In treatment, the physician receives his authority from the patient

Sun Tzu said: In war, the general receives his commands from the sovereign.

Having collected an army and concentrated his forces, he must blend and harmonize the different elements thereof before pitching his camp.

After that, comes tactical maneuvering, than which there is nothing more difficult. The difficulty of tactical maneuvering consists in turning the devious into the direct, and misfortune into gain.

Thus, to take a long and circuitous route, after enticing the enemy out of the way, and though starting after him, to contrive to reach the goal before him, shows knowledge of the artifice of DEVIATION.

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:

After some considerations this chapter's title manoeuvre was translated into (clinical) pathway.

Translation:

In treatment, the physician receives his authority from the patient.

Having collected staff and examined shifts, he must blend and harmonise the different elements thereof before pitching his team.

After that, comes clinical pathway, than which there is nothing more difficult. The difficulty of clinical pathway consists in turning the devious into the direct, and outlier into gain.

Thus, to take a long and circuitous route, after enticing the infection out of the way, and though starting after predisposed conditions, to contrive to reach the goal before onset of those conditions, shows knowledge of the artifice of VARIANCE ANALYSIS.

Ray Murakami

Just as water retains no constant shape, so in healthcare, no constant conditions

Military tactics are like unto water; for water in its natural course runs away from high places and hastens downwards.

So in war, the way is to avoid what is strong and to strike at what is weak.

Water shapes its course according to the nature of the ground over which it flows; the soldier works out his victory in relation to the foe whom he is facing.

Therefore, just as water retains no constant shape, so in warfare there are no constant conditions.

He who can modify his tactics in relation to his opponent and thereby succeed in winning, may be called a heaven-born captain.

The five elements (water, fire, wood, metal, earth) are not always equally predominant; the four seasons make way for each other in turn. There are short days and long; the moon has its periods of waning and waxing.

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:

This part is rather straight forward translation. However, the last paragraph may well stay as it is but a trial was made to put it into the context of the whole system approach in the healthcare.

Translation:

Treatment designs are like unto water; for water in its natural course runs away from high places and hastens downwards.

So in treatment the way is to avoid what is contraindication and to look at what is indicating.

Water shapes its course according to the nature of the ground over which it flows; the practitioner works out the care plan tailored to the patient conditions which the team is facing.

Therefore, just as water retains no constant shape, so in healthcare there are no constant conditions.

Those who can modify their care plan in relation to patient's needs and thereby succeed in treatment, may be called an excellent healthcare performance.

The five elements (medicine, surgery, nursing, allied health, administration) have no fixated priorities; the acute and chronic make way for each other in turn. There are short stays and long; the health demand has its periods of waning and waxing.

Ray Murakami

Do not repeat the treatment which have gained you one good result

Though according to my estimate the soldiers of Yueh exceed our own in number, that shall advantage them nothing in the matter of victory. I say then that victory can be achieved.

Though the enemy be stronger in numbers, we may prevent him from fighting. Scheme so as to discover his plans and the likelihood of their success.

Rouse him, and learn the principle of his activity or inactivity. Force him to reveal himself, so as to find out his vulnerable spots.

Carefully compare the opposing army with your own, so that you may know where strength is superabundant and where it is deficient.

In making tactical dispositions, the highest pitch you can attain is to conceal them; conceal your dispositions, and you will be safe from the prying of the subtlest spies, from the machinations of the wisest brains.

How victory may be produced for them out of the enemy's own tactics--that is what the multitude cannot comprehend.

All men can see the tactics whereby I conquer, but what none can see is the strategy out of which victory is evolved.

Do not repeat the tactics which have gained you one victory, but let your methods be regulated by the infinite variety of circumstances.

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:

The protection of population against epidemics is often misunderstood by the general public. Each time an epidemic of an exotic and deadly disease in foreign country floods news media, people often are panicked as though the disease mentioned is just outside of their doorsteps. However, such a news  scrum rarely encourages people to immunise against known but potentially deadly diseases. Sun Tzu's tricks on how to deceive enemies, which interestingly correspond to tactics to battle against contagious pathogens, also remind us on difficulties of publicising population health policies including epidemic prevention.

Translation:

Though according to the expert's estimate the outbreaks of infection exceed our immunisation in number, that shall advantage them nothing in the matter of quarantine. I say then that quarantine can be achieved.

