SAFe-Practitioner book - SAFe 5 Practitioner (SP) Updated: 2023

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Madden, Mike 2014. The Exclusion of Improperly Obtained Evidence at the International Criminal Court: A Principled Approach to Interpreting Article 69(7) of the Rome Statute. SSRN Electronic Journal,

Materu, Sosteness Francis 2015. The Post-Election Violence in Kenya. p. 177.

Materu, Sosteness Francis 2015. The Post-Election Violence in Kenya. p. 85.

Stein, Shlomit 2017. In Search of ‘Red Lines’ in the Jurisprudence of the ECtHR on Fair Trial Rights. Israel Law Review, Vol. 50, Issue. 2, p. 177.

Peat, Daniel 2019. Comparative Reasoning in International Courts and Tribunals.

Soler, Christopher 2019. The Global Prosecution of Core Crimes under International Law. p. 3.

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Zammit Borda, Aldo 2021. Histories Written by International Criminal Courts and Tribunals. Vol. 26, Issue. , p. 143.

Robles, Alfredo C. 2023. The Defaulting State and the South China Sea Arbitration. p. 189.

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Medical students today pore over the twentieth edition of Williams' classic obstetrics textbook. The recently released Collector's Edition of the original 1903 text, however, not only opens a window to the soul of US medicine and society in general, circa 1900, but also illustrates the timelessness of some aspects of the art and science of obstetrics.

History can be a source of controversy. To some, history is fascinating. To others, it's. . .well, it's history. There is one view, perhaps the majority, that medicine of the past should stay there. After all, in today's world we have recombinant DNA technology, nuclear magnetic resonance imaging, and remote telemetry units as everyday practice aids. Why should the busy clinician dwell on turn-of-the-century medicine, the pre-antibiotic era, the time of blood-letting instead of blood-banking? What can we learn from that? Well, perhaps the first edition of Williams' classic text can answer that for you -- at least with respect to obstetrics.

Published in 1903, J. Whitridge Williams' Obstetrics: A Text-Book for the Use of Students and Practitioners has become a standard. In fact, it is currently in its twentieth edition. Gary Cunningham and his faculty at the University of Texas Health Sciences Center and Parkland Hospital in Dallas have edited the exact editions of this text. As such, it has a very strong institutional bias. Nevertheless, the book is still a standard, recommended to students, house officers, and practitioners as an authoritative "way" of doing obstetrics.

However, the first issue, now released in a special Collector's Edition of 2500 numbered copies (with an Introduction by Steven Clark and Gary Hankins, 2 well-known and respected professors of ob-gyn), gives the reader a chance to see how far we have come in obstetrics since 1903. Of course, the cynical reader might view this book with a bias: Have we really gone so far?

In 1903, Williams' objective, in his words, was to "set forth. . .the scientific basis for and the practical application of the obstetrical art." To do so, he drew on his own extensive clinical experience and education, as well as the published experience of his colleagues and professional forebears the world over. For example, in his discussion of symphysiotomy, Williams cited Neugebauer's "analysis of 278 cases," the "100 cases operated upon in Pinard's clinic," and Bar's "140 operations performed by himself." Clearly, much of Williams' theory and practice was based on an impressive body of medical experience, as opposed to a couple of "series of 1," as further evidenced by his discussion of birthweight, in which he cited the "nearly 3000 children delivered under [his] supervision."

In their introduction, Clark and Hankins talk about our current (advanced) state of obstetrics having made the "transition from anecdotal to evidence-based practice." Yet it is abundantly clear that Williams attempted to support his practices, and the teaching thereof, with as much evidence as he could gather.

While series of cases do not qualify as the currently favored randomized controlled trial (RCT), one cannot dismiss as simply "anecdotal" the observations of the practitioner who has performed 100 or 140 symphysiotomies. The experienced practitioner knows how they succeed, when they fail, and how they heal. Obstetrics, as much as any branch of medicine, has always been a hands-on specialty.

Although large personal series are now considered type III, or at best type II-3 evidence, much of modern medicine is still based on them, as the RCTs are only now being designed -- often by academics who have not practiced any of the medicine in question. (Don't be misled: Williams did not actually endorse symphysiotomy. He claimed that he did "not expect to perform symphysiotomy under any circumstances, and consider[s] that the present enthusiasm for it will eventually disappear.")

But don't forget that Williams was a man of his time and forced to practice therein. For example, there were no antibiotics to speak of in 1903. Thus, the chapters pertaining to infection are as frightening as they are entertaining. Who today would witness puerperal infection with the "gas bacillus" (Bacillus aerogenes capsulatus) causing maternal death in a "Bohemian woman," after which "[w]ithin a few hours. . .her body had nearly doubled in size as the result of the development of gas in the subcutaneous tissues." Such ghastly descriptions, along with sections on tetanus, diphtheria, and other (now rare) diseases and syndromes, make the reader want to run to the lavatory for a thorough hand washing.

Speaking of hand washing, though, Williams was quick to credit Semmelweiss, Oliver Wendell Holmes, and the other giants who brought us the "germ theory" of disease and the practice of antisepsis. And although his terminology and taxonomy are now dated, Williams did a creditable job in 1903 of listing the bacterial species causing puerperal infection, for instance.

