Satonofuji Hisashi has been a career sumo wrestler since 1996. He is no champion wrestler—in fact, he is far from it. His highest attained rank was in the Makushita division in 2005, the third highest of six sumo divisions. Traditionally, the most elite wrestlers sat in a curtained area at the arena—makushita did not and the name thus translates to “below the curtain.” The current salary of makushita is about $800 U.S. per month.¹ If you enter the Isegahama stable today, you might find Satonofuji diligently training, but you will also find him performing lower-ranked sumo duties such as simmering chanko nabe or “sumo stew” for others, sweeping the communal living areas, cleaning the bathrooms, or carrying the higher ranked sekitori sumo’s belongings during tournament days. Now 47, he is currently ranked Jonokuchi, the lowest division, and unlikely to ever achieve Makushita again.

One may ask, “Why doesn’t he retire?” or think, “Clearly, he chose the wrong profession…” However, Satonofuji continues because he has uncovered his ikigai in sumo. Ikigai is a Japanese concept of “reason to being.” It can be defined by an overlap of four pillars:^2,3

• Passion – what makes you excited
• Mission – what makes a difference in the world
• Profession – what you can make a living on
• Vocation – what you’re good at

Another broader definition of ikigai is a “sense of purpose” or “what we wake up in the morning for” or “makes the time fly by.” It is as narrowly or broadly as we define it.

Satonofuji found his ikigai in sumo, but even more specifically, in the yumitori-shiki, or bow-twirling ceremony. He performs this short ritual, spinning, twirling, and sweeping a six-foot bamboo bow artfully above his head, across his body, and toward his feet. This custom is at the end of all the day’s sumo matches, oftentimes to an emptying stadium echoing the shuffling feet and distracted chatter of leaving spectators. But it’s no bother to Satonofuji. He’s “in the zone,” looking upwards to the sky or down toward the ground and without regard for a lack of an audience. His ikigai in the yumitori-shiki is not dependent on the spectators or what others define as a “good” sumo wrestler, but moreso on his own derivations of significance. In a 2022 interview about his performance of the yumitori-shiki, Satonofuji said, “Every single gesture has a meaning, so I put my heart into it.”

Why Ikigai Can Be Important to Us?

Ikigai is associated with improved quality and quantity of lifespan. Who wouldn’t want to live longer and better? In large, longitudinal studies, those with self-reported ikigai had lower rates of functional disability, dementia, and cardiovascular disease, ranging from a 20 percent to 30 percent decrease compared with those without.^4-6

Additionally, in the health care environment where burnout is prevalent, particularly emergency medicine, we search for meaning in a landscape that has increasing boarding, violence against health care workers, loss of autonomy, and depersonalization. A sense of purpose is an integral part of well-being.^7,8 In a national survey of emergency medicine residents, finding meaningfulness in clinical work had the strongest positive association with professional fulfillment.⁹ Furthermore, meaningful work is a cornerstone in the longevity of career academic physicians.¹⁰ For us to continue in dedicated service to our patients and specialty, it’s important to have a sustained sense of meaning in our work.

Ikigai in Emergency Medicine

Ikigai is inherently within us but needs to be deliberately uncovered and identified. Although it is unlikely one finds the whole of emergency medicine to be their ikigai, there are portions of the practice that are. So how does one uncover their ikigai in the craft of emergency medicine?

Start with the pillars and go with the flow. Reflect on an activity where a) your focus is dedicated, b) mind is on the present moment, and/or c) you are doing the task for the sheer sake of doing it. That’s flow. Now—with the context of the four pillars, what makes time flow by?

Reflecting on the pillar of vocation, perhaps you’re an excellent proceduralist or a “productivity” speed demon—the one colleagues ask as backup for a difficult intubation or lumbar puncture, or the one that colleagues breathe a sigh of relief seeing you come on shift when there are 10-hour wait times, respectively. For the pillar of mission, you feel a sense of calling to your community when rendering care to your patient and neighbor in room 14. Or perhaps you express a deep passion in women’s health or resident education. Within these pillars, are there patterns of flow that you uncover?

Embrace the whole of ikigai. An important point is that ikigai is not what is easy to do nor what makes you happy. Struggle, and at times distress, are necessary components of ikigai. Troubleshooting a challenging transvenous pacer that intermittently captures, dealing with a frustrating transfer conundrum, navigating your patient’s complex home health needs, or mentoring a struggling resident ultimately adds deep meaning to those aspects. That sense of accomplishment to “get to the next level,” the gratification of learning something new, the curiosity to dig a little deeper, or even outright failure drives ikigai. Accepting this reality of fulfillment reframes seeing the negative experiences and feelings in a broader light.