Though the pathogen be stronger in numbers, we may prevent it from spreading. Scheme so as to discover its patterns and the likelihood of their spread.

Cultivate it, and learn the principle of its activity or inactivity. Force it to reveal itself, so as to find out its vulnerable spots.

Carefully compare the emerging pathogen with the already known, so that you may know where strength is superabundant and where it is deficient.

In making tactical population protection, the highest pitch you can attain is to isolate them; isolate your population, and you will be safe from the prying of the subtlest contacts, from the infection of the most contagious strains.

How protection may be produced for people out of the disease's own pathogens--that is what the multitude cannot comprehend.

All people can see the treatment whereby the medicine conquer, but what none can see is the strategy out of which treatment is evolved.

Do not repeat the treatment which have gained you one good result, but let your methods be regulated by the infinite variety of circumstances.

Ray Murakami

We can form a single united body, while supporting each speciality or branch under it

By discovering the enemy's dispositions and remaining invisible ourselves, we can keep our forces concentrated, while the enemy's must be divided.

We can form a single united body, while the enemy must split up into fractions. Hence there will be a whole pitted against separate parts of a whole, which means that we shall be many to the enemy's few.

And if we are able thus to attack an inferior force with a superior one, our opponents will be in dire straits.

The spot where we intend to fight must not be made known; for then the enemy will have to prepare against a possible attack at several different points; and his forces being thus distributed in many directions, the numbers we shall have to face at any given point will be proportionately few.

For should the enemy strengthen his van, he will weaken his rear; should he strengthen his rear, he will weaken his van; should he strengthen his left, he will weaken his right; should he strengthen his right, he will weaken his left. If he sends reinforcements everywhere, he will everywhere be weak.

Numerical weakness comes from having to prepare against possible attacks; numerical strength, from compelling our adversary to make these preparations against us.

Knowing the place and the time of the coming battle, we may concentrate from the greatest distances in order to fight.

But if neither time nor place be known, then the left wing will be impotent to succor the right, the right equally impotent to succor the left, the van unable to relieve the rear, or the rear to support the van. How much more so if the furthest portions of the army are anything under a hundred LI apart, and even the nearest are separated by several LI!

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:

Now Sun Tzu's principle can be applied to the resource management in healthcare and importance of the clinic appointment management.

Translation:

By discovering the population's disease statistics and maintaining our care facilities impartial, we can keep our workforces concentrated, while the provisions of care is diversified.

We can form a single united body, while supporting each speciality or branch under it. Hence there will be a holistic healthcare system against separate cases of a whole disease spectrums, which means that we shall have more capacities shared for the few specialised cases.

And if we are able thus to treat a minor case with a superior facility, the chances of having adverse events will be minimised.

The spot where we intend to treat must not be made inflexible; for then the people with health conditions will be able to expect a possible encounter at several different points; and healthcare demands being thus distributed in many directions, the numbers we shall have to face at any given point will be proportionately few.

For should the healthcare demand strengthen in the business districts, it will weaken in the residential areas; should it strengthen in the residential areas, it will weaken the business district; should it strengthen in the suburbs, it will weaken in the city centres; should it strengthen in the city centres, it will weaken in the suburbs. If it disperses to everywhere, it will everywhere be weak.

Numerical weakness comes from having to prepare against possible health demands; numerical strength, from encouraging our health consumers to make prior appointments with us.

Knowing the place and the time of the coming encounters, we may concentrate from the greatest distances in order to treat.

But if neither time nor place be known, then the staff in the left wing of the hospital will be impotent to succour the right, the staff in the right equally impotent to succour the left, the acute facility unable to relieve the chronic, or the chronic facility to support the acute. How much more so if the furthest portions of the staff are anything under a hundred miles apart, and even the nearest are separated by several miles!

Ray Murakami

You may retrieve and be safe from adverse effects if your weaning procedures are more swift

You may advance and be absolutely irresistible, if you make for the enemy's weak points; you may retire and be safe from pursuit if your movements are more rapid than those of the enemy.

If we wish to fight, the enemy can be forced to an engagement even though he be sheltered behind a high rampart and a deep ditch. All we need do is attack some other place that he will be obliged to relieve.

