Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Less is More


The Japanese concept of wabi-sabi can help us appreciate impermanence and approach death as part of life. 

If we spoke a different language, we would perceive a somewhat different world.” Ludwig Wittgenstein   


Words, silence, and gestures play a critical role in medical encounters and the patient-healthcare professional relationship that are at the core of medicine. Not only the words used, but how they are used. These make a great difference to the trust between doctor and patient, and patient and doctor, lest we forget that trust is bidirectional. Rudyard Kipling said exactly a century ago in 1923 to surgeons at the Royal College of Surgeons in London, “Words are, of course, the most powerful drug known to mankind.” He continues, “Not only do words infect, egotize, narcotize, and paralyze, but they enter into and colour the minutest cells of the brain.” Powerful and true.  


Words are, of course, the most powerful drug known to mankind.”—Rudyard Kipling


In this short article I chose words from a different language, a language I don’t understand, and try to relate how they might relate to medicine and well-being. Japanese is spoken by over one million people, mostly in Japan, but also within the Japanese diaspora worldwide. What fascinates me is the vocabulary since there are many words that are untranslatable and reflect the Japanese relationship with nature and the world around them. I am going to discuss six words: Kintusgi (金継ぎ, “golden joinery”), Wabi-Sabi ((侘寂), Komorebi  (木漏れ日), Shinrin-Yoku (森林浴, 森林 (shinrin, “forest”) + (yoku, “bath, bathing”), and Tsundoku (積ん読).  


Kintsugi (gold joining) and Kintsukuroi (gold repair) are ancient Japanese techniques of repairing broken ceramics and transforming them into new, stronger, and more beautiful objects. This highly-refined technique became established in the late sixteenth and seventeenth centuries, but the technique is also a strong metaphor for healing, hope, and recovery. Kintsugi is a beautiful metaphor for healing, both psychological and physical. The 20th century psychiatrist Elisabeth Kubler-Ross wrote,  


“The most beautiful people . . . are those who have known defeat, known suffering, known struggle, known loss, and have found their way out the depths.”


Wabi-sabi is also difficult to translate, but comes from the word wabi meaning austerity, simplicity, the quiet life, and the word sabi maturity, soli- tude, naturalness. Wabi-sabi refers to the aesthetic appreciation of natural imperfection and impermanence. There are, of course, many links with health and medicine, from how we address disabilities to how patients and healthcare professionals approach death. Should clinicians always look for ways of treating the patient? Or could they instead help and guide terminally ill patients to understand that death is a normal stage of life’s journey? The great Irish writer, Samuel Beckett, wrote, “They give birth astride of a grave, then the light gleams an instant, then it’s night once more.” Birth and death are the only two inevitabilities; the rest is full of uncertainties and imperfections. As Dr, Dominic Wilkinson states, “An attitude of acceptance (rather than seeing death as a failure of medicine) would be entirely compatible with modern approaches to palliative care. However, it is possible that wabi-sabi might have some more radical implications.” And he suggests that with wabi-sabi we might be able to envisage a good death in aesthetic terms. Perhaps we should start to move away from the increasing trend for immortality aligned with a perfect world of influencers and selfies as well as the overdiagnosis, overtreatment, and overmedicalization of 21st century life, and appreciate the beauty of the imperfect, the distorted, and even the diseased?   


Komorebi and Shinrin-Yoku are connected in that they arise from the important Japanese connection to the natural world, which seemingly was enhanced during the pandemic. The first word seems to me one of the most beautiful referring to the space between the branches that allows sunlight to gently filter through the dappled light. It’s composed of the kanji characters for tree (), shine through (漏れ), and sun (). As well as highlighting the beauty of nature, the importance of nature, and how we must reconstruct our relationship with it, it also personally explores the entanglement, interweaving and interlacing of modern healthcare. The tree could represent the scientific branches of medicine while the light represents the role that humanities should play within medicine, shining through the leaves, enhancing, and giving context. The humanities and a humane approach to medicine should interplay with the traditional scientific subjects and add the needed light. Integrated not optional. Shinrin-Yoku which is translated as forest bathing furthers this idea since there are numerous books and scientific articles validating its success. Here is the conclusion from an article taken at random, The results of this study suggest that a session of approximately 2 h of forest bathing as part of a 1-day outing in a forest environment can lead to improvements in physiological and psychological health in people of working age, as demonstrated by the decrease in blood pressure and the alleviation of negative psychological parameters after forest bathing.” 


There are many other Japanese words that I could use as examples, but I’ll finish with Tsundoku, the practice of buying a lot of books and keeping them in a pile with the intention of  reading them. It dates from the Meiji era and derives from a combination of tsunde-oku (to let things pile up) and dokusho (to read books). It can also refer to the stacks themselves.  


Nassim Nicholas Taleb wrote, “The writer Umberto Eco belongs to that small class of scholars who are encyclopedic, insightful, and nondull. He is the owner of a large personal library (containing thirty thousand books), and separates visitors into two categories: those who react with ‘Wow! Signore professore dottore Eco, what a library you have! How many of these books have you read?’ and the others—a very small minority—who get the point that a private library is not an ego-boosting appendage but a research tool.” Taleb concludes that unread books are far more useful than read books since we tend to over-protect our knowledge; but isn’t it far more important what we still have to discover, and what is still out there to be learnt about us, humans, our bodies, the brain, our weaknesses, strengths, illnesses, and the world we live in? Tsundoku or the anti-library is the key to unravelling that which we do not know.  


Finally, Dr. Albert Einstein wrote,“Imagination is more important than knowledge.”  Let us use our imagination to look after ourselves, others, and the planet.  



  “Imagination is more important than knowledge.”—Albert Einstein




This piece is dedicated to Dr David Kopacz, who introduced me to the concept of Anti-Library.
















This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.