Aging

My treating older people have been dotted with experiences of ageism which, years later, will recount to me something I regret. So common is ageism, and so natural is it to those of us who have received little training in geriatrics, that functional decline becomes the sine qua non of old age.  

Recently, I read about the origin of the term "ageism," coined in 1968 by an American gerontologist Dr. Robert Butler. Known for his decades-long passion to challenge the deep-seated age-based discrimination in healthcare, Butler called for sweeping policy reforms when older patients were often neglected and simply shrugged off. 

We've all been there. I've lost track of the number of times I said something like "You know that she's very old. She can't tolerate more treatment. You are asking too much. She will soon be no more."

I have learned more about special needs of old people by looking after my dad than any lecture in geriatrics medicine. It's challenging, but I must agree with Butler that many of the ailments of the old are possibly preventable, probably rewardable, and most certainly treatable.

Pineapple

We tend to look inside of ourselves to explain the norms and outside of ourselves to call something deviant.

The debut novel of Jenny Jackson, Pineapple Street, is a good example of such conflict. Think about the chaos when a middle-class New England girl married into a family of much higher social class. Characters in the novel are our witnesses to opposite values. Millennials, who only bought things from Instagram ads, stand in contrast to Generation X who still sift through catalogs from mailbox. Daughters who prefer texting to talking on the phone are decidedly different from their mum who pronounced wi-fi as "whiffy."

The difference between apple and orange, when we come to think about it, can be up to our interpretation. All we need to remember is never compare one with another. Apple is apple. Orange is orange. Pineapple isn't apple, either. 

Back on Feet

Wealth or health (or lack thereof) is the catalyst for tension in almost everyone – though we can often decide which of them is the priority.

My dad has suffered from a stroke and repeated falls recently. Is that an high stakes situation? Absolutely. After everything that had happened last week, and pondering everything that could happen later, our family found comfort in tackling the mess one by one. 

It's like the tangles in our hair. We can't settle unless we start from the bottom and gently work our way up. We must take our time and can't tug or pull.

Be a patient, and be patient.

Medication

In September 2015, a drug company's CEO Martin Shkreli ordered a price hike of pyrimethamine from 13.5 to 750 dollars per pill, after his purchasing exclusive rights to distribution.

Pyrimethamine is a medicine to treat life-threatening parasitic infection in disadvantaged AIDS patients. The reason for lofty profits from jacking up the price is nothing other than greed. There were no development costs because this drug has existed for over 60 years. To prohibit manufacturers from "price gouging" on essential off-patent or generic drugs, the court had ordered Shkreli to repay the profits, and  barred him from the industry for life.

I didn't know this shameful story until my friend recommended me Elisabeth Rosenthal's book An American Sickness. I couldn't agree more with Elisabeth Rosenthal that doctors in training are generally taught little to nothing about the cost of medicine. We have been taught how to prescribe medicine, but knew little about the market. 

Neither doctors nor patients could have heard the story how a drug company intentionally moved its acne medicine from one form to another three times in order to keep its costly brand-name drug status. We knew nothing about the tactic of developing a "new" version (that could be chewed, or broken up and sprinkled on applesauce) to eke out time with patent protection. We didn't know that drugmakers can gain extra months of protection by filing a lawsuit to stymie or delay the launch of a generic.

Now I know.

Lie

You know the feeling: you have a hard time recalling the name of someone you know – in many case, an old acquaintance.

You appear to have recalled someone's face or voice, but not the name. You have to admit having a lousy retrieval system for name. The older you grow, the worse the system will be.

One way to train myself is reading novels with more characters. I don't know your manageable number of characters without the need of a cast spreadsheet. I recently read a novel, First Lie Wins, in which the central character operates under multiple aliases. That gives me the challenging experience of not mixing up Lucca Marino, Evie Porter, Izzy Williams, Regina Hale, Wendy Wallace, and Mia Bianchi. Those are simply different names of one protagonist. 

If I wish to tell you a lie, I would pretend that I didn't get confused with these names.

Muscle

If you have been told about your age-related muscle mass loss, join the club. 

