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.