time when the waitress tried to hide the mistake and asked me to tell her my order again "so that she could trace the dishes for me." Seizing on her mistake and her "courageous move" to deny and hide it, I rose to my feet and taught her a good lesson.

"Take the response of the waitress to the scenario of a doctor," I told my medical students yesterday, "and you will see the point of open disclosure after our making a mistake."

Whilst eschewing the hackneyed moral responsibility of beneficence (meaning "to do good"), I thought about the medical doctor scenario played out in a different setting such as restaurant or departmental store customer encounter. Yes, you might rightly scratch your heads and wonder about similarity of health care service and other customer service. But trust me, they are alike in an intriguing way, but differ under certain circumstances.

This leads me to my recent encounter with a patient who approached my secretary with hostility, "I want to see my doctor NOW. Don't ask me why, you stupid bitch, it's urgent but none of your business."

I phoned up the police.

If this scenario is played out in a different setting, say, when a customer confronts a shop assistant with demands to see her manager, the decision might well have been to calm the situation, hear the customer out under the "customer knows best" mantra. Why, then, is this so different in the health care setting?

Most of us – certainly I include myself – have a long way to go before we will accept that "our patients know best." And, even if you talk to a medical ethicist, he or she will not accept infinite tolerance to patients who are abusive or violent. Although you might argue that health care workers' primary concern is to act in the best interests of their patients, it is equally important to think about the welfare of our staff, and clearly that of a wider patient group instead of one single aggressive patient. It would seem only common sense to put aside the moral responsibility to a violent patient whenever the medical staff is put at risk by that patient's aggressive or demanding behaviour. This we know best.

Gawande

I have been enjoying a book teaching us to make fun of reading and how to enjoy writing. The author didn't say a lot about writing skills. Rather, it's the trick for staying in our writing chairs that really impresses me.

One of the most pleasant lessons was drawn from the perspective of Atul Gawande, an award-winning doctor-writer. The author quoted Gawande, "To be sure, talent helps… Nonetheless, attending surgeons say that what is most important to them is finding people who are conscientious, industrious, and boneheaded enough to keep at practicing this one difficult thing day and night for years on end."

"Skill, surgeons believe, can be taught," says Gawande. "Tenacity cannot… And it works."

And that makes me absolutely impressed.

As every one of us knows very well, it's hard to be mediocre, dogged, and to practice, day after day. During my childhood, I kept writing diary and I wrote plenty. Hmm, I then graduated, got a job, didn’t think a lot about the diary. Not a single page of diary thereafter. Never.

The wonderful lesson from Atul Gawande reminds me of my mentor’s willingness to keep practicing the same thing day after day. By the way, he is élite instead of mediocre, but it's rather beside the point. And, he does it anyway. He keeps blog writing, not to mention seeing his patients, days after days, years after years. This sounds flattering. I know. Bear with me. It's a tale I wish didn't need telling. I have lost count of the number of times I have been late for my clinics and rounds. I rush to the clinics late, time after time, and feel humbled and ashamed of myself whenever I find my mentor already there.

That's humbling, isn't it?

You decide.

Gut Feeling

How many times have you been making decision by gut feeling, which turns out to be wrong?

To be fair, our brains tend to interpret the world within the limitation of sensory perception, which is incredibly biased and doesn't make sense at all. While we think that we are given choices, we have difficulty understanding the fact that we have been coaxed to follow the wrong instinct. Well, if you don't believe me, think about the example of making decisions on what we eat and drink.

Humankind behaviour is such that we have an unspoken tendency to eat (or drink) based on what our senses tell us is the right amount. It seems that every one of us ever since birth, perhaps without even thinking about it, would start crying when hungry and stop eating if full.

I remember studying physiology, and being struck by the tightly regulated feedback loop of satiety signals. Is it true? The literature teems with studies showing how vulnerable we are to bias. Lots. Think, for instance, about the popcorn that moviegoers buy. In a famous psychology study, two groups of people were asked by researchers to rate a movie. As part of the study, each group was given a free bucket of popcorn. One group received an extraordinarily large bucket of popcorn whereas the other got a medium bucket of popcorn. At the same point in time the buckets of popcorn were taken away. Alas, the group with the largest bucket ended up eating a whole lot more popcorn within the same amount of time than the group with the smaller bucket.

What's more, visual cues from the portion size affect not only how much we eat, but how much we drink. I read about an interesting study in which both lean and obese young adults were given a meal of tomato soup in special bowls for lunch. The tricky "self-refilling soup bowls", unbeknownst to them, slowly refilled as their contents were consumed. Believe it or not, these individuals took 73% more than those who consumed tomato soup from normal bowls. Of course, as you might have guessed by now, they did not believe they had consumed more than those who consumed more, nor did they report being more satiated than the other participants.

Oh dear.

No wonder the average dinner plate nowadays is much larger than those used before the 1980's. And yes, as soon as I learn about these funny experiments, I am thinking about bringing my own dinner plate to celebrate the promotion dinner with Bonnie tonight.

Charlie Brown

Charles Monroe Schulz has always been one of my favourite cartoonists. He told us wonderful stories about Charles Brown, whom I shall never forget.

One day, Charlie Brown lied on the bed, murmuring to himself, "Sometimes, I lie awake at night, and I ask, why me?"
Can you imagine how Charlie Brown comes up with the answer himself?
Then a voice answers, "Nothing personal… your name just happened to come up."

One can envisage ourselves engaging in these endless "why me" whines, grumbling and getting upset. And it is true that literally everything can go awry and end up chaotic in a very single person. During my recent trip to Japan, the departure flight had a great deal of delay because of typhoon. On my way back, alas, I could not catch the scheduled flight because of the three-hour Shinkansen train delay. Years ago, I would have complained and asked "why me." Today, the answer of Charlie Brown reminds me that, indeed, it isn't really anyone's fault – just a melodrama of errors, bad luck and poor weather. Come on, we all have bad days every once in a while and, as Charlie Brown said, there is nothing personal. It must have been my turn.

Pastimes

I believe I am the only child I know of who grew up without a television set at home.

I used to either change topics or walk away whenever my classmates exchanged words on television stories. My unnerving conclusion was that people will laugh at me when they found me tongue-tied with the language of television. I use the past tense not because I have become familiar with the television stories but because I get over the inferiority complex of growing up without television.

My love for the alphabet and reading, which endures, started ever since my early years without television. I began to learn writing before going to kindergarten. In my story books, before I could read them for my younger sister, I fell in love with the legends of Robinson Crusoe, Gulliver, Huckleberry Finn, Oliver Twist, and even Ali Baba. I missed numerous television programmes, but I could never miss the chance to visit the library every week. Today my wife still find it unbelievable to hear that I was the librarian throughout the six years at high school.

I am not going to enter the debate here about whether television is a vice or not. There is barely an inkling of what my childhood was about to change if my mum bought a television. But I have the feeling, after so many years, that the absence of television at home left me much more time to read books, which by itself is a blessing. Without a doubt it is.

Hoofbeats

"Don't fill your photo with more than necessary," I told my younger sister during our recent photography trip. "Life is never rosy," I continued, "We'd better crop out the thorn and leave behind the roses that will stay etched in the picture, and our memory."

The trick with selective memory is especially germane to our work in the hospital. The medical encounter, it turns out, has been replete with less-than-exciting patients of all sorts. "Good clinicians think of horses when they hear hoofbeats," I taught my students last night, "but we never forget that the hoofbeats are once in a while made by zebras." There can be no gainsaying the fact that medical doctors are often bored by the frail elderly patients who come in with pneumonia, twenty-four hours a day, seven days a week. Fortunately they seldom stay in our memory; we would rather marvel at our ever making a zebra-diagnosis, which is to stay in our memory forever.

