人比人氣死人

小時候,我曾經以為我有過人的,獨一無二的天才。在心理學上,兒童大多會經過一段自我偉大的時期,認為他會為自己吃飯了、會走路了、會認字了,都是不得了的大事,值得他生命中最重要的人——父母的讚賞。而我很幸運的,享有足夠的能力完成學校和社會認定的重要的事情(數學,科學,國語等等),和樂於鼓勵我的家人,所以很自我感覺良好地度過大半童年。

但是很多人沒有和我一樣的好運氣,有足夠的能力完成社會決定的功課,和支持我的父母在我需要鼓勵的時候給予鼓勵和教導,而不是質疑或責備。就算我再聰明,世界上比我聰明的人多的是。月考我很少得到班上第一名,到了國中更是前十名都離我遙不可及。就算我是班上第一,還有全校第一的人。就算我是全校第一,還有全國第一的人。就算全國第一,你想想,在世界上台灣第一的人會排第幾?而且遊戲規則是誰定的?你在數學奧林匹克世界第一,但是看你的年收入的話呢?如果我的父母因為我比別人差而懷疑我的努力,甚至以我的排名來判斷我的價值,那我的自尊心何在?

在世界上任何地方都有人比人的現象,但是在台灣的社會環境下,這個現象比起西方世界要更危險得多。


「為了公平,每個人都要考一樣的試。請各位爬上那棵樹。」

在加拿大,從一年級到十二年級(高中三年級)都是義務教育,沒有高一的入學考試,也沒有所謂的明星學校。這裡一樣有會讀書考試的人,也有不喜歡讀書考試的人。可是這裡沒有所謂的班級排名或學校排名,你的成績就只有你和你的父母知道。而且更重要的是,十二年的義務教育是全民教育,而不是精英教育。每個人在學術課目以外,都一定要上技術課目和美術課目的課,而且學校把高中畢業當成是目標,把進入大學、大專、職業學校等當作同樣值得慶祝的額外成就。這樣的環境下,喜歡科學的人可以讀到微積分,喜歡機械的人可以用學校的workshop學維修,還有音樂室、美術室、健身房等等,讓想讀音樂的、想做美術的、相當職業選手的,都能有發揮而自我肯定的天地。

當然加拿大不是天堂,社會不公平的地方還是很多,社會上也是有貧富的差距和社會地位的高低。但是至少在學校我沒有聽過類似「你不好好讀書,小心以後當黑手」之類扭曲、歧視的話。

反觀台灣,絕大多數的年輕人都被逼上升學考試、成績掛帥的爬樹比賽。運氣好,有能力和興趣讀書的猴子才能夠受到肯定,但是其他其實佔於多數的人要嘛就是被迫學會痛苦的爬樹,不然就是陷入自卑或憤恨的苦境。如果金魚因為學不會爬樹而含恨度過一生,甚至步入歧途,這是誰的錯?

社會要進步需要時間,但是對每一隻金魚來講,最重要的還是自己身邊的親人。在以爬樹為尺度的社會裡,如果金魚能夠找到看重游泳技術的環境,並且得到親朋好友的祝福和鼓勵,就算他在猴子國裡可能會過得辛苦,但是至少他會是快樂的。

不爬樹的大象

有一個奇妙的國度,住著各種不同的動物。他們各有天份,在動物國裡各自有自己的角色要扮演。

一天,來了一個男人。他說:我們來舉辦一個比賽,看誰是最厲害的動物。

動物們很好奇,也有點興奮。大家都有想要證明自己最厲害的渴望。可是要怎麼比呢?