About half of adults older than 80, like my parents, are having sarcopenia or low relative muscle mass, often defined as skeletal muscle mass being two standard deviations below the mean of a young reference group.

I must admit that I don't visit my parents frequently enough. I hardly ever, if ever, look into the fridge of them. We checked today upon visiting them. I saw an empty freezer and plenty of space after opening the lower door. My wife leaned over and shook her head. Chances are high that my parents aren't taking enough proteins. We don't even need to check with a dietitian. 

Before teaching them squat exercise or body resistance training, we knew the quickest way to reverse the downhill sarcopenia course is to fill up their fridge and stomach. Our home visit then turned into a grocery errand. A fulfilling one.

Technology

In November 2022, the release of ChatGPT became a viral hit within two months. By then, the milestone of reaching 100 million daily active users (within two months, let me repeat here) was a testament not only to the explosion of artificial intelligence, but also to a new era of technology. This year, a powerful model DeepSeek emerged in China and shunned the world.  

Fifty years ago few of us were familiar with VCR, let alone computers. Now that we get problem comprehending TYVM and ICYMI texts from our children, we will get further behind if we don't prepare ourselves with mainstream real-world AI skills.

To get myself less outdated, I borrowed the book Teaching with AI written by two educators, José Antonio Bowen and C. Edward Watson. They cautioned that AI will eliminate some jobs, but it is going to change every job: those who can work with AI will replace those who can't. Rather than banning AI, they clarified the need for teachers to help students move above and beyond what AI produced for them. A few good examples of writing assignments would be asking students to grade a paper produced by AI, and to write a better paper or improve the AI-generated essay (and include tracked changes and comments).

Another way of understanding the new changes is to look at the history of calculators. Think about the days when we were busy with learning multiplication tables, doing long division, or adding long columns of numbers. Then came the technology of calculators. The calculator did not really eliminate the need for human math, but changed which math skills we needed. By the same token, AI won't eliminate the need to write well and with ease, clarity and voice. Trust me, never ask AI to write your wedding vow, or your Valentine's Day love letter.

Diversity

For most people, the words diversity and inclusion are used interchangeably. But hear me out: this is more difficult than what we think to have love or acceptance that transcend every prejudice.

That's the reason many of us will find the book Far from the Tree unsettling. Andrew Solomon, who is gay, wrote seven hundred pages on families coping with deafness, dwarfism, Down syndrome, autism, schizophrenia and transgender children. Despite his proposition that diversity is what unites us all, dwarfs still carry with them the historical and cultural baggage of being "ugly Rumpelstiltskins." Parents still struggle with undue blame on themselves when their sons suffer from autism. "It's because I went skiing while I was pregnant," said one highly educated activist. Many trans kids are referred to as "idiots" and "freaks."

Sadly, we still hear reports of human children with disabilities being discarded in Dumpsters. It's terrifying to think that Andrew Solomon's book could have the same fate soon. Let's pray that its time has not yet come.  

Cat

Japan's connection with cats is always tangible. The legacy of cats goes all the way back to the famous robotic earless blue cat. The Japanese have also created Totoro, Hello Kitty, Guest Cat and the grey kitten from Chi's Sweet Home. 

I couldn't help but feel obsessed to fit in one more book, The Cat Who Saved Books, when my wife shoehorned our travel luggage for Hokkaido trip. That's the story of a mysterious talking tabby cat called Tiger. 

If you love books, you will love Tiger. If you want to discover the way to connect with kind-hearted but introverted people –  otherwise known as hikikomori in Japan – you will be eager to find the feline friend Tiger.

I feel so lucky to have picked the book about Tiger to travel. It's like the best cheese and wine pairing – uplifting and deeply satisfying.

Pottery

No trip to Otaru is complete without a stroll through the glassware studios and stores, This is probably the third, and maybe the fourth, times our family have visited Otaru. We booked a wheel pottery workshop, instead of glass blowing craft class. 

