Secret

You'd think that clinic consultation is private matter, because we assume that no one is overhearing the conversation between doctor and patient in a consultation room. Think again.

Not long ago, I read an inspirational article about privacy in Time magazine. Though the article mentions how children of a certain age think closing their eyes will make them invisible, it remains uncertain whether grown-ups are any smarter. Or perhaps there's not much difference. We've been all fooled by the illusion of privacy.

The illusion of privacy, I was told, dates back to the Hebrew Bible. Unbeknownst to Bathsheda, King David was pacing on rooftop when she stripped for a bath. Fast forward to the era of WikiLeaks (think Edward Snowden) and Internet service provider like Google (think pop-up ad that matches exactly your recent searches in the blink of an eye), and we don't have to be reminded that it's getting more and more difficult to keep our secrets. Nearly everything is being watched in this new age of data. Everyone is not immune to being watched - everyone, that is, including doctor. It's stubborn to get too furious about being audio taped by a patient. Stubborn, that is, unless you are as naive as a child who thinks that you can keep everything under the cloak.

Promotion

Promotion, in general, gives a lot of good feelings. Everyone seems to be talking about job promotion in my workplace. It is fine to look for promotion - it's just that by mistake, some of them thought that I'm keen to get a consultant post in another hospital.

 

I couldn't help laughing the first time I heard the rumour. And I think I'm going to smile and even chuckle the next time I was asked the same question.

A while back, by chance, I was reading an enlightening story about promotion. That's about someone who gets promotion in your office. That one isn't a personal friend, but you do know her. What do you think you'll say to her the first thing when you see her?

"Congratulations."

Yeah, nobody will disagree. And what next? Some of you will say, "You deserved it."

That makes sense, too. But I was told that this answer isn't the right way to get connected with people. "You deserved it" won't engage people simply because it isn't a statement from the perspective of the person being promoted. It's from your own perspective and literally means "I think that you deserved it."

Too often we are saying the same words from our perspective when we hear the news our friends get promoted. Instead of saying "I think that...," I was taught, we should have responded in a better way, "What does it mean for you?" In short, the response should be about her - not about you. And it would make us more aware of what our friend thinks and feels.

I don't really know who will get promoted, but will watch out for the amazing opportunity to practice the way to get connected with others.

Tapper

Like many internal medicine doctors, I often see eighty-something-year-old men and women coming to hospital with a diagnosis of frailty. The word frailty is more or less the same as fragile. Being fragile, a senior gets easily bulged with ailments, and then bursts.

As one of my fragile patients went downhill, one family member after another asked for escalation of treatment to save his life, understandably so. That patient had weak muscles, scanty comprehensible words and quite some bruises (after doctors' attempts at taking blood), and was making each breath with difficulty. That's why he had a tube inserted into his chest (which appeared to have burst), and ended up breathing (through a tight mask) from a pressure machine. And yet, as we read the advance care plan that accompanied the elderly man, we recognized the clearly written statements not to carry out cardiopulmonary resuscitation, not to have ventilator support, not to give artificial nutrition. At the end of that statement, his daughter dated and signed it. It isn't right to be aggressive in terms of treatment, I thought. I thought the family should have thought so.

But, no. The daughter knew she'd signed a document. "It's about my dad's ill health and a fast channel to get him into hospital without having to go thru the emergency room." She knew next to nothing about palliative care of his dad, leaving me awestruck by her convoluted concept. The patient further deteriorated two days ago, when I happened to be on call at night. He was dying. And that's what I told my intern and the patient's family. Easier to understand than the word frailty.

After a hectic night, I taught a large group of medical students. It's about communication. Not communication to sign a advance care plan. Still, the theme is similar. Doctors who want effective communication with patient or family, in a nutshell, have to "unknow" what we know and get the listeners' perspective. Medical students, like doctors, know so much about a topic, and it's rather difficult for them to imagine a listener who can't understand their knowledge and language. Elizabeth Newton, a Stanford University graduate student in psychology, explained this concept nicely in 1990 by performing a now-famous experiment of tappers and listeners. That experiment simply divided a group of people into "tappers" and listeners." For those who are assigned tappers, they picked from a list of well-known songs such as "Happy Birthday to You" and tapped the rhythm of the song on a table. For the listeners, the job was to guess the song.

