Sun Tzu???s Art of War
2004; Lippincott Williams & Wilkins; Volume: 114; Issue: 1 Linguagem: Inglês
10.1097/01.prs.0000129080.26713.fe
ISSN1529-4242
Autores Tópico(s)Dental Education, Practice, Research
ResumoAs I opened the door to my black car on a recent September day, the heat rose from the interior. My hands and suitcase were loaded with papers on this latest trip to Asia. Since I had an opportunity to catch up on my reading during these long flights, my bags were especially full, as the clinically busy summer months had limited my time for such tasks. In my hands was a recent letter sent to my stepfather from his longtime orthopedic physician. The letter was a familiar story. Years of diminishing reimbursement for surgical procedures, the rising cost of malpractice insurance, and the cost of office overhead had forced early retirement. I felt angry and at the same time frustrated by the external pressures placed on our practices over which we have little control. The situation is not different in academic practice. Currently California’s $38 billion deficit has all but eliminated any type of additional compensation and support historically employed in academic practice. In both settings, costs must be met, employees paid, and deficits eliminated. Job security rests not only on academic productivity but also on financial stability and profitability. No different from in a private practice setting. As I read the letter again, I thought of the current challenges that face our specialty. In fact, several of these challenges have been nicely outlined by the strategic plan recently completed by the American Society of Plastic Surgeons (ASPS)/Plastic Surgery Educational Foundation (PSEF) executive committee. Such as plan is a business discipline that provides organizations with the tools to define their futures. This is especially critical in these times of limited resources. The original plan was completed in 2002 and recently updated in 2003. Six themes emerged that have been integrated into strategic objectives. These objectives involve advocacy, education, integration, Tracking Operations and Outcomes for Plastic Surgeons (TOPS), emerging medical trends, and Web-based public outreach. The basis for the need for strategic initiatives comes from not only our organization’s need for survival but also our own need for survival in practice. How are we going to face these issues of diminishing reimbursements? How can we determine and influence legislation on scope-of-practice initiatives? How can we continue to provide resident education with added demands of limited work hours and surgical procedures that are rapidly becoming infrequently practiced? How can we continue to provide our patients with high-quality medical care in a system that demands more cost-effective choices? How can we continue to strive for additional resident education by volunteer clinical faculty when our volunteer clinical faculty have a difficult enough time completing the current demands to keep their practices afloat? How are we going to approach the current malpractice issues? Solutions? I have none, but as I was re-reading Sun Tzu’s Art of War on this long flight to Asia, certain principles rang true no matter what the century. To know one’s challenges, limitations, and external pressures is the key to success in these difficult times, as it was in the Eastern Chou dynasty. The origin of Chinese military thought probably occurred with Neolithic village conflicts four or five thousand years ago. By the second century bc, China had already passed through a thousand years of almost unremitting conflict and had been brutally unified into a vast, powerful, and imperially directed entity. 1 Campaigns became interminable and the scale of destruction was immense, consuming both men and the thoughts they had committed to writing. Most of these writings were lost, but six major ones survived. In the early 1970s archaeologists excavating the Han dynasty tomb of a high-ranking official discovered a large number of immensely valuable texts written on bamboo slips. 1 The military works among them included the major portions of several of the Seven Military Classics, including the Art of War. Only part of the historical writings, including the complete Tso Chuan and essentially two of the Seven Military Classics (including Sun Tzu’s Art of War), has been translated and published. These works have been studied extensively throughout Japan and China. 1 Of the Seven Military Classics, only Sun Tzu’s military strategy traditionally known as the Art of War has received much exposure in the West. First translated by a French missionary more than 200 years ago, it remained the most important military treatise in Asia for more than 2000 years. Although the exact author of the manuscript has been debated, it is often attributed to Sun Wu, who is portrayed as active in the last years of the sixth century, beginning about 512 bc. Conflicts between warring states of Ch’u, Wu, and Yüeh set the scene for this masterpiece. These three southern states lie in the area of modern-day Hupei, Hunan, Honan, and Anhui. The state of Ch’u was Wu’s nemesis and the object of his strategy and efforts. Originally a barbarian state, Ch’u evolved into a state with dominant governmental organization. In 632 bc, at the famous battle of Ch’eng-p’u, the allied states of Chin, Ch’i, Ch’in, and Sung defeated Ch’u’s army, forcing Ch’u to redirect its campaigns of expansion toward the south and southeast, where it subjugated many smaller states and brought them in direct conflict with the state of Wu. Forming