A clinician might not be able to pull a diagnostic rabbit (or zebra) out of a hat at the end of each morning round, as what Dr. Gregory House did. Don't worry. Few of us remember the number of times we hear the hoofbeats, but I will never forget the once-in-a-lifetime chance to make a diagnosis of Wilson’s disease or acute porphyria masquerading the hoofbeats of the horses.

Fracture

"Your humerus bone at the right arm has broken, at the site called greater tuberosity."

I told my friend firmly, with an authoritative tone, when he called me for help after a fall around one year ago.

Months later, I still remember the moment when I was first shown his X-ray at the emergency room waiting hall. "Going to be nonoperative treatment and short period of shoulder immobilization," I advised. "Well, at most two weeks," I continued, almost whispering to myself, "as what I just read from the British Medical Journal yesterday."

This is, of course, terribly strange and coincident that my friend had a humerus bone fracture the day after my reading the same topic. Alas, why on earth should a medical physician (like me) read about the subjects of broken bones? Usually that means doing a lot, and outside my specialty, obviously. Does this story – or revelation, if you prefer – imply that I am a prophet who can look up a subject before it happens?

Quite the opposite.

I have come to see that in real life, we can never make good predictions. Back in 1899, Charles H. Duell, the United States commissioner of patents, predicted that everything that can be invented has been invented. Even the visionary Bill Gates of Microsoft, tech guru that he is, wrote in 1981 that when it comes to computing, "640K should be enough for anyone."

How about the practice of medicine? Having a "highly differentiated" specialty, if not subspecialty, is part and parcel of entering the guild of medicine nowadays. Why should we choose to read something outside our destined interest? This sounds like picking a movie according to our taste, you might ponder. We simply go and buy the front-row seat tickets for the show that interests ourselves. Simple. The question is, who is going to buy the tickets in a doctor's life? Doctors or the patients? Honestly, doctors can never predict who will "buy the ticket" and come through the door of the clinics or hospitals. This reminds me again the gorgeous quote of Sir Geoffrey Vickers, "Even the dogs may eat of the crumbs which fall from the rich man's table; and in these days, when the rich in knowledge eat such specialized food at such separable tables, only the dogs have a chance of a balanced diet."

A healthy balanced diet helps to protect us from breaking a bone, I was told as a child.

Tom Sawyer

I was amused to share The Adventures of Tom Sawyer with the son of my classmates last Sunday. The story is almost funny – except that it's not.

When we look hard enough, we can find ourselves symptomatic of what Tom Sawyer had demonstrated as a professional trickster. This condition is highly contagious, I guarantee, and not easily reversed.

It's all very well for those of us who make mistakes now and then, like what Tom Sawyer did most of the time. And it's nice to laugh at others' blunders. Still, it would then be surprising to find out that we grown-ups have been practicing the three very basic approaches of Tom Sawyer after making a mistake (before he was caught red-handed by Aunt Polly, of course). The first one, as recently described by the senior ethics adviser Julian Sheather, is to run away as far as possible and pretend it hadn't happened. Secondly, if the first trick is unsuccessful, one is to surreptitiously hunt around to see if responsibility for the mistake couldn't be handed over to someone else, or at the very least shared with them. For heaven's sake, what is the third and bravest approach, then? To try and find a way of making out that it isn't really a mistake at all.

I profess, in the sincerity of my heart, that we grown-ups are even more laughable than Tom Sawyer. And, if you don't believe that adults behave similar to Tom Sawyer, well, look around. Leave yourself room to be surprised.

Battle

After arguing and complaining for years, I now find myself trying to quit. Or, at the very least, seeking to lower the wattage a bit.

Perhaps we all have the same memory of our battle with colleagues when we were young. The battlefield was bloody and nasty, the words loud, the air steaming with the smell of dynamite. I stood on one side of the battlefield and the doctor from emergency room on the other, each debating over trivial matters like whether one should have admitted a gentleman with very slow heart rate to the medical unit, instead of orthopaedic unit. With the arrogance of youth – I was fresh out of medical school – I thought to myself, "No such thing. As an orthopaedic intern, I won't give in, even to a senior medical officer who happens to make ill-reasoned decision."

I simply refused to admit the patient to the orthopaedic unit, and challenged the emergency room doctor to come up with one single orthopaedic condition that could have given rise to the problem of slow heartbeat.

Not any more.

Looking back, I have been growing out of this habit of arguing over these years. When I made an effort to clean up my electronic mailbox last week, to my amazement, those bloody (sent) messages with heated debate have been dwindling over the past ten years or so. In the end I am beginning to develop the skill to absorb and ultimately defuse those tumultuous emotions.

I do not wish to deny the importance of embracing one's ideologies and defending one's maxims. At the same time, I have come to realize that it's the quietest voice that speaks the loudest.

Table Manner

With all due respect to the world class table tennis player Wang Nan, she had wonderful performance in women's singles table tennis Olympic game last night.

Did you say she lost her Olympic gold medal? Did she?

If you ask me, I would rather say Wang did well to win a silver. Yes, she won the silver medal with her signature smiles. She cracked a big smile, occasionally sticking out her tongue, even after losing points. The point is not that she wins or loses; her humorous ability to experience moments of pleasure - even in the face of Olympic final - is at the heart of every one of us who watched the game.

As a Tibetan saying goes, "When you smile at life, half the smile is for your face, the other half for somebody else’s." Indeed, her smile radiates throughout the packed Peking University Gymnasium, all the way across the globe via television broadcast.

Watch

To go into solitude and wilderness, one needs to retire as much from the ticking of the time watch as from the society. To speak truly, few of us can stay away from the society without taking off the watch. The idea as to how I can learn to appreciate the tranquillity of nature was suggested to me during my "solo" session at the Outward Bound course ten years ago. I kept remembering everything, putting a tent up, seeing the most exquisite sunset of my life alone at a deserted island, and how I went through the twenty-four hours without wearing the timepiece on my wrist.

Peace and jollity. After all these ten years, I seldom give myself the luxury of both.

My habits of city life ensure that not a day goes by without wearing my wristwatch. And this watch – an inexpensive but faithful wristwatch – has become so important to me that it is the first thing I put on in the morning as I step out of bed and the last thing I take off before stepping back into bed at night. I nearly ran into trouble when my watch stopped running (after my pulling out its knob by accident) this morning. I don’t know what to make of this but simply admit to myself that modern man can't live without a watch. Can I?

Scrub

I taught my students, who were going to the operating theatre with me last week, the scrub techniques. Rituals abound in the operating theatre, I confess, with all the meticulous and universally-agreed ways of washing our hands (or "surgical scrub"). The conventional ways of surgical scrub have been performed in countless times obsessively throughout our career life and with such conviction that they must be gospel. But are they?

I still remember my clumsiness (and that of my students, too) with the elbow operated taps during the very first time of going to the operating theatre. But then the Journal of Hospital Infection recently ran a story describing better types of taps in the theatre suites. The researchers showed that using leg operated rather than elbow operated taps for scrubbing could save 1400 tonnes of greenhouse gas emission a year. Think of it - it was only a matter of changing the water delivery system that resulted in at least a 50% cut in water use!

