Friday, November 21, 2014

By plane, train or automobile?

I have a conundrum. Well it's not really a conundrum but more of a dilemma. And when I mean a dilemma, it's a First World Problem.

I have planned to do a small tour of the southern United Kingdom some time in the middle of 2015. Being the obsessive compulsive person, I have already mapped out my trip in advance. After landing at Heathrow, I embark to Newbury to see a friend, followed by stops at Stonehenge, Bath, Cardiff, Abergavenny (to take in the majesty that is the Brecon Beacons), Oxford before finally seeing another friend in Cambridge.  That will be six towns (UK doesn't really have cities) in eight days.

The quandary here is my method of transport. I didn't have this problem when travelling in USA earlier this year. With the American public transport system being so poor and automobile travel being so popular in the United States, choosing a road trip was an absolute no-brainer. In UK the railway system is considerably better to make travelling by train a viable option, although a bit expensive. Also adding to the equation is that renting a manual transmission car is cheaper than automatic in UK, and I haven't driven manual since I passed my driving test over ten years ago.

So the logical part of me, researched the problem and come up with the pros and cons of travelling by car or by train

Pros of travelling by car / cons of travelling by train
1. The journey time will be quicker - 10 hours 30 minutes compared to 12 hours 31 minutes by train. And the car journey time is including a trip to the Stonehenge, which is not feasible if I go throughout my whole journey by train. If I was going to include Stonehenge in my train journey, I would need to travel to Salisbury and get a bus from there to go to Stonehenge, and that is not something I want to do.
2. I have more freedom of where I can go and I am not limited by public transport. That would definitely help for certain places where public transport is not great, such as Abergavenny and going to St Fagans Castle in Cardiff.
3. I am not limited to train timetables. I can leave and arrive by car whenever I want.
4. I can select hotels or bed & breakfasts in the outskirts of town If I was travelling by train, I would have to select accommodation near the train stations or near the city centre.

Cons of travelling by car / pros of travelling by train
1. Cost: the cheapest price for an automatic car for the dates I have selected is £190.83. That figure doesn't include additional costs like petrol and parking. If I was going by train, it would be £159.80.
2. I would need to get a satnav for the car. If I get the system through the car rental company, it's going to cost £100. So the car rental companies can F.R.O. A better option is to get a prepaid SIM card for my smartphone and use Google Maps or Waze to navigate. At least that is a cheaper option of about £10 and I was going to buy a SIM card anyway.
3. I need to find hotels or bed & breakfasts with car parks. If the parking is free, that would be even better.
4. With a train journey, I don't have to drive. I can sit down and enjoy the view. I can take a lunch on to the carriage. I can catch up on my sleep on a train. When I drove in USA, I got sick of driving at the final days of my trip. I didn't note how many kilometres I drove when I returned the car in San Francisco but I've gone back and calculated I drove a minimum of 2400 km in eight days. For the same time period, I will be driving about 800 km. Not so bad this time but I still would like to keep my driving experience to a minimum.

My problem is basically convenience over cost. If I was stretching this journey out over a longer period, I would consider going by train. With the tight schedule I'm having, I think I might opt to travel by car.

Monday, November 10, 2014

Patients, and my lack of patience with patients

If you have been following my blog, you will know I'm a general practitioner working in Hong Kong. Like with all people, I get frustrated with my work, from the limitations of how I can help my patients to the absurdity of the bureaucracy I go through. Recently, the thing that makes me question why I chose to be a doctor are patients.

There are various traits of certain patients which get me sighing out loud and leaving me in despair. I really wish I could write specifically about my encounters with patients. Unfortunately doctor-patient confidentiality gets in the way of revealing how idiotic some members of the human species are. Other jobs have horror stories regarding over-demanding customers, ignorant clients and just plain stupid people. Patients have a right to complain about the health care professionals they encounter for being rude, incompetent or unhelpful; so why can't it be the other way around as well?

I have been restrained in writing about work, mainly to appease my immediate family. A while back, my parents and my younger brother read my entries and were worried I might get into trouble for my comments due to the sensitive nature of my work. I reluctantly accepted (but did not agree with) their views and have kept any negative writing about my job to a minimum.

If I do write about my job nature, there is no way I would breach patient confidentiality. I have not, do not and will not divulge any details of my patients, such as name, identification number or exact details of their illness, that will identify them to the average internet surfer who glances across my blog.

Recently my frustration levels have been peaking. Finding other avenues of expression are difficult. Talking to my colleagues over lunch has not been able to alleviate any frustrations. We are all in the same boat and pretty much cannot do anything. Sharing my stories with my parents (without the details) only gets a sympathetic nod, because it is difficult for the lay person to understand what a doctor goes through. Eventually the tipping point has been reached and hence this entry.

I know I'm not the only family medicine doctor to feel this way. Ages ago, a blog site "The Moderate Doctor" (which has now become defunct) published an article "The rules of consulting a GP", which were based on the rules of cycling. Naturally it caused quite a stir on the internet before being withdrawn but not before I saved a copy.

I did not make the rules; I'm just going to comment on them. I'm not condoning or denouncing the rules. These are my opinions only and they do not represent any other doctor, my colleagues, my department or my seniors. My opinions are not perfect or intend to offend anybody in anyway...

1. Turn up on time
If you feel your illness warrants an appointment with a doctor, please turn up on time. When making a booking, the time you are given is not simply for guidance - it is the time of your appointment. Latecomers should not, and will not be tolerated. It is of no relevance that your doctor usually runs at least 30 minutes late .The doctor has trained for over 8 years as a minimum and has earned the right to run a bit late - if you can’t accept this you should find another doctor.
I do have some sympathy with my patients on this one. My clinic hours are 9 am to 1 pm and 2 pm to 5 pm. However the appointment times are every 15 minutes, between 9 am to 12 pm and 2 pm to 4 pm, and the last registration time is 12:30 pm and 4:30 pm. This is to ensure that patients do turn up on time and doctors have enough time to see their patients. People who have booked a 9 am appointment are more likely to wait less than patients who have booked a 12 pm appointment. It is not fair but it is the way the system works. 

Another quirk of our system is that if a patient is booking through the automated telephone system, he/she cannot select a time he/she can come. You are either given a morning or afternoon time slot for the next day and the next day alone. If you are booking a follow-up at the shroff in our clinic, there is more leeway in booking the appointment but even with this there are certain times of day when you can be followed up. There are patients who want to be seen earlier so they can get back to work and their are children who want to finish school before seeing the doctor. Yet the constraints with our system cannot make this happen. I really wished they could fix that system to allow patients to book what time of day they can book and what day they can book. 

Nonetheless there are people who will arrive late for their appointment, either through no fault of their own or intentionally. I know if they were in any other system, they wouldn't be attended to. In our current system, as long as you have registered you will be seen by a doctor. This creates the situation in where a patient might register early and just sod off to do something else. If you are not there when I call your number, I will move on. I will go back to calling your number later. If you have to do certain procedures before you have to see the doctor, such as measure your blood pressure or take your temperature, arrive earlier so these are finished before you see the doctor.

If you are a person who has a lot of time on their hands and nothing urgent to do, either retired, unemployed or going to take the day off due to the illness you came to see the doctor for, I think you can afford to wait a few minutes to see the doctor. If you think your time is more important than your health, then go see a private doctor who probably will attend to your immediately.

Turning up on time applies with anything in life. Nobody likes to be kept waiting, whether it is your friend or your colleague. It is basic courtesy and should be extended to everybody you interact with. During my medical school days, I hated any of my peers who turned up late to lectures and especially those who make a chronic habit of doing so. You're just saying to the world that the only timetable that matters to you is your own.

2. Get to the point
The doctor will not be interested that your tummy pain / sore throat / headache started “last Thursday - no wait, I think it was last Wednesday as I was coming back from the shops after having my hair done and I always do that on a Wednesday as that is when I have the time because on Fridays I can’t do it because I have my toenails done that day etc.”. In fact, the doctor may not be that interested whatever you say but your best chance is if you get to the point - fast.
Our seniors and trainers like us to ask open questions when interacting with patients, such as "What brings you here to see the doctor?" and "Can you tell me more about your symptom?" This type of questioning will probably yield information the doctor probably wouldn't have asked and gets the patient to be more involved in the consultation process.

