We

I was asked to speak in a hospital forum about nonpunitive response to medical incidents. An apt illustration of the current climate comes from those stories in which honest doctors who make full confession find themselves viewed unfavourably. Should we then keep our mouths shut?

Hardly. There comes a time in the career of most doctors when things go badly awry. It comes earlier for those who work the hardest. No matter when it comes, however, the struggle is best overcome with support from the others. That's why I shared in the forum my way of handling my downright crestfallen colleague after a medical blunder. My usual response is a conscious effort to make use of the term we instead of the insulating pronoun you. "Did we forget to remove the tourniquet after blood taking?" is much preferred to "Did you leave the tourniquet on the patient’s arm?"

Wait. The human psychology of association behaviour is usually the other way round. Instead of linking ourselves to negative stigma, we tend to keep ourselves separate from the failure by the pronoun they. This is best shown by Robert Cialdini who did an experiment in which students at Arizona State University were phoned and asked to describe the outcome of a football game their school team had played a few weeks earlier. Some students were asked the result of a certain game their team had lost; the other students were asked the result of a different game that their school team had won.

How did the students describe the school team victory? "We beat Houston 17 to 14," or "We won."

How about the lost game? "They lost to Missouri, 30 to 20," or "I don't know the score, but Arizona State got beat." And, do you know what the most remarkable answer was like?

"They threw away our chance for a national championship!"

Farewell

"Will you still go to our departmental Xmas party?" It was the shaky voice of my colleague after attending the funeral service of my respectable patient last night.

I said yes. It wasn't that I did not shiver after temperature plunged from 20 degrees Celsius to five degrees. I did. No, the uneasy feeling of transit from a memorial service to a social event with party theme is difficult to shake off. And, I didn't miss the party that much. Going to say goodbye to my patient is even more meaningful. After looking after my patient for few months, I had never realized how awe-inspiring he was – not until I heard the obituary read by his daughter. It's really hard to say that I looked after him when I found out I knew so little about my patient before.

Actually, I'm going to say that I started to love my patient since last night.

Review

A recent British Medical Journal commentary argued about the fairest peer review system in biomedical publication.

Peer review system has been a time-honoured process of evaluating scientific manuscripts; qualified individuals within a relevant field are often invited to critique and comment upon a submitted manuscript (without monetary reward or academic recognition, in case you're interested to know) before the editors make a final decision to publish it or not.

Is it fair? Not even close. No, it's not fair; but it is a fact. Peer review is done by and large anonymously. It is never easy to be objective. The first sense to judge a manuscript is, if I'm being honest, the stomach. I'm serious. It occurs right in the pit of my stomach when I first judge a manuscript. I listen more to my stomach, far ahead of my heart of hearts, and definitely above my brain, if at all. Unsettling as it is, psychological evidence indicates that we experience our feelings toward something a split second before we can intellectualise about it.

I remember quite well my stomach feeling early this week, after accepting an invitation to review a manuscript submitted to the journal Peritoneal Dialysis International. I didn't know the authors, but my stomach tightened as soon as I read their cover letter. "On behalf of all the authors, I would like to ask you to consider our manuscript entitled XXX for publication in Clinical Journal of the American Society of Nephrology as a case report." All at once, things began to make sense. These were people (or lazy slug, dare I say) who submitted their manuscript to a far more prestigious journal, got rejected, and submitted the whole stuff unchanged (including the cover letter) to a second medical journal.

A decision was made before I read further.

Happy Birthday Jasmine

On the same afternoon in 2009, I was reading What to Expect the First Year, eager to set the stage for Jasmine's arrival. One year later, I brought Jasmine to her first preschool playing class today, carrying with me the special TimeFrames issue. That's an issue devoted to looking back at the stories of the past decade (and what it might presage about the future).

After taking a quick look at the Time magazine's content, I began to realize that quite a lot of changes have occurred since the start of the millennium. Understandable? Definitely, when I consider how many things have changed within just one year of Jasmine's birth. Never before have so many delightful moments of parenting been known to me. And never before have I witnessed so many new skills acquired by a human being within a matter of twelve months.

A year brimming with big surprises, I must say. Though it seems like just yesterday (okay, maybe the day before yesterday) when Jasmine mastered the skill of rolling over, my daughter has run around our living room umpteen times before I finished the first paragraph of this blog.

I can admit it freely now. I didn't think too much about having a baby. I couldn't have been more wrong.

Reciprocity

The psychology professor Robert Cialdini keeps saying that reciprocity is the most powerful of all the forces that influence behaviour - give what you want to receive. The Max Planck Institute for Evolutionary Anthropology in Germany just reported a study that makes this very point.