The joy of ceramics, as mentioned by Florence St. George in her postnatal depression story The Potter's Way, is getting more down to earth with clay. The whoosh of feel-good connection with the motion of rolling is calming and soothing. We learn to get the hang of pottery technique: centring the clay on the wheel, catching up with the wheel, letting go at the right moment. The motion of rolling, as we were taught, should be hard enough for the clay to listen to us, but soft enough so that it doesn't fly off the wheel like a frisbee.

Making the pot at breakneck speed and air bubble can get trapped in the clay. When it goes into the kiln, it could crack, break or explode. 

Nine times out of ten my pot didn't work out. That's fine, as the experience is to restore balance with a lump of clay, and find solace in the therapeutic touch of clay.

Break

Every morning, I carve out a niche for myself to work at my office desk, when I am at a state of productivity Zen. 

This Wednesday, I switched on the computer as usual and planned to invite authors to draft guidelines on dialysis. Except it wasn't as straightforward as that – nothing ever is – because my laptop was not working. Little did I know then that I would come to a standstill like my computer screen.

My eyes darted up and down the dark screen and said "open sesame" over and over in my head. 

Nothing happened. 

These days we can't finish most jobs without a computer. By then, I knew I needed to ask for tech support. 

The computer reset takes time. Still, I'm more than grateful to know my laptop can be fixed. That's just a matter of time. To allow myself to pause, I took a half day off next morning. Discovering the computer break, and a break from my computer, turned out to be a blessing in disguise. That morning, I went for a hike and brief trail run, followed by a bike ride to make my blood donation. 

Plant

The science of plants is something new to me. Before reading The Light Eaters recommended from my friend’s post, I never realized that ferns can have up to 720 pairs of chromosomes, versus humans’ mere 23. 

As I read more about the green world, I get more impressed by the amazing plants. The endurance athletic prowess of fern’s sperm is something we can never compete with. The male gametophyte fern releases swimming sperms when water is present. Shaped like tiny corkscrews, fern sperms can swim up to sixty minutes. But swimming to fertilize eggs is only one feat. To survive, reproduce, and thrive – all while facing the pressures of predators, scarcity, and blight – is another thing entirely. The super-smart ferns have learnt a crafty trick when competition for reproduction gets fierce. To get an upper hand, ferns can emit a hormone that causes the sperm of neighbouring fern species to slow down. Slower sperm means less of that species survive. Which is why the sabotaging fern can enjoy more of whatever is scarce, be it water, sunlight or soil. 

How can plants without brain do that? Nobody knows but there are indeed indicators of memory in plants. The latest research reveals that a wide variety of plants are wired to distinguish themselves from others. And, yes, they can tell whether or not others are genetic kin. When such plants find themselves beside their siblings, they arrange their leaves within two days to avoid shading them. When searockets are surrounded by unrelated plants in the lakeshore dunes of Indiana, they would grow roots aggressively into the sandy soil to monopolize nearby nutrients. But when they grow beside their kin, they would politely confine their roots. 

There are more snippets of hard evidence for plants' kin recognition. We simply don't know how they do this. Do plants have ears? The beach evening primose – a lemon-yellow teacup-shaped flower – has been found to increase the sweetness of its nectar within three minutes of being exposed to an audio recording of honeybee flight. Doesn’t it make sense for the plant to entice pollination? 

Whatever anthropology behaviour you might wish to name for that of the plants, one thing’s for sure: the plants are deeper than what we have perceived.

Magic Number

After the internet, and more specifically the World Wide Web, has changed our knowledge, artificial intelligence is going to transform everything. It's not a stretch to say that artificial intelligence is a game-changer. And it seems inevitable that doctors are being affected, if not under threat. 

A randomised clinical trial, published in JAMA Network Open, found that the use of a large language model did not significantly enhance doctors' diagnostic reasoning beyond that of conventional point-of-care decision support resources such as UpToDate. Surprisingly, though, the large language model alone performed better than the physicians.

