Placebo’s guide – getting into medical school

There are no grades that I’ll talk about (you can see for yourselves in the JUPAS website I suppose); there are few examples of what would bring a person into medical school (there are enough medical doctors around you and it’s easy to ask); what this piece deals with is how you get there after you have got all the requisites – good academic results, reference letters and the much needed luck. Accept this, and read on.

Medical schools in Hong Kong are basically a place for really bright students[1]. For those who are less able to get good grades at public examinations, alternatives include entrance to medical schools in Taiwan, the United Kingdom and Australia.

Medical school isn’t exactly something one should consider if you are asking for money. Yes – really good surgeons do make a million a week – but how many of those are there? You are much better off doing MT jobs and hope for the best. You will work less hours, have better quality of life earlier and hopefully retire earlier. There are certainly jobs in the medical sectors that would provide you with decent hours, but those would usually require either a period of damnation which may be quite long (some 8 years perhaps for physicians to rise to the level where you need not be on-site during on-call period) or an unreasonable curriculum that you will need to finish (e.g. anatomic and cytopathology).

Who do they want as medical students?

It all stems from one thing – a medical school wants to train safe doctors. The idea is, you could at least expect a safe doctor taking care of you when you’re in the hospital – thus, we need doctors (thus medical students) who understand their limits, work as a team and listen to others.

Accept it – medical school is all about vocational training. There is no ‘university’ part involved unless you are part of the academic staff in the university – and even then, not until you receive your fellowship.

You are going to get interviews, and you are going to be asked on why you want to be a medical doctor (once you’re in you will graduate unless you quit) and why you should be offered a place in the medical school.

So why do you want to be a doctor?

It is very natural to ask this question, am I not correct, monsieur? Let’s look at some sample answers:

1.      My mother told me to do so.

2.      I am living in a public housing estate and all I want to do is to get some decent salary to raise my four younger brothers.

3.      It is my dream to become a doctor.

4.      My father is a doctor, and I am to inherit his practice.

And so on, and so forth. These may as well be the real underlying reasons for many doctors out there, but of course, as a reasonably good student you know that there are many ways of presenting the same idea. I am not trying to give standard answers here, but the idea is that you want to help other people out, and medicine is one direct way of helping these folks.

[1] No, the luminance is not required for passing the examinations after you get into the medical school.

TCM practitioners and Laboratory medicine (and other investigations)

To be honest I really do not understand why these TCM practitioners/herbalists are increasingly utilizing laboratory medicine to extend their patient care...

What is the trouble?

The trouble is not of the fact that they could order tests - any layman can order tests themselves and submit their blood sample to the laboratory - some laboratories even offer to take your blood and test it right away provided that you give up your almighty buck to them.

It is also not the fact that they are not (western-) medically trained that matters to me. To be honest I have little problem with bonesetters requesting radiographs - it is in fact helping the patient very much as these radiographs often come with accompanying reports (that are, indeed, easy to read - e.g. "avulsion fracture of the proximal end of the left 5th metatarsal" would be unmistakably understood, and referred to the orthopaedic surgeon)

The trouble is with interpretation. It is perhaps a convention that the common requests for the clinical chemistry laboratory are reported but not interpreted (e.g. blood gas, liver and renal function test panels, etc. see note 1.) and in fact interpreting the liver and renal function tests has not been an easy task even for some specialists... I have recently come across a patient with significant hyponatremia. He was diagnosed to have the syndrome of inappropriate ADH secretion "SIADH", even (1) in a dry clinical picture and  (2) he has been on a thiazide diuretic before admission.

The truth is that interpreting tests takes time and training to learn - and it is important to learn in a supervised manner, that you get the feedback from your senior that your interpretation is wrong.

It is not the first time for us to see people with chronic hepatitis B managed by certain herbalists missed their chance of curative treatment for hepatocellular carcinoma (liver cancer) even though their biochemical picture is strongly suggestive of space-occupying lesions in the liver.

If they are not trained to do the interpretations correctly perhaps they shouldn't order it at all. It's just like calling a medical doctor to look at all the gauges and meters in the nuclear facility.

[1] Of course there exists tests that are interpreted, e.g. Serum electrophoresis, etc. but the majority of tests are not interpreted.

