Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

“Ticking Time Bomb”


If you use a metaphor when speaking with patients, make sure to choose ones that don’t cause unnecessary alarm. 

“You have an aortic aneurysm,” said Dr. Watson in “A Study in Scarlet” when he listened to the chest of a character who they hoped to take to court and sentence to death. The character died the next day. He had a true “ticking time bomb” problem. While it’s been around for centuries, the term “ticking time bomb” has run amok through every field of science and arts given the sense of thrill and urgency it creates. From Sherlock Holmes to gripping climactic endings in innumerable action movies, the term has captured our imaginations and we use it for everything from the truly urgent to the exceedingly mundane. 


A Pubmed search of the term and review of the top 20 results reveals the medical problems/associations that have used this term in recent published scientific literature. Here’s the list: “type A aortic dissection,” “dental implants,” “meat allergy,” “phenological asynchrony”, “in-the bag intraocular lens dislocation”, “esophageal ulcer,” “chronobiological research,” “infected urachal cyst,” “cardiac sarcoidosis,” “AKI in cirrhosis,” “lifestyle related disease among women in Middle East,” “asbestos,” “childhood obesity,” “malaria,” and “reduced adrenal surgeries during COVID-19.” 


At first glance, this is quite befuddling! Here we are, an extremely scientific group of thinkers who insist on proper definitions and term usage for everything (volumes have been written in journals debating the definition of UTI). But upon reflection, the use of metaphors can be a way to communicate complex ideas to patients. In this metaphor, it conveys the urgency of a problem.



Just think about it, if we go back to the original definition of an explosive device set to a timer, will it be of any use if the timer is set for 30 years? A World War I bomb would go off in World War II. Would the world really appreciate it if the Mission Impossible crew could work, retire, and then decide after their grandkids were born if they had enough time to diffuse the bomb? 


I appreciate the sense of urgency that needs to be created for seemingly slow processes. But why “time bomb?” Is that the only term which can inspire action in an otherwise lethargic and couldn’t-care-less population? Could we try “slow moving lava,” or “gathering storm,” or “a great calamity of Sauron approaching?” Equally dangerous but at least more realistic. 


I do have a few suggestions. I think like everything else, cardiologists should get first dibs on this metaphor. Afterall, they “own” the “ticker.” And being a little generous, we should extend this privilege to folks dealing with anything which pulsates. But after that, I think we need to put strict controls on use of this term in medicine. Most important is establishing some time standards. You cannot argue “ticking time bomb” if the event is after next year’s birthday . . .  especially this writer’s birthday. Any further embellishment or distortion of time sense should be met with penalties. Otherwise, we are looking at complete chaos in medical literature with exploding bombs everywhere! 







This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.