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Emergency medicine as a martial art
The Journal of Emergency Medicine, Vol. 17, No. 1, pp. 115–121, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/99 $–see front matter
PII S0736-4679(98)00142-5
Emergency Forum
EMERGENCY MEDICINE AS A MARTIAL ART David W. Harrison,
MD, CCFP
(EM),
FRCPC
Department of Emergency Medicine, Vancouver General Hospital, Director, Residency Training Program in Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada Reprint Address: David W. Harrison, MD, Department of Emergency Medicine, Vancouver General Hospital, 855 W. 12th Avenue, Vancouver, BC, Canada V5Z 1M9
hand. It emerged approximately 500 years ago as a means of self defense against armed assailants. As Okinawan society evolved, it was no longer necessary to train individuals in techniques of mortal combat. The emphasis in karate therefore shifted from the perfection of lethal force to the perfection of personal integrity and character through training in the art. Modern karate training, therefore, encompasses three general spheres— physical training, spiritual or inner development, and the building of character.
INTRODUCTION Emergency medicine is a unique specialty, characterized by the need for immediate, decisive action in response to situations with life and death consequences. Perhaps more than any other specialty we are required to confront our patients’, and therefore our own, inevitable yet somehow unexpected mortality on a daily basis. The ability to remain calm and respond appropriately in such circumstances is an important skill for every emergency physician. Nevertheless, this subject is rarely addressed in the emergency medicine literature. The Asian fighting arts share with the practice of emergency medicine the requirement for instantaneous and appropriate responses to potentially life threatening situations. The martial arts literature and tradition describe a legacy of leadership, moral integrity, and composure in difficult circumstances— qualities indispensable in an emergency physician. This article will explore the relationship between the martial arts and emergency medicine by examining these two disciplines from three perspectives—the parallels between the training of a martial artist and an emergency physician, the need to face death, and the process of developing character.
PHYSICAL TRAINING When training in karate begins, the initiate must learn a new way of moving the body that seems foreign and unnatural. Simple maneuvers such as moving forward or backward in the correct way, maneuvers that we perform every day without thinking, seem almost impossible at first. As basic techniques are learned they are combined in sequences called Katas which, to the uninitiated, resemble a type of dance. The purpose of the Kata is to perfect one’s technique in a series of moves composed of blocks, strikes, kicks, and punches directed at multiple imaginary opponents. At a very early stage participants begin to apply their skills to fighting situations (kumite), in which controlled body contact is allowed, and punches to the head and face are stopped a few centimeters from the target. At the higher belt levels, greater body contact is tolerated. Par-
KARATE Karate originated from the ancient Okinawan empty handed fighting art known as Te, which translates as
RECEIVED: 15 September 1997; FINAL ACCEPTED: 24 August 1998.
SUBMISSION RECEIVED:
18 August 1998;
115
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ticipants in Jiu Kumite, or free sparring, at the senior levels can expect to be the recipient of blows with power similar to those which they themselves deliver. Proficiency in Karate does not develop in a linear fashion. Rather, it progresses through a cycle with four distinct stages. The first stage is characterized by naivete in the martial arts—a state of innocence before training has begun. The initiate is often confident in his or her athletic ability and does not anticipate much difficulty in mastering a martial art. Immediately upon beginning training, the student enters the second stage and experiences a period of extreme awkwardness while learning a completely new way of controlling the body’s motions. The difficulty of moving within the constraints of the art may come as a source of great surprise and frustration. The third stage begins when this awkwardness is overcome and the student is able to perform the techniques, but only with great effort and concentration. After years of training this gives way to stage four when there is no longer a need to consciously attend to the actual mechanics of the art. Any hint of awkwardness disappears, leaving no sign of the struggle that the student endured in the early stages of training. Movements are seemingly effortless, performed with tremendous grace and power. The karateka (karate practitioner) has returned to a state of innocence. THE TRAINING OF AN EMERGENCY PHYSICIAN Three important lessons regarding the training of an emergency physician may be gleaned from the training of a martial artist. These are related to the cycle of innocence, the importance of basics, and the journey of mastery. The Cycle of Innocence Residents often begin training in emergency medicine with a reasonable degree of confidence in their clinical abilities. As they become immersed in the culture of the emergency department (ED), they are soon confronted by their own relative incompetence. The patient presenting with respirophasic chest pain whom they would have previously discharged with a diagnosis of chest wall pain suddenly has a differential diagnosis that includes a variety of life threatening illnesses. Indeed, a healthy paranoia is one of the first skills that must be learned by emergency physicians and warriors alike. If you count on safety and do not think of danger, if you do not know enough to be wary when enemies arrive,
this is called a sparrow nesting on a tent, a fish swimming in a cauldron—they won’t last the day. Zhuge Liang, Mastering the Art of War (1)
The realization of one’s own limitations may be a source of frustration for new residents. It seems as though every clinical assessment or management decision is questioned by the attending. Residents many feel as though their decision making capabilities actually deteriorate in the early stages of training. They are at that painful place where they have lost the innocence of the uninitiated, and have not yet developed the innocence of mastery. Reminding residents that this is a natural phenomenon, and providing them with the analogy of the cycle of training in the martial arts, may make this period of transition less difficult.