That is in the ideal world. For most doctors, I think the general consensus is patients never get to the point. I don't mind them rattling off information, as patients will not know if the information they provide is relevant or not. I can see patients are anxious and might not remember they've mentioned they had chest pain for the fifth time.

What I would like my patients to do is actually answer the question I've just asked. No patient seems to answer a Yes/No question with the appropriate response. Sometimes I will ask "Do you have any chest pain when you are running?" There are many responses that will frustrate a doctor, such as "I have difficulty breathing" - that is not what I asked, a simple "Yes" or "No" will suffice. If I wanted to know if you have any difficulty breathing, I would have or will about to ask that. There are patients who respond with "Yes, I do", which my immediate follow up question is "Is it really chest pain when you are running?" and most of them reply "No, it is just a difficulty in breathing."Again, this is another response which makes me want to tear my hair out.

The worst scenario is when I ask "How long has this been going on for?" and the answer is "Oh, a long time." This doesn't help me as 'a long time' can mean a few days to a year, depending on the patient. I rather you say "let me think" rather than "a long time".

The above situation is why general practitioners are taught to think about "RICE":

Reason: why they have come to consult their doctor. This could be a particular symptom or a fear of a certain disease
Idea: what they think might cause their symptom or problem.
Concerns: what are they worried about. This could be a particular disease or be more social / psychological.
Expectations: how they (the patients) want us (the doctors) to help them, either through reassurance, treatment or investigations.

All that I am saying is get to the point and answer the questions relevantly. If you do this with your doctor, you can probably cut down any time wasted and the consultation will be more efficient. You will have more time to spend doing what you want instead of waiting in a clinic seeing a doctor.

3. Lists
Do not bring a list. Do not refer to a list. Do not say you have forgotten your list. Do not mention the word, list, in a doctor’s surgery. If you have a catalogue of ailments requiring them to be listed, you should probably be seeing a psychiatrist rather than a GP. If you are unable to remember your symptoms and have to write them down, they are unlikely to be of great significance.
I don't mind if a patient makes a list, as long as there aren't too many items on the lists. A list allows the patient to remember what he/she has come for and gives the doctor a framework to deal with. I rather have a patient come to me with the phrase, "I have three problems I want to see you about today" rather than a patient who says, after I spent a lot of time sorting out his/her first problem, "Another thing, I want you to take a look at this..."

There are situations when a patient says, "There was something else I needed to see you about but I can't remember." If you genuinely can't remember what you came to see a doctor for, then it isn't important.

Remember also doctors have a set time frame to work with. The doctor has only a finite amount of minutes to sort out your medical problems. Don't accumulate your symptoms and then see a doctor. There are people who don't see a doctor for several years and when they eventually come for a consultation, they have four problems which have lasted for ages. If you think your symptom requires somebody to see it, don't delay and book appointment as soon as possible. Don't wait until "you have time" to see a doctor, otherwise it might be too late

4. Alternative therapy
Do not ask your doctor what he/she thinks of homeopathy. They may be too polite to tell you - but I doubt it.
I don't mind patients going to seek alternative treatments. If you think your flu symptoms can be alleviated by herbs, then go see a Traditional Chinese Medicine practitioner. If your back ache is improved by a chiropracter or a bone setter, then continue to go see them. Western medicine has its limitations and cannot cure everything.

Just don't ask a Western medicine doctor's view on alternative therapy. We have no frame of reference and the concepts from other fields of medicine don't apply to our field. I get a lot of patients asking me if their ailment is due to "yeet hay" (熱氣), which translates to English as "hot air". This is a Traditional Chinese Medicine term. It doesn't apply to Western medicine, so stop asking us. It is the equivalent of asking who is a better sportsperson - Cristiano Ronaldo or Michael Jordan. They are from different sports and different eras, so they can't be compared. 

5. Man up
Life is tough. We all get ill. Usually we get better. Sometimes we die. There will be a lot of people considerably worse off than you. You are not living in a displaced refugee camp. Consulting your doctor should be a last resort, not a first resort. Look after yourself, prepare to feel unwell occasionally and... man up.
There are legitimate claims to be off work due to illness: when you are afflicted due to a work injury, you are recovering from major surgery or you are battling a significant illness such as cancer. On the other hand, there are times when patients come to my clinic with just a runny nose and ask for three days' sick leave. To avoid kicking up a fuss, I give them the sick leave but only for one day. There are times when I wanted to say to that same patient, "I went back to work with a broken finger and you want to take time off when you have a sniffle?"

I want employers / companies / organisations to limit the amount of sick leave a person can take each year. Somebody should examine the number of days each employee takes off for sickness and analyse how much sick leave each person can take. I'm proposing 6-8 days per year. After that amount has been succeeded, you should get pay docked off. The above amount would be for small things such as common colds or diarrhoea. Bigger stuff such as major surgeries and injuries will come underneath a different banner and I still haven't thought of a good system for that.

Before anybody says I'm a hypocrite for taking time off for my broken finger, I would have happily accepted (and I had expected it) my pay to be docked for the time I was off. It is only fair for my colleagues who pick up my slack and for the patients who have one less doctor to see.

6. Newspaper clippings
These are useful for lighting fires and wrapping up fish and chips. They are not to be brought to the doctor. Never ask your doctor if he has read a particular article - doctors do not make a habit of picking up evidence based medical breakthroughs from the national rags. Any doctor writing for a newspaper clearly has lost touch with reality and cannot be relied upon to provide a sensible opinion. If you mention the Daily Mail, you can expect to be thrown off your doctor’s list.
The more patients who present to me ideas they have read in the newspapers / magazines or watched / listened to on TV / radio programmes, the less I believe in the media. "Advertising is legalised lying", as H. G. Wells put it and I'm inclined to believe him. It's the reason why general practitioners in Hong Kong government clinics hate the Hirudoid adverts on TV. The ads claim Hirudoid cream can help with muscle pain or varicose veins, where there is no scientific proof of it. It is also not helped that specialist doctors such as orthopaedic surgeons don't follow this evidence and prescribe Hirudoid willy nilly to every patient they see.

The basic principle - don't believe in everything you see in newspapers. Not everything in the lay public media is true. Newspaper articles are not fact checked and peer reviewed by an independent body. That is what happens to medical evidence. If there is a miracle cure or a new wonder drug, the doctors would have already known about it.

7. Moaning about hospitals
Do not moan to your doctor about the delays in the hospital system, not receiving appointments, or having to wait months for an operation. Your doctor already knows this so do not waste his time telling him. Complain to the hospital or your MP - or write to the Daily Mail.
If you think there is a problem with the health care system you are in, whether there are not enough doctors or nurses to see patients, the clinics should prescribe better medication to their patients or the long waiting times to see the specialist, don't moan to the general practitioners. We already know there are fallacies with the system. The people responsible for these problems know there are problems. There are always issues with fixing these problems, which are always time, money and not enough qualified staff. I want my patients to have the medication that is most appropriate to them and want them to see the specialists as soon as possible but complaining to me won't make it happen. Write to your local politician or to the head office - that is most effective way of getting your point across. General practitioners are just too busy seeing patients.

If you are whining about the long waiting times or the lack of care in the public sector, go private. If you think your health is that important to you, spend money on it instead of spending it on that new electronic tablet you just brought that is just replacing the old one you just brought a year ago. Prioritise where you spend your money.

8. Bugs
Yes there is a bug around. Do not ask this question - ever. There are always bugs around, life is full of bugs, you will get your fair share, your illness is almost certainly caused by one, there is no treatment available, you have wasted the doctor’s time. Again.
People get ill - that is a fact of life. Even if you exercise and eat right, you will have a common cold one day. You are not totally immune to all germs out there in the world, even if you are the healthiest person in the world.