If we do not wish to fight, we can prevent the enemy from engaging us even though the lines of our encampment be merely traced out on the ground. All we need do is to throw something odd and unaccountable in his way.

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:

Again, Sun Tzu's principle is shown to be in line with low-invasive treatments and preventive healthcare.

Translation:

Treatments may be advanced and absolutely harmless, if you make for the disease's weak points; you may retrieve and be safe from adverse effects if your weaning procedures are more swift than the raising risks of complications.

If we wish to treat, the pathogen can be forced to an interaction even though it be sheltered behind a thick structure and a deep cavity. All we need do is attack some other parts that it will be obliged to react.

If we do not wish to treat, we can prevent the disease from affecting us even though the lines of our immunity be merely traced out on the defence mechanisms. All we need do is to prescribe something disturbs and blocks its mechanism of pathogenesis.

Ray Murakami

No specific plans or instructions can ensure the flawless treatment and errorless care

Appear at points which the enemy must hasten to defend; march swiftly to places where you are not expected.

An army may march great distances without distress, if it marches through country where the enemy is not.

You can be sure of succeeding in your attacks if you only attack places which are undefended.You can ensure the safety of your defense if you only hold positions that cannot be attacked.

Hence that general is skillful in attack whose opponent does not know what to defend; and he is skillful in defense whose opponent does not know what to attack.

O divine art of subtlety and secrecy! Through you we learn to be invisible, through you inaudible; and hence we can hold the enemy's fate in our hands.

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:

In this section, attack and defence are translated into treatment and care, respectively. The enemy is translated to the obstacles in treatment and care. The sentences require creativity in translation and the last paragraph is the pinnacle of them. I read carefully the original contents in the Chinese text and decided to rewrite that part completely regardless of the English translation. I think this is much inline with the original text even outside of the healthcare context.

Translation:

Intervene at points where the health conditions are quick to deteriorate; reallocate swiftly to places where resources are not fulfilled.

A health team may treat a great number of patients without distress, if it operates through streamlined processes where the disruption is not.

You can be sure of succeeding in your treatments if you only treat cases which are not contraindicated.You can ensure the safety of your care if you only follow steps that cannot be mistaken.

Hence that clinician is skilful in treatment whose case does not see what to counter; and he is skilful in care whose case does not see what to mistake.

No specific plans or instructions can ensure the flawless treatment and errorless care. Flexibility and proactivity are the keys for quality and safety of healthcare.

Ray Murakami

The clever clinical director imposes his control on the health risk

Sun Tzu said: Whoever is first in the field and awaits the coming of the enemy, will be fresh for the fight; whoever is second in the field and has to hasten to battle will arrive exhausted.
 

Therefore the clever combatant imposes his will on the enemy, but does not allow the enemy's will to be imposed on him.
 

By holding out advantages to him, he can cause the enemy to approach of his own accord; or, by inflicting damage, he can make it impossible for the enemy to draw near.
 

If the enemy is taking his ease, he can harass him; if well supplied with food, he can starve him out; if quietly encamped, he can force him to move.

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:

Sun Tzu always put emphasis on preventive and proactive measures over responsive and reactive ones. This chapter is about understanding the situation and take precautionary actions against them. Especially analysis of "Weak Points and Strong" is crucial in risk assessment. This section saw quite a lot of rewriting to convey the original meaning after considering the original Chinese text.

Translation:

It could be said: Whoever gives prevention the first priority and awaits the coming of the health risks, will be fresh for the fight against diseases; whoever gives prevention the second priority and has to haphazardly battle against health risks will arrive to hospitals exhausted.

Therefore the clever clinical director imposes his control on the health risk, but does not allow the health risk's implications to be imposed on him.

He promotes healthy behaviours and practices by encouraging them, he discourages risky behaviours and practices by disadvantaging them.

If the health risk is inactivity, he can encourage activities; if it is overeating, he can recommend lean diet; it is hidden, he can make it widely known.

Ray Murakami

The clever consultant looks to the effect of a multidisciplinary team

Thus one who is skillful at keeping the enemy on the move maintains deceitful appearances, according to which the enemy will act. He sacrifices something, that the enemy may snatch at it.

By holding out baits, he keeps him on the march; then with a body of picked men he lies in wait for him.