Experiment consciously. Augmenting your ikigai means either 1) rooting it deeper in a pillar and/or 2) expanding into other pillars. Start small and expand, if you find it meaningful with continued flow. Perhaps you find flow in performing certain procedures. Learning the paramedian approach for a lumbar puncture or new shoulder reduction technique increases your vocation. Or, if you thrive on moving the department, perhaps joining a working group to create a physician-in-triage model may be in the cards. Dedication to your community may expand into areas of passion and/or vocation as you create CPR education workshops for your community’s daycares and schools. Passion for women’s health may lead one to research and advocate for more effective emergency contraceptive options in your department. Starting with small increments ensures that the new task is not overwhelming and allows for an attainable, more concrete objective.

Leverage trustworthy contacts. If you struggle with finding ikigai, talk with a peer, friend, or mentor. Sometimes having the perspective of a trusted individual or talking it out to a conscientious listener can help identify areas of interest. Although no one can truly identify your ikigai but yourself, others may identify talents or focus points that you may not be aware of. They can also elucidate avenues for experimentation. Reflect on others’ opinions and see if those areas are places where you either find flow or would continue to do regardless of any attention from others. Perhaps you feel tedious with interdepartmental conciliation, but in speaking with a mentor, they see you’re a highly effective and involved department chief in conflict mitigation. In further reflection, you uncover the flow is actually in the creative brainstorming of logistical solutions that occurs with the conflict.

Closing Thoughts on Ikigai

Ikigai is not for everyone, nor should it be. It’s simply just one concept of many, like one type of laryngoscope blade, whether Mac, Miller, or D-blade. There is not a ‘best’ blade, but depends on the physician and situation. No one needs ikigai to feel fulfilled and our sense of fulfilment itself can be fluid. There are many competent, fulfilled emergency physicians that don’t need to have deep purpose or marry all “four pillars” in their practice. One’s work can sincerely be and remain a profession alone—perhaps so one’s efforts can be placed in other areas, whether it’s community, family, travel, or other interests. That choice and outlook should be respected.

Although the conception of ikigai into the four pillars is easy to digest, it may be myopic at times. It may constrain ikigai to external validation from others or societal/cultural norms. Per pillars of vocation or profession, Satonofuji was not very good by sumo wrestling standards (i.e., wins, division rank), but he derived ikigai in sumo by the yumitori-shiki. Again, ikigai can only be defined by our own selves and is inherent within. No one can tell you what is “worthwhile” and, thus, if your ikigai doesn’t “fit” into a pillar, that’s perfectly fine. Instead, we should simply recognize, support, and celebrate others’ ikigai, regardless of whether it aligns with others’ or our own. Those that know of Satonofuji’s ikigai come to the tournament, sitting patiently after the matches conclude, to watch the yumitori-shiki. They may not recognize the intricacies of the tradition, but they recognize an individual who has found meaning. They celebrate his sense of ikigai.

Dr. Koo is faculty and an emergency physician at MedStar Washington Hospital Center in Washington, D.C., and St. Mary’s Hospital in Leonardtown, Maryland.

References

1. Nyanchama V. How much do sumo wrestlers make per professional fight? Tuko. Published June 13, 2024. Accessed January 7, 2025.
2. Mogi K. Awakening Your Ikigai: How the Japanese wake up to joy and purpose every day. The Experiment; 2018.
3. García H, Miralles F. Ikigai: The Japanese Secret to a Long and Happy Life. New York, Penguin Books; 2017.
4. Okuzono S, Shiba K, Kim E, et al. Ikigai and subsequent health and wellbeing among Japanese older adults: longitudinal outcome-wide analysis. Lancet Reg Health West Pac. 2022;21:100391.
5. Miyazaki J, Shirai K, Kimura T, et al. Purpose in life (Ikigai) and employment status in relation to cardiovascular mortality: the Japan Collaborative Cohort Study. BMJ Open. 2022;12(10):e059725.
6. Cohen R, Bavishi C, Rozanski A. Purpose in life and its relationship to all-cause mortality and cardiovascular events: a meta-analysis. Psychosom Med. 2016;78(2):122–133.
7. Tang M, Wang D, Guerrien A. A systematic review and meta-analysis on basic psychological need satisfaction, motivation, and well-being in later life: contributions of self-determination theory. Psych J. 2020;9(1):5–33.
8. Hodkinson A, Zhou A, Johnson J, et al. Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis. BMJ. 2022;378:e070442.
9. Sakamoto JT, Lee J, Lu DW, et al. Factors driving burnout and professional fulfillment among emergency medicine residents: A national wellness survey by the Society for Academic Emergency Medicine. AEM Educ Train. 20226(Suppl 1):S5-S12.
10. Lieff SJ. Perspective: The missing link in academic career planning and development: pursuit of meaningful and aligned work. Acad Med. 2009;84(10):1383-1388.