And don't ask me why your kid is always ill. It is not uncommon for kids to have a common cold every 2 months, especially if your kid sneezes without covering his/her mouth or picks his/her nose and eats the contents. Children are not the best obeyers of hygiene rules and it shows.

9. Referral
Never say to the doctor “I have just come to get a referral”. If this is the case - refer yourself. If you discover you are unable to do this, you will realise that this is because you will need to seek the opinion of a suitably qualified medical practitioner (your doctor) to ascertain whether your mystifying collection of symptoms justify the expense of spending taxpayer’s money on a specialist opinion. If you would like to shortcut this process - enrol in medical school. If you have private insurance, it is quite likely your doctor will refer you just so they can shorten the consultation with you, freeing up time for an extended coffee break.
The general practitioner is not a stepping stone. In a pubic health system setting, he or she has to decide whether or not your problem requires specialist care. There are a lot of situations where the general practitioner can sort your problem without the need for the specialist. If you want to see a specialist just because you want an opinion, you are wasting the time of the general practitioner and the specialist, and the finance and resources of the public health sector. Again if you think it is so important that you see HAVE TO see a specialist, go private (a recurring theme). If you are asking a referral just because you want to see a specialist, don't be too surprised if your referral is stratified into the low priority group.

10. Tiredness
If you complain of feeling “tired all the time”, you can expect your doctor to glaze over, look far in to the distance and turn to his iPhone to check for any updates to his large collection of apps. Feeling TATT is not a medical condition - it is simply what happens in life to everyone at some stage. The fact that you have felt the need to consult your doctor about it is a very worrying sign and further confirmation to your doctor that you need to need to consult #5.
I have a little bit more sympathy for patients in this category but only just a little. Tiredness is a valid complaint to come and see a doctor about. It is an easy symptom to be dismissed by a lot of doctors. It's the same with dizziness, numbness and headache. They are symptoms that are very vague, happen a lot, are difficulty to describe and have a hundred different reasons why they occur.

What most patients don't accept is that there might be a psychological element to them. Problems with work, family and relationships could contribute and stress can manifest itself in the form of physical problems.

11. Turn off your phone
It is generally considered to be polite to silence your phone when in a consultation with a doctor. It may be frowned upon if you consider it necessary to answer a call when in the middle of a consultation. However, this is more acceptable than walking in to the doctor’s room whilst in the middle of a telephone conversation and sitting down without acknowledging the doctor’s presence.
I don't mind patients have their phones on during the consultation. I have my phone on during office hours and when my phone rings, I look who it is via caller ID. If it is nobody I know, I end the call. That takes about a second or two, and it doesn't disrupt the consultation. If a patient's phone goes off and the patient ends the call or takes the call to say they are busy and will phone back, that is fine. If you take the call to have a conversation, don't be surprised if I grab the phone and chuck it out of the window.

12. Own your own health
Your health is your responsibility. Do not try to pass this responsibility to anybody else - including your doctor. They will try to help you achieve good health but it is not their fault that you are overweight/smoke/smell or suffer from natural hair loss - please accept this gracefully and deal with it. If in doubt refer to #5.
If you are worried about your own health, take some responsibility and take care of it. Doctors are there to help you. We can't force your to take medication or undergo operations. Don't be surprised if you are suffering from hypertension, diabetes, high cholesterol, heart disease, alcoholic liver disease and chronic bronchitis if you continue to eat poorly, become a couch potato, smoke a pack a day and down several pints of beer per night. Don't be surprised if a medical condition worsens if you don't take your medication or don't go to your follow-ups. This is why there was a vocal opposition from doctors not to give lipid lowering drugs to everybody, even for people with a low risk of having cardiovascular disease. People wouldn't adopt any lifestyle modification if they knew they could take a pill for all the medical ailments.

It is your responsibility to remember to come to your appointments for follow up, blood taking or other assessments. It is fine if you miss the occasional appointment - we all do. People will have to miss their appointments for work or other events. Nobody is perfect to remember all their appointments in life. However if you continue to miss your appointments, don't be surprised if the rebooked date is a long way off.

13. Depression is an illness
Do not confuse depression with feeling a bit down. Depression does not last a few hours or a few days - those are the natural fluctuations of mood that we all experience. We all have bad days. Do not bore the doctor with your mundane stories of life being unkind to you - see #5.
I think this should cover all mental illness. There are a lot of people, most of them in the elder generation and of the lower socioeconomic class, that are resistant to the fact they might have a mental illness. Depression, anxiety and psychotic disorders can affect anyone, young to old, male and female, from the normal guy in the street to the millionaire in his/her penthouse. There is a biological factor to the psychiatric conditions, which is why doctors prescribe medication for this illnesses.

The only way I can get people to think about psychiatric illnesses like medical illnesses is with this analogy: if your blood pressure is too high or too low, it is a medical condition which needs to be treated. It is the same with blood sugar and temperature. So why can't it be the same with mood or anxiety? If you mood is so low that it is affecting your sleep, appetite and your functioning capability, don't you think we should treat it?

And don't think mental illness is a rare disease. 10% of the population will suffer from depression during their lifetime. The current prevalence of depression is about 1-2%. It is likely you will know somebody who has depression.

14. Entitlement
The NHS does not owe you a favour. You are not entitled to anything. The NHS and your doctor are there to help in your hour of need - not because you feel you deserve a payback. Don’t even think of starting on the “I pay my taxes" routine.
Just because something is there, does not mean you are entitled to it. That is why public health care systems don't offer breast enhancement surgeries. And don't think, just because you don't use the health care system often, that when you get an illness you get the best drugs. You will get what everybody else is getting.

15. Scans
Do not request scans under any circumstances. You are not medically qualified and scans will not unearth every medical problem. If you request a scan, it may alert the doctor to a deeper, more important, underlying medical problem - such as complete lack of insight and grandiose ideas of thinking that you have a medical qualification. It is likely to lead to you being assessed under the mental health act.
I am bemused the lay public think science has progressed so far that ordering a simple blood test or ordering a scan will uncover what illness you have. If that is the case, do you think we would still have doctors around? Wouldn't the government just get rid of doctors and set up vending machines so the public can just order which investigations they want? Investigations are just a tool to aid doctors in their diagnosis. Most of the time, the investigations are there to confirm what doctors already know and to exclude other causes.

There have been cases when I have ordered investigations for a patient, the results come back as normal and the patient is disappointed as there is nothing to explain what is wrong with them. There are things that science and medicine cannot always explain. If doctors had an answer to everything, do you not think the medical community would have cured all known illnesses by now?

16. Breathe normally
Try to behave in a normal fashion when your doctor asks to examine you. If he is trying to listen to your chest with a stethoscope, he is attempting to hear the movement of air through your lungs. To enable this you will need to open your mouth and inhale deeply. You will then need to exhale - do not forget this part otherwise you will go blue and feel faint. When inhaling, you should not try to touch the ceiling with your shoulders by shrugging hugely - just simply breathe in a normal manner.
If your doctor is listening to your chest with his/her stethoscope, just breathe normally. If he/she cannot listen, he/she will ask you to breathe deeply/slowly depending on the situation. Also your doctor cannot hear you talking through the stethoscope.

17. Dress appropriately
Please try to consider the most appropriate clothing for the weather conditions and the body part that might need to be examined. A purple satin thong might look great on the Copacabana, but not so good on the doctor’s couch if you have a painful testicle. You might also wish to consider removing some of your 23 layers of clothing prior to entering the consulting room - it’s amazing what you can cram in to 10 minutes but there is little point in spending this precious time turning your clothes the right way round.
If you know you are coming to get your knee examined, don't wear jeans.

18. Use normal English
Your doctor will not expect you to use full medical terminology, but do at least try to use recognisable words and phrases. “I did toilet this morning” is not an appropriate way to describe a bowel movement. “Thingy bob” is not a helpful description of anything. It is perfectly reasonable to use the correct anatomical words to describe sensitive parts of your body. Do not confuse the word “stomach” with “abdomen” – they are not interchangeable. If in any doubt, simply point and ask.
This may not be applicable in Hong Kong but this rule basically implies just to use simple language. Doctors don't expect you to know medical terminology but we do expect you to actually tell us what is wrong with you. Don't say "I have a cold" when you actually mean "I have a runny nose".