男人說:「為了公平,每個人都要比一樣的項目。請各位爬上那棵樹。」

眾多動物中,只有猴子笑了。其他的動物費盡辛苦要學爬樹(小鳥還因此把翅膀折斷,用尖嘴和爪子「爬」樹),但是怎麼樣都比不上猴子的速度。)

尤其是金魚,他如果硬要去試,恐怕連命都沒了還是爬不了一尺。

有些動物因此開始沮喪。「我真的那麼不如猴子嗎?」他們質疑。

「別傻了,你在水裡抓魚的功夫一流,不用跟他們比爬樹也可以很快樂的生活啊。」企鵝的親友鼓勵。他就重拾信心,回到海邊去。

「你一定是不夠努力!我給你那麼多錢去爬樹補習,你竟然連猴子尾巴都碰不到!」大象的家人責備他。大象深受打擊,越來越痛恨這棵樹,痛恨會爬樹的動物,痛恨不了解他的家人,痛恨設定規則的男人,痛恨整個動物國。

他,想到自己一身力量沒有發揮之處,又沒有人欣賞肯定,滿懷怒火忿忿地想:「會爬樹又怎樣?不會爬樹又怎樣?小心我把整棵樹給剷了,再把小看我的人都給踩扁!」

在他越想越氣,正要爆發之際,海豹正好聽到了他的怨氣。海豹說:「大象,你的優點很多,這個比賽如果是比力氣,你就稱王了。但是問題不是在比賽的項目,而是比賽本身。你想想,如果我們和以前一樣,在動物國裡各有所長,扮演各自的角色,而不是浪費心力在某種比賽上比高低,那有多好?」

「可是我不想比也不行啊,我的家人和其他的動物都以爬樹的技術來衡量我的成就。」大象奮怒地說。

「你是你啊!如果你自己能夠在心態上脫離這個荒謬的比賽,善用自己的專長,你的成就一定會比受困於此、活活受氣還要多得多。」海豹說。「像我,我正往海邊回去,到時候也許我會和企鵝比賽抓魚,也許我自己抓魚就很快樂了,但是不論如何,一定會比拼命爬樹還要好!」

大象想想,一方面認為海豹講的有理,一方面還是深恨著讓他受罪的這棵樹,猶豫著是否要屈服于原始的蠻性,不顧後果,剷平對他的不公平。

At a Honda dealer, feeling like a patient

My 10-year-old Honda has been acting weird lately, like an old, weathered man whose body is starting to fail.

The symptoms that I’ve noticed include: morning gas pedal stiffness (it’s hard to get going when I first start the car), irregular rhythm of the engine (it revs itself like a punk kid at the red light), and spastic jerky movements (it switches gears with big spasms). Some abnormal markers on diagnostic tests also showed up (engine warning light, and a “tcs” light which is a mystic acronym jargon that only the specialists will understand).

I suspect that this constellation of symptoms can actually be attributed to a single cause, or at least commonly occur together as a “sticky gas pedal syndrome”. Like any patient under the age of 60 with a new health concern, I googled the symptoms and found that many others have the same problem. Some suggest that it’s an issue with the throttle able, and offered a website where one can buy a new one, replace it for under $10, and avoid hundreds of dollars of dealership diagnostic and repair fees.

But like a scared patient without a courage to take his health into his own hands, nor any ability to judge the accuracy of such information and advise, I rushed to the Honda dealer as fast I could.


The check in process included an agent asking to see my insurance paper, taking down my contact info, asking me some questions regarding the symptoms my car has, and getting me to wait an hour while the doctors, I mean the technicians do diagnostic tests to figure out the diagnosis. Then I will be called, the diagnosis and treatment options will be explained, I will be confused but too timid to ask questions, and say to them “whatever you think is best, doc.”

The parallelism is striking.

There is a paramount imbalance of knowledge. They know every part of my car, and I barely know how to open its hood. They know how much things cost, which parts last longer, which parts you can get from any repair shop for a fraction of the price they charge. I know nothing. In an hour they can tell me: your engine is toast, you should sell it for parts and buy another, or they can tell me: just the cable getting worn out, it will be $200 total. The most I can do is seek a second opinion with another repair shop, and go through the process again.

In this position, I can only trust that they are legit and at least fair about charging me extra for being the official Honda dealer. They can ask for $200 or $1000, either way I will probably have to pay up. They can be nice and explain things to me, or they can be too busy to slow down. They can do unnecessary tests and cost me a fortune, or they can be judicious and use their experience and judgement.

And I’m just getting my car fixed!