The clever combatant looks to the effect of combined energy, and does not require too much from individuals. Hence his ability to pick out the right men and utilize combined energy.

When he utilizes combined energy, his fighting men become as it were like unto rolling logs or stones. For it is the nature of a log or stone to remain motionless on level ground, and to move when on a slope; if four-cornered, to come to a standstill, but if round-shaped, to go rolling down.

Thus the energy developed by good fighting men is as the momentum of a round stone rolled down a mountain thousands of feet in height. So much on the subject of energy.

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:

This is the summary section of this chapter about engagement. The first part is about the engagement between the clinician and the patient and put in the mobile care context. The second and the last part is about engagement within clinical team and put in the context of the multidisciplinary team.

Translation:

Thus one who is skilful at keeping the patient on the move maintains the online presence, according to which the patient will access. He provides some information, that the patient may snatch at it.

By holding out portals, he keeps the patient informed; then with a clinic of picked staff he calls in the patient for an appointment.

The clever consultant looks to the effect of a multidisciplinary team, and does not require too much from individuals. Hence his ability to pick out the right people and utilise a multidisciplinary team.

When he utilises a multidisciplinary team, his staff become as it were like unto rolling logs or stones. For it is the nature of a log or stone to remain motionless on level ground, and to move when on a slope; if four-cornered, to come to a standstill, but if round-shaped, to go rolling down.

Thus the engagement developed by good clinical team is as the momentum of a round stone rolled down a mountain thousands of feet in height. So much on the subject of engagement.

Ray Murakami

The good medical officer will be comprehensive in his onset, and prompt in his decision

The onset of troops is like the rush of a torrent which will even roll stones along in its course.

The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim.

Therefore the good fighter will be terrible in his onset, and prompt in his decision.

Energy may be likened to the bending of a crossbow; decision, to the releasing of a trigger.

Amid the turmoil and tumult of battle, there may be seeming disorder and yet no real disorder at all; amid confusion and chaos, your array may be without head or tail, yet it will be proof against defeat.

Simulated disorder postulates perfect discipline, simulated fear postulates courage; simulated weakness postulates strength.

Hiding order beneath the cloak of disorder is simply a question of subdivision; concealing courage under a show of timidity presupposes a fund of latent energy; masking strength with weakness is to be effected by tactical dispositions.

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:

For the second time, I changed the English translation of the title of this chapter to fit it into healthcare context. Now it is Engagement. The original translation was "energy" and I thought it means what moves a lot of people in a coordinated way after considering this section. In healthcare, what brought people on the same page is engagement. There are many other expressions required creative translations. Those were about the "deceptive" nature of the war which makes enemy believe what is actually not. I have chosen anaesthesia, sedation and relaxant as such elements in healthcare.

Translation:

The onset of a treatment is like the rush of a torrent which will even roll stones along in its course.

The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim.

Therefore the good medical officer will be comprehensive in his onset, and prompt in his decision.

Engagement may be likened to the bending of a crossbow; decision, to the releasing of a trigger.

Amid the turmoil and tumult of treatment, there may be seeming disturbance and yet no real disturbance at all; amid confusion and chaos, your array may be without head or tail, yet it will be proof against defeat.

Induced unconsciousness postulates perfect consciousness, induced calmness postulates vitality; induced weakness postulates strength.

Hiding consciousness beneath the cloak of coma is simply a question of anaesthetics; concealing vitality under a show of timidity presupposes a fund of latent energy by sedation; masking strength with weakness is to be effected by relaxant.

Ray Murakami

Remote deliveries, efficiently applied, are ubiquitous as Heaven and Earth

In all fighting, the direct method may be used for joining battle, but indirect methods will be needed in order to secure victory.

Indirect tactics, efficiently applied, are inexhaustible as Heaven and Earth, unending as the flow of rivers and streams; like the sun and moon, they end but to begin anew; like the four seasons, they pass away to return once more.

There are not more than five musical notes, yet the combinations of these five give rise to more melodies than can ever be heard.

There are not more than five primary colors (blue, yellow, red, white, and black), yet in combination they produce more hues than can ever been seen.

There are not more than five cardinal tastes (sour, acrid, salt, sweet, bitter), yet combinations of them yield more flavors than can ever be tasted.

