VII. PATHWAYS


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

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

3. 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.

4. 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.

5. Managing a clinical pathway with an army of observations and interventions is advantageous; with an undisciplined multitude, most dangerous.

6. If you set a fully specified army of orders in every detail in order to snatch an advantage, the chances are that you will be too late. On the other hand, to detach an ongoing column of an active pathway for the purpose involves the sacrifice of its already dispensed solution bags and supplies.

7. Thus, if you order your observations and interventions to roll over their cutoffs, and make forced STATs without halting day or night, covering double the usual stint at a stretch, doing a hundred rounds in order to wrest an advantage, the leaders of all your three divisions will fall into the hands of the illness.

8. The stronger staffs will be in front, the jaded ones will fall behind, and on this care plan only one-tenth of your army of orders will reach their outcomes.

9. If you march fifty rounds in order to outperform the clinical indicators, you will lose the leader of your first division, and only half your staff will reach the goal.

10. If you march thirty rounds with the same object, two-thirds of your army of orders will be achieved.

11. We may take it then that an army of orders without sufficient nursing carts is lost; without provisions it is lost; without bases of supply it is lost.


12. We cannot enter into alliances until we are acquainted with the designs of our neighbour facilities.

13. We are not fit to lead an army of orders unless we are familiar with the faces of the hospital--its departments and wards, its problems and issues, its risks and hazards.

14. We shall be unable to turn community advantage to account unless we make use of local general practitioners.


15. In healthcare, practice personalisation, and you will succeed.

16. Whether to concentrate or to divide your regimens, must be decided by circumstances.

17. Let your swiftness be that of the wind, your calmness that of the forest.

18. In incision and surgical removal be like fire, in watchful waiting like a mountain.

19. Let your plans be deep and encompassing as darkness, and when you move, proceed like a lightning bolt.

20. When you achieve a positive outcome, let the praise be distributed amongst your team; when you receive new resources, cut it up into allotments for the benefit of the soldiery.

21. Ponder and deliberate before you make a move.

22. He will conquer who has learnt the articulation of variances. Such is the art of pathways.


23. The Book of Health Management says: On the theatre of operation, the spoken word does not carry far enough: hence the institution of prompts and checklists. Nor can ordinary objects be seen clearly enough: hence the institution of visual aids and markers.

24. Prompts and checklists, visual aids and markers, are means whereby the ears and eyes of the team may be focused on one particular point at a time.

25. The team thus forming a single united body, is it impossible either for the brave to advance alone, or for the cowardly to retreat alone. This is the art of handling a multi-professional team.

26. Before the induction of anaesthesia, make use of “sign in” checklist, before the incision of the skin, of “time out” checklist and before the patient leaves the operating room, of “sign out” checklist as a means of confirming completion of tasks by the ears and eyes of your surgery team.

27. A whole team may be affected in its spirit; a chief surgeon may be affected in his presence of mind.

28. Now a team's spirit is keenest in "sign in"; by "time out" it has begun to flag; and in "sign out", its mind is bent only on returning to station.

29. A clever surgeon, therefore, avoids a team's too eagerness when its spirit is keen, but cautions it when it is sluggish and inclined to return. This is the art of studying moods.

30. Disciplined and calm, to await the appearance of disorder and focus amongst the site:--this is the art of retaining self-possession.

31. To be near the area while the operating time is still far from the limit, to wait at ease while the aid is toiling and struggling, to be well-oxygenated while the bleeding is controlled:--this is the art of husbanding one's strength.

32. To refrain from intercepting a team member whose points are in perfect order, to refrain from attacking an objection drawn up in calm and confident way:--this is the art of studying circumstances.

33. It is a medical axiom not to advance treatment uphill for the patient, nor to operate him when the patient's complications are downhill.

34. Do not prescribe for a patient who hoards medications; do not administer drugs whose adverse reaction is keen.

35. Do not swallow bribe offered by the patient. Do not interfere with a patient that is returning home.

36. When you summon a patient, leave an outlet free. Do not press a desperate family too hard.

37. Such is the art of healthcare.

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

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