Marshmallow

Mention the words "skipping class" and you're likely to conjure images of Holden Caulfield, whining rants about "phony" lectures. As a matter of fact, all students have skipped class - some teachers, too.

One of the best-kept secrets about skipping class is that we don't always tell people we skip class. You know, teachers don't take attendance most of the time. When a medical student was recently caught skipping class for one whole week, little did he realize his classmates told the teacher he skipped classes because of preparatory work for the freshman orientation camp. We could not help laughing when we heard the excuse of camping - yes, camping, a pretty lame one - and skipping class. I was to find out later that this student explained to his lecturer that he skipped class simply because he rated the camping more important than the class.

But wait: can we stop laughing and make sense of it? The answer: I can. This remarkable student illustrates very well the fundamental steps of human decisions. The three steps of deciding to skip classes is worth recounting. First, he perceived a situation. Second, he used his power of reason to calculate whether skipping classes is in his best interest. Third, he used the power of will to execute his decision. A test of willpower indeed! The implicit importance of the second and third steps - reason and will - is so pervasive. Such were the kinds of issues taught by moralists for much of the twentieth century. Students have been reminded that candies and soda decay the teeth, smoking chokes the lungs, unsafe sex heralds unwanted pregnancy and bad disease. The list goes on and on. When things went wrong, we gave longer lectures and sermons.

Admit it. We failed. We failed because we forgot the crucial step. What does that mean? The first step is actually the most important one. Self-discipline and self-control can't replace the hidden process of perceiving. The emphasis should really be on how the student perceives the camping. Which brings me to the famous marshmallow psychology experiment. A group of four-year-olds were sitting in a room, with a marshmallow in front of them. They were instructed that they could eat the marshmallow right away, but that the psychologist was going to leave the room and if they waited until he returned he would give them two marshmallows. Try imagining it. How can we, as parents, teach our kids to resist the temptation to pop the marshmallow in the mouth? Should we ask them to calculate the marginal cost (second step)? And how about biting the lip to control their impulse (step three)? Nope. In the experiment, children could wait three times longer when they were able to perceive the marshmallow in a new mental frame. Say, children who were told to imagine the marshmallow was a fluffy cloud could do much better. With just a shift in the frame of reference, the change in human decisions has never been bigger.

Evidence

Not a day passes in medical school without someone teaching us the highest level evidence from the randomized controlled trials, which lie at the heart of modern clinical medicine. Everyone touts it as an elixir to make you a top-notch doctor.

Years ago, when I showed up as a young intern prepared to learn about patients with plaque-clogged heart arteries in the coronary care unit, my senior smiled and asked me the details of big names like ISIS-2 trial. I tried to think of answers to his question how many patients we need to treat with aspirin and clot-busting drug in order to save one life. Following his lead, I was convinced with the power – at least in front of an examiner – of reciting the level I evidence. Doctors love the exact number of absolute risk reduction, perhaps more than they love patients.

With time, I started seeing the need to look beyond the level I evidence. And I wonder how on earth one could ever quantify the treatment benefit of paying attention to bedside manner, asking patients about their concerns (of not quitting his smoking after a heart attack, say), making an effort to remember the name (and not the bed number) of our patients. To truly optimize outcomes for our patients, as Anand K. Parekh wrote in the New England Journal of Medicine last month, we first have to win their trust.

Humor

Now that my nineteen-month-old knows more words and goes through her growth spurt in the sense of humor, Jasmine often gives us a riotous chorus of impromptu laughter.

My wife pretended to prepare meal for Jasmine. "My baby, do you want eggplant? Let me cut it into pieces." Jasmine shook her head and said no.

"I bet you want to wash you hands and try this yummy fish, right?"

She said no again.

"Fine, let's then pick tomato."

Jasmine agreed with this jolly good idea, and leaned forward intently to wait for her mum to prepare the plastic toy tomato.

Of course, my wife was proud with her pretend play when she handed Jasmine "prepared tomato."

"Too hot," answered Jasmine, with a fit of giggles.

Granuloma

Uncertainty is a key word in science and medicine. Classical description of a disease as we learn from the textbooks, and as we admire it in straightforward presentation, is never happening in real life.

"How true," I whispered as I taught my students yesterday on a chest radiograph from a lady with cough and fluid in her lung. As soon as I showed them the picture, most students pointed to the fluid without hesitation.

"So is there anything abnormal you can spot out?" I smiled. They just stared at the film without blinking, their hearts running fast. No one answered. "Look at this cluster of innocent-looking players at the top," I finally spoke aloud, my fingers pointing at the area what we call granulomas – which are nothing but a large aggregate of host cells and tuberculosis bacteria.

"Take one more look at the chest film of your patients," I explained. "And you'll see these footprints left behind after an attack by the tuberculosis." Although this is for student learning, it's not just for them to learn. I'm learning too. When I went back to my office and read up the topic from the recent issue of the medical journal Lancet, I began to know more about the microbial mystery of granuloma. This is an eerie thought when I found out new theory about granuloma. In the old days, granuloma seems like a cocoon keeping the tuberculosis in quarantine. Now, we're taught that the granuloma also provides the primary growth niche for this organism. Another way of looking at this granuloma is to view its wall as shielding itself from immune-based killing mechanisms and making it very difficult for antituberculosis drugs to penetrate. Granulomas, alas, are no longer considered an innocent guy.

Classifying anyone as distinct binary categories - either good guy or bad guy - is overly simplistic, I know.