Malachite green, melamine, plasticizer and pink bug drink in Starbucks - 4 of 4

Pink bugs in starbucks

IT was quite a sight - I went back to work in the hospital just to find that the nurses are all there chattering about Starbucks drinks made from insect fragments. My first reaction to it was like...

Okay. Topic to write on.

Cochineal

Cochineal is a type of insect that feeds on cactus. It contains a compound known as carmine (wiki) which is usually used as its salt in product as a kind of red colouring. Historically it is produced in Spain and is extremely valuable. The value of cochineal fell much following the discovery of artificial red dyes in the previous century.

So why are we using cochineal?

In fact, this is likely to be the only reasonable red colouring for use in food. The other legal food red colouring these days is Red 40 (wiki) which is under attack[1]. The cochineal red coloring can be obtained in two forms, carmine, and cochineal extract.

Cochineal extract is prepared from a water-alcohol extraction of powdered, dried cochineal.Carmine on the other hand are further filtered and is more chemically pure.

Comments like "Are we eating insect fragments? - Oh I still remember there are quiet a few red fragments there when I had my strawberry frappucino - That must be the insect fragments" are everywhere[2]. These comments are of course factually wrong - if a industrial pulverizer can leave insects fragments alone then it wouldn't be called a pulverizer at all. And we are talking about powdery food additive which are freely soluble in water (and they cannot have insoluble components of more than 1% by weight (by UN standards).

Food standards with regard to insect fragments

To understand the ubiquity of insects in our common food, one must understand what standards are set there - FDA (of america) has set some ground rules for food in america (and those approved in america are usually allowed in Hong Kong - go figure). These are a few examples of "action level" of FDA[3] (i.e. they will accept the product if the count is below these...):

(1) Cinnamon, ground - 400 or more insect fragments per 50 gram
(2) Chocolate -  60 or more insect fragments per 100 grams
(3) Canned orange juice - 5 or more fly eggs per 250 ml

Can you imagine you accepted a can of orange juice with 4 fly eggs? I guess if these are acceptable, cochineal extract is just a mere mental inconvenience... Plus it is healthier than those artificial substitutes... 

[1] http://thechart.blogs.cnn.com/2010/06/30/food-dyes-a-health-risk/
[2] "...不免令人聯想到，可能是被攪碎的蟲子翅膀、身體...", "...現在想想，難道這就是尚未被碾碎的蟲子翅膀或其他身體部分..." etc. Obtained from a google search on "胭脂蟲 翅膀 starbucks"
[3] http://www.fda.gov/food/guidancecomplianceregulatoryinformation/guidancedocuments/sanitation/ucm056174.htm

Malachite green, melamine, plasticizer and pink bug drink in Starbucks - 3 of 4

Plasticizer

There has been quite a fuss surrounding taiwanese drinks back then in 2011 - you hear all those 'completely artificial' drinks from taiwan and many of us stopped buying drinks from these taiwanese outlets. Whereas it is true that these drinks are artificial, the health impact they had in human is debatable.

The case was that a supplier of clouding agent added a plasticizer called Bis(2-ethylhexyl)phthalate also known as DEHP into its product.

Clouding agent

Clouding agent is a type of food additive which causes the drink to become cloudy.

This cloudy lemonade is an example of what a drink would

look like if a clouding agent is added to it[1]

Typical clouding agent contains gum arabic, palm oil as well as citrus extracts. By nature of its palm oil, it is easy to spoil and gives a rancid taste when spoiled. There, they noted that DEHP, when added to it instead of palm oil, will produce a very nice clouding effect with little chance of spoiling. All these contribute to a better product, except... that DEHP is an antiandrogen (That is, it interferes with male sex hormone production and/or the effect of male sex hormone).

And then, as usual, with the ultra-sensitive investigations available, suddenly we are worried about the presence of DEHP everywhere - taiwanese drinks included. But when it comes to a drug...

There are also other plasticizers similar to DEHP and their toxicity are also similar. 

Augmentin

Augmentin is a very common penicillin-type antibiotics. Arguably, it is the most commonly prescribed antibiotic both in in-patient and out-patient settings - mostly because of its broad spectrum (the ability to kill many different kinds of bacteria).

The tablet of it contained 2.7 ppm of DIDP, 1.1ppm of DEHP and 3.5ppm of DINP.