If there is any moral from this story, it would probably be the creativity for those of us who have been doing all the mundane jobs (such as scrubbing before an operation). As simple as it seems, the creativity to find a new way of doing a mundane job can be fun. For those of you who get used to two packets of sugar for the morning coffee, think of the way of tearing each packet and putting it one over another into your cup.

Have you ever thought of putting one packet of sugar over the other and opening both of them with just one single tear?

Trash

A friend of mine has made a vow (to his wife) that for every new toy brought into his home, another old one must go.

This is a hard idea to swallow, and it will definitely stick in your throat if you have an addiction, say, to shopping and costuming yourself.

Making an effort to hold back buying new stuff is never easy; chucking your old collections of textbooks and lecture notes, directories, shoes, toys, comic books, jewelry (or fill in whatever worthy of your collection here) is even more difficult. Fear of needing them someday and worth of fortune in the future, habit, and nostalgia... There are thousands of reasons for our penchant to fill our homes to the brim. We keep everything lest we throw the baby out with the bath water. Yet, I learned a lesson during my recent Herculean task of cleaning my home. Over last few weeks, I learned to enjoy the tidying process. As it turned out, there were dozens of computer floppy diskettes that I will never open again, bunches of keys that I am unable to find out what to open with, not to mention load of books that are outdated.

Believe me, you can never imagine how many of your collections should have gone to the trash. We simply amass astonishing amount of stuff without setting aside time to send away those unnecessary and useless stuff. And of course, it would also hold true if you spell the word "stuff" in my previous sentence the other way, replacing the alphabet of u by a.

Scramble

The online puzzle game Scramble has addicted my mind to its fun with alphabets for quite a while. Every now and then I find myself carried away by this remarkable word game, in which we line up the scrambled letters to from a new word.

Although chances are that I am killing time by juggling with the alphabets, there are occasionally good lessons to learn. Trust me, the word game sparkles with amusing examples of life lesson. Think of the word "trust", and drop the letter t – alas, trust without the t is rust.

It may seem odd to most of us, but in reality we get tempted to ride the roughshod over the feelings of other, getting our own way, finding fault, without even considering the treading upon the other people's pride. All these serve no better purpose than rusting the trust.

Building trust is somewhat difficult, but losing it is simply a piece of cake. When the issue of referring sick patients to the intensive care unit was raised in my hospital this week, for instance, a Pandora's box has been opened. For years, referral of patients was made on the basis of mutual trust. If one is to make a new proposal that intensive care unit referral should only be made by senior consultants – but not the frontline medical doctors caring the sick patients – you can imagine the consequence of this move.

Do I smell a rusty box?

Invention

We spoke about the fashionable buzzwords or clichés during lunch meeting the other day. Like so many geeks, I must admit, I hardly come to fall in love with the new thing. That being said, vogue words can be quite fun and that’s how they got to be vogue words.

Nowhere is the classical language in the Anglo-Saxon times more creative than the new clichés that are born every now and then. Well, obviously new words and phrases have to be born. The nub of the problem is birth control. Just as if you print too much money, its value goes down, so if you grant too many fashion words or buzzwords, the fun of them becomes debased.

There are, of course, numerous examples I found myself carried away by the brilliant buzzwords. Think of the scene of birds laying their eggs – as what I did during my recent reading The Selfish Gene. The best buzzword that strikes a chord, indeed, comes from the Japanese who invented the word saku-taku-no-ki.

Saku – the special sound a mother hen makes tapping on an egg with her beak.
Taku – the sound a chick makes tapping from within.
No-ki – the moment the tappings come together.
Saku-taku-no-ki – the very instant a chick pecking on the inside and the mother pecking on the outside reach the same spot. The egg cracks open. A new life is born, in just the way a new cliché comes to life.

Leave

After the Nestle drivers and delivery workers ended a three-day-old strike, we heard a new story from another bank company in Hong Kong. To my amazement, they announced granting a day off for the employees on their very days of birthday. Like many "aha" ideas, it's so simple you wonder why nobody had thought of it before.

Why? You might ask. As Gordon Livingston has pointed out, life's two most important questions are "Why?" and "Why not?" The trick is knowing which one to ask.

If we are to program a computer to simulate a model of absence from work, it should probably take a whole year to complete the task. Absence from work is a strange term – but we've got quite used to it. The dictionary describes it as "nonattendance at work by an employee when attendance is expected by the employer." Think of it as not quite a simple phenomenon but more than mere human behaviour of calling in sick.

We may propose that much absence is attributed to sickness. Or is it?

If sickness is a major (true) cause of absence then one would expect absence rates to have fallen over the past 100 years as health care has improved. As a matter of fact, the rates of absence have not declined; they started to rise in all industrialized countries from about 1955. Clearly, sickness alone cannot be the sole cause of absence.

But I digress. How about an entitled leave on your day of birthday? This is not to say that leaves cause no blips. The fundamental difference between such leave and the absence by phoning in sick, as we can imagine, is that the former is planned ahead and therefore less costly to the organisations. This might not have measurable impact on the absence rates, I must admit. After all, the best litmus test touted for predicting worker absenteeism remains to be economic model. An essential tenet of the economic model is that employees absent themselves in order to engage in more attractive alternatives. This means that when unemployment is high absence rates would tend to plummet, indicating that employees may be considering the trade-offs (cost-benefit analysis, in technical terms) when they decide whether to phone in sick. If being absent implies a greater chance of job loss when jobs are scarce, the relative value of leisure may decrease.

All right, I am exaggerating – but only a little.

Birth

My colleague raised questions about the developmental milestones of babies and toddlers this afternoon. Can we imagine what we are able to do after birth? To be honest, not much.

As I reflected on what I managed to do after birth – I had premature birth - I was drawn back to those scenes of National Geographic, where a newborn elephant (not to mention our immediate ancestors chimpanzee) is able to walk with the herd and hold onto his mother on the very first day of life.

To that matter, what are we to think? Are we humans born too soon? Good question – to which I'm afraid the answer is affirmative. In biological or anthropological terms, precocious animals (like us) are born helpless and must be fed and taken care for a long time, whereas altricial species (such as gorilla and elephant) refer to those relatively mature and mobile from the moment of birth. The question, as you might then ask, is why we are born so soon, putting ourselves in even more jeopardy in case of premature birth (like me).

For example, a renowned anthropologist has concluded that human beings should have a 21-month gestation period, instead of 9 months in our mothers' womb and 12 months out of the uterus. From my anthropology reading, the most important reasons for our "premature" birth are related to the bipedal gait (walking upright with two rear limbs instead of walking on four) and our large brain. Compare us with the monkeys and the great apes. Their infants are always delivered in an occiput posterior position, facing their mothers. Imagine giving birth to your kid as a monkey mother, inside a forest with enemies around you. The occiput posterior positioning of your baby is the best way for you to guide it out of the birth canal towards your nipples and wipe mucus away from its mouth to assist breathing. You simply do not require assistance. It is much safer to give birth alone, away from your rivals and predators.

For humans, the evolution of a bipedal gait and a large brain has brought about competing demands (or adaptations) in the shape of the human pelvis. The human (female) pelvic outlet became smaller than our primate ancestors, making birth more difficult for humans. To overcome the ordeal of obstructed labour, almost unheard of in other primates, human infant is to be born in an occiput anterior position, facing away from its mother. This creates difficulty for the mother, as attempts to guide her infant out of the birth canal may result in extension of the head and damage to the infant. It is this disadvantage that has resulted in the involvement of others to assist childbirth. Contemporary anthropological studies of aboriginal cultures confirm that assistance during childbirth is universal. Obviously, midwifery has developed not as a result of conscious endeavour on the part of human beings; rather, its origin is in the evolution of human beings, where by a process of natural selection women who were more likely to accept assistance during childbirth were more likely to withstand the rigours of a long labour, and survive. That being said, human babies have to be born early, before getting too large and then obstructed on the way out of the narrow pelvis.