Imagine how scared an powerless you will feel in a big hospital with countless doctors in authoritative white coats rushing about, patients screaming in agony or puking their guts out around you, and never ending ringing of the phone, beeping of unknown medical devices, and calling code-blues overhead, waiting for your loved one to be seen and cared for. The wait, which can be hours, is felt to be even longer because you don’t know how much longer it will be. You don’t know if you can go to the bathroom because you may miss the doctor, you don’t know if it’s safe for your loved one to take a sip of water, and you may not even have an idea what’s wrong with your loved one and if he or she will get better (there is no selling the parts and getting a new car here).

What we as health care professionals can do, is at least be mindful of what our patients and their families are going through. For us, it could be the fifth time being woken up to see someone in the emerge with vague abdominal pain, or yet another patient who doesn’t speak English which makes our job difficult, but for them, we can be their first contact with the medical team after hours of waiting for this very real crisis. It’s easy to forget that and lose patience when the worried family press us for that morphine we said we’d give an hour ago, because it’s up to the nurses to fill our orders. We can say: “talk to your nurse”, or “let me see what I can do for you” and find out what’s holding things up, and perhaps start the IV that the nurse is too busy to get around to do.

Also, we should keep the patients in the loop as much as possible. Update them on what’s going on, what the short term and long term plans are, when they can expect which things to happen, and to check for questions often. Sometimes it seems like our job is to check lab results, check vitals, talk to patients about their pain, bowel, and appetite, and write a progress note. But when I update the patient on an improving lab result that they have been worried about, that could be enough to improve their pain, bowel, appetite, and their day could go so much better.

The hour of diagnostics is up, and they found a dirty throttle body, cleaned it at no cost, and just charged me the diagnostic fee of $75. I’m impressed by their time management, which is more than I can say for many doctors. Of course, patients are not cars, and we can’t always be expected to predict how much time a patient will take as we could for cars. But there are many lessons that we can learn from a good car dealership nevertheless.

數學遊戲兩則

我和Tina開車在路上,需要決定晚餐去哪裡吃。到最後有兩個選擇,一是BBT,二是暱稱「漫畫店」的茶棧。

「好,我知道了。我們各想一個數字,誰大就贏。你贏就去漫畫店,我贏就去bbt。」她提議。

「呃,ok好。」我說。

「想好了嗎?不能改喔。這遊戲靠的是良心喔。」

「Ok。想好了。」

「好,那你先說。」她說。

「兩兆。」

「……噗哈哈哈哈…我想九十九。」然後Tina就一直說只有我這種人才會想到兩兆這種數字。

而我就很開心的開到了漫畫店,吃之前還看了幾頁柯南。

吃飽以後,還有頗多蝦仁煎沒吃完,這時候大小姐又突發奇想了。

「好,這次只能猜1到100的數字,大的人贏,輸的人吃。」

我馬上說:100*\(^o^)/*

Tina:(; ̄O ̄)不算,你這次要用想的,還我用說的,而且你不能猜100了。

然後就連她都覺得太好笑了,我們笑成一團。

我說:好啦,我有一個遊戲。你我各猜個數字,加起來奇數我贏,偶數你贏。

然後我竟然連贏三局,真的是運氣很好。不過我很尖頭鰻,最後幫她吃完。

我說:其實我有必勝的方法,剛剛才想到。要不要試試看?

她說:好啊。

我說:好,想好數字了嗎?一二三!

我:三萬兩千…
她:二十。
我:…三百二十一。贏了。

Tina: (O_o)

我:(^з^)-☆

我:我還有另一招必勝的方法。想好數字了嗎?一二三!
Tina: 五萬四千…
我:x + 1, where x = Tina 的數字。
Tina: …三百二十。
我:我贏了。
Tina (做完加法):(°_°)那三百二十一。
我:那我x+1=三百二十二。相加得奇數。(⌒▽⌒)

最後今晚的數學遊戲就在Tina解出她的必勝數字後圓滿告一段落。試問,她要說什麼數字才會必勝呢?

Please don’t play mind games with your doctor

I have taken this sad truth as a fact of life: most patients that I interview have an incomplete idea of many crucial aspects of their health. They don’t know what tests have been done, what they are for, what medications they are on, what conditions they have… And the list goes on.

Take for example, several weeks ago I interviewed a relatively well educated and intellectually intact patient, and this is how it roughly went:

Me: sir, what medical conditions do you have?