Wait, does it mean a chatbot can be the solution? Even if that were a good idea, we should be mindful of the pitfalls. We shouldn't just copy and paste what patients say to a chatbot. That brings me to the story of Nicky in Blue Sisters, a beautiful novel written by Coco Mellors. Nicky suffered from endometriosis, a painful condition in which the cells in her uterus are growing in the wrong places. Sadly, Nicky died of fentanyl overdose. Can you imagine how many times Nicky had been asked to rate her pelvic pain on a scale of one to ten? 

It was a riddle: Choose too low and she might not get the painkillers she needed, choose too high and she'd be dismissed as hysterical. A chatbot can never imagine that Nicky had to do tricks with the number. She tried six, seven, eight, nine ... She never dared consider herself a ten. 

That riddle can never be solved by a chatbot, not even by a doctor without empathy. 

Gravel

Forget, for a moment, we don't have enough hours in the day.

I was recently taught this trap we all get snared in. At first glance, it feels undeniably true because we have more things on our task list than time to do them. But it's no longer the case if we can offload any nagging tasks that have the lowest-yielding bids for our time.

David Allen calls it "brain dump", a tool to banish those energy-sucking tasks from our brain with a mental spring cleaning. 

Demir Bentley and Carey Bentley, the productivity power couple, ask us to imagine pushing a wheelbarrow full of gravel. The more gravel we add in, the heavier the wheelbarrow becomes, and the more energy required to push it. Notice the way we fill up the wheelbarrow. It all seems so easy. Fill the wheelbarrow first with the trivial tasks, the size of gravel. Then the last bit with heavy rock, which turns out to be the highest-ranking or priority task. By that time, the wheelbarrow can hardly fit the rock. 

A good habit, in other words, is to triage our task list and fit in the most important one first. Get the rock in our wheelbarrow first. Once we have settled the rock, the gravel will find the way to go in (or out wherever appropriate). 

Trail Run

I didn't begin running seriously until my late forties, and have hit the roads and pavement since then.

I'd never heard of trail running before. With not an iota of idea about the hardship of trail run, I joined one few years ago. That afternoon, I brought nothing – not even a water bottle. It had never crossed my mind to wear special shoes. Ask any experienced trail runner, and they'll tell you I'm an idiot.

I suppose, looking back on it now, I was simply lucky to have finished the trail run without getting injury circumnavigating the terrain.

Not anymore. Fast-forward to this weekend. I managed to join my second trail run, this time with a new pair of shoes. When race day arrived, I was nervous but felt ready to enjoy the experience as much as possible. This is the first time I brought along water in a running vest. I didn't know how to use the bite valve, and ended up opening the lid to drink. I didn't prepare too much but tried to soak up the experience after taking off from the start line. Pretty soon, I came to realise that I didn't descend fast enough when the stair spacing is too narrow for me to place the whole foot on the step. My cadence, on the other hand, can be high to go downhill with rugged landscape. I fetched bananas twice for replenishment, my face aglow in the sunlight and my heart rate quickening above 170 beats per minute.

If you're new to trail running and wondering whether you can do it, let me reassure you even an idiot like me can do that. Call me an idiot if you want, but it's okay to make rookie errors. What brings me the most joy is being able to explore the nature and my body. There's nothing better than a trail run to just forget about life for a few hours and enjoy the fresh air and scenery.

Universe

The more I thought about time, space and universe, the more fascinated I became by what I have learned from Jorge Cham and Daniel Whiteson. They wrote a witty and entertaining book Frequently Asked Questions about the Universe. 

Will time ever stop? Why can’t we teleport? Do we live in a computer simulation? 

Yes, I know, that might seem like an outrageous question. Then again, maybe it doesn’t. 

As we can see, simulation is no joke. People start to imagine a future in which everyone is running a simulation of a universe in their home computers. The idea that the world isn’t real and that there could be simulated people inside of them running more simulations might be technically feasible. That’s a simulation inside a simulation. Why not? The more simulations being run, statistically speaking, the more likely that the so-called universe is a big video game. 

We don’t currently know whether the world we live in is real, and we might never know.

Inheritance

If you're looking for a contemporary vision of medication abuse, go to read the novel My Year of Rest and Relaxation by Ottessa Moshfegh. 