The Importance of Basics Teaching beginners and slow students is not only fascinating but pleasurable. The talented student is likely to learn so fast that small stages in the learning process are glossed over, creating an opaque surface that hides the secrets of the art from view. With the slow student, the teacher is forced to deal with small, incremental steps that penetrate like X-rays the very essence of the art, and clearly reveal the process through which the art becomes manifest in movement. George Leonard, Mastery (2)
Basics are emphasized in the early training stages of both medicine and the martial arts. Where the two differ is in the general acceptance that many of the basics acquired early in medical education will be forgotten after we enter into clinical practice, if not before. How much of the minutia that we learned for our board examinations do we actually remember? Why do we retain so little? We do not remember it because we do not have occasion to retrieve it from memory. We do not retrieve it from memory because we do not need to. We do not need to because it does not have clinical relevance in our daily practice. In martial arts only those basics that have sustaining value by virtue of their direct relevance to more advanced techniques are taught. One may recognize mastery in a martial artist by observing a performance of the first personal Kata ever learned. The mark of an accomplished karateka is the degree to which the basics of the art have been mastered—not in the demonstration of advanced or sophisticated techniques—and certainly not in the demonstration of irrelevant minutia. Can you imagine applying this same standard to that which we teach our residents? To adopt such an approach to teaching would have a
Emergency Medicine as a Martial Art
profound impact on how we train our residents, requiring us to revisit our priorities in medical education. Indeed, it behooves us as physicians and educators to make the critical distinction between basics and minutia, thereby ensuring that more of the essential material is retained beyond the point of entry into clinical practice. The problem of identifying, learning, and retaining material essential to the practice of emergency medicine is exacerbated by the broad based nature of our specialty. Patients may present with problems that are acute, life threatening, and relatively infrequently encountered. Our ability to respond appropriately in such circumstances depends on our ability to maintain our knowledge of these important, yet uncommon presentations. The ability to achieve a balance between irrelevant minutia and essential detail required to deal with such circumstances is one of our greatest pedagogical challenges. If we defend the current standards to which we hold our graduating residents, then we must question our own clinical competence. It is indisputable that senior residents preparing for their examinations have a database far more extensive than that of the average attending physician. We must therefore consider two possibilities— either the material that we teach our residents is inappropriate, or the material that we retain as clinicians is inadequate, or both. We must somehow address the fact that we hold our residents to a standard that we do not ourselves maintain. The answer to this dilemma may be to acknowledge the partial truth of each of these seemingly incompatible positions. While we adjust our expectations about the quality and quantity of material that residents should retain, we need to emphasize that same material in our own continuing medical education. In doing so we may reduce the disparity between the standards that we impose on our residents, and those that we adopt for ourselves. We can either perpetuate the over-learning of questionably relevant data and hope that clinical competence will be maintained after our knowledge undergoes the usual attrition, or we can embrace the philosophy of the martial artist. We can learn to value the repetition of carefully chosen basics before and after graduation from a residency. To this end we need to develop the Beginner’s Mind. If we are truly studying the art then we must adopt the attitude of always the beginner, of being able to do the basics anew each time. This is difficult, not because it takes effort but rather because it doesn’t. . . Even the student of many years still practices the basics as if for the first time. This has been called beginner’s mind, a mind that is fresh, renewed each moment. Terrence Webster–Doyle, Karate the Art of Empty Self (3)
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The Journey of Mastery By maintaining the Beginner’s Mind the karateka embarks on what has been called the life long journey of mastery. Martial arts training is divided roughly equally between Kihon (basics), Kata, and Kumite. Practitioners of all ranks, including those who have attained the rank of black belt, continually practice all three components of the art, seeking to improve Kumite by the mindful repetition of basics and Kata. Instructors can impart only a fraction of the teaching. It is through your own devoted practice that the mysteries of the art are brought to life. Gichin Funakoshi, Karate-do Kyohan—The Master Text (4)
In medicine we lack a systematic approach to the journey of mastery. The major emphasis on our education ceases at the moment of our graduation from a residency. Subsequent continuing medical education is haphazard. There is no equivalent for Kata and the repetition of basics is mostly ignored. Maintenance of our skills depends largely on our experience in clinical practice, which has striking similarities to Jiu Kumite, or free sparring. Both activities represent the culmination of years of training and provide us with the opportunity to apply our skills in unpredictable, highly charged situations. They also share the potential to contribute to the attrition of important skills if we engage in them to the exclusion of other activities. If we do not maintain and continually improve on a clinically relevant fund of knowledge throughout our career, we fail to embark on a journey of mastery and never truly mature in our clinical abilities. Instead we encounter a static plateau, or worse, a gradual downward spiral leading to boredom, complacency, and eventual burnout. This phenomenon, burnout, is identified as one of the greatest hazards in the practice of emergency medicine. It has many causes and results in part from the stagnation of our growth as individuals. I am privileged to know a woman who after 10 years of emergency nursing displays no sign of burnout. She is the epitome of a non judging, compassionate healer. She is also one of the most highly spirited individuals I have ever known. She has been involved in the martial arts for 25 years. I asked her one day how she has managed to stay fresh after ten years in the emergency department. She said, “You can’t think of it as a career, really. It’s an education. Every day I go to work and I learn so much about myself and humanity.” This statement should not be mistaken for some expression of New Age sentimentality. It comes from a highly pragmatic person who in the
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dojo wields a weapon like one possessed—a woman who has learned to love the journey. If there is any sure route to success and fulfillment in life, it is to be found in the long term and essentially goal-less process of mastery. . . the real juice of life, whether it be sweet or bitter, is to be found in the process of living itself, in how it feels to be alive. George Leonard, Mastery (2)
The processes of learning a martial art, of mastering the art of emergency medicine, and of mastering ourselves, share one common, fundamental feature. They are a journey and not a destination. “How long will it take me to master a martial art?” “How long do you expect to live?” is the only respectable response. George Leonard, Mastery (2)
FACING DEATH IN THE EMERGENCY DEPARTMENT Despite the transition of Karate from a jutsu (method of combat) to a do (way of life), the code of conduct of the Japanese Samurai warrior, known as the Bushido, and the Zen influences that were part of the culture of feudal Japan continue to have their influence in modern martial arts. The Bushido therefore merits further examination. For the Samurai warrior the expectation of violent death was a way of life. His whole purpose in life was to die in the service of his master. The Samurai therefore spent every moment of every day with the knowledge that he was to die. How did the Samurai manage to live with the knowledge of his inevitable fate always before him? He learned to accept death by becoming familiar with it. We often fear that which we do not know. Looking death in the face helped the Samurai to overcome his fear and perform his duties in intimate relationship to that which we as physicians often view as our most dreaded adversary—mortality— our patients’ and, symbolically, our own. Emergency physicians, like the Samurai warrior, must learn to confront death—from the slow lingering kind that we see in the eyes of the person with terminal cancer, to the incomprehensible murder of a young child. Whatever its form, our encounters with death reinforce our own mortality, contribute to our burnout as physicians, and leave us with two possible alternatives. We can deny our mortality and that of our patients, or we can take the example of the Samurai. We can overcome our fear of death by embracing it as our constant companion. The Bushido states that there is a time to fight and a time to die. Proficiency in the martial arts was intended