Easy job? If you answered "yes" to this question then you - like the tappers in the experiment - may be suffering from the curse of knowledge. The tappers predicted that listeners would get the correct answer 50 percent of the time. In reality, the listeners correctly identified 2.5 percent of the songs. Why? The tappers heard the song in their heads at the same time of tapping. While the tappers had the knowledge, the listeners were simply perceiving a bunch of disconnected taps, like a kind of bizarre Morse code.

And so, I told the students, when we give a lecture on a medical condition like atrial fibrillation, the listeners are more often not following what we say. We are giving them a bunch of Morse code.

Winner

Philip Pullman once said, "All we need is the word 'Once...' and we're off." He is referring to the appeal of classics such as "Snow White", "Cinderella" and many Grimm tales.

All right. Everyone take a seat. Now I'm going to tell a story, not from the Brother Grimm. That's my daughter's favorite recently, and it comes from an amusing author in Japan.

Once there was a family of sweet potatoes, and for years this family had lived with routines underneath the ground. My daughter noticed this, and smiled when she found out the sweet potatoes brushed the teeth every morning, went to potty, got hungry now and then, just like her. They hid everything underground, and no one would dare to steal anything from there.

But it wasn't long before the sweet potato family felt a thump. Or earthquake?

"Oh, no," the daddy sweet potato said, "is it a giant there?" Frightened, he slammed the door shut at once and ran back to gather everyone at the living room.

"Oh, papa, that's not a giant. I saw many children above there. Wait, wait! They're knocking at the door."

The children kept on knocking and called, "Come, we found sweet potatoes. Let's pull and get them out."

The sweet potatoes heard a loud crack from above. "Oh, for goodness' sake! Let's line up and prepare for the tug-of-war." Not long afterwards the sweet potatoes felt the pulling force from boys and girls above.

"Heave-ho, heave-ho!"

When the sweet potatoes nearly gave way to the children, I heard my daughter chanting heave-ho together. My daughter watched anxiously for a minute or two, and really wanted to lend a helping hand. But it's too late. The sweet potatoes were losing the game. And on they rolled as though drawn by a giant, along the rope, up the stairs, until suddenly - hop! All the sweet potatoes were pulled out.

Well, what else did you expect? The sweet potatoes ended up being eaten. "Nothing tastes as good as baked sweet potatoes," the children were busy licking out and guzzling every bit of their harvest.

"Someone's been eating my leg."
"There's a bite out of my back - look!"
"And mine."
"And mine."

Everyone could see that the children were enjoying the sweet potato feast. My daughter wasn't, though; she felt sad about the sweet potatoes.

All gone, every one of them. Not really. Surely it couldn't be that simple? Can you hear the sound? Funny sound really.

Boooom. Booooooooooooom. Booooooooooooooooooooom. My daughter pinched her nose. She almost laughed her head off when the boys and girls could not stop farting. They were farting as often as dogs are panting after running for miles.

Now, who is the winner? Round one to the sweet potatoes, I thought.

Physics

In the middle of the summer holidays, a number of high school students came to my hospital. They sat on either side of the doctor in the clinic, going around with the doctor who saw patients everywhere in the hospital. This could have been the first time they stayed in a public hospital.

I haven't thought much about the high school education before the students joined us. We talked about everything, and then I realized that high-school days are pretty far away in my life. For a moment I was puzzled how much high-school teaching I could still remember.