The powder for syrup reconstitution contained 88ppm of DIDP and 1.4ppm of DINP.

The maximum allowable intake level of DIDP is 2200 microgram per day[2]. 2.7ppm is 2.7mg/kg = 2.7microgram/g. An augmentin 375mg tablet is about 500mg in weight. by proportion, it contains about 1.35 microgram of DIDP. A full course of augmentin thus contain 28.35 micrograms of DIDP (1.35 x 3 times per day x 7 days). The daily dose is about 0.18% of the maximum allowable intake level. One has to take a 500x overdose of augmentin tablet in order to see a reproductive effect of DIDP. To be honest, if one takes a 500x overdose augmentin I would worry about the brain of the patient more than the antiandrogen effect of DIDP/DEHP/DINP...

For the powder, it has a vastly higher amount of DIDP at 88ppm. 88ppm is 88mg/kg = 88 microgram per gram. The 457mg/5ml syrup contain around 1g of powder for 5ml of syrup. Thus, there is 88 microgram of DIDP in 5ml of syrup. A full course thus contain 1232 microgram of DIDP. The daily dosage, which is 176 micrograms, represents 8% of the maximum allowable intake level.

And then they take away all the oral augmentin available from the clinics and hospitals. Compare the risk of patient requiring the use of second line antibiotics (which are more expensive / had more side effects / had narrower spectrum / less suitable) with these small risks of anti-androgenic effect from plasticizers... well, not that the ban is incorrect, but the negative impact is so much worse than the woes it caused.

For the matter, the maximum allowable dose level of DEHP is 418ug/day for adults, 58ug/day for children and 20ug/day for neonates; and none was defined for DINP. One can try to do the mathematics, but it is exceedingly unlikely for anybody to become affected by the dose level available in the syrup or the tablet.

You get the idea.


[1] The picture taken was from a natural cloudy lemonade, which is a mixture of water, sugar and lemon juice. The clouding effect is natural and is not due to a clouding agent. This photo is (C) 2009 JJ Harrison, used per CC-BY-SA 2.5 license. (Further information available from Wikipedia)
[2] http://oehha.ca.gov/prop65/CRNR_notices/pdf_zip/DIDPMADLfinalrisk042310.pdf

Malachite green, melamine, plasticizer and pink bug drink in Starbucks - 2 of 4

Melamine

Melamine is a trimer of cyanoamide (H2NCN). The industrial use of melamine is basically as a polymer: (after mixing with other chemicals)

(1) Thermoset plastic - melamine resin is very durable. The only problem with it though is that it heats up in microwave, thus it cannot be used in a microwave.
(2) Melamine foam - it can be used as a soundproof/insulation, as well as an abrasive cleaning agent (quite well known by now in Hong Kong and perhaps Japan as 激落君)

On the other hand, since melamine contain more than 60% nitrogen by weight, it has been considered for use as a (rather unsuccessful) nitrogen source in the feed for livestocks[1]. In the melamine-tainted milk incident, it was used to increase the apparent nitrogen content of the milk because some assays measure protein content in milk by measuring the nitrogen content.

The acute toxicity of melamine is very low. the LD50 (lethal dose-50, i.e. the dosage of the medication to kill 50% of a population, usually of laboratory animals, e.g. mice, rats) is around the same as salt, at >3000mg/kg. Chronic toxicity is another problem - melamine by itself requires consumption of large amount of pure melamine without good water intake. This is almost impossible for adults.

Melamine has been implicated in several incidents, including one involving pet food in the past. Together with the 2008 melamine tainted milk incident, it was noted that melamine primarily cause complications due to two mechanisms:

(1) the hydrolysis product of melamine (co-contaminants due to the use of low quality of melamine) inhibits a liver enzyme called uric acid oxidase which decomposes uric acid - this leads to a high blood, and thus urine level of uric acid and cause kidney problems.
(2) melamine is also excreted unchanged in the kidneys, causing stone formation.

Again - the addition of melamine is one act of pure fraud. It is definitely not something acceptable in any society. but then as talked the day before, the dose defines the poison. In the Sanlu milk that caused this whole scandal, the dose detected was up to 2,500mg/kg (=part per million, and later up to >6197mg/kg), which is very high - and this dose is only causing the disease in infants because they almost do not drink anything else - the lack of water intake increases the precipitation.