In battle, there are not more than two methods of attack--the direct and the indirect; yet these two in combination give rise to an endless series of maneuvers.

The direct and the indirect lead on to each other in turn. It is like moving in a circle--you never come to an end. Who can exhaust the possibilities of their combination?

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:

The hint for this translation came from a conversation with a Zen monk, Venerable Yushi Shimada who is a Facebook/Twitter friend of mine. I thought these passages illustrated that the limitation of options did not necessarily limit what we could do about with them. It seemed to me that the notion was relevant to modern healthcare, too. But I thought I would need better examples for today's audience than Sun Tzu used to describe it.

Then Yushi mentioned about our previous discussion about the movie "Matrix" on indistinctness between physical reality and virtual reality. Then I found that I could translate those passages within the context of remote healthcare delivery. I really appreciate Yushi for that.

Translation:

In all healthcare deliveries, the direct method may be used for the first encounter, but remote methods will be needed in order to maintain access.

Remote deliveries, efficiently applied, are ubiquitous as Heaven and Earth, continuous as the flow of rivers and streams; like the sun and moon, they are timely and repeatable; like the four seasons, they accommodate any stages of life.

There are not more than sixteen bits, yet the combinations of these can record more melodies than can ever be heard.

There are not more than eight bits each for three primary colours, yet in combination they can record video streams with more hues than can ever been seen.

There are not more than blood-oxygen level test, yet pulse oximetry yield more favours than other methods ever be tested.

In healthcare, there are not more than two methods of delivery--the direct and the remote yet these two in combination give rise to an endless series of manoeuvres.

The direct and the remote lead on to each other in turn. It is like moving in a circle--you never come to an end. Who can exhaust the possibilities of their combination?

Ray Murakami

Effectiveness of your health team may be like a grindstone dashed against an egg

Sun Tzu said: The control of a large force is the same principle as the control of a few men: it is merely a question of dividing up their numbers.

Fighting with a large army under your command is nowise different from fighting with a small one: it is merely a question of instituting signs and signals.

To ensure that your whole host may withstand the brunt of the enemy's attack and remain unshaken-- this is effected by maneuvers direct and indirect.

That the impact of your army may be like a grindstone dashed against an egg--this is effected by the science of weak points and strong.

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:

In the English text this chapter is titled "Energy" but "Delivery" would be more suitable in the healthcare context. This part also requires creativity in interpreting. As counterparts of the priorities for establishing military superiority,  these principles were selected from the healthcare context: individualised patient-centred care, effective health information systems, population immunisation programmes and evidence-based healthcare.

Translation:

The healthcare of a large population is the same principle as the healthcare of a few patients: it is merely a question of catering for individual needs.

Treating with a large health organisation under your command is nowise different from treating with a small one: it is merely a question of instituting effective health information systems.

To ensure that your whole population may withstand the outbreak of the infectious diseases and remain unshaken-- this is effected by immunisations targeted and standard.

That the effectiveness of your health team may be like a grindstone dashed against an egg--this is effected by the science of indications and contraindications.

Ray Murakami

The consummate clinical leader cultivates the health ethics

The consummate leader cultivates the moral law, and strictly adheres to method and discipline; thus it is in his power to control success.

In respect of military method, we have, firstly, Measurement; secondly, Estimation of quantity; thirdly, Calculation; fourthly, Balancing of chances; fifthly, Victory.

Measurement owes its existence to Earth; Estimation of quantity to Measurement; Calculation to Estimation of quantity; Balancing of chances to Calculation; and Victory to Balancing of chances.

A victorious army opposed to a routed one, is as a pound's weight placed in the scale against a single grain.

The onrush of a conquering force is like the bursting of pent-up waters into a chasm a thousand fathoms deep.

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:

This part was translated with the principle of evidence-based medicine and application of a clinical pathway.

Translation:

The consummate clinical leader cultivates the health ethics, and strictly adheres to method and discipline; thus it is in his power to control success.

In respect of clinical evidence, we have, firstly, Measurement; secondly, Evaluation of validity; thirdly, Calculation of prognosis; fourthly, Balancing of values; fifthly, Making decision.

Measurement owes its existence to evidence; Evaluation of validity to Measurement; Calculation of prognosis to Evaluation of validity; Balancing of values to Calculation of prognosis; and Making decision to Balancing of values.

