Friday 23 November 2012

The governor general who succeeds in a health campaign makes many statistics

Now the general who wins a battle makes many calculations in his temple [before] the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat: how much more no calculation at all! It is by attention to this point that I can foresee who is likely to win or lose.


Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

This is one of the most famous quotes from Sun Tzu. In applying this principle into healthcare, I feel the urge to mention a historical figure, Florence Nightingale. In a BMJ Quality & Safety article titled "Florence Nightingale gets no respect: as a statistician that is" by D Neuhauser, we can see how she fought the battle against the hierarchy and bureaucracy of British Military with her outstanding calculations as a "passionate statistician."

Translation:

Now the governor general who succeeds in a health campaign makes many statistics in the population health office before the campaign is conducted. The general who fails in a health campaign makes but few statistics beforehand. Thus do many statistics lead to success, and few statistics to failure: how much more no statistics at all! It is by attention to this point that I can foresee who is likely to succeed or fail.

Ray Murakami

Wednesday 21 November 2012

Healthcare is out of ordinary

All warfare is based on deception.

Hence, when able to attack, we must seem unable; when using our forces, we must seem inactive; when we are near, we must make the enemy believe we are far away; when far away, we must make him believe we are near.

Hold out baits to entice the enemy. Feign disorder, and crush him.

If he is secure at all points, be prepared for him. If he is in superior strength, evade him.

If your opponent is of choleric temper, seek to irritate him. Pretend to be weak, that he may grow arrogant.

If he is taking his ease, give him no rest. If his forces are united, separate them.

Attack him where he is unprepared, appear where you are not expected.

These military devices, leading to victory, must not be divulged beforehand.



Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

This is the part I really like. Quite a few medical procedures contradict what ordinary people experience in daily life and medical settings are quite different from places of daily living sometimes. From the population health view points, the general public's perceptions on health and welfare issues are often very remote from the realities and policies to address them tend to contradict to "the common sense" and create severe conflicts. It would be too much to say "All healthcare is based on deception" but it is sure that healthcare is out of ordinary.

Translation:

On the whole, healthcare is out of ordinary.

Hence, when able to attack, we may seem unable; when using our forces, we may seem inactive; when we are near, we may seem far away from the cause of a disease; when far away, we may seem we are near.

Use visual examinations and markers to discover hidden diseases. Approach non-invasively, and crush it.

If a condition is sure to emerge at all points, be prepared for it. If a disease is difficult to cure, prevent it.

If a condition should respond to a certain stimuli, seek to stimulate it. Resort to weak interventions, that the symptoms may grow evident.

If a tumour is taking up nutrition, suffocate it. If a stone is formed by concentration, crush it.

Attack microorganisms when they are unprotected, using the antibiotics they are not resistant to.

These medical devices, leading to treatment, must not be exposed beforehand.

Ray Murakami

According as circumstances are relevant, one should modify one's plans


The general that hearkens to my counsel and acts upon it, will conquer: let such a one be retained in command! The general that hearkens not to my counsel nor acts upon it, will suffer defeat:--let such a one be dismissed!

While heading the profit of my counsel, avail yourself also of any helpful circumstances over and beyond the ordinary rules.

According as circumstances are favorable, one should modify one's plans.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"
Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

As the words "my counsel" are too strong to retain I adopted "the best practice" implying the best practice of evidence-based medicine. It is interesting that Sun Tzu made the case for a need to modify plans beyond ordinary rules according to circumstances.

Translation:

The governor general that hearkens to the best practice and acts upon it, will succeed: let such a one be retained in leadership! The governor general that hearkens not to the best practice nor acts upon it, will suffer failure:--let such a one be dismissed!

While heading the profit of the best practice, avail yourself also of any special circumstances over and beyond the ordinary rules.

According as circumstances are relevant, one should modify one's plans.


Friday 9 November 2012

Seven considerations to forecast excellence or average

Therefore, in your deliberations, when seeking to determine the military conditions, let them be made the basis of a comparison, in this wise:--

(1) Which of the two sovereigns is imbued with the Moral law?
(2) Which of the two generals has most ability?
(3) With whom lie the advantages derived from Heaven and Earth?
(4) On which side is discipline most rigorously enforced?
(5) Which army is stronger?
(6) On which side are officers and men more highly trained?
(7) In which army is there the greater constancy both in reward and punishment?

By means of these seven considerations I can forecast victory or defeat.


Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

Here, Sun Tzu deals with benchmarking between two armies. Amazingly, those principles quite easily fit into the benchmarking between healthcare organisations with little modifications. It might be the trace of the fact that health organisations were in some extent modelled on military organisations.

Translation:

Therefore, in your deliberations, when seeking to determine the healthcare conditions, let them be made the basis of a comparison, in this wise:--

(1) Which of the two governors is compliant with the legislation?
(2) Which of the two general managers has most ability?
(3) With whom lie the advantages derived from Environment and Geography?
(4) On which side is discipline most rigorously enforced?
(5) Which organisation has a stronger framework?
(6) On which side are health officers and staff more highly trained?
(7) In which organisation is there the greater constancy both in reward and correction?

By means of these seven considerations I can forecast excellence or average.

Ray Murakami

Wednesday 7 November 2012

The five heads every health director should be familiar to

The Moral Law causes the people to be in complete accord with their ruler, so that they will follow him regardless of their lives, undismayed by any danger.

Heaven signifies night and day, cold and heat, times and seasons.

Earth comprises distances, great and small; danger and security; open ground and narrow passes; the chances of life and death.

The Commander stands for the virtues of wisdom, sincerity, benevolence, courage and strictness.

By method and discipline are to be understood the marshaling of the army in its proper subdivisions, the graduations of rank among the officers, the maintenance of roads by which supplies may reach the army, and the control of military expenditure.

These five heads should be familiar to every general: he who knows them will be victorious; he who knows them not will fail.



Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

The expression "Moral Law" requires some creative interpretation. We are no longer living in a world under the rule of virtue so it must be rewritten to fit a democratic context. However it would be still relevant that the rule should be in accordance to the people's needs and therefore observed by the people. Other translations are rather straight forward, just seeking the equivalent of military expressions in the healthcare context.

Translation:

The legislation asks the people to comply with the rules, which have been enacted in democratic processes so that everyone should follow it.

Environment signifies hours of sunshine, cold and heat, weather and seasonal variations.

Geography comprises distances of facilities, population, health risks, security, density of residence and life expectations.

Professionalism stands for the virtues of wisdom, sincerity, supportiveness, courage and strictness.

By method and discipline are to be understood the marshalling of the healthcare organisation in its proper subdivisions, the divisions of duties among the practitioners, the maintenance of facilities by which services are delivered to the customers, and the control of healthcare expenditure.

These five heads should be familiar to every health director: he who knows them will be successful; he who knows them not will fail.