Impartial

For the past two weeks, I have been reading Rafe Esquith's book Teach Like Your Hair's on Fire. I learned about the six levels of moral development, as first proposed by the Jean Piaget and then simplified by Rafe. These six levels seem simple. Yet implementing them is anything but simple.

You might be less eager to learn the basic levels, but I have to briefly mention all these six levels - one by one. Level I thinkers simply act out of fear. Most children do. They do homework to stay out of trouble. To move up the ladder, we can use Level II thinking and do homework for reward such as the homework chart gold stars. Can we do better? Yes, Level III refers to the stage kids learn to do things to please people: "Look, Mommy, is this good?" And on the path to moral reasoning, children should be taught to reach Level IV: follow the rule. And it works. That's why we have classroom rules or the Ten Commandments.

According to Rafe, we should aim higher like Atticus Finch in To Kill a Mockingbird: become a Level V thinker and achieve a state of empathy for the people around. To paraphrase Atticus, You never really understand a person until you consider things from his point of view ... until you climb inside his skin and walk around in it. The most desirable level, however, is the Level VI (the Atticus Finch Level) where a thinker has a personal code of behavior. He does not base his action on fear, or a desire to please someone, or even on rules. He has his own rules. There will be times when the Level VI thinkers become heroes by not following rules. Think Martin Luther King Jr. Or Mahatma Gandhi.

A few weeks ago a friend of mine who is a passionate doctor confessed that he would go the extra mile delivering "better" attention to certain special patients or families. It's one of the worst kept secrets of doctors who are supposed to treat all patients equal. As a clinician serving the public sector, understandably, I should be impartial and avoid favouritism.

The hard truth is, most doctors do have favoritism. Many a time when our patient and family are nice. Remember Level III? Nice patients deserve better care, don't they? Sometimes, out of fear (think Level I). Many doctors learn the hard way that it's rarely a good idea to finish a clinic consultation too quickly when the patient enters the clinic with the whole family. You can call this a veiled threat of complaint. Or call it "squeaky wheel gets the grease" phenomenon, as what Dr. Detsky wrote in the Journal of the American Medical Association some years ago. Pretending that this phenomenon is not so is probably not helpful, in Dr. Detsky's word, and raises the next question - is it wrong?

Emperor

There is more than one way to run a successful classroom. I learn this after reading the teaching guru Rafe Esquith's Teach Like Your Hair's on Fire.

But there is only one way to face a mistake in front of students: Admit it. I know this because I've made one today.

It's harder to do than it might seem. To begin, frank discussion with genuine expectation of divergent views is an exception rather than the norm between teacher and students. If anything, many students avoid disagreeing with their teacher for fear of being ridiculed or because they don't want to present an unpopular view. I've played the dictator enough as a teacher to understand why students prefer to shut up.

This morning, I brought my intern to the operating theatre and showed her the way we inserted a catheter into a patient's tummy for dialysis. Layer by layer. One stitch after another. Everything seemed smooth and clean. And my intern appeared impressed. At the end, we pulled out the catheter from the skin wound. And then out of nowhere, we saw a tiny piece of what-appears-to-be-skin near the wound. No more than the size of a hole created by ticket punch. I didn't really want to be distracted by that small piece of skin.

"Hmm," my intern said, eyeing that stuff with suspicion. "What's that?"

"I don't know. Perhaps a small piece of skin being peeled off."

My intern leaned. She leaned further. There was a curious silence.

She then picked up the skin and brought it closer to me. It took me a while to even bother taking a close look, only to learn that it's a torn piece of glove. My surgical glove.

I felt (and looked) like an idiot.

An idiot emperor who was pointed out by someone he is naked.

Consent

I was looking at a chest radiograph of my patient whose right lung was drowned in a bag of fluid. He had been taking a new blood thinner and had difficulty with breathing for two weeks. The figure of oxygen saturation was swaying up and down like a sail on a ship, as if it might capsize any time in the rough sea. Rising panic.

I washed my hands and put on my gloves. The idea is to put in a catheter and drain out the fluid, before my patient was "drowned." His daughter was standing next to me, and I promised her I'll do my best.

I didn't use a check-in-the-box list that forewarns my patient and his daughter every possible complications. All the worries with wait-and-see (when the right lung was squished and left one squashed). All those concerns with blood thinner (Oh sorry, but there isn't antidote). All the structures that I could bump into accidentally, from artery to nerve to lung to liver.