19. Medication
You may find yourself needing to take medication on a regular basis. Try to familiarise yourself with the preparations and the reason for taking them. Keep a written list of your medication on you at all times. Under no circumstances should you try to pronounce any of the tablets without referring to your list. Do not attempt to spell these medications to a doctor over the phone - this seems to induce an acute attack of dyslexia even in the most competent of patients. There are approximately 2547 different types of “little white pills” and this is not a helpful description.
If you are taking medication and want to refer to it, bring the drug's name along to your consultation. Doctors cannot always identify the drug from the appearance alone. It is like asking you to identify sugar and salt from the appearance alone. Also don't say "the previous medication" either. If you want to be exact, bring the name of the medication to the consultation.

Having said this, I have had to learn the appearance of most of the common drugs I have prescribed. Our department has also tried to make it easier by photographing all of our main drugs and putting the photos on our internal website to help with situations like these. Yet it doesn't help that the Hospital Authority continually changes the supplier of the drugs, which will affect the appearance as well.

20. Symptoms
Do not confuse symptoms with a diagnosis. It is your role to describe your symptoms to your doctor, and his/her role to try to formulate a diagnosis. This will not always be possible as patients often present with normality, believing that they are unwell. Avoid phrases such as “I have an ear infection” when in fact you simply have a painful ear, or “I have a chest infection” to mean that you have a cough.
The two symptoms I hate the most are numbness and dizziness. It's because patients expect that numbness and dizziness is the same with everybody, when there are variations. Numbness can mean loss of sensation, pain, pins and needles sensation, ant-crawling sensation and being wrapped in cotton wool to name a few. Dizziness can mean vertigo (the world is spinning around), unsteadiness, giddiness and lightheadedness. If the doctor asks you to describe something and you can't, he/she will give you some options. It is best to try to select at least one instead of saying "it's just numbness/dizziness".

21. Vaccinations
You should take up all offers of vaccination or immunisation. If you decide not to, you should never darken your doctor’s door again. Do not come bleating to the doctor when your child goes down with measles - where’s your dandelion munching NCT practitioner when you really need them? 
If doctors didn't think vaccinations were helpful, would we still be offering them? If you are of ill health or are genuinely concerned about catching an infectious disease, get yourself vaccinated. If you still think the measles vaccine causes autism, please go read the literature again. Don't come crying to the doctor if your child gets an infectious illness that could have been prevented by immunisation.

22. Bodily secretions
Do not bring these in to the doctor’s room unless specifically asked to. If the doctor wants to see your baby’s 2-day old nappy he will ask you. Do not offer this, and continue to unravel the package in the doctor’s room even after he has told you it will not help with the diagnosis. Listen carefully to instructions on how to collect a specimen if one is requested - use the appropriate containers. Stool should be in a pot, not deposited freshly in a plastic bag and put through the letterbox. You would think that this would not need to be pointed out, but sadly, in our experience, it does.
Thankfully I don't see this much in my practice but I do get the occasional patient blowing his/her nose into a tissue and showing me what the nasal secretions look like.

23. Gifts
It is perfectly reasonable to offer a gift to your doctor. Do not expect anything in return.
 Actually not many doctors want gifts. Doctors are adequately paid. Just your appreciation is enough.

24. Bloating
This phrase should not be heard in a doctor’s surgery. The exception is in some females over the age of 50. It should not be heard from anyone under this age, and never in a male.
I think the complaining about bloating is a British cultural reference. I get patients presenting to me about bloating and I think it is a legitimate complaint. It can cause distress and there is medication for it. 

25. Requesting letters
Your doctor’s NHS role is to provide you with appropriate health care. It is not to provide letters for you to any organisation that requests one. This includes airlines/car hire companies/gyms/drama schools/insurance companies/beauticians/housing departments/solicitors/trichologists or bed manufacturers. Any such requests are likely to be met with a guffaw, a long delay and a suitable bill.
Unfortunately this is never the case. If there is a claim that requires a letter from a doctor, then we need to issue one. I think requesting letters regarding one's health is reasonable.

26. Over dramatisation
Try to avoid over dramatisation. Phrases such as "the worst sore throat ever" or "I thought I was going to die", will undoubtedly be met with a confused look from the doctor as he is faced with a normal looking pharynx, or leave him scrabbling around searching for even the slightest remnant of a significant clinical sign on examination. The doctor will certainly have come across many, many more severe clinical cases than yours, and he is likely to point you towards #5. 
Thankfully I don't think this happens at all.

27. Cancel if you are better
If your symptoms have improved significantly prior to the appointment with the doctor, it is perfectly acceptable to cancel your appointment. Interesting as it may be to you, the doctor will have no interest in an historical set of symptoms that have now miraculously disappeared. Time, as they say, is a great healer - if it has done it's job then give yourself and the doctor a 10 minute break.
There are a number of people who make appointment but don't come for various reasons, either they are too busy with work or their symptoms have resolved. If you can't come to your appointment, cancelling will free up a space for somebody who genuinely needs to see a doctor. 

28. Dental problems
If you have a dental problem, please consult a dentist not your doctor. Your doctor is not a shortcut to antibiotics or pain relief. He will very likely have less dental experience than your vet who would probably be a better option for you. Just because the doctor is "free" does not mean that he can manage all of your problems - dentists are there for a reason, we believe. The lack of easy access to NHS dental provision is not your doctor's fault - he has enough problems to deal with without trying to sort out the shortfall in other areas of the NHS.
It's the same problem with the Hong Kong health care system. There is not a public dental care system and everybody has to go private. I will get a number of patients who want me to refer them to the dentist in the public sector for their dental problems, and the public sector only deals with certain tooth problems such as teeth injuries (chipped tooth, etc.) or civil servants. The whole system needs a revamp.

29. Familiarity
The doctor/patient relationship is a complex one - let's try to keep it that way. Some doctor's will not take kindly to being addressed by their first name - particularly if they have not met you before. It might be sensible to ask the doctor if it is appropriate to address them by their first name - as a rule of thumb this might be considered after you have been consulting them for a period in excess of 25 years.
Again, something that doesn't occur in Hong Kong (thank goodness). However it would be nice to be called "doctor" instead of "mister".

30. Furniture
Do not move the furniture in the doctor's room. This has been carefully placed to ensure the doctor can see, hear and examine you in an optimum fashion. Moving the chairs can disturb this ecosystem and upset the very heart of the consultation. Do not encroach on the doctor's desk, borrow pens without asking, or assume that your children can turn the room upside down and leave without a passing comment.
I haven't encountered patients dramatically moving seats but I have had children fiddling with stuff on the desk. Kids will be kids - they will want to muck about with stuff. I'm fine with that, as long as they don't break anything. And most patients who want to write something down will ask if they can borrow a pen. It's better than waiting for them to find a pen in their own bag, which can take ages.

31. Appointments
Your appointment is for you. The doctor will be expecting to discuss with you any significant problems that may need medical intervention. He will not be expecting to discuss your child's illness, or to see your partner at the same time. Unless specifically mentioned at the time of booking the appointment, there is unlikely to be a "book one, get one free" offer. Just like tickets for the cinema - book for two people if you need to. If you find yourself starting a sentence with " I know I shouldn't do this but" , you are probably not going to get the response for which you were hoping.
I have had this problem only a few times and I always keep saying, "I can't help this person unless I can see him/her and ask about the details." I just had a patient bring his mother's investigation report to look at and I said the same thing. I need to know the concerned person's full medical history, the current condition and to perform a physical examination before I know what is wrong with him/her.

I've also have relatives come in for patients for various stuff, such as to collect medication or to ask for investigation results. This situation breaks all kinds of rules. What if the patient has low blood pressure already and I continue to give him/her the anti-hypertensive medication which could cause a whole lot of problems? What if I the patient didn't give the relative permission to see his/her investigation results, which would breach doctor-patient confidentiality? There is a reason why telephone consultations haven't taken off in Hong Kong yet; it is fraught with issues.