An efficient clinical team opposed to a well-established condition, is as a pound's weight placed in the scale against a single grain.

The onrush of a clinical pathway is like the bursting of pent-up waters into a chasm a thousand fathoms deep.

Ray Murakami

The skilful clinician puts himself into a position which makes harm impossible

To see victory only when it is within the ken of the common herd is not the acme of excellence.

Neither is it the acme of excellence if you fight and conquer and the whole Empire says, "Well done!"

To lift an autumn hair is no sign of great strength; to see the sun and moon is no sign of sharp sight; to hear the noise of thunder is no sign of a quick ear.

What the ancients called a clever fighter is one who not only wins, but excels in winning with ease.

Hence his victories bring him neither reputation for wisdom nor credit for courage.

He wins his battles by making no mistakes. Making no mistakes is what establishes the certainty of victory, for it means conquering an enemy that is already defeated.

Hence the skillful fighter puts himself into a position which makes defeat impossible, and does not miss the moment for defeating the enemy.

Thus it is that in war the victorious strategist only seeks battle after the victory has been won, whereas he who is destined to defeat first fights and afterwards looks for victory.

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:

The Hippocratic Oath and the principle of evidenced-based medicine would help to interpret this part. The patient privacy means that the clinician's excellence may not be widely known to the public. The phrase "only seeks battle after the victory has been won" quite matches the principle of evidenced-based medicine.

Translation:

To see recovery only when it is within the ken of the common herd is not the acme of excellence.

Neither is it the acme of excellence if you treat and cure and the whole community says, "Well done!"

To lift an autumn hair is no sign of great strength; to see the sun and moon is no sign of sharp sight; to hear the noise of thunder is no sign of a quick ear.

What the ancients called a clever clinician is one who not only cures, but excels in curing with the privacy of the sick protected.

Hence his practice bring him neither reputation for wisdom nor credit for courage.

He cures his patients by making no harm. Making no harm is what establishes the certainty of safety, for it means treating a condition that is already supported by evidence.

Hence the skilful clinician puts himself into a position which makes harm impossible, and does not miss the indication for treating the condition.

Thus it is that in healthcare the competent clinical director only seeks decision after the evidence has been examined, whereas he who is destined to fail first decides and afterwards looks for evidence.

Ray Murakami

The good clinicians of old first put themselves beyond the possibility of harm

Sun Tzu said: The good fighters of old first put themselves beyond the possibility of defeat, and then waited for an opportunity of defeating the enemy.

To secure ourselves against defeat lies in our own hands, but the opportunity of defeating the enemy is provided by the enemy himself.

3. Thus the good fighter is able to secure himself against defeat, but cannot make certain of defeating the enemy.

Hence the saying: One may know how to conquer without being able to do it.

Security against defeat implies defensive tactics; ability to defeat the enemy means taking the offensive.

Standing on the defensive indicates insufficient strength; attacking, a superabundance of strength.

The general who is skilled in defense hides in the most secret recesses of the earth; he who is skilled in attack flashes forth from the topmost heights of heaven. Thus on the one hand we have ability to protect ourselves; on the other, a victory that is complete.

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:

"First, Do No Harm" is the maxim as old as healthcare itself. Defensive tactics and offensive tactics would translate to conservative treatment and active treatment, respectively. Also we can discuss evidence based medicine. One problem is interpretation of hiding in the defence. How about putting in the context of palliative care and see it as a skilful pain control?

Translation:

It is said: The good clinicians of old first put themselves beyond the possibility of harm, and then waited for an opportunity of addressing the conditions.

To secure ourselves against harm lies in our own hands, but the opportunity of addressing the condition is provided by the condition itself.

Thus the good clinician is able to secure himself against harm, but cannot make certain of addressing the condition.

Hence the saying: One may know how to recover without being able to do it.

Security against harm implies conservative treatment; ability to address the condition means taking the active treatment.

Standing on the conservative indicates insufficient evidence; attacking, a superabundance of evidence.

The general who is skilled in conservative treatment removes a pain in the most secret recesses of the body; he who is skilled in active treatment flashes forth from the topmost heights of heaven. Thus on the one hand we have ability to protect ourselves; on the other, a cure that is complete.