I managed that patient not long after hearing the story of Montgomery v Lanarkshire Health Board, a British court case in which a Scottish mother was awarded £5.25 million compensation in claiming her doctor who "failed" to alert a risk of traditional birth. The diabetic mother had a small build and her larger-than-average baby's shoulder was stuck at the birth canal.

One of the key implications is that patients should have been told every single risk and information. Otherwise, a doctor can be found guilty in not providing an informed consent.

Clearly, I failed in my case.

I admit that it's not easy to set a standard in the way we disclose the risk of every single medical procedure. There is always a complicating factor: our patient. To answer this question, Lisa Rosenbaum does a fantastic job of admiring paternalism in this week's New England Journal of Medicine.

To paraphrase Lisa Rosenbaum, "The spirit of informed decision making reflects the recognition that only patients are experts on their own values. But our approach assumes a value framework not all patients possess. What if the patient's preference is to know less?"

Inside Out

The list of animated movies is long this summer.

Those yellow creatures wearing goggles and blue overalls, if you ask me, pale in comparison with the story of Riley. This eleven-year-old only child had to move with her parents from Minnesota to San Francisco. Poor little girl. Her apprehension rose with the new school, the new hockey team, and the new way a pizza tastes. Riley struggled with the five emotion characters coming from her prefrontal cortex; she simply didn't know how to put them in the right order.

I can't tell you how many times my daughter cried throughout the movie. Okay, the truth is she cried a lot, so much so that I'm convinced that it's a touching story.

On the way back from the cinema, we talked and went over her feelings carefully, the way you feel for a hurting aphthous ulcer with your tongue. She began to tell me her worry about new school year. One after another. And soon we discussed how much she feels unprepared for our domestic maid's leaving this year (after working for us for five years). That is one of the worst feelings we can think of, to have had a wonderful maid, to know you had the luck, and then to lose it.

It's time, I know, to teach my girl the nuts and bots of finding an island to keep track of wonderful memory. The way five paper dolls (Ticky and Tacky, Jackie the Backie, Jim with two noses and Jo with the bow) are stored in Julia Donaldson's The Paper Dolls.

Dive Hard

Anyone who has tried scuba diving or snorkel will attest to how gorgeous the underwater world can be. I tried that in Mexico more than ten years ago.

We snorkeled with our five-year-old daughter this time in Okinawa. To be totally honest, it scares me. My wife bought her fins and snorkel before departing. We learned the know-how by watching the YouTube and rehearsed at our bathtub.

Turns out, we didn't have to say much. She did well except some problem with fitting the diving mask to seal off seawater. It was so heartwarming to find my daughter singing when she was under the water. I felt the way she lighted up when she discovered a school of fish swimming by.

A whole new world.

Parent

Travel with friends and one's kid can be minefields for parents, in case the kid gets whinny or moody.

I call myself lucky during my Okinawa trip, not because my kid didn't act out. She did. On the very best days - though those were very, very rare - my daughter would smile for the whole day. The real luck is that we travelled with the most placid classmate of my daughter. An easygoing boy who is the second happiest kid in the world, next to Mr. Happy in Roger Hargreaves's stories.

Another stroke of luck comes from my pick of book for this trip. I happened to finish the novel Everything I Never Told You before leaving for Okinawa, and it's hard to find a better one. Fortunately I managed to borrow the inspiring book by Robin Berman: Permission to Parent.

"When my kid goes down the rabbit hole, I try so hard not to go down with him. But it's so tough not to go tumbling down after him," says Robin Berman - a quote I keep coming back to. To make myself clear: it's really hard not to get stirred by our child's pain. Picture your child breaking down in tears, telling you her friend doesn't want to play with her anymore. You might not have to imagine too far. Admit it: not so long ago, your kid told you exactly the same piece of news. Of course, I did. Robin Berman told us a similar story that goes like a textbook answer to stay out of the rabbit hole.

The daddy in the story did a great job by giving his tearful daughter a long cuddle. "I bet that does not feel good." Cool as a cucumber, he wiped away her tears. "What are you going to do now?" he asked.

"Well, I guess I can play with a girl I know with brown eyes and brown hair."

"You mean you?" the dad blurted out the obvious answer.

"Yes."

"Great idea," the dad replied, and off his daughter skipped.

How did the daddy feel? He was just as upset as his daughter, but he didn't let his true emotion complicate the rabbit hole issue. A very clever approach.