Patient: nothing, I have been healthy.

Me, knowing any question worth asking once is worth asking twice: any medical problems in the past?

Patient: nope.

Me: ok… What about your heart?

Patient: oh yeah, I had a heart attack and almost died 5 years ago.

So I went through the rest of his body systems one by one to help him remember other things like heart attacks that are generally considered “past medical problems”.

Me: ok, sir, do you take any medications?

Patient: no.

Me: nothing? No medications?

Patient: no.

Me: what about the diabetes and high blood pressure you told me about?

Patient: oh yeah I take metformin, metoprolol, candesartan, aspirin, Lipitor…

Me: orz…

Why did you say “no”? What did you think my question meant before? What if I was less patient or busier, and believed your answers when you so definitely gave them?

I don’t think the patients meant to do this on purpose. Usually it is simply miscommunication or something being lost in the language barrier. And sometimes we are at fault for asking unclear, ambiguous, or misleading questions.

But every so often, I can’t help but imagine a patient must be pulling a prank on me when I take a history. Maybe one day I will ask someone about their surgical history and they will say: “nothing, doc.” “And what’s this beeping in your chest?” “JUST KIDDING! I have a robotic heart! 😀 GOTCHA!!!”

Only in Taiwan

have I seen the following senario so widely accepted to be the norm:

My grandma, who is a happy and pretty healthy 82 year-old, recently had a cough. She has been afebrile, and maintained good hydration and appetite. She has no constitutional symptoms like malaise and weight loss either. Her cough is productive of some yellow phlegm, and it’s been going on for about a week, so she was prescribed some antibiotics and some antitussives, and was asked to follow up in the clinic in 3 days.

Bread and butter primary care, right?

Except she went to a pediatrician‘s office.

And the thing is, I would not have thought twice about this situation a few years ago, because that is really normal in Taiwan where I grew up. There are virtually no family docs (and no patient knows what family docs do even if they see one) on the streets where medical clinics tend to cluster and where patients go see doctors. There is no concept of longitudinal care either; if the doctor in this clinic isn’t helping, patients will go to the next one down the street. (And if all else fails, or if the patients decide the problem is serious enough, they will present to the best tertiary hospital they can get to.)

So that’s what my grandma did after seeing two different pediatricians and still had the cough. She went to an ENT surgeon’s clinic.

Yes. Ear, nose, and throat surgeons who went through years and years of extra surgical training to operate on some of the most vital (airway) and aesthetically important (face) areas of the body are common go-to doctors for mild URTI in Taiwan.

Imagine the hilarity if that happened in Canada. If a 82 year old woman is referred to a pediatrician for a case of mild URTI or bronchitis? Or, heaven forbid, an ENT surgeon? The primary doctor who made the referral would not even be taken seriously enough to be yelled at. The pediatrician’s or ENT’s secretary (or medical office assistant) would probably politely talk to the primary doc’s secretary and ask him or her to check the correct addressee.

Now, this is not a criticism of the patients or the doctors in Taiwan. Both parties are doing what everyone is doing, in a way how everything has been done. In other words, this is the current medical culture of Taiwan, and no one can be faulted for doing things in the most culturally accepted way.

But just because something has always been like that in the past doesn’t mean it should alway be the same in the future. Think about the downside of having streets of medical clinics run by specialists, advertised to be the former attending doctors or even heads of departments of prestigious tertiary hospitals and academic centers, to whom hundreds of ill patients and their worried families present any condition under the sun. The patients have only their understanding of the specialty title to base their self-referral on. “ENT? Sounds like a good doctor for coughing which is kinda in the throat.” “Stomachache? Probably like the ones I had when I was a kid. Let’s see the nice pediatrician who saw little Johnny last week.”

Well, for starters, the specialists would either go mad and burn out (“WHY AM I SEEING 30 CASES OF VIRAL DIARRHEA A DAY AS A COLORECTAL SURGEON!?”) or become content with being a GP. There goes years of intense, valuable specialty training. Also, the patients are probably getting suboptimal care because of their inappropriate self-referral. They can decide that an internist is the best for their child who is vomiting, but the internist may very well not know the complete list of differential diagnoses of pediatric vomiting by heart.

