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It's About Time

Cheung, Anson W., MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: July/August 2018 - Volume 13 - Issue 4 - p 245–247
doi: 10.1097/IMI.0000000000000541
Presidential Address

From the Division of Cardiothoracic Surgery, University of British Columbia, St. Paul's Hospital, Vancouver, BC Canada.

Accepted for publication July 12, 2018.

Presidential Address presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 13–16, 2018, Vancouver, BC Canada.

Disclosure: The author declares no conflict of interest.

Address correspondence and reprint requests to Anson W. Cheung, MD, St. Paul's Hospital, 1081 Burrard St, Vancouver, BC Canada V6Z 1Y6. E-mail: acheung@providencehealth.bc.ca.

First of all, welcome to Vancouver and the 2018 International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) Annual Meeting. It is an honor to stand before my colleagues and mentors today as the president of ISMICS. Dr. Rashmi Yadav, Giulia Veronesi, Joseph Lamelas, and Sebastien Gilbert have crafted a wonderful program for you this year. In the next 3 days, it will be filled with inspirational talks, educational lectures, and opportunities to network with colleagues from all around the world.

I would like to take this opportunity to acknowledge a few people that have played a very important role in shaping me. Firstly, I would like to thank my parents. They were not typical Chinese parents, the Helicopter type. My father was a professional soccer player, as were my grandfather and uncle. Unlike today's players, salaries in those days were not something you write home about. Money was tight and my father did not have the opportunity to receive an education. Despite his grade 4 education, he became quite a successful businessman after his playing career. He had taught me a lot via his actions. He taught me perseverance and how to face defeat and failure. He taught me leadership skills because he was the captain of his professional and national team for a number of years. I am sure that I have also inherited some of his competitive genes and perhaps some showmanship. My loving mother taught me how to be compassionate and generous.

I am very fortunate to have the opportunity to meet and work with many pioneers in our profession, Dr. Norman Shumway and Ed Stinson in transplantation at Stanford University, watched from a distance, seeing Dr. Bruce Reitz performing the first Heartport case in 1995 was a truly eye-opening experience. Seeing how Dr. Bartley Griffith and Robert Kormos worked tirelessly in advancing mechanical circulatory assist were inspirational. There are too many others to mention.

A few of them have even more profound impact on me. Dr. Kim in Winnipeg was the one that got me hooked on cardiac surgery; he taught me how to sew a vein graft proximal anastomosis as a medical student. Dr. Andrew Hamilton helped me stitch up a stab wound to the ventricle while I was a junior resident in general surgery. Dr. Alan Menkis, our past ISMICS president, taught me how to think outside of the box and to push the envelope in a responsible manner. Dr. Neil McKenzie taught me so many technical tips and tricks that we called the art of surgery.

I am so fortunate to have the opportunity to practice here in Vancouver, a beautiful and truly international city. To make it such a wonderful place to live is the people that I work with at St. Paul's Hospital every day. My chairman Sam Lichtenstein, the mad scientist and Einstein lookalike, fosters an innovative environment. My great gratitude to all my surgical partners who pitch in often, allowing me to pursue academia. The caring and fun-loving nurses, perfusionists, anesthesiologists, and allied health that make getting up early each morning a pleasure experience. In addition, collaborators in cardiology and radiology have helped me tremendously in my academic development.

The ISMICS family has played a very important role in my career. I still remember my very first annual meeting in New York City back in 2002 while I have just started my practice for a couple of years. I was amazed with all the sciences and innovations at the meeting. Unlike other professional societies, I was taken by how approachable all these famous surgeons were. Many of you are first timer here at the meeting, and I hope you will have similar experience that I had. Just like any other families, the ISMICS family enjoys traveling together around the globe, enjoying each other's company over food, drinks, and occasionally singing and dancing.

Last but not least, I have to thank the most important person in my life Jessie, my wife for 26 years, my best friend, soul mate, and love. I have to thank Jessie's parents for giving birth to a beautiful and loving person and treated me as their very own son. Jessie and I have known each other for 37 years; together, we have many wonderful adventures around the globe, cycling in Italy, Taiwan, and Japan, for example, skiing locally in Whistler/Blackcomb and on the Austrian alps, and hiking up mountains in Australia and Peru. Jessie supported me in all levels, especially those rough patches in life. She supported me financially thru all those minimum wage years in internship and residency training. More importantly, she is my most honest critic and has kept me on track for all these years. She is not shy of showing her dismay when I step over the line. Giving her approval here after I stupidly sprint ahead on the Inca trail with the porters and left her behind with the pack. Jessie, thank you for sticking with me and I look forward having many more adventures with you until the end of “time.”