Of course, it's hard to resist the temptation to compare the original with the copy. Certainly, in terms of modern medicine, there is no comparison between Williams' book and the exact edition by Cunningham and colleagues. Not only does the original Williams text have no mention of antibiotics, electronic fetal monitoring, or electron micrographs, but it didn't even include an Apgar score! Still, the descriptions of normal vaginal delivery were remarkably similar in 1903 to the ones in 1997. Indeed, some things never change: the "ideal food for the newly born child is the milk of its mother," said Williams in 1903 -- a similar comment to Cunningham's in the twentieth edition: "[H]uman milk is the ideal food for neonates." (This is a trick, of course. As the twentieth edition appropriately states, breast-feeding fell out of vogue in the 1960s and 1970s. Obviously, Williams was quite a bit more modern than many of his disciples' disciples.)

On the other hand, obvious differences are often evident. Eclampsia, according to Williams, is "always serious," with a "maternal mortality [that] varies from 20 to 25 percent." Williams advocated control of convulsions with chloroform, large doses of morphine, the application of hot packs (for diuresis), and croton oil/olive oil mixture for catharsis. The pregnancy should then be terminated as expeditiously as possible. The syndrome usually disappears after delivery, although "[i]f the patient does not show marked signs of improvement shortly after delivery, from 300 to 500 cubic centimeters of blood should be withdrawn. If beneficial results follow, the procedure may be repeated as necessary." As expected, Cunningham and associates at Parkland agree that "eclampsia is still a deadly disease," but advocate "(1) control of convulsions, (2) correction of hypoxia and acidosis, (3) blood pressure control, and (4) delivery after control of convulsions." Obviously, bleeding the patient is no longer in favor in Dallas, even though their protocol has many similarities, at least in theory, to Williams'.

Perhaps one of the more impressive aspects of Williams' first text, even today, is the illustrations. Multiple line drawings, even of micrographs, were provided by K.M. Montague and F.S. Lockwood, whom Williams acknowledged in his book. Aside from the obvious (ie, genuine photographs, photomicrographs, and the like), the illustrations in the current Parkland text, by multiple artists, are often nearly exact copies of drawings from the original edition, and sometimes not as good. In fact, almost all of Williams' artwork could have been used in the new edition without apology.

Pure medicine aside, the history buff will find the social anthropology represented by this book fascinating. Speaking on the course of induced abortion, Williams said that the patient's "statements are entitled to but little weight, and the decision to interfere [ie, perform the abortion] should be based entirely upon objective symptoms and conditions," rather than the patient's desires. This authoritative approach to patient care is fairly alien to our current respect for patient autonomy and informed consent.

In another vein, consider the discussion of the racial differences in pelvic architecture:

"The mesatipellic variety [of pelvis] is observed in the women of the lower races, notably among the Bushmen, Hottentots, and the lower classes of negroes; while the platypellic forms are found in all the higher races. But even among civilized whites considerable racial differences are not infrequently noted, and it is generally stated that the pelves of the English and Holstein women are broader than other nationalities; while the Jewesses living in the vicinity of Dorpat have extremely small pelves."

The reader might wonder, "Did people really talk like that?" More to the point, "Did people really think like that?" The answer, of course, is yes. Dr. J. Whitridge Williams was a Professor at Johns Hopkins University; Obstetrician-in-Chief to the Johns Hopkins Hospital; and Gynaecologist to the Union Protestant Infirmary, Baltimore. Turn-of-the-century US produced no better, either scientist or gentleman. Thus, a practicing of Williams' first edition serves as a window to the soul of US medicine, and society in general, circa 1900. It is for the reader to decide what, if anything, "is history."

Power of Passion

One of the things that immediately stands out about Johanna’s approach to the Professional Agile Leadership class is her unbridled passion. I’ve heard her say, more than once, that this is her favourite class to teach.  📌

And trust me, it isn’t just words. You feel it. I share that enthusiasm, too.

As I’ve always observed, the questions are so interesting that this zest makes her sessions dynamic and engaging.

Perfect Audience and the Art of Engagement

But it’s not just about the instructor.

It’s also about the audience.  🌍

It’s a unique joy to realise that the type of people that come to the agile leadership class is predominantly the type Johanna and I, as consultants, often engage with inside organisations.

These attendees are decision-makers, strategists, and visionaries. Their diverse experiences and curiosity lead to discussions that are just so much fun.

Rich Experience with the Agile Vanguard

Beyond her palpable enthusiasm lies Johanna’s vast reservoir of experience. She’s been on the frontline, engaging with organisations at various levels, trying to help them understand agile practices, lean, and all the flavours.  🚀

Her skill in having intricate conversations with leadership, managers, and those holding pivotal positions gives her a unique edge.

The Ripple Effect of Conversations

The essence of our work in agility often lies in its ripple effect.  🔄

As I’ve always believed, when Johanna or I engage in transformative conversations, convincing somebody in a leadership position to move towards agility means helping many.

Johanna thrives on this.

Seeing a transformation in motion, grasping the changing dynamics, and understanding its more significant implications is where she draws her passion.

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