to allow the warrior to postpone the latter until the appropriate time. Until that time this intimate relationship with death did more than help the Samurai to overcome his fear of dying. It provided him with an impetus to live his life to the fullest. He made every move as though it might be his last. Take life in your hands and squeeze every second to the last drop. Enter all your daily activities as if this were your last day. Hariya Sekiun, as quoted in The Classic Man, by Richard Kim (5)
Knowing when to accept death and not intervene in the inevitable demise of a terminally ill patient is a valuable lesson that we could learn from such a philosophy. Moreover, familiarity with our own mortality may furnish us with an opportunity to significantly enrich our own lives. For existence is impermanent as the dew of evening and the hoarfrost of morning, and particularly uncertain is the life of the warrior, and if he thinks he can console himself with the idea of eternal service to his lord or unending devotion to his relatives, something may well happen to make him neglect his duty to his lord, and forget what he owes to his family. But if he determines simply to live for today and make no thought for the morrow, so that when he stands before his lord to receive his commands he thinks of it as his last appearance and when he looks on the faces of his relatives he feels that he will never see them again, then will his duty and regard for both of them be completely sincere. . . Daidoji Yuzan, The Code of the Samurai (6)
CHARACTER DEVELOPMENT THROUGH THE MARTIAL ARTS—FACING DEATH IN THE DOJO If the budo (martial arts) are not perceived and pursued as a means of Seishi o Chuetsu (confronting the fear of life and death), then they are reduced to the level of an inconsequential exercise. Dave Lowry, Jo: The Art of the Japanese Short Staff (7)
Human experience has demonstrated that as new challenges are met, the difficulties of yesterday— difficulties that may have elicited significant anxiety when first encountered— become inconsequential by comparison. The degree of anxiety produced by specific circumstances does not depend on the magnitude of the threat itself, but on our adaptation to the situation. This process of adaptation to difficult circumstances applies to how we face personal challenges, aggression, and conflict in our daily lives. Although our world is not without danger, few of us
Emergency Medicine as a Martial Art
will ever face a situation in which our life is directly threatened by another individual. Embarrassment, inconvenience, or financial hardship have replaced physical injury or death as the most serious consequences of interpersonal conflict in the majority of situations. Because of our lack of adaptation to aggression, these minor threats now elicit the same emotional and physiological fear responses once reserved for life and death circumstances. The study of a martial art provides an opportunity to encounter challenges, aggression and conflict, and our reactions to them, in the controlled environment of the dojo—and to adapt to them. Although many are drawn to the martial arts as a means of self defense, the real emphasis of the budo (martial way) has shifted from a means of defending against death, to a means of defending against those things that have come to symbolize physical threat in our society. In doing so we must ultimately face ourselves. The rigorous training is not an end in itself. It is designed to enable the student to experience aspects of himself that usually remain hidden, or that he was unable to see because his prevailing idea of himself obscured his views. He is often pushed beyond the limits he would have chosen for himself, finding that he can go far past the point of apparent physical endurance. He learns about his capabilities under this and related kinds of pressures. Usually he begins to see that he is not what he thought he was, and that what he remembers of himself may well have been inaccurate. Herman Kauz, The Martial Spirit (8) Our practice, therefore, becomes a mirror, a direct perception of who we really are, and not the idealized image of whom we wish to be. In this honest, uninhibited observation, there is the beginning of the understanding of the self. . . Terrence Webster-Doyle, Karate the Art of Empty Self (3)
Martial arts have thus evolved from a means of self preservation, to a means of self enlightenment—a way of confronting our own demons. The art is about taking a closer look at ourselves, not about defeating others. As soon as you concern yourself with the “good” and “bad” of your fellows, you create an opening in your heart for maliciousness to enter. Testing, competing with, and criticizing others weaken and defeat you. Morihei Ueshiba, The Art of Peace (9)
Such close self examination results in the development of our ki (pronounced kee), our quiet center. Ki is somewhat akin to the soul of new age or Judeo–Christian traditions. It is the physical and spiritual center of the person. In Eastern culture, and in the martial arts in
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particular, the Ki resides in the Hara. Hara loosely translates as belly. It is located about four centimeters below the navel and midway between the anterior abdominal wall and the vertebral column. It is believed that from this point all of a person’s physical, psychic, and spiritual forces emanate. The martial arts literature is full of references to Ki and the quiet centeredness that was considered essential to success on the battlefield. Completing a residency in emergency medicine exposes the individual to many of the same challenges experienced by a martial artist. Residents must learn to face life and death. We expect them to give 100% of themselves during their years of training. Their capacity for endurance and self discipline is tested. Any weaknesses in the individual are invariably exposed during this process. The rigors of training may bring the trainee to a point of crisis, being required to rise to challenges heretofore considered insurmountable and face personal attributes that were previously hidden. Eastern philosophy recognizes this time as having the greatest potential for personal growth. The Chinese character for crisis is a combination of the characters meaning danger and opportunity. Any one of the many disciplines that push an individual to personal limits of endurance has the same potential to stimulate personal development. This applies equally to athletic endeavors, the martial arts, and the practice of medicine. The martial arts are unique only inasmuch as this perfection of character is identified as the ultimate goal of the endeavor. Iron is full of impurities that weaken it; through forging, it becomes steel and is transformed into a razor sharp sword. Human beings develop in the same fashion. Morihei Ueshiva, The Art of Peace (9) The ultimate aim of the art of karate lies not in victory or defeat, but in the perfection of the character of its participants. Gichin Funakoshi, Karate-do Kyohan—The Master Text (4)
This forging of character is meant to produce in the individual a unique combination of strength, integrity, and compassion. In the words of Zhuge Liang, “A dragon in repose” (1). The Japanese express this combination of attributes in the phrase Bushi no Nasake. The phrase Bushi no Nasake means “Gentleness of the warrior.” This expression of Bushido means that the strongest and greatest men must also be those who are in closest touch with feelings such as compassion, gentleness, and justice, not only toward their peers but toward all beings. Louis Frederic, Dictionary of the Martial Arts (10)
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THE MARRIAGE OF BODY, MIND AND SPIRIT So we can see that development in the martial arts proceeds simultaneously along various paths. As one begins to train, the emphasis is on learning the physical aspects of the art. On another level the goal of training becomes not the mastery of movement but the mastery of stillness. Stillness of the heart. Refinement of character. Spiritual strength and composure in the face of death. It is the marriage of technical proficiency, character development, and a strong spirit that produces the capacity for equanimity in the face of conflict or danger. This allows the martial artist, or the emergency physician, to take charge of—and perhaps even enjoy—threatening situations. This is not meant to imply that emergency physicians are any more likely to wish trauma upon their patients than are martial artists to invite physical assault upon themselves. The essence of the martial arts is to prevent violence. Our mission as physicians is to prevent suffering and death. Nevertheless, we will continue to relish those cases that represent tragedy for our patients and triumph for our abilities as care givers. Inasmuch as people will continue to suffer serious injuries and illnesses we must have the passion for the struggle, the technical skills and the composure required to fight a good fight on their behalf. There is a saying in the martial arts, “It is best not to fight. But if you have to fight, it is best not to lose.”