As I sat in my office, contemplating the details of what I will speak to you today in my presidential address. An epiphany came to me; our profession is completely obsessed with time. “It's About Time” to talk about time.

Time transcends religion, science, and philosophy. It is engrained in arts, business, industry, sports, and sociology. Time is an entity that is not only critical in our personal lives but also critical in our professional lives. It defines “life” as we know. As a surgeon, not only is time crucial for our patients, but also it is a vital component of the care we provide.

To a patient, it is about the date and time surgery, length of the surgery, and the number of days in hospital or when a patient can start playing golf again. Preoperatively, it is about when to hold medications, when to be NPO. Postoperatively, it is about when to start standing, walking, doing stairs, eating the first meal, or when to see their family doctor or internist.

For us, it is both technical and artistic. Intraoperatively, it is all about cardiopulmonary time, cross-clamp time. In transplantation, it is all about heart or lung warm and cold ischemic time. Postoperatively, it is both an art and science to determine whether it is time for your patient to be discharged. In research, it is about prolonging time to the first morbidity and mortality event.

Our profession is defined by time.

First, we need to define time. What is the definition of time? Nowadays, when you have an unanswered question, we go directly to the source, the highly reputable Wikipedia. According to Wikipedia, “Time is the indefinite continued progress of existence and events that occur in apparently succession from the past through the present to the future.” From this definition, time has no confines. It is infinite, fluid, and transcendental. As Albert Einstein coined it as the “Four dimension, he believes that there is no separation of the past, present and future, therefore ‘Time is an Illusion.’”

Can we measure time and how do we measure it? The science of measuring time is called horology. A variety of devices have been used to try to capture time as a finite entity. As early as 1500 BC, Egyptians were measuring time with a variety of instruments, initially very crude measures based on shadows cast on a dial then more sophisticated with the water clock that could measure hours, even at nighttime. It was not until the 11th century that Chinese inventors and engineers invented the first mechanical clock. At present, the most precise device measuring time is atomic clocks, which can be accurate to seconds over many millions of years. Many of us are guilty of collecting some of these expensive timepieces with sophisticated mechanics and complications, trying to capture time.

However, can time really be captured?

In reality, the most accurate description of time is that time is a paradox. The only time you can capture is the present, yet it is an endless depiction of the past and future.

At any given time, time is the beginning and the end; it is day and also night.

When is the beginning of time? Someone once asked the late Sir Hawking, “Did God create the universe?” He answered, “Time didn't exist before the Big Bang, so there was no time for God to make the universe in.”

We define time obsessively with calendars, clocks, and watches that measure to the millisecond, yet the most liberating thing is to be experiencing a moment not knowing how long we have. Time flies, yet it can be at a standstill. There is not enough of it when you are having fun, yet it drags on during times of boredom and despair.

It is considered priceless, yet we monetize it as a means to measure it, as if it is something tangible one can buy or spend.

Definitely, time, it is the one thing that money cannot buy.

We exaggerate its availability by making statements like, “I have no time or I have all the time in the world.” Time seems endless when you are born, yet its finality is so abrupt when you die. Time is definite, yet infinite.

The value and measure of time will change in the eye of the perceiver. The perception of time is altered by life-changing experiences; this may be the passage of time with age, the accumulation of experience, certain realizations at noteworthy milestones, or it may be a result of unexpected injuries or illness. In this domain, our patients can teach us more about this than anyone else, from health to illness, hospital to home, complication to recovery, anticipation to reflection, and agony to hope. I thought I knew what it meant just hearing and seeing countless patient stories of the resilience of the human body and spirit. However, it was not until recently that I was finally able to appreciate the paradox of time for myself.

Let me tell you a personal story of when time stopped, well kind of.