32. Urgency
The urgency of an appointment is defined on medical grounds - not based on upcoming events in your social calendar. The fact that you are flying to Barbados in 2 days does not open up a new range of treatments to enable your doctor to manage your minor symptoms relating to a viral infection or the common cold. In addition to this, there is no medical evidence to support the fact that if you have an impending holiday / wedding / birthday your common cold is more likely to turn in to life threatening pneumonia. The doctor is still perfectly correct in these situations to point you in the direction of #5.
Every patient thinks their condition needs urgently seeing to, requesting the best medication or to see the specialist right away. It's not going to happen. If you are in the public health care system, the medication prescribed will be based on effectiveness and cost. If you are in the public health care system, your referral to the specialist will depend on your symptoms and not necessarily on severity. Everybody thinks their back pain is the worst, but you've got other people to contend with.

I really wish these issues were in a minority of my patients but to be honest, at least everybody shows some issues that have been mentioned. I understand that patients are not knowledgable in medicine and are worried about their diseases. Yet patients also have to have realistic expectations of what a publicly funded health care system can provide and that medicine cannot provide a cure or an answer to everything.

Monday, October 20, 2014

Vacations I want to go on.

For the past two vacations I have had, going back to work was so bad I suffered a relapse of my depression. Thankfully I'm much better but still having residual symptoms at the moment.

I probably shouldn't go on such fantastic holidays such as a three week road trip in the Western United States or going to see the Formula One Singapore Grand Prix, with concerts by Robbie Williams, John Legend and Jennifer Lopez. Despite all this, my mind wanders to what trips I want to go in the future. Currently I'm planning going to back to the UK between March and May to see my younger brother and his family, with a quick detour to Wales.

Yet there is always another part of me think about other ideas about where I can go on holiday...

1. Edinburgh Festival Fringe
Having turned my back on movies and started enjoying British comedy more, the Edinburgh Festival Fringe has more appeal for me. I want to see shows my comedians I watch on TV or listen on the radio. I want to see the next big thing in comedy and the best place is the biggest arts festival in the world. It would also give me a chance of visiting Scotland.

2. Melbourne International Comedy Festival
Like the Edinburgh Festival Fringe, the Melbourne International Comedy Festival is another arts festival I want to go to because it's a hotbed of comedy talent. I was planning to go in March 2015 to coincide with the ICC Cricket World Cup final. I had already researched the attractions I wanted to go to, including the National Sports Museum, the Melbourne Aquarium, the Melbourne Zoo and the Royal Botanic Garden. However having spent a gazillion dollars on my last two dalliances, I've postponed going to Melbourne to a later date.

3. Scandinavia trip
I was planning this trip recently, mainly because I have never been to Scandinavia and I wanted to see most of it in one go. The simple trip would be Oslo - Stockholm - Copenhagen but I have an extended version here. I wanted this to be a road trip but having looked at the exorbitant prices of car rentals, it would be most likely done by train instead.

4. Eastern Europe
Due to troubles in the Balkans and the recent infighting in Ukraine, the only places which have any appeal to me in Easter Europe are Budapest, Krakow and Prague. Budapest and Prague have reputations of being beautiful cities and Krakow is most famous for the Nazi concentration camp. I remember going to the Dachau concentration camp in 2003 and it was horrifying and eye-opening at the same time.

5. Eastern USA road trip
Returning to the theme of the road trip, I had ideas of this way back in 2005. The main cities would be Boston, New York City, Philadelphia and Washington D.C. but anything could have been tagged to that.

6. Caribbean cruise
Another idea I had ages ago. Even though I can't swim, I would love to lounge around and go to exotic locations. I even did the research and found that it would be very expensive to go alone. It would be best if I could go with my significant other on this one.

7. The Pan American Highway
Probably the ultimate road trip for me. I don't want to transverse the whole of the American continent; only the Central American portion between Mexico and Panama. Again I need the time, money and logistics for this. The main worry for me is the car - do I rent one and return it at the end, if it is possible, or buy a car at the beginning and sell it at the end.

You can get the general theme of my fantasy vacations: either comedy festivals or trips cramming as many places in one time.

Wednesday, October 01, 2014

A vicious cycle

It's happening again. Every so often, I have "episodes. The duration between these episodes vary, from every two months back in my final university years to several months in recent times. Most of the times these episodes are not very intense and after a night's sleep, I "reset" myself and it is like nothing has happened. However this episode has been very severe, so severe in fact that I had to take a day off last Friday.

What am I talking about? The vicious cycle of my depression. The symptoms during the episodes are the same. I dread the oncoming day when I wake up with all the problems that I will encounter. I have difficulty getting up in the morning and lay there in bed, willing myself to start the day. When I get to work, the situation is no better. Throughout the whole day I just want to get to the end, rushing through my consultations as quickly as possible and saying "Yes" to almost every request and every question from my patients. After my work day has ended, there is still job-related tasks I need to do and I try to hide away from the responsibility.

Those are just my behavioural symptoms. Then there are the psychiatric symptoms of pervasive low mood. I laugh at jokes and watch TV shows / listen to radio comedy programmes with amusement but my baseline is always sadness. I completely feel drained all the time and always use weekend afternoons to nap - not a good use of my free time.  What hampers me most is the poor motivation and abysmal concentration. I have difficulty initiating tasks and maintaining focus is a chore. Even with programmes I like, playing them only results in pausing them after a few minutes. All of these psychiatric symptoms are surrounded by the baseline feeling of hopeless about my future, something I'll go into detail much later.

During intense depressive episodes, I get the biological symptoms. There is the chest ache and difficulty breathing but the somatic complaint I most commonly feel is the muscle ache in my arms. When I have the aching sensation in my biceps, I know I have a severe form of depression hanging over me. My appetite is the same, which I'm grateful for. I had a similar depressive episode 10 years ago which made me binge eat and caused me to gain 10 kg in a few months, which I have never been able to shed since. On the flip side, I'm excessively sleeping with wanting to go to bed straight after I had my dinner and evening shower at 21:30. Nobody of adult age goes to bed at that hour.

So why has this come about? My mum reminded me why I have these severe depressive episodes, A piece of advice I have forgotten since my university days, attending my psychiatrist and clinical psychologist. I have a tipping point regarding my depression - go past this point and you have the sombre side of me. I get closer to the tipping point if I have stress. I can tolerate low levels of stress, yet the more stressful things happening to me at once, the closer to the tipping point I get.

Lately my tipping point has been breached. There is the underlying work dissatisfaction, the worry about my future, the resentment of myself for being single for the rest of my life, the annoyance of still living with my parents when I'm in my thirties and the list goes on. Recent events include not finishing my protocol for the audit I have to do in my clinic for my GP higher training, starting an online diploma course on dermatology (skin diseases for the uninitiated readers) and just coming back from an excellent weekend trip to Singapore watching the F1 Grand Prix. I really should stop going on holidays, or more exactly going fantastic holidays where I do something outrageous. When I come back from a vacation is always a downer. I know everybody suffers from this but for me, I don't think my brain can handle the situation well. I really should go on shitty holidays from now on, or not go on holiday at all.

Thankfully for the past few days, my mood has improved. I still feel grumpy when I go back to work but at least I can do my job (just).

I hate going through these episodes. I always wish this is the last episode but I always know that it will always lurk around the corner.

Friday, August 22, 2014

Sick leave

Lately I have been feeling guilty. During a six week period over this summer, I have taken three separate days off due to illness. Although all three days were legitimate reasons (diarrhoea, diarrhoea and, guess what, diarrhoea), I still feel bad about taking time off work due to being sick. I loathe to take sick leave. If a doctor takes a day off for illness, there is one less doctor to see patients. Eventually this will create a backlog of patients that need to be seen and sometimes other doctors have to bear the brunt of this situation.

During my hospital rotation of two years, I only took one day off due to genuine illness. I still had to take sick leave off when attending my psychiatrist appointments but my work schedule can be arranged beforehand. I was even better during my first two years of general practice, where I took ZERO days off due to illness (but still taking time off to see my shrink). That was a statistic I could feel smug about.