Call it old wives' tales; call it evolutionary speculation; call it, as Darwin did, "content to remain an agnostic" – whatever you call it, there seems a grain of truth in the story.

Heart Breaking News

There is no better way to learn making reckless conclusion on hearsay than reading the "stunning" newspaper story in Hong Kong.

Lest you doubt the impact of heart-breaking news among the local media, consider the recent talk of the town concerning patient death after the doctors' attempt to open the blocked arteries with balloon.

The balloon procedure meant to prop open an artery, called angioplasty, is always a high-stakes treatment decision (or gamble, if you like) and in particular so if performed in an emergency setting. Cataclysmic uproars after the death of two patients undergoing such procedure is fueled by the large-circulation newspaper coverage with eye-catching words like "irrational heroic medicine", "victim of the cutthroat hospital", and so forth. Along with the front-page news comes a flurry of charges to lambaste the hospital in question. On this matter, I find it disheartening to believe that only one newspaper quoted the viewpoint (alas, from representatives for the patient rights) that dissemination of stories like this might not be in the best interest of the community because they discourage medical doctors from providing treatment for high-risk patients with heart attacks.

This reminds me of the famous legend about a newspaper editor who hits a pothole on his way to work, spilling coffee all over his new suit, and immediately orders a series on street maintenance when he arrives at the office. It is simply tragic for our newspaper editors and reporters to act on the prima facie evidence, in a knee-jerk manner.

If you don't believe me, read the newspaper.

Weather

One of my favourite sayings comes from Richard Carlson, author of the Don't Sweat the Small Stuff series, "There's no such thing as bad weather – only different kinds of good weather."

I admit it. There are times when I was too serious about weather, getting myself overwhelmed and uptight.

When I first arrived at Hallstatt in Austria last month, I met all that rain. The city, supposedly rich in pastel-coloured houses casting spectacular reflections onto the glassy water of the lake, did not seem to live up to its fame. To my amazement - believe it or not - the rainy day finished with a breathtaking rainbow over the scenic lake. Now and then, we are blessed with all these wonders. At first, my younger sister got disappointed with the rainy weather during her maiden outdoor photography trip at the Peak (with the new camera I bought her) this Sunday. Bad luck? Not necessarily. By noon, we were soon enthusiastic to take countless shots of the fabulous waterfalls that one can never see on a sunny day. I was overjoyed, and still am.

In a way, I have learned the tricks and come to appreciate all these different kinds of "good weather." The downpour and lightning this morning, for instance, did not seem to annoy me even though I ended up being trapped in the elevator. After all, I cannot demand that weather be fired or resign on the basis of its "bad character."

At any rate, the weather is what it is, and it obviously won't care what we think about it. Let it be.

Skating

As the saying goes, you can't teach an old dog new tricks. While there may be a grain of truth in this, I am inclined to think the opposite. Whatever your age, taking time off to do something different can be one of the best times of your life.

I decided to learn ice skating this year. The other day, I went to the ice skating rink after work and asked about lessons that fit my schedule. The receptionist at the counter smiled, apparently having already figured out my mind. "Yes, we have skating class for beginners," she replied. "May I ask how old your kid is?"

Denying adults (ahem, like me) the right to learn skating simply because they have a lot of candles on their birthday cakes reeks of ageism. When my friend heard of my joining a beginner skating class for the first time last night, he almost laughed his head off. Oh no, not any more. There is no question that old dog cannot learn new tricks. It can't. And you can't. You can't teach an old dog. Don't worry. I can simply learn to stop calling myself an old dog.

Problem solved. Case closed.

Disclosure

On my way home after dinner with my first-year medical doctor colleagues, I had a chat with one of them.

We spoke about disclosure of medical errors, which haunt bitterly many of the doctors - young and experienced ones alike. Such stories are always cropping up in the news nowadays. Hardly a day goes by without the press reporting medical errors. What if you prescribe the wrong medication to your patient who gets into trouble? What about wrong diagnosis? Or worse: Should you make immediate disclosure if you cut something which you shouldn't in the operating theatre? And yes, I did make one such blunder last week.

Time and time again doctors make mistakes, each time we agonize over whether to disclose the story, but every time the debate goes on with a barrage of controversies.

That reminds me of the maxim by James Hacker (from my favourite book Yes Prime Minister): If you are incompetent you have to be honest, and if you are crooked you have to be clever. It would, of course, be just naïve optimism for medical doctors to rate ourselves as always competent, not to mention clever. If that is the case, candid and early disclosure is a legitimate option, isn't it?

Internship

The month June comes to an end. That means another new batch of fresh graduates from the medical school.

Utter the phrase "new interns" and the mind envisages the relentlessly action-packed life of a harried and sleep-deprived neophyte, frustrated and surrounded by murmuring patients inside a hospital where he or she knows very little.

Medical intern training is known – and often despised - as a source of stress (and it is), fatigue (that too) and endless crises that need to be resolved (guilty there as well).

We can argue all day about where to draw the line between medical on-the-job training and reasonable workload. But trust me, it is this very first year of medical internship where most of the doctors learn, in ways no medical textbooks or lectures could deliver. It has been said that medical schools do not graduate physicians; they graduate young men and women who are prepared to learn to be physicians during subsequent years of increasing responsibility and stress.

I am not trying to whitewash or defend the medical education system where budding interns get their training tethered to the extended duration shifts and long hours of sleepless work. All I am saying is that we do have to find ways to overcome the stress during the training. Level of stress and mental performance is best illustrated by an upside-down U graph or Yerkes-Dodson Law. Simply stated, stress varies with challenge; at the low end, too little breeds disinterest and boredom (as any intern with tonnes of clerical job can testify). When the challenge increases it boosts interest, motivation and sense of great pride – which at their optimal level produces maximum cognitive efficiency. As challenges continue to soar and become overwhelming, stress intensifies; at its extreme or tipping point, the interns’ performance and learning collapse.

Neat solution? Nope. Obviously, fresh graduates cannot solve all the problems. The key point, perhaps, is to acquire the ability to recognize when one needs help – before the straw breaks the camel's back.

Coffee

After coming back from Austria, I have numerous nights without good sleep and need to begin each day with coffee. What, you might ask, is wrong with having coffee? The irony is that I had just returned from Austria, a country with great passion for coffee culture.

Most coffee aficionados know this. When ordering a cup of the brown stuff in Austria, a "coffee, please" doesn't suffice. You will find dozen of coffee variations in a decent Kaffeehaus (coffee house), where ordering simply "coffee" can never impress the waiters who take pride in their coffee variety. True, I won't forget the aroma of the Maria Theresia coffee. For amateur coffee drinker like me, nevertheless, I can't understand all the fuss.

"The more exposure people have to higher-quality coffee", my sage mentor once said, "the less willing they'll be to experience anything else." He is certainly right. People walking barefoot in poverty will never know how big a loss that would be for them to be denied the luxury of (nonexistent or unheard-of) Mercedes-Benz. To that end, I leave the Seven-Eleven, self-satisfied with a can of down-to-earth Nescafe coffee in my hand.