Composure in Battle The martial arts literature is replete with esoteric descriptions of that state of mind which allowed the Samurai warrior to deal with danger, thereby maintaining his composure in battle and ensuring victory. Examination of a few of these yields insights into how this state of mind might be applied to the practice of emergency medicine. Miru no kokoro means “Mind of vision.” A global vision that takes in the opponent and his or her surroundings, while evaluating his or her position in space and the time interval that might be needed to close with him or her. Louis Frederic, A Dictionary of the Martial Arts (10) Fudoshin means “Immutable in heart.” It is that state in which the mind is not troubled by anything external. A person knows no fear in the face of danger, aggression, or unexpected events. It is total impassivity before the hazards of life. Louis Frederic, A Dictionary of the Martial Arts (10)
Iwa o mi means steady as a rock, the same state of mind under all conditions, not influenced by external factors. Richard Kim, The Classic Man (5)
All of these phrases imply a sense of detachment, a loss of the self, which is universal among descriptions of master warriors. Herein lies a paradox. Did these ancient warriors depersonalize themselves and their adversary to the point that emotion was completely absent from the engagement? Are we to do the same in our practice of emergency medicine? The answer to this question is found in the examination of the concept of Empathy for the Enemy.
EMPATHY FOR THE ENEMY It has been said that the martial arts begin and end with respect. The martial arts promote a philosophy of humility, acceptance and compassion for all people. The code of Bushido required that even mortal enemies be granted a measure of dignity commensurate with their conduct on the battlefield. Every true martial artist, ancient and modern, therefore begins from a position of acceptance and compassion for others. To engage another Samurai in battle was to enter into an intimate, almost mystical relationship with him. Antagonists were said to move and breathe with one another. This allowed a master warrior to understand completely the other’s thinking and feeling. In doing so he was able to perceive the other’s intent before it had been expressed, to make the appropriate offensive or defensive response before the opponent had initiated his first move. The process of engaging the enemy in this way may be described by five simple words: Compassion, insight, understanding, empathy, response.
APPLICATIONS TO EMERGENCY MEDICINE What is the relevance of all of this to emergency medicine? Are we really able to learn anything from a 500year-old martial art that was initially intended for dispatching one’s enemies with a blade? Let us examine the parallels. In emergency medicine we undertake a training program that tests the mettle of our most talented young physicians. Each initiate must endure an arduous and sometimes painful cycle of learning that eventually returns the initiate to a state of innocence—the point of mastery and yet the place from which the journey began. In doing so the individual must develop not only the technical skills of the profession, but the strength of character and moral principles incumbent on persons
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who have great responsibilities. We must then maintain what we have acquired throughout the duration of our career, or face the possibility that our lack of diligence might have fatal consequences. Our specialty is defined by our ability to work in a difficult and sometimes hostile environment where we encounter the relentless face of death. We are required to make immediate decisions in the context of resuscitations with little room for error. In doing so we must remain focused on the task at hand while not being emotionally invested in it—Fudoshin. We cannot afford to have our performance influenced by external factors— Iwa o mi. At the same time we must maintain a global perspective of our surroundings in order to respond to whatever else might be transpiring in the department— Miru no Kokoro. All of this must be accomplished while we maintain the sensitivity required to meet the needs of those around us with composure, kindness and integrity—Bushi no Nasake. Finally, we must teach these skills to a new generation of emergency physicians. Perhaps the greatest challenge facing the individual emergency physician is to maintain Bushi no Nasake. In the final analysis this single attribute may influence our sense of personal integrity, the quality of our care, and may hold the key to our long term fulfillment and longevity in our profession. I can recall a conversation early
in my career with my mentor, who had once struggled with questions regarding the meaning and value of his vocation. In short, he had feared that he was burning out. He had consulted with his own mentor, recognized as a true patriarch of our specialty, in this regard. He had concluded from their conversation that the key to fulfillment in emergency medicine hinges on the one act that has defined the great care givers of our time, from William Osler to Mother Teresa. From this one act springs Bushi no Nasake. His advice was simple and provocative. “You have got to love the patients.” Ron M. Walls,
MD
Emergency physicians and martial artists do indeed walk parallel paths. By examining the footsteps of our brothers and sisters in the martial arts we may gain significant insights into our own journey. We should learn from this wise tradition and reap the benefits for our patients, our students, and ourselves. Compassion, Insight, Understanding, Empathy, Response. These are the culmination of years of training dedicated to developing technical proficiency, integrity of character, and spiritual depth. Over the centuries this has proven a very effective formula for killing people. Imagine if we were to apply this formula to healing them.
REFERENCES 1. Zhuge L, Ji L. Cleary T, ed. Mastering the art of war. Boston: Shambhala Publications; 1995. 2. Leonard G. Mastery. New York: Penguin Books; 1992. 3. Webster–Doyle T. Karate, the art of empty self. Middleberry: Atrium Publications; 1995. 4. Funakoshi G. Karate-do Kyohan, The master text. Tokyo: Kodansha Press; 1973. 5. Daidoji Y. Sadler AL, ed. The code of the samurai. Tokyo: Tuttle Publications; 1992.
6. Kim R. The classical man. Hamilton: Masters Publications; 1986. 7. Lowry D. Jo: The art of the japanese short staff. Santa Clarita: Ohara Publications; 1995. 8. Kauz H. The martial spirit. Woodstock: The Overlook Press; 1988. 9. Ueshiba, M. The art of peace. Stevens J, ed. Boston: Shambhala Publications; 1992. 10. Frederic L. A Dictionary of the Martial Arts. Crompton P, ed. Tokyo: Tuttle Publications; 1988.