Yet over the past year, I had to take twenty and half days of sick leave. That was over three times the amount I had taken in the prior four years, if you included the advance sick leave I had to take for my psychiatrist appointments. I know growing old means you get more aches and pains but a 300% increase was just taking the piss. However the figures are skewed as I broken my left ring finger that time, which required to me take eleven and half days off work. Then I had to spend another eleven half-day sessions (five and half days in total) for following up with the orthopaedics surgeon, the occupational medicine doctor, the physiotherapist and the occupational therapist just so I can get back to normal. Seventeen days were taken off work just because I broke a finger!

Mainly the reason why I hate taking sick leave is because I hate people who take sick leave, especially for trivial matters. Unfortunately I see this a lot due to my job nature. There are patients who, within the first signs of a common cold, come to the doctor immediately and demand (not ask but DEMAND) a couple of days off work just because they got a blocked up nose. There are people who genuinely should have sick leave, from getting injured at work or having diarrhoea and fever while working in a kitchen. Yet there are people who frequently take time off work because of benign symptoms. Don't those people realize if you are taking time off work due to trivial illnesses, there might be something ELSE wrong with you?

There should be a limit of how much sick leave you can take during a year. After that certain amount has been breached, there should be a deduction in your salary. I was happy to accept I would take a cut off my salary for the month I was out due to my broken finger but it didn't happen. I think there should be a look at people who take too much time off due to illness.

Wednesday, July 23, 2014

Annual leave

In the past year, I have been sent emails (twice) by Human Resources to take some time off. Not because I'm working too hard but I have accumulated so much annual leave, it had become a concern to them. It is a rule (which I never heard of) that government employees need to take 10 days annual leave to avoid accumulation. I don't know how they going to enforce this rule. It's not like they can force you to take annual leave or take away your annual leave either. The only problem is when you change contracts, the annual leave would not be transferable. This would mean the department would have to give you time off to clear your annual leave before your contract expires, and that becomes a logistic nightmare, or they have to reimburse you financially for your annual leave, which they don't want to do.

At one point, I had around 50 days of annual leave, which meant I could have gone on holiday for two and half months. Or I could have split up the annual leave and not come into work on Saturday mornings again for the next two years. Thankfully for Human Resources, I have taken time off for my examinations and my longest holiday to bring the figure down to 30 days.

I was talking to a colleague about this "problem" (and what a problem to have). Maybe the reason is that I don't have a family or any responsibilities. They have to take time off to take their kids to doctor appointments or school interviews. Also they need to take time off to spend time with their children, either during the summer holidays or going on vacation.

I pondered this and looked at my annual leave record. I have never taken my full quota of annual leave in a single year. Even when I was doing my hospital rotations, where we are suppose to clear our annual leave so the quota doesn't get unfairly passed on to the general outpatient clinics, I have never cleared my lot. I have spent about 3 weeks of annual leave on examinations (plus some extra days as examination leave). The others have been spent going on vacation but that is about once per year. Some people have gone on 2-3 holidays per year. One year, I only spent just over the minimum requirement of annual leave to avoid Human Resources badgering me.

Perhaps I'm a workaholic. I do arrive to work very early to tidy up patient summaries, even though I don't have to. I have volunteered for overtime, even though I personally don't need to, and have used a weeks' annual leave to do overtime. I never take a day or two out just to relax at home. Hopefully this will be remedied as I will be taking some time off this summer to spend time with my dogs when my parents are away.

Thursday, July 17, 2014

Planning a Melbourne trip

I've been wanting to go Australia for a long time, since I've not been there since 1989. I have never been to Melbourne and next year has so many sporting events in the area. There is the annual F1 GP and Australian Open but also the Cricket World Cup and the Asian Cup will be held in Australia, with a few matches in Melbourne.

I was thinking of attending the Australian Open in late January while going to see an Asian Cup match. Yet I plan to go on a short trip in early November, so it will come to early and also there weren't many matches in the Asian Cup that I could see plus have an genuine interest in any of the sides.

Fast forward to March 2015 and there is the Australian F1 Grand Prix with a quarter final match of the Cricket World Cup within the following few days. I didn't mind who played in that Cricket World Cup match. The problem would be the F1 Grand Prix. It is spread over four days and I didn't fancy going for the whole four days. I was hoping only to go on Saturday and Sunday. However most tickets are for the entire Grand Prix. The only single day tickets are for general admission, which means you don't get a seat but you can stand in the general zones allocated. I don't fancy standing for the entire day, so I'm thinking of my last option.

In late March 2015, the Cricket World Cup final will be in Melbourne. Around the same time, the Melbourne Comedy Festival starts. Again, I don't mind who plays in the final. I'm hopeful it will be England but I'm not hedging my chances. The lineup for the Melbourne Comedy Festival is not finalized but I have had a look at the 2014 program, and there are enough names I recognize to make it worthwhile going.

So if I can't find individual day tickets for the stands for the Australian F1 Grand Prix, I'm thinking of going to the Cricket World Cup final instead with a few shows of the Melbourne Comedy Festival thrown in, plus the standard touristy stuff of holding koalas.

Friday, July 04, 2014

Stuff I learned and observed on my USA road trip - general

Two months ago, I went for my longest vacation on my own. I spent seventeen days in Las Vegas, San Diego, Los Angeles, Yosemite National Park and San Francisco, with part of the journey driving on the Pacific Coast Highway. I'm not going to write a typical holiday blog, showing where I've been and sharing photos. Ever the practical person, I'm going to write about what I've learned and observed on this trip.

There were a lot of Indians flying to and from San Francisco
Perhaps due to the number of Indians working in Silicon Valley, the Cathay Pacific flight I was flying on was 60-70% filled with Indians, most elderly people. They were probably going to the States to visit their relatives. I'm just surprised they were using Cathay Pacific as their airline. Surely Air India should be laying down more flights to capitalize on the number of Indians flying to USA.

If you are going to get a SIM card for your phone, best buy beforehand and have the card delivered to your home address
I was trying to get a pay-as-you-go micro SIM card for my smartphone to use while on holiday. I forgot to look at the airport when I arrived and I found it difficult thereafter to find my requirements afterwards. People said to try the major pharmacy stores such as Walgreens and CVS but they only stock normal pay-as-you-go SIM cards and normal pay-as-you-go phones.

I later tried major stores but for some inexplicable reason, the mobile phone rates in USA are preposterously high. Even pay-as-you-go SIM cards are expensive. You will get better prices if you search on the internet and get the card delivered to your home.

However if you are just going to use data, it's not worth buying a SIM card. Just use the free Wi-Fi
Like London, most of the major cities in USA have pretty good free Wi-Fi . Most of the Las Vegas hotels, fast food outlets, Starbucks and major department stores have free Wi-Fi which you can connect to without jumping through too many hoops. This practice should be learnt by Hong Kong businesses, which has pitiful free Wi-Fi. US & UK businesses have learnt that free Wi-Fi keeps people on their premises and more likely to spend money at their businesses

When paying for something in USA, remember the additional costs...
There are a lot of added-on items when you pay for stuff in USA. Anything retail will get a sales tax added on to the price. As each state has its own different sales tax, it's not always included in the displayed price. I understand if the business operates in several states and has to quote one price for one product but for individual businesses which just operate in one state or in one place, I wish they include this in the mentioned amount. This will avoid the situation of having to calculate the amount and accumulating tons of change.

The other big add-on is service charge in restaurants. I was astonished to find the amount required to tip is 18-20%. In UK and Hong Kong, the usual amount is 10% and is added on to the price afterwards. This is something which should be included in the price itself, and not just in USA. If you don't offer takeaway service, the prices in restaurant should include everything, from taxes to service charge. That is a better reflection of the overall price of a meal.

Remember to bring photo ID with you everywhere
Photo ID is required for two main reasons: 1. To prove your age and 2. To prove your identity when using a credit card.

Even if you look 33, you will get carded if you want to buy alcohol. I found this out while trying to buy frozen margaritas in Las Vegas. It wasn't the staff's fault, since there were security cameras all around the premises noting every action.