I can probably go on with the problems with the current medical model in Taiwan, but I think you get the idea. The bottom line is, this model probably poses a serious drain on the health care dollar, creates unnecessary confusion and suboptimal care for the patients, and leads to much headaches and burnouts for the doctors.

The big question is, how do we change it?

That, my friend, is a good question. If you can answer it well, you should consider becoming Taiwan’s health minister.

As for me, I just ordered some delish Chinese take out and will be too distracted after the break 🙂

Yum yum yum yum.

Gender equality

is hard to come by. With an emphasis on “equality”, which I would define as being equal, or the same. In the literal sense, of course male and female cannot be the same, nor is it desirable for male and female to be the same. Gynecomastia, virilization, hirsutism, etc. are symptoms for men and women whose hormone balances tip towards the opposite sex.

Ok, enough tongue-in-cheek. No one means “equality” in its literal sense when they discuss the topic of gender equality. So, what do they really mean?

There is no specialty for which the gender ratio is 50:50. There are more male orthopods, and there are more female ob/gyns. There are more female medical students and general practitioners today, which is a shift from the previous era. Is that inequality? Is it unfair that, under the current admission standard, more female medical students are selected over male ones? Should it be tweaked so that we have a 50:50 split every year?

It turns out that equality is a very difficult notion to define. Perhaps it means that men and women are given equal opportunities, responsibilities, reward, and respect. That is all fine in words but complicated in practice, because men and women are biologically and therefore fundamentally different. The average men have higher water and lean mass content than the average women (actually the medical literature defines “typical men” as white males in their 25-35s or something like that but it works for our argument). The average men have higher testosterone than the average woman. This biological difference results in some phenotypical differences that are fundamental to each gender and therefore difficult to change. Such things include: greater physical strength and higher rate of aggression in the average male, and greater social skills and higher rates of depression in the average female. Note that I have deliberately used the “average” male and female because there are of course variability in each population, and we need to focus our discussion on the populations to avoid “but there are some women who are twice as strong as your skinny ass” type of rebuttal. 

But the fundamental difference between the genders end pretty quickly after basic biology and perhaps some psychology. Beyond that, as we move further away from the XX vs XY end of the divide and closer towards the Office vs Kitchen stereotypes, biology plays a smaller and smaller role. If the average women spend more time in the kitchen than the average men, I’d argue that has to do more with society than with biology. And I’d further argue that since society change as people change, there is no reason why the average women have to spend more time in the kitchen than men. Same goes to earning money. Becoming good doctors. And winning presidential elections.

In other words, I think that differences between men and women are due to two factors: biology and society/environment. (Good old multifactorial, nature vs nurture explanation.) Some differences between genders are more due to biology than society, and some the other way around.

So the issue becomes, what kind of societal pressures is in place to keep men and women live life differently? And which of these pressures are desirable and which are not? For one clear case of societal pressure as example: the guy usually buys the diamond ring and proposes to the girl. Is it a desirable societally-pressured inequality? Should we strive for equality and start a movement where girls propose to guys (with awesome computer gadgets, perhaps)? Another societal and historically based inequality: the baby usually takes on the dad’s last name. Does it have to be that way? Should we make the “family name” the mom’s name or the dad’s name based on a coin toss?

Nah probably not. Either proposal would be kinda weird. But any shifting of paradigm in society would be kinda weird at first, so it being weird doesn’t mean we shouldn’t do it. On a societal level, what gender inequalities should be kept and which ones should be fought needs to be dealt with on a case-by-case basis as our culture evolves.

On an individual basis, though, the above argument does not apply. As I mentioned, people are different and probably follow a normal distribution for aggressiveness, emotionality, assertiveness, chivalry, etc. This means there are probably many women more aggressive than many men, many men more emotional than many women, and so on. How a couple could work out the balance will be unique to that couple, and it may very well carry a wide range of normal.

So when someone say: “men should get their balls back and be manly” or “women should be nicer and more girly” in a relationship, I would say: depends on who you are talking about, what their relationship is like, and on what circumstances you are basing your critique. If you are critiquing on the society as a whole, then I would say: good on ya, trying to shape our culture one facebook comment at a time!