Chores

Try this. Ask a wife and a husband (or yourselves if you happen to be married) to estimate what percent of the time they each do the dishes, fold the laundry, walk the dog, make the bed, turn out the lights, and all the humdrum chores throughout the day. Can you guess what the answers would be? Their estimates will usually sum to more than 100 percent. This reminds myself how we human accept more responsibility for good deeds than for bad, and for successes than failures.

One of psychology's maxims is that most of our responses and behaviour can be explained by this self-serving bias. I think there is a lot of truth here. I have just used couples sharing house chores as an example to illustrate the point, not because they are the worst one being infected by the bias (they aren't) but because my domestic helper happens to resign recently. Be honest, medical doctors exhibit similar - if not more - degree of self-serving bias. We are keen to take credit for patients' improvement but tend to blame (treatment) failure on the patients. Sometimes our patient has cancer, say, and then suffers from relapse of the disease after one cycle of cancer drugs. Guess how we doctors describe the aforementioned fact, "Ms A fails the induction therapy."

You see. Is Ms A who fails or the drug prescribed by we doctors fails?

P.S. The guy who is writing this blog is not immune to such bias (Ouch!) – I tend to rate my writing as better than others.

Risk

An easy-to-read chart, intended for posting in physicians’ offices, has been recently described, comparing the odds of death in the coming 10 years for different ages and diseases. It was even suggested to have similar charts to be placed in the waiting room of every doctor’s office.

Risk, indeed, is a difficult concept, often mixed with emotion and mathematics. We humans tend to fear some diseases more than others. Some fears we exaggerate, others we underplay. Many women, for instance, worry breast cancer far more than heart disease, although five times as many women die of heart disease. The amygadala (a pair of almond-shaped emotional control centres within our brain's primitive core) sends more neural projections up to the cerebral cortex than it receives, as brain researchers noted. That makes it easier for our feelings to hijack our thinking than for our thinking to rule our feelings. Well, this sounds a little primitive for we genius humans, but it is really the case. In the forest, our ancestors – and probably me too - jumped at the sound of rustling leaves, leaving the cortex to decide later whether the sound was made by a predator or just by the wind.

Yesterday afternoon, medication incidents related to drug allergy were high on the agenda in my hospital, where people discussed the ways to curb the incidents of giving ampicillin (by mistake) to patients with known allergy to penicillin, for example. To my open-mouthed astonishment the Prime Minister proposed to stop keeping antibiotics at all the medical wards. This courageous move would theoretically force the doctors to prescribe and order medication from the pharmacy, which then scrutinizes the allergy list before sending the drugs to the medical wards. That being the case, you might ponder, it should help to save life. Great move? Let's step back and think. Think of the thorny delay in getting the antibiotic for an elderly hospitalized for pneumonia, in particular with the really long "boarding time" for our patients waiting for a bed in the emergency room nowadays. Of every 100 patients with pneumonia and delayed administration of antibiotic (say, after four hours), an extra patient will die, according to numerous published studies. Such inherent risk of delayed drug administration, as you can see, looms large as compared to the woefully meager benefit in double-checking the drug allergy by another human. I cannot help thinking about the metaphor of denying young people the availability of condom merely "for the sake of safety."

Alas, intuition (or hysteria, if you wish to call it) gone awry defeats rationality.

Reading

Should doctors or medical students read more literature? No, I am not referring to medical literature published in the New England Journal of Medicine here, but literacy reading in the area of humanities.

This question comes to my mind partly because I am currently reading Ian McEwan’s novel about a neurosurgeon who knows literally nothing outside the lens of his dissecting microscope within the operating theatre. His tale helps shed light on the mess of a doctor's life immersed in a universe of Latin and Greek names (running through the big list of items, alas, like hippocampus, abducens nerve, amygdala, globus pallidus, blah, blah, blah) and many many corporeal facts.

Not long ago, I heard about a medical doctor taking a three-month sabbatical to sit on an island in the Mediterranean and do very little more than reading novels. Does art really make people better doctors? Or is it too big a claim? Good question. Indeed, there is nowadays growing enthusiasm in accepting the value of arts and humanities in medicine. The public might soon want an educated doctor – someone who masters the requisite clinical skills and superb knowledge in anatomy, but also the talent to read a patient as a real human being with thoughts and emotions. Go and quiz the medical students the antidotes for opioid or benzodiazepine overdose, and most of them might be able to give you the answers. As for the pain pathway, some nose-to-the-grindstone students might even lecture you on the mu receptor. So, why bother the extra reading? If there is something doctors can learn from novels in particular, then perhaps it is the compassionate judgment. At the very least, a doctor needs to care (or bother, whatever you call it) in order to sense that a human is in pain. This, I must agree, can be learnt a whole lot more from a novel than from the Harrison’s Principles of Internal Medicine.

Urine

I was struck by how often the book Saturday by Ian McEwan led to revelations. Pearls are found throughout the story of a day in the life of Henry Perowne, a neurosurgeon and his minute-to-minute thoughts in reaction to those events.

One startling story is about the neurosurgeon's thought whilst flushing the loo, when he remembered a magazine lying around in the operating suite coffee room. At least one molecule of his own urine will at some time fall on him one day as rain, according to an article in that magazine. The numbers say so, by statistical probabilities, I presume. This reminded Henry Perowne the famous nostalgic lyrics "We'll meet again, don't know where, don't know when."

So, my hat's off, not to greet my own molecule of raindrops, but to the life lesson taught by this story. The lesson for the rest of us is pretty obvious. Think again, if it is really the case that someday somewhere we will meet again the one we appreciate as well as the ones whom we don't like, we might be able to treat everyone of them in an equal manner, and with love.

Emotion

I am writing this blog after a week of seemingly overwhelming hassles.

My classmate had delivered her baby, went home and, alas, suffered from secondary postpartum haemorrhage (excessive bleeding after childbirth). I rushed to hospital, trying to get help for her, and ended up at home at five in the morning. I had less than two hours' sleep before going back to work. As I walked to the train station, the vendor machine swallowed my coins but did not deliver me a can of coffee that I badly wanted. I went to the convenience store to buy another one and then almost tripped on the stacks of newspaper on the ground. As is often the case with bad luck, the story never ended until we got another blow, say, from the unrealistic remark by the insane Prime Minister at my workplace.

A friend was kind enough to offer me the solution by sharing his own story. Like most men (you know what I mean), we can be pretty stubborn and argue fiercely until we are blue in the face. This time, to my surprise, he quoted me in a composed manner the advice he learned few years back (when his face was blue, of course), "A man would not react to a dog on the street when it barks on you." I hardly had a clue which dog he was referring to – be it the vendor machine or the Prime Minister. But there is the moral: we can forget the moans and groans, and focus on the big stuff instead. It might have been years before my friend could tell anyone of his story and see any humour in it. But in a way it was this tiring week, for all its rough-and-tumble life, that was my awakening – at peace of mind.

Freedom

The Prime Minister despised the idea that someone teaches him how to spend the money in my last story. But could it really be wrong to exercise his freedom of choice? This reminds me of the argument on clinical freedom, long cherished by medical doctors as essential to effective practice. Can a doctor be as noble as the Prime Minister to claim (or reclaim) the freedom to make his/her own choice in terms of medical expenditure?

If you wish to (it is not really necessary), we can regard the clinical freedom as the right – some seemed to believe the divine right – of doctors to do whatever in their opinion was best for their patients.

