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.