The story in Hong Kong

According to the Centre for Food Safety, melamine-tainted food that has been seen in Hong Kong had concentration up to 68ppm (in chocolate bars).This level, together with the target population, is unlikely to cause any damage even in the worst case scenario (child eating it as the only food - in which case the parents should be prosecuted for child abuse I think).

And then we see a boycott of milk products from China, as well as all other diary products in Hong Kong because of a detection of concentration averaging around 3 part per million.

And then we saw the hospital authority opening special clinics for those children who "supposingly" had taken melamine-tainted milk. To be honest, if anything, if we have a look at the balance between:

(1) Loss of work hours of parents and study hours for children
(2) Risk of contracting disease from clinic attendence
(3) Delay of other patients in same / different department (e.g. ultrasound appointment)
(4) Pressure of work to our paediatric colleagues

vs

(1) The remote risk of having renal disorders from locally bought milk powder/other products

I think most of us could judge.If the child had Sanlu, Mengniu or Yili infant milk powder from China I think it is very acceptable for doctors to consider a streamlined investigation protocol for them. For others, I think the readers can now decide.

[1] The use of non-protein nitrogen sources in animals has been a practice in farming for quite some time - compounds such as ammonia, urea and biuret can be feed to the ruminants and would eventually be incorporated into protein for the animal because of bacterial action in the ruminant stomach.

Malachite green, melamine, plasticizer and pink bug drink in Starbucks - 1 of 4

It is not news that people are easily manipulated[1].

The collective stupidity of people never fails me... Looking at the list of feared substance that occur in Hong Kong, I can only say, good luck, my friend. Below lists a handful of substance that has been publicized in Hong Kong for being added to food (legally or illegally) and are of utmost hazard to your health:

(1) Malachite green
(2) Melamine
(3) DEHP (Bis(2-ethylhexyl) phthalate and other similar plasticizer)
(4) Cochinea colouring

This is the first installment of a four-article series on the public reaction to chemical substances identified in food.

Malachite green

Malachite green is an aniline dye which is commonly used in production of green articles made of e.g. silk, leather or even toilet paper. Another use of it is in eradicating protozoan disease, notably Ichthyophthirius multifiliis which is better known as white spot disease (白點病), a prevalent parasite of freshwater fish. 

Malachite green has been implied in causing cancer, change in genetic material, abnormal babies as well as toxicity to lung[2]. Together with its metabolite in fish, leukomalachite green, these produces an increase of liver DNA adduct in rats (a measurement of genotoxicity), in a dose-related manner in concentrations above 91ppm[3]. There is also an increase in lung adenoma (a benign tumor) in the tested rats.

There is, however, in this 2-year tumorigenesis study, no increase in the occurence of liver tumor.

According to the press release by CFS, HKSAR[4], the samples concerned contained  16ppm and 0.0025ppm respectively (by LC-MS/MS among other methods[5,6]), well below the concentration that has been observed to cause significant genotoxicity.

In fact, most of the samples acquired in Hong Kong afterwards contained up to 5ppb (part per billion) only - which is, higher than the EU directive (<2ppb) but lower than the Japanese directive (<10ppb).

The ban is correct

I for one am surprised that samples would contain as much as 16ppm, far above the possibility of contamination, and this points much more to (illegal) usage of malachite green in that particular case. The ban means that future products would be tested for it with sensitive assays and the fisheries will have an incentive NOT to use malachite green in their fish-farming practice.

But the reactions are stupid

The dose makes the poison - Paracelsus

The trouble though, with these incident is that most of those who wrote about these had little idea that toxicity is related to the dose - even something as innocent as pure water or pure oxygen could be a poison if given in large enough a dose and/or long enough a time period, but even cyanide could be nontoxic if given in small enough a dose.


What people says about these malachite green-tainted eels?

"致癌鰻魚驚世大發現"[7] - Written by a chemistry teacher.