The US must have a lot of credit card fraud cases or situations where somebody uses a stolen credit card quite often. Whenever you use a credit card for a large amount, they will always ask for photo ID to prove you are the owner of that credit card.

I didn't know if US businesses would accept my Hong Kong ID card or my international driver's license as a form of photo ID, so I played it safe and used my passport.

Your iPhone uses the GPS to tag locations for your photos and not your phone signal
The iPhone tags the nearest town/city to your photos. So if you look back at your pictures in the future, at least the location can jog your memory as to where you taken the photo. Probably good for drunken nights out.

If you have an iPhone but no SIM card, a useful app is to help you navigate around major cities is City Maps 2Go
This app is from a company called Ulmon. The map is quite detailed, covering major attractions, shops and transport links. The best feature is that it uses the GPS to help you navigate on the map, so if doesn't matter if you don't have a SIM card in your iPhone.

Monday, June 23, 2014

Stuff I learned and observed on my USA road trip - California

Two months ago, I went for my longest vacation on my own. I spent seventeen days in Las Vegas, San Diego, Los Angeles, Yosemite National Park and San Francisco, with part of the journey driving on the Pacific Coast Highway. I'm not going to write a typical holiday blog, showing where I've been and sharing photos. Ever the practical person, I'm going to write about what I've learned and observed on this trip. For this entry I'm going to write about California

The San Diego Zoo is better value than SeaWorld San Diego
Let's just go on price alone - a day pass at San Diego Zoo will cost you US$51 while SeaWorld San Diego is $84. Even if they were the same price, San Diego Zoo is more worthwhile. San Diego Zoo has more to see, with more exhibits and animals. I went there for six hours and I didn't get to see all of the animals.

SeaWorld, however, has more interaction. They have more shows and more activity where you can get up close to the animals. If you have kids, it will probably be better to go to SeaWorld. Also the carpark at SeaWorld is US$15 for the whole day, while it is free at San Diego Zoo. If you are a little bit older and like nature, San Diego Zoo is more appropriate to you.

Downtown Los Angeles really needs some redevelopment
It is a pity how rundown the downtown area of Los Angeles is. In normal cities the downtown area is a vibrant place at the centre of all activity. In Los Angeles, it's full of cheap stores and deteriorating buildings. There is potential there, especially in the Broadway theatre district. They have a number of old theatres, which have great architectural merit to them. If only they had a number of wealthy people in that area to help fund an upgrade.

Good other places to visit in California - Santa Monica Pier, the elephant seals at San Simeon, Yosemite National Park, Pier 39 in San Francisco, the Steinhart Aquarium at the California Academy of Sciences in San Francisco.
For those who love piers (and I should know having lived in Brighton with its famous Palace Pier), the Santa Monica Pier will not disappoint. It is a traditional pier, with lots with fairground games, a small theme park with rides, food stalls selling lots of goodies and your traditional souvenir shops. It's a nice day out and very different from the hectic bustle of Los Angeles.

Just near Hearst Castle in California is a beach full of elephant seals. Not just one or two, not just in double figures either - literally hundreds of them. Most of them are just lying down, catching the Californian sun for a nice tan. Occasionally you see two of them fighting, arguing who has that bathing spot.

The Yosemite National Park is a great place if you want to discover nature. There are many activities you can do: hiking, cycling, autotouring, etc. There are variety of hiking trails, from the novice to the ambitious, giving you spectacular views of lakes and mountains. The only problem with the park is that takes ages to drive into the centre - about 1.5 hours. If you are going to Yosemite for a few days, try to camp or stay in one of the lodges to cut down on your travelling time.

Pier 39 in San Francisco has the traditional shops but has a great site where sea lions just sunbathe. It's a nice sight to see but it can get smelly and loud quite quickly.

The California Academy of Sciences in San Francisco is quite impressive in its own right, with a good display about earthquakes. The most outstanding feature is the Steinhart Aquarium in the basement. Most aquariums are small and poorly lit. The Steinhart Aquarium is very extensive and well displayed.

Sunday, June 22, 2014

Stuff I learned and observed on my USA road trip - driving in USA & road trip

Two months ago, I went for my longest vacation on my own. I spent seventeen days in Las Vegas, San Diego, Los Angeles, Yosemite National Park and San Francisco, with part of the journey driving on the Pacific Coast Highway. I'm not going to write a typical holiday blog, showing where I've been and sharing photos. Ever the practical person, I'm going to write about what I've learned and observed on this trip. For this entry, I'll sharing what it is like to drive in USA

There must be some forgetful drivers in USA if they require all cars to automatically turn on their headlights when you start your vehicle
I already find automatic headlights annoying in cars in Hong Kong. They suppose to only turn on when the brightness level goes below a certain point but they turn on when it is still bright. You see a few cars having their lights on in broad daylight and the driver is none the wiser.

In the US it is even more of a nightmare. The headlights automatically turn on when you start the car, even if it is the sunniest day on record. You have to turn the headlight switch to off to make sure your lights are not dazzling the car in front. It was bloody annoying have to do that every time I had to start the car, since most of my driving was during the day. The only way to explain this situation is there must be enough forgetful drivers in the US who don't switch on their headlights to cause enough accidents that car manufacturers have to install this function in.

I'm surprised there are not more traffic accidents in USA
My mother still worries about me, even though I'm thirty three years old. She was worried since it would be my first time driving in a foreign country and driving on the right side of the road. I didn't get into any accidents while driving in USA. Driving on the right side of the road was easy-peasy but it did take some time getting use to the gear shift and the handbrake being on the right hand side and the seat belt being on the left. I was constantly clutching at thin air, trying to grasp the seat belt when I was setting off.

What my mother should have worried about are other drivers on the road. I thought Hong Kong drivers were bad until I drove on the freeways in California. US drivers use indicators and yield to other motorists less than drivers in Hong Kong. I had to be on constant alert and checking my mirrors whenever I wanted to cross lanes.

What is even more confusing are traffic lights. I knew you could turn right on a red light as long as you yield to other traffic and pedestrians. What I didn't know is that when turning left at traffic lights at cross junctions, the opposite direction could be green as well and you had to yield to the traffic coming towards you. It makes traffic more efficient as there are less stoppages for cars. However your are more likely to have traffic accidents. Yet the system seems to work since I didn't see one traffic accident while I was driving. I would thought roundabouts would be a more efficient way to sort out this traffic conundrum. Yet I only found one roundabout in the whole of my trip in USA and I'm sure it boggles US road users.

If you are going for a long road trip, get a good car
I learnt this the hard way. I was driving for eight days, from Las Vegas to San Francisco, via San Diego, Los Angeles and Yosemite. I thought a cheap car would do, so I got a Chevy Sonic. It's a small compact car with good fuel economy.

However it was shit to drive. The handling was awful, as it didn't respond very well to the steering wheel and the balance was not quite right at high speeds. The car was so small that when there was a strong wind you could feel the car being pushed to the side. I honestly felt I was going to tip over at two points during my journey. The footbrake was very bad, especially when stopping suddenly at high speeds. I expected the acceleration to be very poor but I didn't expect I had to put my foot down all the way to get some decent speed. The Chevy Sonic would be OK for 1-2 days for city driving but a whole week drove me crazy.

Next time I do a road trip (which I plan to do in Eastern USA or Western Europe in a few years time), I'm definitely getting a sports car. At least it would be decent drive and I get a sunroof to enjoy the light.

If you are going on a long road trip, take somebody with you
Driving for long stretches is a knackering ordeal. You might not expect that, being constantly sitting own. Yet you have to be vigilant all the time and I did find myself nodding off, having to pull over and take a rest. I planned to drive for one hour and then rest. However, with my time constraints and having difficulty finding somewhere to stop, I had to stop every two hours instead.

It would be good if I brought somebody along (even though I wanted this trip to be some alone time for me). At least the other person could share in the driving. Even if the other person couldn't drive, at least he/she could keep you awake by talking to you. Blasting your iPhone or radio at full volume doesn't keep you eyes open.