PII S0736-4679(98)00142-5
Emergency Forum
EMERGENCY MEDICINE AS A MARTIAL ART David W. Harrison,
MD, CCFP
(EM),
FRCPC
Department of Emergency Medicine, Vancouver General Hospital, Director, Residency Training Program in Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada Reprint Address: David W. Harrison, MD, Department of Emergency Medicine, Vancouver General Hospital, 855 W. 12th Avenue, Vancouver, BC, Canada V5Z 1M9
hand. It emerged approximately 500 years ago as a means of self defense against armed assailants. As Okinawan society evolved, it was no longer necessary to train individuals in techniques of mortal combat. The emphasis in karate therefore shifted from the perfection of lethal force to the perfection of personal integrity and character through training in the art. Modern karate training, therefore, encompasses three general spheres— physical training, spiritual or inner development, and the building of character.
INTRODUCTION Emergency medicine is a unique specialty, characterized by the need for immediate, decisive action in response to situations with life and death consequences. Perhaps more than any other specialty we are required to confront our patients’, and therefore our own, inevitable yet somehow unexpected mortality on a daily basis. The ability to remain calm and respond appropriately in such circumstances is an important skill for every emergency physician. Nevertheless, this subject is rarely addressed in the emergency medicine literature. The Asian fighting arts share with the practice of emergency medicine the requirement for instantaneous and appropriate responses to potentially life threatening situations. The martial arts literature and tradition describe a legacy of leadership, moral integrity, and composure in difficult circumstances— qualities indispensable in an emergency physician. This article will explore the relationship between the martial arts and emergency medicine by examining these two disciplines from three perspectives—the parallels between the training of a martial artist and an emergency physician, the need to face death, and the process of developing character.
PHYSICAL TRAINING When training in karate begins, the initiate must learn a new way of moving the body that seems foreign and unnatural. Simple maneuvers such as moving forward or backward in the correct way, maneuvers that we perform every day without thinking, seem almost impossible at first. As basic techniques are learned they are combined in sequences called Katas which, to the uninitiated, resemble a type of dance. The purpose of the Kata is to perfect one’s technique in a series of moves composed of blocks, strikes, kicks, and punches directed at multiple imaginary opponents. At a very early stage participants begin to apply their skills to fighting situations (kumite), in which controlled body contact is allowed, and punches to the head and face are stopped a few centimeters from the target. At the higher belt levels, greater body contact is tolerated. Par-
KARATE Karate originated from the ancient Okinawan empty handed fighting art known as Te, which translates as
RECEIVED: 15 September 1997; FINAL ACCEPTED: 24 August 1998.
SUBMISSION RECEIVED:
18 August 1998;
115
116
D. W. Harrison
ticipants in Jiu Kumite, or free sparring, at the senior levels can expect to be the recipient of blows with power similar to those which they themselves deliver. Proficiency in Karate does not develop in a linear fashion. Rather, it progresses through a cycle with four distinct stages. The first stage is characterized by naivete in the martial arts—a state of innocence before training has begun. The initiate is often confident in his or her athletic ability and does not anticipate much difficulty in mastering a martial art. Immediately upon beginning training, the student enters the second stage and experiences a period of extreme awkwardness while learning a completely new way of controlling the body’s motions. The difficulty of moving within the constraints of the art may come as a source of great surprise and frustration. The third stage begins when this awkwardness is overcome and the student is able to perform the techniques, but only with great effort and concentration. After years of training this gives way to stage four when there is no longer a need to consciously attend to the actual mechanics of the art. Any hint of awkwardness disappears, leaving no sign of the struggle that the student endured in the early stages of training. Movements are seemingly effortless, performed with tremendous grace and power. The karateka (karate practitioner) has returned to a state of innocence. THE TRAINING OF AN EMERGENCY PHYSICIAN Three important lessons regarding the training of an emergency physician may be gleaned from the training of a martial artist. These are related to the cycle of innocence, the importance of basics, and the journey of mastery. The Cycle of Innocence Residents often begin training in emergency medicine with a reasonable degree of confidence in their clinical abilities. As they become immersed in the culture of the emergency department (ED), they are soon confronted by their own relative incompetence. The patient presenting with respirophasic chest pain whom they would have previously discharged with a diagnosis of chest wall pain suddenly has a differential diagnosis that includes a variety of life threatening illnesses. Indeed, a healthy paranoia is one of the first skills that must be learned by emergency physicians and warriors alike. If you count on safety and do not think of danger, if you do not know enough to be wary when enemies arrive,
this is called a sparrow nesting on a tent, a fish swimming in a cauldron—they won’t last the day. Zhuge Liang, Mastering the Art of War (1)
The realization of one’s own limitations may be a source of frustration for new residents. It seems as though every clinical assessment or management decision is questioned by the attending. Residents many feel as though their decision making capabilities actually deteriorate in the early stages of training. They are at that painful place where they have lost the innocence of the uninitiated, and have not yet developed the innocence of mastery. Reminding residents that this is a natural phenomenon, and providing them with the analogy of the cycle of training in the martial arts, may make this period of transition less difficult.