Thoughts such as these have led many to conclude that the quest for a professional independence or autonomy is praiseworthy. On closer examination, the suspicion is that such "freedom" is merely personal (rather than professional) preference, fashion, snobbery or elitism dressed up as an objective judgment. Don't get me wrong. I am never an advocate to badmouth the trust in medical doctors' effort to put patients' interests first. On the other hand, we should never forget the lessons that we learned from the lawsuit story of Vioxx, the once-popular drug which had been promoted as an effective and safer alternative to the traditional painkillers, and then turned out to double the risk of heart attacks and strokes (and thus taken off the worldwide market).

I do not have a neat solution to the tricky question of clinical freedom. There is no denying that medicine is both science and art. We can argue all day about where to draw the line between them. Sure, we should at least allow for some version of clinical wisdom, or at least for a certain degree of preferences. On this view, if you ask me what the bottom line would be, the answer seems to heed the advice by the famous cardiologist John Hampton, "if we do not have resources to do all that is technically possible, then medical care must be limited to what is of proved value and the medical profession will have to set opinion aside."

John Hampton bade farewell to the clinical freedom 25 years ago, insofar as resource is concerned, with the resonating words "clinical freedom is dead, and no one need regret its passing." To which we may add, Amen.

Prime Minister

The dreams that I made over the last few days have been overwhelmingly trembling. You didn't believe me? I didn't think you would.

Anyhow, I went to meet the Prime Minister and got a chance to speak to him, in my dream of course. We spoke about the seismology and pre-detection of earthquake. Needless to say, this is a controversial subject. "Isn't it better to keep track of warning sign than knowing nothing at all, Prime Minister?" I suggested.

"Impossible," the Prime Minister stared at me and asserted. "Out of the question."

"Why not?" I remained earnest. "We cannot predict earthquake but it would not be unreasonable to pick up the advance warning, akin to detecting the rise in hepatitis B virus DNA titre before the active inflammation that strikes at the liver. Nowadays, we have the means to detect scientifically the nondestructive primary waves, which travel more quickly through the earth's crust than do the destructive secondary waves."

"No one in their right mind could contemplate such a stupid proposal," he replied without a moment's hesitation. "You don’t even know what you are detecting."

I tried to assure the Prime Minister that early detection of the sign that heralds a shake will help us to plan ahead, such as arranging quake-proof accommodation and advice people to seek a safer place that can withstand tremors….

"No." The Prime Minister stopped me there. "That would be too much a commitment. Think of the money involved."

"Money," I gasped, horror-struck, "that should not become an excuse for lowering the standard…"

"Nonsense!" The Prime Minister admonished me. "None of your bloody business. KM. Don't teach me how to spend the money."

"Yes Prime Minister." I said humbly. With that, I woke up from the nightmare with my lips quivering.

I am still wondering if this dream comes out of my recent bedtime reading Yes Prime Minister, or out of my real life encounter with the Prime Minister.

History

The awful earthquake rocked China and shocked everybody. It was unnerving for me to hear the news from Sichuan because I had just read the chapter of earthquake from Bill Bryson's A Short History of Nearly Everything two weeks ago.

They may seem more than simply coincidence. There is a feeling, as creepy as that delivered by one of the most intense earthquakes (at Lisbon, Portugal) in recorded history, that my reading the quake chapter presages the disaster mystically. A sign of omen or prophecy? Do I deserve to be called a highly gifted and clairvoyant genius who is foretelling an earthquake?

Of course, that may turn out to be a self-fulfilling fallacy when we sit down to think about it. It is worth remembering that history always repeats itself: the devastating earthquakes in Tokyo, Turkey, Mexico, to name but a few.

And, that is exactly the reason I read the book A Short History of Nearly Everything, no more and no less.

Notebook

Sherlock Holmes and Dr. Watson are alike in an intriguing way. Curiosity. An important gene to be possessed by a detective and clinician alike.

I do not dare to compare myself with more than a tiny fraction of Sherlock Holmes. In any case, I merely follow Sherlock Holmes’ way of keeping a notebook to make room for mysterious cases. A doctor's notebook may seem a far cry from that of a detective, but it is the very first building block in our search of knowledge. During all these years of clinical practice, I had no inklings of the truth in countless encounters, which were simply jotted down. Every now and then, the answer might dawn on one of them after months, or years, as I keep on reading.

For reasons not well understood at the time, I met a handful of diabetic patients with exquisitely painful legs few years ago. All of them found their place in the collection of my notebook. One weekend few months later, the answer just dropped into my lap while the words "diabetic muscle infarct" caught my eyes (during my literature search on a completely irrelevant subject). My next patient with diabetic muscle infarct ended up with a quick diagnosis by magnetic resonance imaging, and I ended up with making three publications out of the exhilarating diagnosis.

True wit, however, is rare in real life – at least in the doctor’s life – and a thousand barbed arrows fall at the feet of the archer for every one that flies. I admit that I don’t have much wit, except a notebook to keep score or tally of the missed arrows.

Tall-in-the-Saddle Confidence

While the funny story of Yes Prime Minister has given me hours of pure joy, the dialogue inside this witty comedy is a classic in itself.

"May I just clarify the question? You're asking who would know what it is that I don't know and you don't know but the Foreign Office know that they know, that they are keeping from you so that there is something we don't know and we want to know but we don't know what because we don't know."

Sure, politics and clinical medicine are utterly different apart from the common theme that we know really little in both situations. “He who knows best knows how little he knows," as Thomas Jefferson noted before. The American Journal of Medicine recently devoted a whole issue on the overconfidence of medical doctors who "think a lot of patients are cured who have simply quit in disgust." When I say "quit in disgust", I am referring to those who leave the doctors, as well as those who leave this world and never return to the doctor's clinic.

In the high-tech medical world nowadays, the low-tech hospital autopsy - not the crime-solving forensic autopsy glorified in television, but the routine autopsy done on patients who die in hospitals - is a rarity and seldom performed (to, believe it or not, unravel the diagnostic errors of medical doctors).

The cognitive pitfall of “not knowing what you don't know” is a situation perpetuated by the (all too often biased) feedback that most of we doctors get. True, our patients will return to our clinic and give us an idea how good we are making diagnosis. Is this feedback really what we want, though? The nub of the issue, however, concerns the characteristics of patients who will return to the same doctor. Think about it. Why should you go back to the same doctor who has made a cock-eyed and silly diagnostic mistake? For the similar reason, a guy who died of a mysterious blood clot lodged in his lung can never get back or feedback to his dear doctor.

Too Good to be True

During the lunch I talked with my friends about winning the lottery, making precise prediction, and all those that will be too good to be true. Miracles, nonetheless, should always be interpreted doubly cautiously when they seem too extreme to be true. That may not be the kind of advice most of us want to hear. But that doesn't make it any less the truth.

This reminds me of the story that Oscar winners were found to live longer than their less successful peers. Alas, what a wonderful world, in which winning the Academy Award adds to your longevity, giving four extra years of life!

Few years after publication of this too-good-to-be-true finding in a renowned medical journal, another closer look at the illusory statistics makes us re-think. As a matter of fact, the original analysis measured the survival from performers’ day of birth, instead of counting from the time when they won the award (or entered the contest). In other words, this gives them an inbuilt survival advantage by crediting the winner’s life-years before winning toward survival subsequent to winning; the winners simply had to survive long enough to win the award.

As a corollary, the same can be said of winning the Nobel Prizes, which are never awarded posthumously. Longevity can therefore be as important a factor as ingenuity in winning a Nobel. For example, the German physicist Ernst Ruska, who invented the electron microscope in 1932, had to wait for more than half a century before he was honoured with a Nobel Prize in 1986.

