- Email: [email protected]
Timing
DISSECTING ROOM
The Refractory Timing “To everything there is a season, and a time to every purpose under the heaven.” Ecclesiastes iii:I
uccessful comedians, acrobats, sportsmen, dancers, musicians, actors, and lovers know that getting the timing right can mean the difference between success and disaster, between pleasure and pain both for themselves and others. Expertise, training, practise, and sensitivity to your audience or partner, combined with fine judgment, will create a satisfying experience for both parties. In health care, sensitivity and good judgment are also needed to get the timing right—when giving bad news, providing information, or when telling children about death, sex, or adoption. The timing of screening, of making a diagnosis, of administering therapies, and of undertaking surgery and sequences of adjuvant therapies all have tremendous consequences for individuals’ wellbeing. Earlier is not necessarily better— coercive healthism may be fashionable but it is not necessarily conducive
S
to a contented existence. Having—and knowing when to give or withhold— is the mark of a controlled, caring health professional. This ability is not accommodated in guidelines or achieved by bureaucratic regulation. It rests more in trust and an appropriate attitude—a desire to do no harm, to care, to build trusting relationships, and to make every consultation important. Such an approach will ensure a constructive experience for giver and recipient. Timing can also be about fixing, choosing, adjusting, ascertaining, or recording of times. It can be about coordination in time, which brings to mind the internal combustion engine where timing denotes regulation of a valve operated mechanism so that valves open and close in correct relation to the crank. Fine-tuning is needed to achieve perfect timing, the maximum efficiency of many moving parts, and maximum speed.
A health system or hospital is an equally complex mechanism, which needs perfect coordination of a multitude of moving parts, and the opening and closing of doors to achieve quiet functioning, maximum throughput, and speedy operation. Imbalance of facilities at any point will disrupt this synchronisation, impede care-giving, and cause anguish to patients. There are many different sizes of cogs, cranks, and valves in a smoothly functioning health system —a place where the cleaner can be just as essential as the clinician. Similarly, timing within trial management requires careful planning, foresight, and adjustment while running to ensure that patients are informed and protected during the course of a trial and to achieve maximum benefit for all the participants. The maintenance of a complex research machine that will deliver maximum power in the shortest time demands diverse skills and great wisdom to produce and publish data in an ethical and timely fashion—“A time to be born and a time to die”. Refractor e-mail: [email protected]
A heartening tribute Chou’s Electrocardiography in Clinical Practice, 5th Edition Borys Surawicz, Timothy K Knilans. Philadelphia: W B Saunders, 2001. Pp 709. $99.00. ISBN 0721686974. nown to many for more than 20 years as an authoritative, commonsense guide to electrocardiography, this text has been revised and released as a posthumous tribute to Te-Chuan Chou (its first author who died in 1995) by Boris Surawicz, with a section on paediatric electrocardiography by Timothy Knilans. The previous editions of this book provided the right amount of key information in a highly accessible format for interpretation of the electrocardiogram by the expert clinician. You could read the whole thing, and then pick it off the shelf a year later and go back to find the criteria for a specific diagnosis without difficulty. I have owned copies of the second and third editions. When you sat down with them, it was like sitting down in a
K
1704
clean, plain office with some basic furniture and a strong cup of coffee, along with a few choice tracings pulled from the teaching file cabinet and some expert advice on what was important and what you needed to know. The new edition is a little more like hitting the stacks armed with the information your teacher provided, and then looking back at what you had learned before in the light of some newly (re)discovered papers. There is, therefore, a richer texture to Chou’s Electrocardiography in Clinical Practice, and this is an improvement in almost every instance. Moreover, Surawicz’s extensive knowledge helps advance our understanding of electrocardiography in the light of new developments in clinical science. Surawicz has tried to keep it simple, but, sometimes, he just cannot help
himself, and one delves into the subgroup analysis of some study that provides an informative context for what you need to know, even though it is not really why you picked up the book in the first place. Perhaps a more modular approach with footnotes would be a helpful way to organise the text in the next edition, so that the key teaching points stand out from the background information. I would not leave anything out, however. I am glad, for example, to be reminded why the intrinsicoid deflection is not called intrinsic. It is hard to improve upon a standard in the specialty, but I am happy to report that Surawicz has succeeded in rejuvenating Chou’s gift to those of us who still believe that the electrocardiogram matters. John F Schmedtje Jr Consultants in Cardiology, University of Virginia Health System, PO Box 8337, Roanoke, VA 24014, USA
THE LANCET • Vol 359 • May 11, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
