Mantra

Medicine is not only about science, it's sometimes about dogmas handed down from generation to generation. Sometimes, these universally accepted dogmas are more often wrong than right.

That's what I taught the two medical students joining me last week for apprenticeship program. The greater the ignorance, to paraphrase Sir William Osler, the greater the dogmatism.

Our conversation started when a senior consultant taught us the rules and dogmas of using diuretic in patients who have weakening of the heart's pumping capabilities. Seemingly, we're inculcated to use continuous infusion of diuretic in case of acute heart failure. I listened and was tempted to say that it doesn't really matter with either intermittent boluses of diuretic (one dose at a time) or continuous infusion. But, of course, I didn't say it openly. Instead I passed my phone sheepishly to my students after opening a page of the New England Journal of Medicine to prove my point. They nodded.

Few days later, we brought a patient to have emergency endoscopy at night because he was bleeding from an ulcer in the stomach. Our conversation, again, was about how to give the stomach remedy called proton pump inhibitor. I pointed to studies that said giving the drug as intermittent bolus is as good as continuous infusion. Hold on, I reminded my students, to take a look at what the doctors did in reality.

The truth is, our patient was receiving continuous infusion of proton pump inhibitor, a practice that is more expensive and inconvenient - but simply in accordance to the dogma.

Campers

We went camping with three other families at the beginning of this year. It's hard to imagine anything more exciting than bringing kids to sleep in the open air, under nothing more than a tent.

Real phobias aside (say, in case my daughter says no to the smelly loo, yuck), family camping will just give us the right mix of fun and imagination. No matter whether it's the first time or the third time, everyone feels nervous and excited at the same time.

As I learned from the parent guide, there are few essentials for the successful camp-out: friends (the more the better), a tent (the bigger the better), sleeping bags and, of course, the permit for children to build the tent together (like banging the tent stake into the ground).

While we were out, we could think of 101 ideas for a fun day without screen time. There are plenty of other things we can do without iPhone. Musical chairs, frisbee, racing, studying shy Mimosa pudica, digging sand - the list is endless. Things don't have to work out the way classic camping definition suggests, such as building a campfire to roast marshmallows. The truth is, boiling water to make hot chocolate and adding marshmallows were impressive enough for our kids. And if these activities don't make it worth sleeping rough, nothing will.

Courage

I have had difficulty in telling the difference between pronouncing "my pleasure"" and "my pressure" for as long as I can remember.

Yes, you read me right. And yes, they sound similar to my ears. I admit that my phonic skill is not as good as my six-year-old daughter.

And yet.

And yet.

I taught my daughter how similar the two words "pleasure" and "pressure" turn out to be.

Yesterday, before my Christmas holiday ended, we met our friends and decided to have bike ride. My daughter has learned riding bikes without training wheels for more than six months. But now we were talking about going to the cycling trails on a public holiday. Few things turn her stomach more than trying something new. Many, and I am among them, will demur to going beyond our comfort zone.

No one, least of all a six-year-old, can discount the intimidating effect of riding bike parallel to somewhat-like-Tour-de-France-team at arm's length. Or even in opposite direction. My daughter wanted to say no. She was afraid and didn't dare join our bike ride.

"No. I really don't want to," I heard her declare.

I simply smiled and said brightly, "I know you can try, and I'm here. I will stay behind." My daughter then put on her helmet, reluctantly at first, learning her way to transform pressure into pleasure. And she did.

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.