TEN SAMURAI LESSONS ON EM
A 17th century Samurai provided advice that is directly applicable to your pursuit of excellence in Emergency Medicine.
The famous Samurai Miyamoto Musashi died in 1645. He is widely regarded as having been a "kensei" or "sword saint", someone who has attained the highest level of mastery as a swordsman. The concept of kensei is based on the Buddhist notion that one becomes "enlightened" by dedicating oneself fully to an occupation. Probably sensing his impending death from cancer, Musashi retreated to the cave of Reigandō in 1643 to compose his thoughts. He wrote, "I take up my brush to explain the true spirit of this Ichi school as it is mirrored in the Way of heaven and Kwannon. The time is the night of the tenth day of the tenth month, at the hour of the tiger (3-5 a.m.)." Musashi's advice and wisdom was compiled in "Go Rin No Sho" or "A Book of Five Rings".
Here are just ten lessons adapted from A Book of Five Rings for you to consider.
1. Go to the Capital.
"When I was twenty one I went up to the capital and met all manner of strategists, never once failing to win in many contests."
You should strive to train at the leading centers for emergency medicine. You want to test your abilities with the best physicians in the world, not just locally. Select your residency program based on the resources that are there, the patients and pathology that you will see, the strength and vigor of the faculty, and the quality of the other residents that the program attracts. You will only have one opportunity to complete a residency; don't settle for one that won't demand your best.
2. The Way is in Training.
"In strategy it is necessary to treat training as part of normal life with your spirit unchanging."
Musashi was a painter, a sculptor, a blacksmith, a carpenter and a samurai. He advises that you never stop learning, improving, and expanding your skills. Emergency Medicine is such a broad field that you will always have new things to learn. If you find that your knowledge is weak in an area, count that as a blessing because you have identified a place to devote yourself until you achieve mastery.
3. Broaden your knowledge and never stop learning.
"Become acquainted with every Art."
Emergency Medicine interfaces with almost every specialty in medicine, to one degree or another. By choosing this profession you take on the burden of knowing your own specialty as well as the parts of everyone else's specialty that will impact your patient. You must strive to become educated about many different fields. Your skills and judgment have to be respected by the other physicians with whom you must consult; the best way to accomplish that is to "speak their language" and be as familiar with their literature as they are.
4. It is bad to repeat the same thing several times.
"The 'mountain-sea' spirit means that it is bad to repeat the same thing several times when fighting the enemy. There may be no help but to do something twice, but do not try it a third time. If the enemy thinks of the mountains, attack like the sea; and if he thinks of the sea, attack like the mountains."
Perhaps more so than most other specialties in medicine, emergency medicine requires adaptability. Patients come to us undifferentiated and one of our major pitfalls is premature closure. If one approach is not working, realize quickly that it may be the wrong approach for that particular patient in that particular situation. Develop the skills necessary to broaden a differential diagnosis or employ a different treatment or technique. There is a reason why the Roberts and Hedges textbook of Clinical Procedures describes eight methods for reducing an anterior shoulder dislocation.
5. The Gaze in Strategy.
"It is important to see distant things as if they are close and take a distanced view of close things."
This concept is akin to situational awareness: being fully aware of your surroundings at all times. It can be dangerous in a critical environment to allow yourself to become distracted. Develop a sense of what is truly important and what is not. We have a tendency in high stress situations to focus on the task at hand to the exclusion of everything else. For example, it is very difficult for a physician performing in a technical procedure, such as a resuscitative thoracotomy, to also keep the rest of the resuscitation running as an effective leader. Concentration on the procedure induces tunnel vision and makes it hard to see and hear other information. It is difficult to do, but learning to see everything simultaneously, both near and far, allows you to react instantly to a changing situation.
6. Be Calm and Alert.
"Both in fighting and in everyday life you should be determined though calm."