The Importance of Basics Teaching beginners and slow students is not only fascinating but pleasurable. The talented student is likely to learn so fast that small stages in the learning process are glossed over, creating an opaque surface that hides the secrets of the art from view. With the slow student, the teacher is forced to deal with small, incremental steps that penetrate like X-rays the very essence of the art, and clearly reveal the process through which the art becomes manifest in movement. George Leonard, Mastery (2)
Basics are emphasized in the early training stages of both medicine and the martial arts. Where the two differ is in the general acceptance that many of the basics acquired early in medical education will be forgotten after we enter into clinical practice, if not before. How much of the minutia that we learned for our board examinations do we actually remember? Why do we retain so little? We do not remember it because we do not have occasion to retrieve it from memory. We do not retrieve it from memory because we do not need to. We do not need to because it does not have clinical relevance in our daily practice. In martial arts only those basics that have sustaining value by virtue of their direct relevance to more advanced techniques are taught. One may recognize mastery in a martial artist by observing a performance of the first personal Kata ever learned. The mark of an accomplished karateka is the degree to which the basics of the art have been mastered—not in the demonstration of advanced or sophisticated techniques—and certainly not in the demonstration of irrelevant minutia. Can you imagine applying this same standard to that which we teach our residents? To adopt such an approach to teaching would have a
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profound impact on how we train our residents, requiring us to revisit our priorities in medical education. Indeed, it behooves us as physicians and educators to make the critical distinction between basics and minutia, thereby ensuring that more of the essential material is retained beyond the point of entry into clinical practice. The problem of identifying, learning, and retaining material essential to the practice of emergency medicine is exacerbated by the broad based nature of our specialty. Patients may present with problems that are acute, life threatening, and relatively infrequently encountered. Our ability to respond appropriately in such circumstances depends on our ability to maintain our knowledge of these important, yet uncommon presentations. The ability to achieve a balance between irrelevant minutia and essential detail required to deal with such circumstances is one of our greatest pedagogical challenges. If we defend the current standards to which we hold our graduating residents, then we must question our own clinical competence. It is indisputable that senior residents preparing for their examinations have a database far more extensive than that of the average attending physician. We must therefore consider two possibilities— either the material that we teach our residents is inappropriate, or the material that we retain as clinicians is inadequate, or both. We must somehow address the fact that we hold our residents to a standard that we do not ourselves maintain. The answer to this dilemma may be to acknowledge the partial truth of each of these seemingly incompatible positions. While we adjust our expectations about the quality and quantity of material that residents should retain, we need to emphasize that same material in our own continuing medical education. In doing so we may reduce the disparity between the standards that we impose on our residents, and those that we adopt for ourselves. We can either perpetuate the over-learning of questionably relevant data and hope that clinical competence will be maintained after our knowledge undergoes the usual attrition, or we can embrace the philosophy of the martial artist. We can learn to value the repetition of carefully chosen basics before and after graduation from a residency. To this end we need to develop the Beginner’s Mind. If we are truly studying the art then we must adopt the attitude of always the beginner, of being able to do the basics anew each time. This is difficult, not because it takes effort but rather because it doesn’t. . . Even the student of many years still practices the basics as if for the first time. This has been called beginner’s mind, a mind that is fresh, renewed each moment. Terrence Webster–Doyle, Karate the Art of Empty Self (3)
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The Journey of Mastery By maintaining the Beginner’s Mind the karateka embarks on what has been called the life long journey of mastery. Martial arts training is divided roughly equally between Kihon (basics), Kata, and Kumite. Practitioners of all ranks, including those who have attained the rank of black belt, continually practice all three components of the art, seeking to improve Kumite by the mindful repetition of basics and Kata. Instructors can impart only a fraction of the teaching. It is through your own devoted practice that the mysteries of the art are brought to life. Gichin Funakoshi, Karate-do Kyohan—The Master Text (4)
In medicine we lack a systematic approach to the journey of mastery. The major emphasis on our education ceases at the moment of our graduation from a residency. Subsequent continuing medical education is haphazard. There is no equivalent for Kata and the repetition of basics is mostly ignored. Maintenance of our skills depends largely on our experience in clinical practice, which has striking similarities to Jiu Kumite, or free sparring. Both activities represent the culmination of years of training and provide us with the opportunity to apply our skills in unpredictable, highly charged situations. They also share the potential to contribute to the attrition of important skills if we engage in them to the exclusion of other activities. If we do not maintain and continually improve on a clinically relevant fund of knowledge throughout our career, we fail to embark on a journey of mastery and never truly mature in our clinical abilities. Instead we encounter a static plateau, or worse, a gradual downward spiral leading to boredom, complacency, and eventual burnout. This phenomenon, burnout, is identified as one of the greatest hazards in the practice of emergency medicine. It has many causes and results in part from the stagnation of our growth as individuals. I am privileged to know a woman who after 10 years of emergency nursing displays no sign of burnout. She is the epitome of a non judging, compassionate healer. She is also one of the most highly spirited individuals I have ever known. She has been involved in the martial arts for 25 years. I asked her one day how she has managed to stay fresh after ten years in the emergency department. She said, “You can’t think of it as a career, really. It’s an education. Every day I go to work and I learn so much about myself and humanity.” This statement should not be mistaken for some expression of New Age sentimentality. It comes from a highly pragmatic person who in the
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dojo wields a weapon like one possessed—a woman who has learned to love the journey. If there is any sure route to success and fulfillment in life, it is to be found in the long term and essentially goal-less process of mastery. . . the real juice of life, whether it be sweet or bitter, is to be found in the process of living itself, in how it feels to be alive. George Leonard, Mastery (2)
The processes of learning a martial art, of mastering the art of emergency medicine, and of mastering ourselves, share one common, fundamental feature. They are a journey and not a destination. “How long will it take me to master a martial art?” “How long do you expect to live?” is the only respectable response. George Leonard, Mastery (2)
FACING DEATH IN THE EMERGENCY DEPARTMENT Despite the transition of Karate from a jutsu (method of combat) to a do (way of life), the code of conduct of the Japanese Samurai warrior, known as the Bushido, and the Zen influences that were part of the culture of feudal Japan continue to have their influence in modern martial arts. The Bushido therefore merits further examination. For the Samurai warrior the expectation of violent death was a way of life. His whole purpose in life was to die in the service of his master. The Samurai therefore spent every moment of every day with the knowledge that he was to die. How did the Samurai manage to live with the knowledge of his inevitable fate always before him? He learned to accept death by becoming familiar with it. We often fear that which we do not know. Looking death in the face helped the Samurai to overcome his fear and perform his duties in intimate relationship to that which we as physicians often view as our most dreaded adversary—mortality— our patients’ and, symbolically, our own. Emergency physicians, like the Samurai warrior, must learn to confront death—from the slow lingering kind that we see in the eyes of the person with terminal cancer, to the incomprehensible murder of a young child. Whatever its form, our encounters with death reinforce our own mortality, contribute to our burnout as physicians, and leave us with two possible alternatives. We can deny our mortality and that of our patients, or we can take the example of the Samurai. We can overcome our fear of death by embracing it as our constant companion. The Bushido states that there is a time to fight and a time to die. Proficiency in the martial arts was intended
