Cliffhanger

I've been reading A Manual for Cleaning Women, a collection of short stories by Lucia Berlin. Her tales of pink-collar workers are pretty cool. Some are good. Some are otherworldly (and somewhat drunk). Some are truly touching.

But, to be honest, I love another story book more: Once Upon an Alphabet. This is Oliver Jeffers' collection of short stories, each of them dedicated to an alphabet, from A to Z. I read this book with Jasmine recently. We both love the twenty-six crazy stories. Always entertaining, from the alpha to the omega.

The story plot is simple but always a spark of joyful game. Turn to the page H, we were introduced a lazy Helen, who lived in half a house. Where is the other half? It had fallen into the sea during a hurricane a year and a half ago. Think about it. A half-sized house on the edge of sea cliff. Literally a cliffhanger plot.

"Oh, what shall we do?" Nothing. Being lazy, and not owning a hammer, Helen hadn't quite got around to fixing it yet. Which was fine.

Until the horrible day she rolled out the wrong side of bed.

Ugh.

The story ends with a bit of drama, with Helen plunging all the way into the sea.

The first time we read this story, we were almost laughing our heads off. We read the story the second time this morning, before my daughter took the school bus. Jasmine turned out to build a new ending.

"Dad. Let me finish. What if Helen is able to swim and dive? She must. She must go to the bottom of the sea and find the other half of her house, and live there happily ever after. The End."

Six

Few days ago, my daughter picked up a book at my study: Father to Daughter: Life Lessons on Raising a Girl. So we read together. We became absorbed in the lessons right away. After all, one of the precepts in this book is to be involved in the daughters' lives.

Now my daughter is six this week. I know that's a big milestone for a little girl, and I'm glad that she put on her roller skates for the first time on her birthday. I have always had faith that my wife will pick the best gift, such as new roller skates, for our daughter.

What about me? I couldn't think of a better poem than that written by A. A. Milne (who also wrote Winnie the Pooh and Friends), to celebrate Jasmine's sixth birthday: Now We Are Six.

When I was one,
 I had just begun.
When I was two,
 I was nearly new.
When I was three,
 I was hardly me.
When I was four,
 I was not much more.
When I was five,
 I was just alive.
But now I am six,
 I'm as clever as clever.
So I think I'll be six now and forever.

Coding

The easiest way to distinguish between efficiency and effectiveness is applying the rule of the American management guru Peter Drucker: efficiency is doing the job right, effectiveness is doing the right job.

The only thing you need to know about ineffectiveness, on the other hand, is looking at the canonical example of demanding complete diagnostic coding in hospital patient discharge summary.

The truth is that doctors are supposed to code the diagnosis, besides writing a summary of what happened after a patient was discharged from hospital. Writing a summary deserves significant attention - even if it isn't easy - to let subsequent doctors carry on with the care. No one questions why we need to write good summary, but it is intriguing to conceive how diagnosis coding is linked with patient care. If writing patient discharge summary is like painting a picture, coding means naming each and every colour that has been used.

So let me repeat, once more: diagnosis coding has nothing to do with patient care.

There's an expectation now among our hospital administrators that the diagnostic coding should be as meticulous as forensic examination. Their rules are pretty strict. Writing the code 487.8 indicative of influenza is okay; it isn't when the auditor finds out the patient suffered from influenza A. I just received a letter telling me to change the code to 487.1, supposed to be more specific for influenza A (and not the influenza B virus). Disagreement about my original coding can take on the feel of a Supreme Court decision that will discipline me. I sheepishly ticked the box literally meaning "Pleaded Guilty" on the audit form, amended the coding and returned two copies of the summary acknowledging my mistakes. I felt how woefully the auditors had wasted their time parsing voluminous charts and combing through the laboratory results in this exercise, and wondered what purposes they serve. There is no evidence of real patient risk being infinitesimally reduced by such meticulous diagnostic coding. Obsession with such paperwork can override actual patient care - impersonal at best, distraction at worst.

In fact, I could offer dozens, indeed hundreds, of examples in which doctors are pushed to come up with as many codes as we can.

I really don't have much of a temper, but audits like these put me over the top.

Farewell

I didn't work today.

I went to my daughter's school because it's the parent-teacher interview. The school principal advised us to list any questions that we want to raise. And, keep questions short. I felt that perhaps I should make use of this chance to tell my daughter's teacher one single life event that matters. A lot.