After observing 3-year-olds' behaviour in a between-subjects design, researchers concluded that children are much less likely to help a person who has been seen to harm someone else – in this case adult actors tearing up or breaking another adult's drawing or clay bird. But it was the judgment of intention that characterizes the linchpin. Indeed, the odds are low for a toddler to help one person even if that person tried to harm someone else but didn't succeed. And as if that's not enough, when the toddler observed a person accidentally cause harm to another, the youngster was more willing to help that person.

Hooray for the toddlers' ability to understand another's intent.

In fact, such ability has been demonstrated to be universally present even in preverbal infants. Few years back, Yale professor Paul Bloom conducted similar experiments and published their findings in Nature. At the age of six months and 10 months, babies were shown one figure (made of wood and with large eyes glued onto it) initially at rest at the bottom of a hill. The babies witnessed events in which the figure struggled to climb the hill, and on the third attempt was either aided up by a helper who pushed it from behind, or was pushed down by a hinderer. In the test phrase, the babies showed a robust preference for the helper over the hinderer. And then, the hindering figure was either punished or rewarded. In this case, the babies preferred a character who was punishing the hinderer over ones being nice to it.

The moral of these two studies is enormous, particularly to parents like me. I remember reading once that experience may be the sculptor of the baby's mind but it is we adults who provide the chisel.

I'd better behave myself.

William Osler

A glance at my dialysis patient's blood count reminds me the Recession – everything went down except the level of anxiety. It's the third month like this. I told my patient, "Well, we don't really know what's happening. Your white cell and platelet counts are both coming down, almost as quickly as you're going anaemic." I suggested him to have a bone marrow test to figure out the problem.

Of course, my patient didn't believe me. He was nervous about the bone marrow biopsy examination. "Yeah, I bet you must have come to this decision after several round of blood tests," he hesitated. "But I'd rather wait and see. I'm feeling well."

I shook my head, but I gave in. All I knew was that I couldn't be sure I would miss something treatable. After all, the patient has already a problem list long enough to bother about, including his diabetes, kidney failure, blocked blood flow to the legs.

My patient returned to my clinic last week. "C'mon, let's be brave," I asked him again. "Have you decided on the bone marrow study?"

"No, I guess not," my patient answered. "Not at the moment. I wish you don't mind. Can I say something? The problem seems to start ever since my leg problem three months ago. Right? The vascular surgeon saw me when my toes turned dark. And then I was told to take the medication cilostazol, which is supposed to open up my blocked blood vessels. I have a hunch that it's this drug that causes the plummeting blood counts that you kept mentioning to me over the last few months. I never have problem with my blood counts before taking cilostazol."

I paused, nodded, and was wordless. There was nothing to say. I looked at my patient for as long as I could without embarrassment, and then took a quick look at the desk reference of drug information. Bingo! The problem with blood counts after taking cilostazol has been well documented before. My patient has a point. Who in his right mind would want to go for a gruesome and painful bone marrow biopsy procedure if the problem might be solved by stopping a medication? I had never thought about it.

Well, we all know the moral of this story, don't we? William Osler taught us almost a century ago to listen to the patients because they are trying to tell us the diagnosis.

Dictionary

When I walked into my office of the new hospital building, I saw an uncluttered desk. The only thing I wish to do to my room is to keep it tidy. I make the wish like we make New Year's resolution.

To celebrate the new office, I bought a gift for myself last night. It's the seventh edition of the Oxford Advanced Learner's English-Chinese Dictionary. The last dictionary I bought has been with me for over twenty years, like a loyal golden retriever with dog-eared pages.

"Gee, why do you need to buy a dictionary in printed hard copy when we can search any word on the net?" you might ask.

My first answer is, "I don't know." I mean that. I can't say why. I simply like to go back to the printed dictionary. That's how looking up words has been for me ever since I got my first elementary learner's dictionary at the age of six. This is how it works: each time I home in on the word when I leaf through the pages, I meet other words in the neighbourhood. It's just the same for drinking coffee: you've always wanted to get your coffee at the café, but instead you meet your friends sitting around. I guess old habits like addiction to dictionary or coffee die hard.

Keeping the habit of having a good cup of coffee has always been easy, but a decent printed dictionary? That's another story – Oxford University Press, the publisher of the Oxford English Dictionary, said that they're considering not printing their next edition. Such move is, obviously, related to the free, instant online dictionary. The printed copy currently sitting on the desk of my new office was published in 2008, and it seems to be the last edition that I can buy.