The Refractory Timing “To everything there is a season, and a time to every purpose under the heaven.” Ecclesiastes iii:I
uccessful comedians, acrobats, sportsmen, dancers, musicians, actors, and lovers know that getting the timing right can mean the difference between success and disaster, between pleasure and pain both for themselves and others. Expertise, training, practise, and sensitivity to your audience or partner, combined with fine judgment, will create a satisfying experience for both parties. In health care, sensitivity and good judgment are also needed to get the timing right—when giving bad news, providing information, or when telling children about death, sex, or adoption. The timing of screening, of making a diagnosis, of administering therapies, and of undertaking surgery and sequences of adjuvant therapies all have tremendous consequences for individuals’ wellbeing. Earlier is not necessarily better— coercive healthism may be fashionable but it is not necessarily conducive
S
to a contented existence. Having—and knowing when to give or withhold— is the mark of a controlled, caring health professional. This ability is not accommodated in guidelines or achieved by bureaucratic regulation. It rests more in trust and an appropriate attitude—a desire to do no harm, to care, to build trusting relationships, and to make every consultation important. Such an approach will ensure a constructive experience for giver and recipient. Timing can also be about fixing, choosing, adjusting, ascertaining, or recording of times. It can be about coordination in time, which brings to mind the internal combustion engine where timing denotes regulation of a valve operated mechanism so that valves open and close in correct relation to the crank. Fine-tuning is needed to achieve perfect timing, the maximum efficiency of many moving parts, and maximum speed.
A health system or hospital is an equally complex mechanism, which needs perfect coordination of a multitude of moving parts, and the opening and closing of doors to achieve quiet functioning, maximum throughput, and speedy operation. Imbalance of facilities at any point will disrupt this synchronisation, impede care-giving, and cause anguish to patients. There are many different sizes of cogs, cranks, and valves in a smoothly functioning health system —a place where the cleaner can be just as essential as the clinician. Similarly, timing within trial management requires careful planning, foresight, and adjustment while running to ensure that patients are informed and protected during the course of a trial and to achieve maximum benefit for all the participants. The maintenance of a complex research machine that will deliver maximum power in the shortest time demands diverse skills and great wisdom to produce and publish data in an ethical and timely fashion—“A time to be born and a time to die”. Refractor e-mail: [email protected]
A heartening tribute Chou’s Electrocardiography in Clinical Practice, 5th Edition Borys Surawicz, Timothy K Knilans. Philadelphia: W B Saunders, 2001. Pp 709. $99.00. ISBN 0721686974. nown to many for more than 20 years as an authoritative, commonsense guide to electrocardiography, this text has been revised and released as a posthumous tribute to Te-Chuan Chou (its first author who died in 1995) by Boris Surawicz, with a section on paediatric electrocardiography by Timothy Knilans. The previous editions of this book provided the right amount of key information in a highly accessible format for interpretation of the electrocardiogram by the expert clinician. You could read the whole thing, and then pick it off the shelf a year later and go back to find the criteria for a specific diagnosis without difficulty. I have owned copies of the second and third editions. When you sat down with them, it was like sitting down in a
K
1704
clean, plain office with some basic furniture and a strong cup of coffee, along with a few choice tracings pulled from the teaching file cabinet and some expert advice on what was important and what you needed to know. The new edition is a little more like hitting the stacks armed with the information your teacher provided, and then looking back at what you had learned before in the light of some newly (re)discovered papers. There is, therefore, a richer texture to Chou’s Electrocardiography in Clinical Practice, and this is an improvement in almost every instance. Moreover, Surawicz’s extensive knowledge helps advance our understanding of electrocardiography in the light of new developments in clinical science. Surawicz has tried to keep it simple, but, sometimes, he just cannot help
himself, and one delves into the subgroup analysis of some study that provides an informative context for what you need to know, even though it is not really why you picked up the book in the first place. Perhaps a more modular approach with footnotes would be a helpful way to organise the text in the next edition, so that the key teaching points stand out from the background information. I would not leave anything out, however. I am glad, for example, to be reminded why the intrinsicoid deflection is not called intrinsic. It is hard to improve upon a standard in the specialty, but I am happy to report that Surawicz has succeeded in rejuvenating Chou’s gift to those of us who still believe that the electrocardiogram matters. John F Schmedtje Jr Consultants in Cardiology, University of Virginia Health System, PO Box 8337, Roanoke, VA 24014, USA
THE LANCET • Vol 359 • May 11, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.