The other reason you should bring somebody along is to take photos. I knew I shouldn't be operating my cameraphone while driving and I highly DO NOT recommend this practice. I only did it when I knew I didn't have any cars around me, driving on a straight bit of road and driving at low speeds. I didn't take my eyes off the road either. I just basically pointed the camera and shot photos blind. With somebody else, they could take decent photos and not blurred photos of other cars.

If you are going to take the Pacific Coast Highway road trip, go from Monterey to San Luis Obispo
The Pacific Coast Highway, or California State Highway, starts in Monterey in the north to San Clemente in the south. For most of the journey, the road goes through some towns with a lot of traffic lights, so it was quite annoying having to start and stop all the time. I started off in San Clemente and by the time I reached Huntington Beach, I was so bloody annoyed. I said to myself, "Sod this!" and used the freeway to get to Santa Monica.

From Santa Monica to Arroyo Grande (where I was staying for one night), there are a few nice beaches and views. However the best part of the trip was from San Luis Obispo to Monterey. That section of the Pacific Coast Highway is free of any traffic lights. It is a long winding road and if I had a sports car, I would have enjoyed driving along it. The views are great with big mountains, large stretches of ocean and dense forests to take photos of.

It would be better to drive from north to south than from south to north as the ocean is on your right hand side and it would be easier to stop off and take pictures. I was driving with the mountain to my right and the ocean to my left. This meant if I wanted to take decent photos of the ocean, I would have to stop off and cross the road or cut across oncoming traffic.

Saturday, June 21, 2014

Stuff I learned and observed on my USA road trip - Las Vegas

Two months ago, I went for my longest vacation on my own. I spent seventeen days in Las Vegas, San Diego, Los Angeles, Yosemite National Park and San Francisco, with part of the journey driving on the Pacific Coast Highway. I'm not going to write a typical holiday blog, showing where I've been and sharing photos. Ever the practical person, I'm going to write about what I've learned and observed on this trip. In this entry, I'll be talking mainly about Las Vegas.

If you think you can gamble yourself a fortune in Vegas - think again
The whole of Las Vegas casinos are designed for you to stay in the casinos and lose money. There are no exit signs in the casino floors and there are no windows so you don't realize how long you've been gambling. I remember reading a statistic that the odds of you winning are stacked against your by about 2.5 to 3.0 to 1.

I gambled away about US$50 while I was in Vegas, mainly playing video poker and blackjack. Your most probably way of winning in the casinos is to play blackjack at the tables. Even with that, you need a good memory to count the cards, a stack of cash and a lot of time on your hands.

If you want to visit Las Vegas but don't like gambling, a good choice is the Vdara Hotel and Resort
There are a few hotels on the Las Vegas Strip that don't have casinos: Mandarin Oriental, Trump International, The Signature at MGM Grand and Vdara. If you don't gamble or fancy a more quieter hotel, you should pick these a hotel without a casino

I picked Vdara for a variety of reasons. It was about HK$700-800 per night cheaper than Mandarin Oriental, despite the latter having better reviews. Also the floor space of the Vdara hotel room was larger than the Mandarin Oriental. The most important thing was the location. The Signature at MGM Grand is at the southern point of The Strip while Trump International is a little bit off The Strip at the northern point. Vdara was right in the middle of The Strip, so it was convenient to walk to any other hotels/casinos for food or gambling. The service and facilities were very good at Vdara, so I highly recommend it. Also they have a few cute ladies at reception / concierge and also one good looking bloke, so that's always an incentive to annoy the staff.

If you are going to visit the Grand Canyon, splash out and pay for a helicopter/plane ride
The cost of a road trip to the Grand Canyon is certainly cheaper by half. Yet the whole trip will take about 14 hours, most of which will be spent in the vehicle, and you only get the view from the ground.

A helicopter ride will cost about HK$3700, depending on which package you pick. It only takes about 4 hours, from pick up from your hotel to drop off at your hotel. The view is great from the air, as you can also see other places such as Henderson, Boulder, Lake Mead, Hoover Dam and Meadville.

I haven't been on a road trip to the Grand Canyon but other people on my helicopter trip have been on both and they have said that the helicopter trip is worth the money.

Good shows to see in Vegas are Penn & Teller and Terry Fator
Everybody knows Penn & Teller for their magic tricks. They swap things around so the show is fresh. Unfortunately they don't allow videos/photos to be taken during the show. This is made up by the performers as they stay in the lobby after each show to take photos with the audience and sign stuff.

Terry Fator was the first winner of "America's Got Talent". He's a ventriloquist, comedian, songwriter and singer. The range of voices and dummies he has performing is quite impressive. It's a good show for the family as well. He's also a very lucky guy since his gorgeous looking on-stage assistant Taylor Makakoa is also his wife.

I have more respect for people who use guns in their jobs
I did got to a shooting range while I was in Vegas. Firing guns takes a lot of upper body strength. I think the most surprising thing about shooting guns is the recoil, which can be very significant. The range master said I was OK since I got my shots on the target (not on target) since some people will miss the target completely.

I think movies and media make it seem so easy to fire guns and get them on target. Now I know better. Still it is still no justification for carrying machine guns for leisure (Yeah, I have a gripe with the Second Amendment).

Wednesday, May 21, 2014

Thinking to the future after Arsenal's FA Cup win

Moments after the dust has settled on Arsenal's (very nerve racking) FA Cup final win over Hull City, I'm already looking towards next season and how the Gunners can improved. The side could have won the Premier League season, after leading the table in February. Yet the team capitulated in the second half of the campaign, with the lack of recruitment and injuries seriously affecting our results.

Some of the current players will not be at the training ground in July. Emiliano Viviano, the Italian national goalkeeper, will return to his parent club Palermo after a season on loan, warming the bench. Kim Kallstrom will return to his original club Spartak Moscow. 

Other players will leave as free agents after not being offered or turning down new contracts. Lukasz Fabianski seems to be tired playing second fiddle to Wojclech Szczesny and decided to move on. Bacary Sagna doesn't seem to like his new contract terms and seems destined to join Manchester City. Niklas Bendtner has finally broken Arsene Wenger's patience and will be finding a new club this summer.

Other players need to be cleared out. Park Ju Young and Johan Djourou should be let go. Younger players such as Ryo Miyaichi and Thomas Eisfeld need to go out on loan, while others such as Serge Gnabry need to be played more. The only player I can't decide on is Abou Diaby. He just keeps getting injured and it is harsh to just eject a player just because of that. He has the ability to be a great box to box midfielder like Patrick Vieira but I honestly don't see it happening. 

So there are plenty of places need to be filled. A back up goalkeeper is required, even though we have Damian Martinez returning from Sheffield Wednesday. A right back is required, but one that will not stifle the development of Carl Jenkinson. I wouldn't mind seeing Micah Richards at Arsenal, although he did burn a few bridges by ridiculing Szczesny for posting a selfie after a win over Tottenham. Richards would also help cover the centre back position, which is another area the Gooners need to invest in.

I would like to get a specialist defensive midfielder in, as Mikel Arteta and Mathieu Flamini seem a bit lightweight. Gareth Barry and Esteban Cambiasso are available on a free, so they could be options. Another player that has been touted is Bayern Munich's Javi Martinez, who is out of favour with Guardiola.

A pacy winger is required, as shown by the lack of options after Walcott and Oxlade-Chamberlain got injured. Jérémy Ménez and Angel di Maria are touted as possibilities.

Finally Wenger needs to get two strikers. Not just one but two. After Giroud, there is nobody we can count on. Sanogo is either crap or hasn't reached his potential. I have longed for Karim Benzema to come to the Emirates Stadium, as he can play out wide as well. Other strikers that haven been mentioned include Antoine Griezmann, Mario Mandzukic and Loic Remy,

Arsene Wenger has also been looking further ahead in time, with Rosicky and Arteta getting on. Lars Bender and Julian Draxler seem destined to come to Arsenal but they are not immediate priorities.

Wenger will have that kind of money that is required to spend on the 6-7 players he requires. It just depends if he is willing to spend it.