Central to the idea of "relaxation" is a young New York woman's numbing herself to near-coma with a remarkably huge repository of dangerous drugs. Risperidal, Ambien, Valium, Ativan, chewable melatonin, trazodone, Nembutal, Benadryl, NyQuil, Xanax, Lunesta, and her list goes on and on.

The tragedy of this miserable woman goes all the way back to her baby days when her mother, a bedroom drunk, crushed Valium into her milk bottle to "console" her for colic and crying. 

You might wonder how a zombie poisoned by that many psychotropic medications could have survived. Well, she could barely arouse the enthusiasm to stand up straight. She took a shower once a week at most. She didn't do much in her waking hours besides watching movies. That woman didn't have to work as she had all her bills on automatic payment plans. She didn't have to worry about property taxes on her apartment, because rent money from the tenants in her dead parents' old house upstate showed up in her checking account by direct deposit every month. 

In short, she survived by inheriting the fortune from her parents. Or, should we say, she inherited the misfortune from her mother who mixed alcohol with sedatives?

Fix

Nearly 30 years ago, I had no idea about patient safety as a junior medical intern, much less keep my patients safe. 

The vivid real-life stories from Amy Edmondson's Right Kind of Wrong reminded me of the internship experience. She mentioned the near-fatal mistake of complex failure in a ten-year-old boy, whose face turned blue after surgery. The boy was given a morphine overdose – several times more than was appropriate. 

Alas, that story was exactly what I had encountered in a surgical unit where a domestic maid was found unarousable after an appendicitis operation. Within minutes of being paged by the nurse, I rushed to check on the patient and found a near-empty bag of morphine. I ordered a dose of antidote, which worked like true love's kiss for Aurora. That fixed the problem and my patient woke up. End of the story. 

Except that it's not.

Looking back, I was so naive to take a quick fix without reporting the incident. I dared not speak up. And that's it. 

As a matter of fact, we tend to take short cut in the working environment, even for simple process failure like running out of clean linens. The so-called "first-order problem-solving", as you can imagine, is simply walking to another unit and taking linens from their supply. Problem solved. Minimal time and effort.

It is time for me to quit the first-order problem-solving habit. We better think about what Amy Edmondson dubbed "second-order problem-solving." That could simply mean reporting the shortage of linens and taking the initiative to work around the linen ordering system.

Legend

In his 2018 book Through My Father's Eyes, the son of Billy Graham recounts his personal relationship with his father, an iconic American evangelist.

In 2007, the Billy Graham Library (ahead of his death at the age of 99) was dedicated in the presence of former American president Jimmy Carter (who recently died at the age of 100).

Carter also followed Jesus and taught Sunday school classes before, during, and after his time in the White House. 

Both are legendary.

Humor

For those of you who like the witty hashtag on Twitter (or X, or whatever you call that), you should have heard of Jimmy Fallon who likes to tweet movie or song title, add one word to change the meaning and tag it to ask for more suggestions. Those humor habits with social media users could have started with Jaz-Z who hashtagged #mylaugh years ago.

If you're anything like me (bad news: you are), you might be less obsessed with hashtag and more old-fashioned. A nerd like me would have prefered  The New Yorker magazine caption contest, which comes up with a blank cartoon for anyone to create funny captions. That would be good exercise to rewire our brain to stress less and laugh more. I learned this kind of writing during my high school days, when a newspaper posted a blank cartoon every week and invited submission of short fiction on that cartoon. To me, back then, the comic story crafting meant a conscious desire to be funny, to make people laugh, and to reward myself with pocket money. 

Another prime example of humor habit, as I recently learned from Paul Osincup, is game called Guess the Punchline. The goal isn't to build six-pack abs (which will be used only when you laugh too much), but to exercise your humor muscle. All you need to do is pause a video after a comedian like Jimmy Fallon made a setup, and guess the possible punchlines. Here's an example of the setup: According to most studies, people's No.1 fear is public speaking. Number two is death.

What's the punchline?

"This means, to the average person, if you go to a funeral, you're better off in the casket than doing the eulogy."