What's the deal? The dosage isn't even remotely near the carcinogenic levels. To make it worse, he further wrote "孔雀石綠經已被証實為可以致癌的物質" - when has it been classified to be a known carcinogen? The WHO publishes a list of known carcinogen - one can check here. There are some borderline evidence of carcinogenesis - e.g. a significant increase in "pooled liver adenoma and carcinoma"[8]. Yes, one can say that it is a potential carcinogen (with all the indirect evidence) but proven to be carcinogenic?

And then the worst in the article: "右圖為被過量孔雀石綠浸過的甲魚，魚身已被染成綠色" - what's remaining in the malachite green tainted fish is mostly leukomalachite green which had longer half-life (of 10 days) than malachite green - which is not coloured at all. To add to it, the observed amount (even the wow-factor 16ppm detected) will unlikely add any colour to the specimen.

Please, for god's sake - learn before you teach.


[1] Do you really expect a source on this? It's April Fool's day!
[2] Srivastava S, Sinha R, Roy D. Toxicological effects of malachite green. Aquat Toxico. 2004 Feb 25; 66(3): 319-29.
[3] Culp SJ, Beland FA, Heflich RH et al. Mutagenicity and carcinogenicity in relation to DNA adduct formation in rats fed leucomalachite green. Mutat Res. 2002 Sep 30;506-507:55-63.
[4] http://www.cfs.gov.hk/english/press/2006_10_06_1_e.html
[5] Tang HPO, Choi JYY, Analysis of Malachite Green in Fish Samples. Downloaded from: http://www.govtlab.gov.hk/g/texchange/malachite_a.pdf,
[6] Tang HPO, Choi JYY, Analysis of Malachite Green in Fish. Downloade from: http://www.govtlab.gov.hk/g/texchange/malachite_b.pdf
[7] http://www.plkchc.edu.hk/CustomPage/59/chemsir/dailylife/eel_malachite_green_toxic.htm
[8] Culp SJ, Mellick PW, Trotter RW et al. Carcinogenicity of malachite green chloride and leucomalachite green in B6C3F1 mice and F344 rats. Food Chem. Toxicol., 44 (2006), pp. 1204–1212.

Two other kinds of personalities

Coming from the previous post on borderline and paranoid personality, maybe today we could talk about two other personality disorders - these two are very common in daily parlance, though those speaking of it quite often have little idea what's under the words...


Histrionic personality disorder

People with histrionic personality tend to be self-centered and attention-seeking. They have a shallow, labile affect which they display in a dramatic manner. They are often flirtatious and inappropriately seductive – however, their sexual feelings, like their emotions, are often shallow and they often fail to achieve orgasm despite elaborate displays of passion.

They are overconcerned with physical attractiveness. They often repeat themselves, often to achieve self-deception (as in believing in one's own lies)

Narcissistic personality disorder

People with this disorder have a grandiose sense of self-importance and are boastful and pretentious. They are preoccupied with fantasies of unlimited success, power, beauty and intellectual brilliance. They think that they are special and entitled to special services and favors.

The phenotypic feature is thus the tendency to exploit others, as well as being envious of other's success.

Placebo: Ahh it is really difficult to write an article a day.

Personality problems

People with personality problems are commonly seen in clinics[1]. It is in fact a cluster of problems which is even more troublesome than most other psychiatric problems. Some of these problems affects the person (patient) more than others, others affect the people surrounding the person having the problem.

"Psychosis, you can treat, but personality disorders, not really." - said my friend who is now a psychiatrist.

This in fact reflects both the resistance to treatment, as well as the general resentment that such disorder actually occurs in our population, and in our clinics.

Some personality disorders are very traumatic to others (not that these are not traumatic to oneself):

Paranoid personality disorder

People with this kind of personality are suspicious and sensitive. One can see a marked sense of self-importance but you can always feel a hint of shame, and humiliation, in their eyes, even after minor setbacks.

They are keen observers, as observant as the best scientists, they search not for scientific hypotheses, but attempts by others to deceive them.

They are very sensitive to rebuff, they are prickly and argumentative and they often read between the lines to see non-existent threatening meaning in obviously innocent remarks. They never forgive others for real or imagined threats, and they often seek revenge in this modern society by hiring lawyers and proceeding to litigations (often unnecessarily).

Borderline personality disorder

You see extreme efforts by them to avoid abandonment - they manipulate others by acts such as recurrent suicidal behavior to relieve themselves of their chronic feeling of emptiness. They are impulsive, they can't control their anger.