We have a great influence on the people around us by our demeanor. If we project anxiety, uncertainty, or fear, our patients and our fellow staff will respond similarly. If, on the other hand, we can remain calm and alert in all situations, we project confidence, competency, and control. If you only rarely raise your voice, it is certain that when you do, people will pay attention and appreciate the importance of what you are saying.
7. You should not have a Favorite Weapon.
"To become over-familiar with one weapon is as much a fault as not knowing it sufficiently well."
Knowing only one way of intubating is a mistake. Not only will there be patients in which a different approach to airway management may be best but there will be situations when your "favorite" laryngoscope is inoperative or unavailable. Becoming equally familiar with multiple techniques will serve you well. Developing those skills takes determination.
8. Use your Intuition.
"Perceive those things that Cannot be Seen."
There is a great deal of sensory information flooding an Emergency Department. Sights, sounds, smell, verbal and non-verbal communications are all messages. Most of that information does not reach our consciousness. However, that doesn't mean that it hasn't been received. Excellent clinicians have developed the ability to pay attention to the subconscious information cues and sense when "things aren't right". Many refer to this as intuition, as if it were a mystical ability that some people possess. In fact, it is not mystical at all; it is simply paying attention to the "voice in your head" that tells you to "take another look at the x-ray" or "check the medication dose again" or "take this patient seriously because there is something very wrong". Malcolm Gladwell makes the point in his book, Blink, that "great decision makers aren't those who process the most information or spend the most time deliberating, but those who have perfected the art of 'thin-slicing' – filtering the very few factors that matter from an overwhelming number of variables."
9. There is nothing truly new.
"There should be no such thing as "This is the modern way to do it" duelling."
Medicine and technology are changing fast. Textbooks seem to be out of date before their first printing. New medications, new devices, and new approaches seem to assault us daily. We are pressured to know the very latest. However, Musashi warned against adopting the "new" as "better" simply because it is new. Human physiology and human diseases have changed very little over the centuries. Knowing the fundamentals is paramount. With a solid foundation, one can choose what of the "new" is likely to be of use. Further, it is surprising how much that is touted as "new" is really just "rediscovered". For example, intraosseous infusions were proposed in the 1920s and used during World War II. The technique was largely abandoned until the 1980s when a pediatrician from the Cleveland Clinic was visiting India during a Cholera outbreak. He observed dehydrated children being resuscitated with intraosseous lines. He went on to publish an editorial, "My Kingdom for an Intravenous Line". Intraosseous lines are again a mainstay of emergency resuscitation.
10. Select the Right People.
"The foreman carpenter allots his men work according to their ability."
Emergency Medicine is a "team sport". Throughout the entirety of your career you will be working within a team. There is strength in teams but there can also be danger. Understand that you cannot do everything yourself and that you have to rely on others. Your challenge is then to select the best people to help you and give them assignments that they can accomplish for you. Pick with the right skills, knowledge and experience, who really want to be involved, and who are team players. That is what selecting a residency class is all about. If you want to be a member of that class, those are the attributes that you must convey.
"Any man who wants to master the essence of my strategy must research diligently, training morning and evening. Thus can he polish his skill, become free from self, and realize extraordinary ability. He will come to possess miraculous power."
--Myamoto Musashi, The Book of Five Rings, Reigandō, 1643
Gladwell, Malcolm. Blink. The Power of Thinking without Thinking. New York, Little, Brown and Company. 2005.
Gough, Leo. Miyamoto Musashi's The Book of Five Rings: A Modern-day interpretation of a strategy classic. Oxford. Infinite Ideas, Ltd. 2009.
Orlowski J. My kingdom for an intravenous line, Am J Diseases Child, 1984;138:803.
Roberts JR, Hedges JR. Clinical procedures in emergency medicine, 5th ed. Philadelphia, W.B. Saunders/ Elsevier, 2010.
Lee Shockley, MD
Former Program Director
Denver Health Residency in Emergency Medicine