to allow the warrior to postpone the latter until the appropriate time. Until that time this intimate relationship with death did more than help the Samurai to overcome his fear of dying. It provided him with an impetus to live his life to the fullest. He made every move as though it might be his last. Take life in your hands and squeeze every second to the last drop. Enter all your daily activities as if this were your last day. Hariya Sekiun, as quoted in The Classic Man, by Richard Kim (5)
Knowing when to accept death and not intervene in the inevitable demise of a terminally ill patient is a valuable lesson that we could learn from such a philosophy. Moreover, familiarity with our own mortality may furnish us with an opportunity to significantly enrich our own lives. For existence is impermanent as the dew of evening and the hoarfrost of morning, and particularly uncertain is the life of the warrior, and if he thinks he can console himself with the idea of eternal service to his lord or unending devotion to his relatives, something may well happen to make him neglect his duty to his lord, and forget what he owes to his family. But if he determines simply to live for today and make no thought for the morrow, so that when he stands before his lord to receive his commands he thinks of it as his last appearance and when he looks on the faces of his relatives he feels that he will never see them again, then will his duty and regard for both of them be completely sincere. . . Daidoji Yuzan, The Code of the Samurai (6)
CHARACTER DEVELOPMENT THROUGH THE MARTIAL ARTS—FACING DEATH IN THE DOJO If the budo (martial arts) are not perceived and pursued as a means of Seishi o Chuetsu (confronting the fear of life and death), then they are reduced to the level of an inconsequential exercise. Dave Lowry, Jo: The Art of the Japanese Short Staff (7)
Human experience has demonstrated that as new challenges are met, the difficulties of yesterday— difficulties that may have elicited significant anxiety when first encountered— become inconsequential by comparison. The degree of anxiety produced by specific circumstances does not depend on the magnitude of the threat itself, but on our adaptation to the situation. This process of adaptation to difficult circumstances applies to how we face personal challenges, aggression, and conflict in our daily lives. Although our world is not without danger, few of us
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will ever face a situation in which our life is directly threatened by another individual. Embarrassment, inconvenience, or financial hardship have replaced physical injury or death as the most serious consequences of interpersonal conflict in the majority of situations. Because of our lack of adaptation to aggression, these minor threats now elicit the same emotional and physiological fear responses once reserved for life and death circumstances. The study of a martial art provides an opportunity to encounter challenges, aggression and conflict, and our reactions to them, in the controlled environment of the dojo—and to adapt to them. Although many are drawn to the martial arts as a means of self defense, the real emphasis of the budo (martial way) has shifted from a means of defending against death, to a means of defending against those things that have come to symbolize physical threat in our society. In doing so we must ultimately face ourselves. The rigorous training is not an end in itself. It is designed to enable the student to experience aspects of himself that usually remain hidden, or that he was unable to see because his prevailing idea of himself obscured his views. He is often pushed beyond the limits he would have chosen for himself, finding that he can go far past the point of apparent physical endurance. He learns about his capabilities under this and related kinds of pressures. Usually he begins to see that he is not what he thought he was, and that what he remembers of himself may well have been inaccurate. Herman Kauz, The Martial Spirit (8) Our practice, therefore, becomes a mirror, a direct perception of who we really are, and not the idealized image of whom we wish to be. In this honest, uninhibited observation, there is the beginning of the understanding of the self. . . Terrence Webster-Doyle, Karate the Art of Empty Self (3)
Martial arts have thus evolved from a means of self preservation, to a means of self enlightenment—a way of confronting our own demons. The art is about taking a closer look at ourselves, not about defeating others. As soon as you concern yourself with the “good” and “bad” of your fellows, you create an opening in your heart for maliciousness to enter. Testing, competing with, and criticizing others weaken and defeat you. Morihei Ueshiba, The Art of Peace (9)
Such close self examination results in the development of our ki (pronounced kee), our quiet center. Ki is somewhat akin to the soul of new age or Judeo–Christian traditions. It is the physical and spiritual center of the person. In Eastern culture, and in the martial arts in
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particular, the Ki resides in the Hara. Hara loosely translates as belly. It is located about four centimeters below the navel and midway between the anterior abdominal wall and the vertebral column. It is believed that from this point all of a person’s physical, psychic, and spiritual forces emanate. The martial arts literature is full of references to Ki and the quiet centeredness that was considered essential to success on the battlefield. Completing a residency in emergency medicine exposes the individual to many of the same challenges experienced by a martial artist. Residents must learn to face life and death. We expect them to give 100% of themselves during their years of training. Their capacity for endurance and self discipline is tested. Any weaknesses in the individual are invariably exposed during this process. The rigors of training may bring the trainee to a point of crisis, being required to rise to challenges heretofore considered insurmountable and face personal attributes that were previously hidden. Eastern philosophy recognizes this time as having the greatest potential for personal growth. The Chinese character for crisis is a combination of the characters meaning danger and opportunity. Any one of the many disciplines that push an individual to personal limits of endurance has the same potential to stimulate personal development. This applies equally to athletic endeavors, the martial arts, and the practice of medicine. The martial arts are unique only inasmuch as this perfection of character is identified as the ultimate goal of the endeavor. Iron is full of impurities that weaken it; through forging, it becomes steel and is transformed into a razor sharp sword. Human beings develop in the same fashion. Morihei Ueshiva, The Art of Peace (9) The ultimate aim of the art of karate lies not in victory or defeat, but in the perfection of the character of its participants. Gichin Funakoshi, Karate-do Kyohan—The Master Text (4)
This forging of character is meant to produce in the individual a unique combination of strength, integrity, and compassion. In the words of Zhuge Liang, “A dragon in repose” (1). The Japanese express this combination of attributes in the phrase Bushi no Nasake. The phrase Bushi no Nasake means “Gentleness of the warrior.” This expression of Bushido means that the strongest and greatest men must also be those who are in closest touch with feelings such as compassion, gentleness, and justice, not only toward their peers but toward all beings. Louis Frederic, Dictionary of the Martial Arts (10)
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THE MARRIAGE OF BODY, MIND AND SPIRIT So we can see that development in the martial arts proceeds simultaneously along various paths. As one begins to train, the emphasis is on learning the physical aspects of the art. On another level the goal of training becomes not the mastery of movement but the mastery of stillness. Stillness of the heart. Refinement of character. Spiritual strength and composure in the face of death. It is the marriage of technical proficiency, character development, and a strong spirit that produces the capacity for equanimity in the face of conflict or danger. This allows the martial artist, or the emergency physician, to take charge of—and perhaps even enjoy—threatening situations. This is not meant to imply that emergency physicians are any more likely to wish trauma upon their patients than are martial artists to invite physical assault upon themselves. The essence of the martial arts is to prevent violence. Our mission as physicians is to prevent suffering and death. Nevertheless, we will continue to relish those cases that represent tragedy for our patients and triumph for our abilities as care givers. Inasmuch as people will continue to suffer serious injuries and illnesses we must have the passion for the struggle, the technical skills and the composure required to fight a good fight on their behalf. There is a saying in the martial arts, “It is best not to fight. But if you have to fight, it is best not to lose.”