People often quote these borderline people to have intense, but brief, and unstable relationships, and this is true, and in addition, approaching the end of their relationship, you see paranoia in their behavioral pattern, and they become suspicious when they are stressed.

What's the personality problem described here?

[1] Not that I don't have one. I am a dependent person. Dependent on my girlfriend.

Test concepts

To be honest, these days, many patients come to the hospital for tests rather than for consultations, and for (self-prescribed) treatment rather than diagnosis.It seems to us that when we offer a test (instead of history taking and physical examination), the patients are more satisfied and many of them still hold the belief that the tests are invariably correct.

And this is not a small mistake to make.

When we look at tests, we look at the test result (e.g. a blood test), compared to the actual result (whether the patient actually have that particular condition).

condition    test	present	absent
positive	true positive	false positive	TP/(TP+FP) = PPV
negative	false negative	true negative	TN/(TN+FN) = NPV
	TP/(TP+FN)=Sn	TN/(FP+TN)=Sp

Where:
PPV = Positive predictive value
NPV = Negative predictive value
Sn = Sensitivity
Sp = Specificity


Sensitivity and Specificity are inherent to the test itself - it depends on the test itself, and the cutoff value chosen only. When different values are chosen as the cutoff for a test, the sensitivity varies with specificity, and we can plot a graph that is known as the "Receiver operating characteristic curve" (Wiki on ROC curves)

Sensitivity measures how good the test is at detecting the condition when the condition is present. Specificity measures how good the test is at ruling out the condition when the condition is absent.

The detail for the ROC curve isn't that important - but it is important to know that if you pick a value that makes the test more sensitive, the specificity will go down, and if you pick a value that makes the test more specific, the sensitivity will go down. The clinical implication that, if you want doctors to have very few misses in diagnosing a condition, doctors are going to do a lot more tests on everybody, and most of these tests will turn out negative.

Take the sample ROC curve above as an example, if you want the sensitivity to go as much as 90% (i.e. 90% of patients who have the disease the test will be tested positive) then the specificity will fall to 40% (i.e. only 40% of those who do not have the disease will test negative - or, put it the other way round, 60% of those who do not have the disease will test positive). These patients who are so unfortunate to have a false-positive result will be subjected to confirmatory tests, which are often more invasive and incur morbidity and mortality - for example, a 0.25-0.5% risk of death following a diagnostic coronary angiogram.

And then we come to the positive and negative predictive value. We talked about the sensitivity and specificity being inherent to the test and being related to the cutoff value chosen - the positive predictive value and negative predictive value depend very much on the prevalence of the condition (i.e. the number of people having the condition in the population)

For example, let's say we have a population of 1000 (e.g. in a secondary school) that we are going to test for drug use. There are, let's say, 20 students abusing the drug. And our tests are 95% sensitive while 95% specific.

condition    test	present	absent
positive	19	49	PPV = 27.9%
negative	1	931	NPV = 99.9%

We can see that the tests is inappropriate for this application - We are going to have 49 false positive among these 1000 students. Imagine the psychological trauma and the effect of labelling in these students while confirmatory tests are being done.

Imagine the same test being done in another school where drug problem is very severe - 200 students are abusing the drug:

condition    test	present	absent
positive	190	40	PPV = 82.6%
negative	10	860	NPV = 98.8%

The result looks much nicer compared with the previous one - with the same test, same cutoff (and thus same sensitivity and specificity). We can see that this test is much more suited to the application in this particular school.

What does all these mean to the readers, then?

Looking at it, human decision making is also a test (even if no laboratory resources are used), It means that, the higher the quality (i.e. the lower the miss-rate) you require from the doctor, the more tests will be done on you, and many of them will eventually going to be negative, and worse still, some of them are going to be false positives.

Nursing - is it really THAT attractive?

A whole lot of people are asking about the working condition/hours/undergraduate curriculum (and so on and so forth) of nursing in the forums. I have always wondered - why is there so much interest in the society in becoming a nurse? Granted, salaries for nurses are among the highest if you look at the admission grades, but then is it really such an attractive package? If so, are those who aimed at pursuing the nursing profession suitable to do it?