Ray Murakami

If you know the enemy and know yourself, you need not fear the result of a hundred battles

Thus we may know that there are five essentials for victory:
(1) He will win who knows when to fight and when not to fight.
(2) He will win who knows how to handle both superior and inferior forces.
(3) He will win whose army is animated by the same spirit throughout all its ranks.
(4) He will win who, prepared himself, waits to take the enemy unprepared.
(5) He will win who has military capacity and is not interfered with by the sovereign.

Hence the saying: If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle.

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:

The last paragraph is the famous one and would not need any modifications or explanations. Most of the rest can be translated straightforward by simply matching corresponding concepts. However, the aspect of preparations for the both sides would require some consideration. You may discuss about antibiotic resistance, however, more simple care plan initiative is discussed here.

Translation:

Thus we may know that there are five essentials for healthcare excellence:
(1) He will win who knows when to treat and when not to treat.
(2) He will win who knows how to handle both superior and inferior symptoms.
(3) He will win whose health team is animated by the same spirit throughout all its ranks.
(4) He will win who, prepared care plans, waits to take actions before the conditions deteriorate.
(5) He will win who has healthcare capacity and is not interfered with by the politics.

Hence the saying: If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle.
Ray Murakami

The general practice is the bulwark of the community health

Now the general is the bulwark of the State; if the bulwark is complete at all points; the State will be strong; if the bulwark is defective, the State will be weak.

There are three ways in which a ruler can bring misfortune upon his army:--

(1) By commanding the army to advance or to retreat, being ignorant of the fact that it cannot obey. This is called hobbling the army.

(2) By attempting to govern an army in the same way as he administers a kingdom, being ignorant of the conditions which obtain in an army. This causes restlessness in the soldier's minds.

(3) By employing the officers of his army without discrimination, through ignorance of the military principle of adaptation to circumstances. This shakes the confidence of the soldiers.

But when the army is restless and distrustful, trouble is sure to come from the other feudal princes. This is simply bringing anarchy into the army, and flinging victory away.

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:

To apply this part of the text of Sun Tzu into the current health context where the focus is shifting toward community care and shared decision making, it would be justifiable to substitute "the community health" for "the State" as the objective of protection. This translation enables us to discuss implications of dubious health choices and pro-market health reforms.

Translation:

Now the general practice is the bulwark of the community health; if the bulwark is complete at all points; the community health will be strong; if the bulwark is defective, the community health will be weak.

There are three ways in which a community can bring misfortune upon its health team:--

(1) By commanding the health team to advance or to retreat, being ignorant of the fact that it cannot obey. This is called hobbling the health team.

(2) By attempting to govern a health team in the same way as it administers a commercial business, being ignorant of the conditions which obtain in a health team. This causes restlessness in the clinician's minds.

(3) By employing the officers of its health team without discrimination, through ignorance of the medical principle of adaptation to circumstances. This shakes the confidence of the clinicians.

But when the health team is restless and distrustful, trouble is sure to come from quality and safety issues. This is simply bringing apathy into the health team, and flinging clinicians away.

Ray Murakami

An obstinate practice by a small staff must be exhausted by the lager population

It is the rule in war, if our forces are ten to the enemy's one, to surround him; if five to one, to attack him; if twice as numerous, to divide our army into two.

If equally matched, we can offer battle; if slightly inferior in numbers, we can avoid the enemy; if quite unequal in every way, we can flee from him.

Hence, though an obstinate fight may be made by a small force, in the end it must be captured by the larger force.

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:

Sun Tzu was very clear in stressing the importance of numerical superiority and tactful exploitation of it. The same is true for healthcare. The news media often praise the newest developments and treatments in medicine without considering the resources they require. The media also criticise clinicians and current practices without insights in the scarcity of resources they are provided. According to Sun Tzu, such misconceptions would have serious consequences if accommodated into health policies.

Translation:

It is the rule in treatment, if our available resources are ten to the target population's one, to propagate it; if five to one, to recommend it; if twice as required, to optimise its usage.

If equally matched, we can offer it as an option; if slightly scarce in resources, we can avoid utilising it; if quite unequal in every way, we can discourage it.

Hence, though an obstinate practice may be made by a small staff, in the end it must be exhausted by by the larger population.

Ray Murakami