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