an alliance with Chin, Ch’u began clashing with Wu around 584 bc. During this initial period, Wu emerged victorious from every significant encounter, greatly blunting Ch’u’s power and curtailing influence. As the decades passed, Wu commenced increasingly aggressive actions against Ch’u’s cities, forcing Ch’u (from 538 bc) to undertake massive defensive preparations, including the construction of walled cities and other fortifications. It would seem by all accounts that Sun Tzu was entrusted with the overall command of Wu’s military forces for the purpose of effecting their reorganization and training. The last major battle between Ch’u and Wu occurred in 519 bc, well within Ch’u’s territory. Although outnumbered and not as strong as Ch’u, Wu defeated its opponents, demonstrating many of the teachings of Sun Tzu. Wu’s victory marked the first incursion and occupation of Ch’u territory by any state. This culminated in the overall defeat of Ch’u in 506 bc. 1 Sun Tzu’s Art of War consists of 13 chapters of varying lengths, each ostensibly focused on a specific topic. In the extant Art of War, Sun Tzu repeatedly emphasizes the need for rationality and self-control and stresses the vital necessity of avoiding all engagements not based on extensive, detailed analyses of the situation, the combat options, and one’s own capabilities. Detailed calculations were apparently performed in the ancestral temple before a campaign was mobilized. Although not all chapters are applicable today, some bear mentioning and can be applied to the current situations and challenges faced by our profession. 1 As with any conflict or challenge, initial estimates are important. The ASPS/PSEF has begun much of this effort by presenting a strategic plan that takes into account current and future environments and how best to position our Society. The same truths hold for our own practices, as insurance carriers change daily and practice reimbursement diminishes. Initial Estimates Thus when making a comparative evaluation through estimations, seeking out its true nature, ask: Which ruler has the Tao (Way of men)? Which general has greater ability? Who has gained the advantages of heaven and earth? Whose laws and orders are more thoroughly implemented? Whose forces are stronger? Whose officers and troops are better trained? Whose rewards and punishments are clearer? From these I will know victory and defeat. Advocacy and knowledge are critical to any organizational success. We do this in our own practice, knowing which administrator to hire, which employees work better to develop the organization, and which groups collaborate more efficiently. We select colleagues to trust and to whom we can entrust our patients’ care, hospital staff to support our programs, and friends to support our own emotional well being. Above all, we identify and promote those qualities of strength within ourselves and limit those forces that are considered weak and not so strong. It is no different on a national scale. The ASPS must continue to expand and open ongoing dialogues with leaders of our sister organizations, taking another look at how our separate interests can combine to function more efficiently and successfully under common goals. We must try to improve our strength in state societies as well as our strategies to increase payment for reconstructive surgery. These continued evaluations will increase communication and allow more formalized and stronger action. Once the initial estimates have been determined, a plan to deal with the current situation is necessary. Planning Offensive One who cannot be victorious assumes a defensive posture, one who can be victorious attacks. The victorious army first realizes the conditions for victory, and then seeks to engage in battle. The vanquished army fights first, and then seeks victory. One who knows the enemy and knows himself will not be endangered in a hundred engagements. One who does not know the enemy but knows himself will sometimes be victorious, sometimes meet with defeat. One who knows neither the enemy nor himself will invariably be defeated in every engagement. Warfare is the Way (Tao) of deception. Thus although you are capable, display incapability to them. When committed to employing your forces, feign inactivity. When your objective is nearby, make it appear as if distant; when far away, create the illusion of being nearby. Display profits to entice them, create disorder and take them. If they are substantial, prepare for them, if they are stung avoid them. If they are angry, perturb them; be deferential to foster their arrogance. If they are rested, force them to exert themselves. If they are united, cause them to be separated. Attack where they are unprepared. Go forth where they will not expect it. Thus the highest realization of warfare is to attack the enemy’s plans; next to attack their alliances; next to attack their enemy; and the lowest is to attack their fortified cities. A general commanding a large number is like commanding a few. It is a question of dividing up the numbers. Fighting with a large number is like fighting with a few. It is a question of configuration and designation. How many times have we wondered why our actions are not successful? Is it because of poor planning or, as explained by Sun Tzu, a lack of knowledge of our enemies? Is it because of our lack of ability to adapt? Physicians tend to be conservative, often with the philosophy of “if it isn’t broken, don’t fix it.” Are we reacting to our own environment, much like an amoeba? Or can we be more proactive, anticipating and knowing what our “enemies” are planning? This anticipation and proactive nature might limit our reactive responses and prevent many of the issues that we as physicians face. Nationally, our organization has advanced the concepts of evaluating technologies to benefit our practices. E-learning, Web-based technology, and expanding industry partnerships all assist with the public perception of plastic surgery. Waging War If it is not advantageous do not move. If objectives can not be attained, do not employ the army. Unless endangered do not engage in warfare. When it is advantageous move; when not advantageous, stop. Anger can revert to happiness, annoyance can revert to joy, but a vanquished state cannot be revived, the dead cannot be brought back to life. Why do I bang my head against the wall? Because it feels so good when I stop. Perhaps if we know that the wall is solid and not passable, altering our approaches makes more sense. Perhaps walking around the end of the wall is the better forward progress. Military Disposition In antiquity those that excelled in warfare first made themselves unconquerable to await the moment when the enemy could be conquered. Being unconquerable lies with yourself; being conquerable lies with the enemy. Thus one who excels in warfare is able to make himself unconquerable, but cannot necessarily cause the enemy to be conquerable. Thus it is said a strategy for conquering the enemy can be known but yet not possible to implement. How can we become unconquerable? How can we avoid the potential conflicts that often engulf our practice and organizations? Only through cooperation and good patient care do we win. We have centuries of Hippocratic ideals leading our profession. For decades we have cared for the maimed, injured, hurt, and suffering. We can still see this enthusiasm and idealism in the eyes of our medical students. Unlike the recent scandals that have swamped the stock and money market industry, our CEOs are ourselves. For the most part, we have the trust and admiration of the public. We have a time-honored profession, with foundations in honesty, integrity, and compassion—a foundation that few can claim. Frequently, we become cynical, which serves only to undermine our specialty and professional interactions. To become truly unconquerable, we must utilize the foundation that has been laid before us. In the end, our support of these Hippocratic ideals will ultimately serve us. Unity requires patience, understanding, and perhaps sacrifice, but it is vital and critical for our survival. Nationally, our own plastic surgery organization has attempted to unite through information and TOPS. Concerted efforts to gain data and information to scientifically support our patients’ desires will serve not only our patients but also our profession. Military Combat The location where we will engage the enemy must not become known to them. If it is not known, then the positions that they must prepare to defend will be numerous. If the positions the enemy prepares to defend are numerous, then the forces we engage will be few. Configuration of terrain is an aid to the army. Analyzing the enemy, taking control of victory, estimating ravines and defiles, the distant and near. . . one who knows these and employs them in combat will certainly be victorious. One who does not know these nor employ them in combat will certainly be defeated. In this ever-changing medical environment, it is hard to know the territory. Our national organization must continue to focus on this level and advocate for all of us. Advocacy may meet the needs of membership, but advocacy has to go beyond this. Advocacy must ensure the continued survival of our group representation. Sensitivity to the changes in our environment as well as sensitivity to changes in our practice is critical. The extant Art of War contains one succinct, critical passage that exemplifies the principles and tactics proposed. In general, in battle one engages with the orthodox and gains victory through the unorthodox. In warfare the strategic configurations of power do not exceed the unorthodox and orthodox, but the changes of the unorthodox and orthodox can never be completely exhausted. The unorthodox and orthodox mutually produce each other, just like an endless cycle. Thus the orthodox may be used in unorthodox ways, while an orthodox attack may be unorthodox when unexpected precisely because it is orthodox; a flanking or indirect assault would thereby be considered normal and therefore orthodox. A frontal feint by a large force designed to distract or lure an enemy would be unorthodox. 1 Our national societies, academic practices, and private practices, as well as individual surgeons, will be faced with extreme challenges over the next decade. Resident education is changing, with stricter guidelines from the Accreditation Council for Graduate Medical Education (ACGME). Consumers are demanding continued maintenance of certification. We have begun to address these demands on an individual and organizational level. Estimation of these challenges has already begun. The implementation, deposition, and the waging of our actions will require cooperation, insight, stable leadership, and perhaps an orthodox approach with unorthodox ways. The bounds that hold all of us are our profession and our commitment to patient care, a truly noble cause to which perhaps we can apply some insight from these ancient Chinese approaches to warfare. Of course, as Tom Clancy recently wrote, “do not kick the tiger in the ass unless you know where his teeth are.” 2
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