Passion

My friend told me that great erhu player does not become an alpha by accident; unrelenting persistence in the focus on a task every day is always the case. I can't agree more. Think of Rice Condoleezza, the United States Secretary of State. Long before Rice became Stanford University's youngest - and first female - provost, she began studying at Alabama's Birmingham Conservatory at the age of 10, rising at 4:30 a.m. to spend two hours at the ice skating rink before school and piano lessons. How can she do it?

To be precise, how can she keep up? To be passionate about an activity seems to be inborn but not quite etched into our DNA. Most of us simply grow out of this keen sense of repeating a job without getting bored. I have lost count of the number of times I saw a baby stumbles, in his relentless efforts, simply to learn eagerly the amazing skill of walking. Or, take a look at how preservative a toddler learns to talk. It is only several years later, around the start of junior school, that an awful lot of us seem to lose our innate drive to go on resolutely in pursuit of any basic daily job.

You might argue with me whether losing this yearning for any mundane task can be the reason to distinguish champions from the under-achievers. I am not making this up. I still remember a study published in the British Medical Journal more than five years ago, when the researchers set out to test whether medical students who were unable to comply with simple administrative tasks - for example, supplying a photograph at registration for the paediatric module - were more likely to struggle and subsequently to fail the examinations. Believe it or not, almost half the medical students who did not complete this basic task of providing a recent photograph (despite written and verbal reminders) failed the year-end examinations!

I learned the lesson and decided to take a look at my dialysis patients who are required to complete a training course before the start of home-based peritoneal dialysis. During the training which lasts around a week, the patients are instructed to come back to the dialysis unit every morning before 9 a.m. For those patients who arrived late for training in over 20% of occasions — after controlling for a host of other variables — they were then shown to have over 50% increased odds of developing infection problems with the subsequent dialysis procedures.

If all these proved anything, it's that we are to think small. In any case, dreaming big dreams is worth the bother, but it seems that fostering a habit of doing every small simple task everyday - and doing it well - can pay off in many stunning ways.

Shrink

If the tunnel fee of the Tate's Cairn Tunnel is raised, does anyone demur? On the other hand, if the grocery product - be it yogurt, toothpaste or toilet paper - shrinks in size without change in price, does anyone make a sound? Not much - and that's a problem.

Unbeknownst to most of consumers, manufacturers around the globe have been quietly trimming the content of their packaged products to maintain their profit margins. People might read intently the price tag during shopping and complain about the flagging economy. But trust me, most of us have never realised that decades-old tactic of product downsizing with the "same price". Under the disguise of a strategy called "weight out" in industry parlance, Dreyer's ice creams no longer come in the half-gallon (65 oz.) tub; the 12% smaller cartons hold only 56 oz.

All this - and there's much more, but I won't labour the point - is incredibly difficult for a consumer to take note of. Utter the phrase "consumer fraud" and the mind envisages a shrewd and cunning businessman in front of us. Now, I am having trouble deciding whether our health care management boss belongs to one of those businessmen. Reductions in services on the weekend are the norms in most hospital settings, under the disguise of restricting doctors' work hours (in order to minimize medical mishaps). Those of you who admire the improved patient safety, as a result of reduced sleepiness and fatigue of medical doctors, might not have paid attention to the staff shortfalls on weekends. All right, I am exaggerating - but only a little. If you don't believe me, come to hospitals and take a look at the hospital parking lots on weekends.

If you ask me what is the difference between downsizing the ice cream silently and cutting the hospital service on weekends, the obvious answer is that the former cost-control measure won't kill.

Erhu

Listening to her erhu teacher playing the instrument, as my wife told me, always makes her look stupid as a novice.

And her teacher said, "What does it take to be an erhu player? It takes audacity, devotedness and endless hours of playing erhu." The sentence went off in my head like a Roman candle.

The teacher went on to tell my wife his story when he was young: "When I was riding the bus to and from school, I clinched the passenger pole, running my fingers on that pole as if it was the string of an erhu. You need to tell yourself playing erhu twenty-four hours a day is feeling good." Then he added: "Even if it isn't." That sentence hit me hard.

It is hard not to be intimidated by his long hours devoted to playing musical instrument.

This leads me to the question how many working hours are enough — or too much — for doctors to learn. Many hospitals, including mine, have called for and mandated a reduction in doctors' working hours. Nobody really dares to answer for sure if medical doctors in training nowadays still have to work all night to learn how to heal? Often overlooked is that limited working hours can mean a step backward. Skills are lost, dependency fostered and patient care fragmented. And one thing seems certain: shorter and shorter working hours make us look small before an erhu guru.

Toothache

Once upon a time, a guy from Pluto came to visit a specialist gastroenterologist. "I hate to bother you, and as we all know, it is late," a voice pleaded eagerly. "But I'm in trouble and need to talk to you about my indigestion…"

"Fine – can you tell me how the indigestion is bothering you at such late hours?"

"Oh, yes. The stomach problem all started when I took the steak for my dinner."

"When did you start to have indigestion after taking steak?"

"Not a long time ago. I can be quite sure that the problem comes when my left lower wisdom tooth began to ache yesterday. It must be the culprit, I bet."

"I’ve got an answer to that!" screamed the gastroenterologist who has been exhausted after a whole day’s clinic work. "Gotta get your dentist - and not a gastroenterologist like me - to loosen the Gordian knot."

"Sure, my wisdom tooth used to be cared by my wisdom teeth dental surgeon, who happened to be on vacation. What a pity! How can I trust my incisor dentist who has been taking care of my incisor teeth but never touches my wisdom tooth?"

"Just a moment," the specialist gastroenterologist drew a deep breath and asked in a polite manner. "It is not for me to stick my head in there, but it's the left lower wisdom toothache that bothers you. Would it be fine, then, to let the right teeth to do the job?"

"No, no. You didn't seem to know my problems, Doc." Disappointment and resignation hang in the air. "Let me tell you, throughout the years, I chewed the steak with my left wisdom teeth, whereas the right teeth are dedicated to chicken meat. This is what we mean by specialised care."

Your jowls might drop when you hear this story. It won't take us long, nevertheless, to discover that similar stories abound at our specialised outpatient clinic. Amid all the frustration and annoyance, I have to learn that a bottle dedicated to carry urine for laboratory analysis should never be used to contain urine for another purpose, such as a dipstick test.

Titanic

The New York Times ran a story describing the discovery that the shipbuilder of the Titanic struggled for years to obtain enough good rivets and riveters and ultimately settled on faulty materials that doomed the ship, which sank 96 years ago Tuesday.

The selection of the rivets has been a subject of interest. Great ships like Titanic require three million rivets that acted like glue to hold everything together. In the case of Titanic’s rivets, the builder company ordered No. 3 bar, known as "best" — not No. 4, known as "best-best." Buying the No. 4 bars cost a lot more for the shipbuilders, but the cost of getting the selection wrong turned out to be much greater.

The pages of history are replete with examples of Titanic story. Even though we have had almost one century to learn the lesson of Titanic — on which more than 1,500 people died — the recurring theme of Titanic every now and then was almost a textbook example of how we humans keep on repeating the errors. The sinking of Titanic reminds me of an all-too-common condition of osteoporosis, or thinning of the bones secondary to aging. This devastating disease breaks the bone and renders a poor old lady in great pain – not to mention the healthcare costs of broken hip. Anyone of your granny who has been faithfully taking calcium supplements in hopes of staving off osteoporosis can be forgiven for being confused by our healthcare structure. In the public health sector, you simply have no access to measurement of the bone density – not to mention the "No. 4 bar" drugs that have been well proven to tackle osteoporosis.