Our domestic helper will leave us after living with us for six years.

Two days later, we will bid her goodbye and I don't think our eyes will be dry at the airport. She has been taking good care of my daughter since her birth. It's been wonderful, until we have to say goodbye.

We have always dreaded the time of eventual separation. This is, quite simply, because we realize how lucky we've been having a trustworthy domestic helper who loves our daughter. This is a gift for which I was - and still am - grateful.

Satisfaction

I proudly carry a hospital pager - known colloquially as a bleep - with me seven days a week. I view my pager the way soldiers view their honour badges - they're insignia not to be taken away. That sounds good for a workaholic like me.

The only mistake I made was not realizing the importance of pauses.

I learned about the beauty of the pauses and silences when I watched Circle Mirror Transformation by the Pulitzer Prize-winning playwright Annie Baker last night. There were quite a number of pauses between drama scenes, and every one of them was as important as the dialogue. This is, of course, correct. We need pauses.

I daresay this is important after taking a break today. It's not that I don't want to go back to hospital and see patients - believe me, I do. Luckily, I did something as meaningful as going to work. I learned the richest of lessons from a medical ethicist (such as the moral dilemma of doctor's deceiving patients) after attending a daylong workshop. Then I finished my reading Your Medical Mind by Jerome Groopman who discussed how to navigate a medical decision, all the way from doctor's rubber-stamping to dictating patient's decision. If you ask me, this book is a must-read for the medical students and doctors.

But perhaps the most satisfying way to finish my day is that I have a chance to teach a group of elite medical students this evening, and for that, I am grateful.

Game

Imagine someone asking her son, "How was school today?"

"Good."

Not so uncommon to find such economy of words, huh?

"What did you do?"

"Stuff."

Is this always the case when we ask our children about their experiences? It might not be, though - not by a long chalk.

Heck, it's sometimes harder to get a school-age child to open up than that of Ebenezer Scrooge's wallet. Try as you might, you just can't make a child talk to you. The more you ask, the more you get stuck. If you've ever poked a snail to coax it out of the shell, you know what I mean.

Recently, I learned a new trick to encourage my daughter to recollect and share her stories after school.

This is how it works for me: "Tell me two things that really happened today - the best part of your day and one not-so-best part. And one thing that are fake. Then I'll guess which two are true."

A good mix of memory integration, humour and imagination. This sidesplittingly funny game has now become the ritual of our dinner.

Working Hours

We doctors have a long history of working long hours. We're trained to do so. Shortly after graduating from medical school, accomplishing the task of internship requires that we define forty-eight hours - not twenty-four - in a day.

With time, we unknowingly enter an addiction loop of long-hour working, which means staying on task until it's done instead of breaking the whole thing into manageable chunks. That explains why I won't be home until eight on most of my working days. I started to worry when I read an meta-analysis published in the medical journal Lancet last week.

The downside of working 55 or more hours per week, they report, is that there is an increased risk for stroke. Bile and dread inched up my throat. I thought to myself: Scary.

Well, that's what the researchers found after pooling data from nearly 530,000 adults who were free of stroke at baseline. During roughly 7–8 years' follow-up, the longer working hours one is engaged in, the higher the stroke risk. That is, the dose-response relationship between working hours and the risk of stroke speaks volumes to the threat - and for good reasons. For one thing, our brain weighs three pounds (only 2% of an adult's body weight) but consumes 20% of all the energy the body uses. The wear and tear of long working hours could have explained the energy crash or sudden exhaustion of the brain. For another, those who overwork tend to ignore their health. That doesn't mean the increase in stroke risk simply comes from smoking and drinking after long working hours; those risks have been factored in when the researchers calculated the odds.

Ahem. Sure enough, I'm not calling for a cut in doctors' working hours based on an observational study. All those conclusions drawn without a more experimental way - such as random allocation of individuals working long hours to reduced working hours - should be taken with at least that much of a grain of salt. To that matter, what am I to think? I am not sure what to say, but I didn't go back to my hospital after giving a lecture in another hospital yesterday. I went to meet my daughter in the playground instead of heading back to work.

Playground. Yes, it's unusual.

Even if the Lancet paper isn't rocket science, it makes me less guilty of leaving work early this Friday. Hooray.