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.