Many of you might be aware that I had one of those life-changing incidents last year. Let me recreate the crime scene for you. I was out cycling on a beautiful, sunny Vancouver afternoon. I was pedaling hard on a straight stretch of tarmac with a 2-degree downgrade, going at 56 kilometers an hour, which I later found out on my bike computer. A driver decided to make a sudden left turn into my path. Logically, I slammed on my brakes, and at that very moment, I had an out-of-body experience while muttering a few choice words in my head. Time did not just slow down, it actually stopped. Everything in front of me was clear as crystal—I saw an incoming car on the left, her car across the road, and a curb on my right. The only options I had to avoid becoming a pancake were to release my brake, gain control of the bike, jump the curb on the right, and try to steer around her, and by miracle, I ultimately did. Unfortunately, she did not stop, hit me, and broke my left leg. At least, I cheated death for the time being. I was unable to operate for 2 months recovering and reflecting. I became very interested in the subject of “time”; first of all, I have never had so much time in my hand. Since then, I have been asking people on their perspective on time. I would like to share some of their perspectives. A mother of a very young heart transplant patient once told me, “Time can be your best friend or the worse enemy.” The transplanted heart is giving her child more time with them; however, every day that passes, she has one less day to live. Her husband happened to be a television reporter, and his perspective on time is quite different. For him, “Time means deadline and two minutes,” he explained. He faces deadlines for his stories every day, and he has to condense all his works into 2-minute segments. Recently, a retired cardiac anesthetist and good friend of mine gave me another perspective. After his retirement, he became a palliative care physician, providing care in hospice and patients' own home. The most frequent question his patients pose is “How much time do I have?” To them, time is both a blessing and a curse, more time with friends and family, or more time suffering from pain.

Time can be the most patient teacher or the cruelest punisher.

Thus, what does time have to do with minimally invasive surgery? Well, for cardiac surgery, there was a time when full sternotomy with cardiopulmonary bypass and in thoracic surgery, a large, gaping thoracotomy incision was innovation beyond its time and was considered the standard of care.

For the past two decades, we have seen an explosion in the growth and popularity of minimally invasive surgery. A revolution first lead by our thoracic colleagues and adopted by cardiac surgeons more recently. Despite initial concerns of increased surgical time, we have seen a tremendous improvement in our techniques and a reduction in complications. With innovation and research, we now have long-term outcome data for minimally invasive surgery. We are better at selecting patients who might benefit from these techniques. There is a common saying, “Time heals all wounds.” With minimally invasive surgery, it means less time, less pain, and improved surgical healing, so patients can get on with their lives. It has not always been a smooth journey, but time has given us perspective, context, and opportunities. What matters now is that we continue to strive to improve for the betterment of our patients.

This is especially true for one of my patient, a 40-year-old man experiencing familial dilated cardiomyopathy. He had a very enlarged left ventricle measuring 94 mm in diameter, low ejection fraction of 20%, and severe mitral regurgitation. He had multiple admissions to hospital with heart failure requiring inotropic support. He was referred to our center for cardiac transplantation. Our team tries to delay his transplant to buy him a little more time. Our consensus was to refer him for transcatheter mitral plication. He unfortunately has a very wide coaptation gap, and his mitral insufficiency remains torrential after applying the clip before the final release. The team decided that he should be evaluated for other alternative mitral intervention. He ultimately received a transapical mitral valve replacement with a novel device. For more than 2 years, he had significant improvement in his symptoms and was in NYHA 1 to 2 and returned to full-time work. Unfortunately, he had a sudden deterioration later requiring a left ventricular assist device, which was implanted off pump and minimal invasively. Eight months later, he received a successful cardiac transplant. For him, time and time again, he counted on us to do what is right so that he can gain more quality time being himself and quantity of time enjoying life with people he cares about.

Whether the patient comes to us with MICS as one of the options or the only option, they are all looking for one common outcome—more time to spend doing the things they love and with the people they love. Nelson Mandela said, “We must use time wisely and forever realize that the time is always ripe to do right.” It is about time that we rally together to make minimally invasive surgery the new criterion standard. Because for our patients, it's about time.

I hope you find your time with us here is well spent or at the very least well wasted as Martha Troly-Curtin's wise words, “Time you enjoy wasting is not wasted time.”

Keywords:

Innovation; Innovations journal; Time; Cardiothoracic surgery; ISMICS

©2018 by the International Society for Minimally Invasive Cardiothoracic Surgery