Not much. Let me think. How about Newton's three laws of motion? The first law states that every body perseveres in its state of rest, or of uniform motion in a right line, unless it is compelled to change that state by forces impress'd thereon. Yes, of course, it's all about the kid's resistance to change. No, not changes. They don't like changes. They really don't. Kids react to changes with vehement opposition. My daughter - and many other children, I'm sure - doesn't want to go out after she has started drawing at home, and once in the playground, doesn't want to leave, and by night time, doesn't want to sleep.

Now think about Newton's second law. We're taught that motion doesn't require the action of a force, but a change in momentum does. That is proportional to the force causing it. That's easy to understand. To speed things up we need to push it. Beautiful, I know, but does it mean I have to push my three-year-old daughter? Wait. The third law states that we can't push something (or someone) without it pushing back.

Let me summarise. A force can cause change, and a harder one gives more drastic change, which can backfire because of another force - you guessed it: action and reaction (or rebellion). What an important rule that would be.

Reactions

How can you get the golden-brown colour and fabulous aroma by cooking food?

Temperature is the trick.

And by temperature I really do mean high temperature. Chemically it's something called caramelisation reaction, which occurs when we heat food in an oven, grill or oiled frying pan up to around 160^oC. That doesn't mean we get nothing below 160^oC. By the time the temperature rises to 140^oC, it will kick start another set of Maillard reaction. These reactions between proteins and sugars explain the secret of many cooks. Brushing a little egg white on the surface of flour, I was told, provides extra protein to react with carbohydrates, helping it brown and adding taste. Notice how much we love the freshly baked bread after these reactions in the oven. 

So now I know why cooking food in a microwave oven doesn't work wonder. In the case of the microwaves, they are tuned to the vibration frequency of water molecules. The heat comes directly from the water in the food, whereas caramelisation and Maillard reactions only happen with dry heat. Alas, without these miraculous reactions, the tasty aroma molecules won't appear.

Take one more look at these reactions in the kitchen, and then outside. You'll see a similar thread of theory around us. There are similar reactions around, whatever your subject. Take final year medical students; once sitting in the library and reading lecture notes only, they now are mandated to go to the medical wards and work as part of a team - in the form of apprenticeship. One tried and tested method is to give them a quota. That means the students have to see a minimum number of new patients, and take blood from, say, no less than six patients. We'd like to aim high and let the students work hard, more or less like achieving the temperature of 140^oC. That is really tough when you compare to spoonfeeding in the classroom (the microwave-equivalent in the kitchen). But, at the end, we hope it will give them a glimmer of golden-brown splendour.

How high should we raise the bar? I don't have the right answer but I remember another important rule in cooking: less desirable molecules can appear after too high a temperature. Go beyond 200^oC, and be prepared to get the bitter-tasting carcinogenic stuff.

Shoe Box

Some time in the summer, at the end of an academic year when Obama was 17 years old, a party was thrown in Hawaii. The old picture of Obama and his date in that party was recently taken out of his schoolmate's shoe box, and shown to the readers of Time magazine.

The years have gone by in the blink of an eye, and oh, photographs are no longer developed. Gone is the day of putting old photographs in an album or shoe box. For about as long as the Internet has existed, the photos of teenagers are more often stored on Facebook than in a shoe box. A few mouse clicks give them the digital footprints. Long lasting one, and easily retrievable. It's almost like a diary online for a myriad of stories, starting from the dish at a restaurant to the ceremony of tying the knot. Letters are giving way to electronic mails, and shoe boxes are giving way to Inbox.

When shoe boxes packed with old memories were as big a part of many old guys' treasure chests, we had to make sure the shoe box wasn't thrown away when we moved. Part of the challenge of maintaining the shoe box is the need to keep buying sachets of dehumidifier. Back in my home and office, I have been making use of boxes to keep track of history. Everything. Clinical photographs captured in slides (something you can't see without a slide projector), a handwritten letter written by my mentor (after I failed in a postgraduate professional examination), and hundreds of letters from my wife during my year of overseas training. Boxes are small, I know, when you think about the size of Dropbox nowadays. My boxes, however, capture far more things than Dropbox can hold.