Composure in Battle The martial arts literature is replete with esoteric descriptions of that state of mind which allowed the Samurai warrior to deal with danger, thereby maintaining his composure in battle and ensuring victory. Examination of a few of these yields insights into how this state of mind might be applied to the practice of emergency medicine. Miru no kokoro means “Mind of vision.” A global vision that takes in the opponent and his or her surroundings, while evaluating his or her position in space and the time interval that might be needed to close with him or her. Louis Frederic, A Dictionary of the Martial Arts (10) Fudoshin means “Immutable in heart.” It is that state in which the mind is not troubled by anything external. A person knows no fear in the face of danger, aggression, or unexpected events. It is total impassivity before the hazards of life. Louis Frederic, A Dictionary of the Martial Arts (10)
Iwa o mi means steady as a rock, the same state of mind under all conditions, not influenced by external factors. Richard Kim, The Classic Man (5)
All of these phrases imply a sense of detachment, a loss of the self, which is universal among descriptions of master warriors. Herein lies a paradox. Did these ancient warriors depersonalize themselves and their adversary to the point that emotion was completely absent from the engagement? Are we to do the same in our practice of emergency medicine? The answer to this question is found in the examination of the concept of Empathy for the Enemy.
EMPATHY FOR THE ENEMY It has been said that the martial arts begin and end with respect. The martial arts promote a philosophy of humility, acceptance and compassion for all people. The code of Bushido required that even mortal enemies be granted a measure of dignity commensurate with their conduct on the battlefield. Every true martial artist, ancient and modern, therefore begins from a position of acceptance and compassion for others. To engage another Samurai in battle was to enter into an intimate, almost mystical relationship with him. Antagonists were said to move and breathe with one another. This allowed a master warrior to understand completely the other’s thinking and feeling. In doing so he was able to perceive the other’s intent before it had been expressed, to make the appropriate offensive or defensive response before the opponent had initiated his first move. The process of engaging the enemy in this way may be described by five simple words: Compassion, insight, understanding, empathy, response.
APPLICATIONS TO EMERGENCY MEDICINE What is the relevance of all of this to emergency medicine? Are we really able to learn anything from a 500year-old martial art that was initially intended for dispatching one’s enemies with a blade? Let us examine the parallels. In emergency medicine we undertake a training program that tests the mettle of our most talented young physicians. Each initiate must endure an arduous and sometimes painful cycle of learning that eventually returns the initiate to a state of innocence—the point of mastery and yet the place from which the journey began. In doing so the individual must develop not only the technical skills of the profession, but the strength of character and moral principles incumbent on persons
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who have great responsibilities. We must then maintain what we have acquired throughout the duration of our career, or face the possibility that our lack of diligence might have fatal consequences. Our specialty is defined by our ability to work in a difficult and sometimes hostile environment where we encounter the relentless face of death. We are required to make immediate decisions in the context of resuscitations with little room for error. In doing so we must remain focused on the task at hand while not being emotionally invested in it—Fudoshin. We cannot afford to have our performance influenced by external factors— Iwa o mi. At the same time we must maintain a global perspective of our surroundings in order to respond to whatever else might be transpiring in the department— Miru no Kokoro. All of this must be accomplished while we maintain the sensitivity required to meet the needs of those around us with composure, kindness and integrity—Bushi no Nasake. Finally, we must teach these skills to a new generation of emergency physicians. Perhaps the greatest challenge facing the individual emergency physician is to maintain Bushi no Nasake. In the final analysis this single attribute may influence our sense of personal integrity, the quality of our care, and may hold the key to our long term fulfillment and longevity in our profession. I can recall a conversation early
in my career with my mentor, who had once struggled with questions regarding the meaning and value of his vocation. In short, he had feared that he was burning out. He had consulted with his own mentor, recognized as a true patriarch of our specialty, in this regard. He had concluded from their conversation that the key to fulfillment in emergency medicine hinges on the one act that has defined the great care givers of our time, from William Osler to Mother Teresa. From this one act springs Bushi no Nasake. His advice was simple and provocative. “You have got to love the patients.” Ron M. Walls,
MD
Emergency physicians and martial artists do indeed walk parallel paths. By examining the footsteps of our brothers and sisters in the martial arts we may gain significant insights into our own journey. We should learn from this wise tradition and reap the benefits for our patients, our students, and ourselves. Compassion, Insight, Understanding, Empathy, Response. These are the culmination of years of training dedicated to developing technical proficiency, integrity of character, and spiritual depth. Over the centuries this has proven a very effective formula for killing people. Imagine if we were to apply this formula to healing them.
REFERENCES 1. Zhuge L, Ji L. Cleary T, ed. Mastering the art of war. Boston: Shambhala Publications; 1995. 2. Leonard G. Mastery. New York: Penguin Books; 1992. 3. Webster–Doyle T. Karate, the art of empty self. Middleberry: Atrium Publications; 1995. 4. Funakoshi G. Karate-do Kyohan, The master text. Tokyo: Kodansha Press; 1973. 5. Daidoji Y. Sadler AL, ed. The code of the samurai. Tokyo: Tuttle Publications; 1992.
6. Kim R. The classical man. Hamilton: Masters Publications; 1986. 7. Lowry D. Jo: The art of the japanese short staff. Santa Clarita: Ohara Publications; 1995. 8. Kauz H. The martial spirit. Woodstock: The Overlook Press; 1988. 9. Ueshiba, M. The art of peace. Stevens J, ed. Boston: Shambhala Publications; 1992. 10. Frederic L. A Dictionary of the Martial Arts. Crompton P, ed. Tokyo: Tuttle Publications; 1988.