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Highlights from this issue
  1. Ian Wacogne, Deputy Editor, E&P
  1. ian.wacogne{at}

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Recently I've learnt how to tie my shoelaces. Or, to be clearer, relearnt. I need to explain, of course. In an idle moment—of which, naturally, I have many—I found myself watching the three-minute TED video, It answered a conundrum for me; I couldn't previously understand how people could avoid needing to use double bows in tying their shoes. This video demonstrated something that is probably familiar to anyone who has done any stitching: that there are two types of bows you can do when tying your shoelaces: a strong one and a weak one. Interestingly, you can tell which one you do in two ways: if you do the weak one without a double knot, the lace falls apart in minutes, but also it lies along the axis of your foot. The strong bow falls across the foot.

A little further thought reveals that the weak lace is based on a granny knot, whereas the stronger lace is based on a reef knot. I decided to try to learn the stronger lace. My first efforts were rubbish. It required me to try to tie the knot in a sort of mirror image to what I'd been doing for some 40 years, and my efforts made those sketches of people battling with deck chairs look graceful. Then I realised something: I could keep the top part of the knot—the trickier bit—the same if I threw the starting half hitch at the base the other way round. At first this felt very strange—like writing with my non-dominant hand—and which led me to recall my grandad's favourite joke: “I'd give my right arm to be ambidextrous”. But, the knot was better, and I didn't need to add a further double knot on the top. I continued to use this new half hitch, and after a couple of months, a new problem emerged—I was getting so proficient with the new knot that I couldn't tell whether I was doing the old or the new knot simply by asking myself “Does this feel awkward”—they both felt about the same. I got no feedback that I was doing the right, harder, knot simply from it feeling awkward. Anyway, a few months on, and I can do the right knot each time. It saves me a few seconds each time from not having to do the double knot, and, provided I live to be 134 years old, I will be in net time credit.

All this is by way of introducing a new Quality Improvement series to E&P—Equipped. In this issue, and my editor's choice, Claire Lemer, Ronny Cheung and Bob Klaber (the latter of whom has been helping me curate the series) introduce Equipped with some very simple but compelling reasons to get interested in Quality Improvement (see page 175). Their definition is that it is the unceasing quest for excellence for patients in their journey through their care, but for me, the very least of it has to be that it's a lot more fun than doing yet another meaningless audit—although hopefully more about audit in a later issue.

The shoelaces thing is, of course, an utterly trivial example, and quite probably an utter waste of time. I need to get out more. But, I had been doing it wrong, and there was a faster, better way of doing it; and, interestingly, I'd built in a work around the double bow, which compensated for my poor method. Quality Improvement feels a little like this at times. We might have a nagging feeling that something should be done better, but it takes a lot of effort to make that change. Sometimes there are good, reasoned arguments against change—“I'm not falling on my face all the time, so why should I learn a new knot?” Sometimes we're just too busy for change, which in my mind is a bit like the old joke:

Teacher: “Johnny, why did I see you pushing your bike to school this morning?”

Johnny: “I was late, Miss, and I didn't have time to get on it…”

Isn't it time we looked around and figured out which bicycles we're pushing? Well, I will, as soon as I've knotted this shoelace…