Did I hear the word "shame"? Is it a shame to close our eyes and pray that the bones will stay fine but not fall apart like the Titanic? That question sounds difficult for our healthcare finance boss to grasp.

Quarter

Many years ago, a psychology professor showed that he could significantly change people's ratings of their own moods by arranging for them to "find" a quarter on the floor of an experiment room before they made their mood ratings.

A pretty fascinating scenario, you might think. And what better way to go beaming with joy after simply bumping into a coin than manipulating all those complicated molecules like endorphin and serotonin?

But think again. We are simply humans whose ups and downs can be the result of completely inconsequential events. The emphasis, perhaps, should not be on unleashing our high spirits after a minor incident such as finding a quarter on the floor, the positive (albeit unspoken) impact of which has rippled throughout centuries. Another lesson we can glean from that experiment is to appreciate how vulnerable we are – to be irked and shaken by trivial events. We don’t have to be taught to laugh after finding twenty-five cents. Rather, we need to learn to remain unscathed after losing five hundred bucks.

Doctors' Gender

A few days ago my consultant mentioned that female medical graduates outnumber the male counterparts in medical schools. Such a comment did not raise much of an eyebrow until my attention was caught by a recent study which found that male medical consultants, on average, completed 160 more episodes of care each year than their female colleagues in the United Kingdom.

Well, I dare say you can guess what happened and how people responded. From the viewpoint of quantity - which was always the focus of the economists, accountants and people at management level alike - these figures represent a setback, not to mention the females doctors juggling the roles of childbearing and spending time with their infants.

Ruminating upon this, my thoughts turn to the debate (or riddle) that male and female doctors can be equal. That reminds us the criticism that the book Men Are from Mars, Women Are from Venus increases the division between the sexes. In a similar vein, can't we see each gender as doctors and not by gender?

Don't ask me why, but when a female patient requests to be seen by a female doctor, the evidence for the fundamental difference between male and female doctors is overwhelming. And, think of a doctor scurrying between patient consultation at a gallop in the clinic, squeezing meagre time for teaching, leaving little (if any) for patient's question. How many times have you seen a male doctor - I won't deny it - like this?

The accompanied editorial in the British Medical Journal this week further reminds us that, after controlling for all demographic factors, male doctors in the United States were three times more likely than women to receive complaints and get involved in litigation. Another frequently cited meta-analysis (based on 23 observational studies of communication between doctors and patients and three large studies from doctors' own reports) in 2002 reported that female doctors spend more time with their patients, talk with them more, engaged in more emotionally focused talk, seek patient input more actively, and that their patients speak more.

Chances are male and female doctors can never be equal, other than the fact that male and female doctors are equally important for their complementary roles to medicine.

Mathematics

In his elegant book All I Really Need to Know I Learned in Kindergarten, Robert Fulghum teaches us many golden rules that we can extrapolate into the sophisticated adult world. Very true. Another way to appreciate his wisdom is to see how the subsequent teachings after our kindergarten can be remarkably wrong.

As we move on from the kindergarten to elementary school through graduate school, we learn the mathematics. We were taught that "one plus two equals three" and then "minus one plus one balances out each other." Simple enough? Unfortunately, this doesn’t happen in real life. Imagine two grown-ups fighting with each other (that happens every now and then!). First, one slaps on the face of another, who then returns with another slap (and makes sure that the blow lands with the same force). It should be obvious that such equation cannot be computed from what we learned from the mathematics class. Anyone with an iota of common sense, let alone those who have attended kindergarten, realizes that "one plus minus one" here does not add up to zero.

Am I making too much of this?

Not really. I wasn't sure how many of us have tried to re-do something that we did it wrong at the first place, keeping the false hope that "minus one plus one" would negate each other. My patient went home after being hospitalized for chest pain and developed a major heart attack two days later. I called him and asked if there is anything we can do (to be exact, re-do) for him. No way! He didn't want to see us again.

Admit it. Minus one plus one never adds up to zero – not anymore after our kindergarten days.

Age

On the weekend evening, I sat with my old classmates at an outdoor food stall when a waitress said to us (not my classmate's son!), "Hey, young boys, anything to order?"

What are we supposed to feel about her remark? Must we see it as lip service? Or do we quietly congratulate ourselves for appearing young? Would it be terribly stupid to grow old and yet acknowledge we remain young?

Absurd as it might seem to you, that depends upon how you define "young." One thing is for sure: we are living longer. Centenarians, who were encountered at a frequency of an appearance of Halley's comet, are now everywhere. Numerous countries have raised retirement ages by as much as five years.

Indeed, an unprecedented increase of the "oldest old" has simply pushed the definition of "old" farther. Imagine my medical student addressing a 55-year-old patient "senior citizen" when his 96-year-old granny has just come to visit him.

It might not be accurate to call me "young boy", but neither is it appropriate to call anyone older than your dad an "old guy."

Moderation Rules

New technology and science make numerous dreams feasible. But it takes us long to realize that the spectacle of high-tech science does not necessarily make life easier.

"We won’t have long to wait to find out this," I told myself after my preparation of the teaching material for an intensive review course for doctors sitting for examination.

At a glance of recent medical literature, the rule of moderation strikes me. As a matter of fact, the title of this blog can be read either in the straightforward sense of "rules about moderation" or in the graffiti sense of "moderation rules!"

For example, two recently published compilations of clinical trial data — called meta-analyses — tell us that normalizing the haemoglobin levels of our anaemic patients with kidney failure or cancer by the high-tech anaemia drugs can hasten their death, instead of doing them good. I was soon reminded of recent evidence that liberal blood transfusion actually do more harms than benefits in critically ill patients with low haemoglobin levels. Low haemoglobin level has been thought to be dangerous, but pushing it high might not be wise, either.

What next? We are then taken aback by the recent news that a big clinical trial was halted prematurely when a startling increased risk for death was noted among diabetic patients who were assigned to intensive glucose-lowering therapy.

So. What have we learnt? The close resemblance of this moderation rule from clinical trials performed virtually everywhere on this planet is striking. To me that sounds convincing. But, I simply wonder if we should apply the same moderation rule to our kids who are nowadays caught up in an endless race of extra tuition sessions, tennis classes, piano lessons, French courses - and the list goes on.

Overcoat

The moment I prepared packing my gears for the Sapporo winter trip tomorrow, I started to worry about the performance of my digital camera in the wake of plummeting mercury and snowy freezing weather.

I must admit I just don't know if I need to go back to my manual Nikon FM2 camera, an old-styled but robust camera that works without batteries. Ever since the user-friendly digital camera gaining popularity, most of the manual cameras (including mine) have been locked up in oblivion. But wait a minute, I start to think about their values.

I bring all this up because of my recent encounter with the use of conventional unfractionated heparin in hospital. This anti-clogging drug, so-called unfractionated heparin that had been the standard for many years, is no longer the recommended first choice ever since the newer low-molecular weight heparin (with its ease of administration and better safety profile) has come to the market. When a lady with prosthetic heart valve required the administration of long-forgotten unfractionated heparin in my hospital last week, alas, the situation ended up in a hopeless mess. Most of us cannot, even if we want to, remember the proper way to use unfractionated heparin anymore.

All these old-fashioned gagdets are simply like ill-fitting overcoats – too awkward to parade but too warm to discard. It is only the frigid temperature that brings us to rethink their values.