I personally think that being a nurse, or for that matter a doctor, is a job that is in fact not really well paid for the necessary work. The price-performance ratio might as well be better for nurses but basically there is too much risk to bear for that particular salary. If I were for the salary, the medical industry would be down on the bottom of the list in applying for jobs.

For that mere 20k/month salary, one has to deal with infectious blood, urine, faeces, cerebrospinal fluid or even semen -- and then, as much as I hate to say it, unreasonable patients represent a significant portion of daily work in a hospital environment, be it in public or in private sector -- if you are lucky, you get scolded, if you are unlucky, you could be (unreasonably) complained, harassed or even beaten. Contracting HIV during procedures such as suction and blood taking is not something unheard of in the industry.

And here goes the shift work. Most nurses need to work shifts - be it in the operating theatre or wards - some may be exempted from shift work because of work location (outpatient department, day ward, etc.) but these places are often staffed by nurses with morbidities such as psychiatric illness or autoimmune diseases. Shift work imposes a lot of stress on the physical, psychological and social well-being of an individual.

If I were them, I probably wouldn't choose this subject as a career - there are a lot of career choices in which, if one is willing to work in such hazardous environment, in such irregular hours I think they are going to success and excel wherever they work.

New immigrants from China

Talked with a few other fellow doctors in the recent week and we kind of summarized what we saw in terms of the epidemiology of diseases in these new immigrants. These represent of course, anecdotal evidence and are not backed up by statistical tests[1].

Demographics of these new immigrants

There are basically four groups of immigrants. The first of them would be the ladies aged around 30-40 by now, which corresponds to the time when the vast interest in searching for wife in mainland began. The second, would be the kids that were first raised in mainland and brought to Hong Kong in the past 10 years. The third, would be working people holding the one-way permit, and the last group is the rather old people that were brought to Hong Kong to be cared after. I will focus on the first two groups.

First group of new immigrants: Ladies around 30-40

The major illness that comes in this group is anxiety-depression and female genital tract diseases. It is of no surprises that the prevalence of VDRL positivity and HPV positivity is much higher in this group of people and we are seeing a lot of really young patients with cervical cancer.

For the psychiatric part though, are really the fault of the Hong Kong people - their husband by the time now is already some 60, 70, or 80, and more often than not their husband are of the lower social class, and their health is poorly managed. You see them crippled by illness such as cerebrovascular accident, chronic obstructive airway diseases et cetera and it is really an ever-lasting difficulty for these ladies to care for their husband.

As to the female genital tract aspect however, it is more of a selection bias which I do not attempt to discuss here.

Second group of new immigrants: Kids raised in China

The problem with these kids is mostly psychiatric, and sometimes learning. It is not a surprising thing that students in Hong Kong in the past (during the British rule) has been shown to be superior in terms of their mental capability compared with peers in the western countries.

And our education system, unsurprisingly, is extremely high stress -- our top students (whom, are selected from a population of a mere 7 million) are able to get into the top universities, more often than our mainland counterparts (whom are selected from a country of 1.2 billion). After all, when we say that our medical examination is having so high a standard that it fails half the candidate, do we remember that our HKCEE fails (as in making the student not acceptable to matriculation courses) up to 80% of candidates in the past[2]?

The problem with these kids (or young gentlemen/ladies) is that they find it very difficult to position themselves in Hong Kong, where even local professionals have difficulty in living a reasonably cozy life.They often end up in two routes - one is early psychosis, and another substance abuse. They often do not have enough money and as a result, they will buy what they can afford - ketamine. The street price of ketamine, according to the police who presented in the HA toxicology conference this year, is around HKD$120 per bag, and each bag, could be used by first-time abuser for 5-6 times, thus it is just around HKD$20 per trip. Comparing the experience of two ketamine trips to a so-so lunch in [insert fast food chain here] which would cost you about the same amount of HKD, and without the knowledge of the consequences, I am sure we can understand why these kids would choose ketamine over the lunch.

I guess we can talk about the other two groups in the next few days...


[1] We do, however, have a firm belief that if statistical tests are being done then it has a real high change of being significant although an analysis like this has almost zero chance of passing through the ethics committee...
[2] Of course we understand that the medical doctors are a selected group compared with the relatively unselected group of HKCEE sitters...but anyways, there are three kinds of lies - lies, damn lies, and statistics.