Thoughts on Poker and Medicine

While listening to Simon Carley on risk at #SMACC2013 I had one of those thoughts.

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First I hope any serious poker players can forgive my over simplifications of a wonderful game. I also hope everyone can forgive my extreme stretching of this metaphor.

 

So why is medicine like a poker game?
It’s about prediction and probabilities, sometimes we are accurate and can be quite sure of ourselves but sometimes we get caught out by a surprise card or unlikely diagnosis.

In emergency medicine we often concern ourselves with the dangerous diagnoses, most poker players consider these options and likelihood their opponent will draw them. If you have played against a person/disease many times you can be more confident that you will be able to  judge their strength or recognise their tells.

In both luck plays a role that both doctors and card players are uncomfortable with. Everyone will have a “bad beat” where you are confident that you have the correct response or reaction but something unlikely/rare happens and you lose. This leads to both groups having superstitions and sayings which are similar.

“You play the man not his cards” sounds a lot like “It matters more which patient has the disease than which disease the patient has”

Like poker, medicine can be played at a number of stakes. Is it a life and death situation or just trying to rid someone of a minor irritation.

Texas Holdem

Medicine is most like Texas holdem (heads up).
I’ll explain why with an explanation of how it’s played and the similarities.

Heads up poker is played against one other person. You have your own cards and there are a number of communal cards which you make your best hand from. In this way a poker hand reflects a medical consultation information is slowly revealed and you attempt to gauge your position and certainty.

The rounds are as follows:

Pocket cards:

File:Pair of Aces.jpg

Firstly you are given two cards, an initial impression. You know from a glance if this patient is sick or not. Your system 1 is firing on all cylinders. You may get an instant diagnosis from the end of the bed, ?pocket Aces.

But you also know when you don’t have an idea. You know it will be hard or perhaps you just don’t want to play this hand.

Everyone makes their bets, some times this is easy. The patient is dry start some fluids, pain relief/Raise. Other times you don’t want to initiate much treatment until you have more information/Check.
In medicine you can’t really fold. unless you take the next chart (don’t be this person).

 The flop:

Three cards are turned over. This equates well with the history, it’s where the money is. Based on what you know about the patient and you impression most times you can have a very good idea about how you are placed. But there is some difficulty. Many diseases are difficult to tease out, are you being bluffed by your opponent. Previous experience with the opponent/disease can help you here. Are they likely to play passively or do they often show their strength?

The Turn:

This is the physical exam. (might be giving too much credit here)

This adds to what has come before. The reaction to this, tells/focal signs often increase your confidence in your diagnosis. But again it can leave you feeling unsure. But often it makes minimal difference, your impression can remain unchanged based on presence or absence of some signs. This is also often when you take a little time to think of any other possibilities you may have forgotten, a few extra questions whilst examining.

 The River:

 The investigations. Everything is back, all the information you are going to get is there.

This confirms or refutes your previous thoughts. You often know where you stand are you “the nuts” ?

But everything can change and swing based on one investigation/the final card. Is the bloody D-dimer positive? 

Then the final rounds of betting, are you all in for one diagnosis or are you still unsure of yourself? Often you know your badly placed (Pt is sick) but you can’t be certain of why.

 Finally the hands are revealed; in medicine like in poker you may never find out if you were right. Your opponent may never reveal their cards.

The best you can hope for is to learn from your mistakes, minimise your losses and be ready to play again.

But remember, in the end the house always wins.

 

 

Comments

  1. Pik Mukherji says:

    Kudos! Have had near exact conversation with several of my residents but launching point very different. In my case, we were discussing the variabilities between attdgs. Or, as the resident put it: “You guys are schizophrenic managing certain cases.” Why do some attdgs D/C a CP that others would admit? Why does this pt. get a CT scan when his twin brother case got sent home without one? Sometimes there are actual data point answers to these questions. Sometimes there are answers which the attdg can’t verbalize, relegated to “gestalt.” But often we know that the answer is in the practice pattern. “He’s a cowboy.” Or: “He’s super conservative.”
    What does it have to do with poker? When high level players discuss a hand they sometimes disagree between a few options on how to play it. But much more often they are in agreement, especially when referring to playing aggressively vs. conservatively. There are times for each style of play, and no great player can be full tilt all the time. But all players have a “deep down” preference. They are aware that if they prefer aggressive play, they sometimes have to pull back from their natural tendency. Or, if they’re inclined to conservative play, they know they have to push themselves out of their comfort zones once in a while to make a push with their big stack and eliminate a player.
    What kind of attdg are you? Cowboy or Right leaning, it only matters that you are aware of your tendencies and know that once in a while you should resist your natural impulses. What do I mean? Pts. who are sicker carry a higher risk when you do less. Intervening has it’s own risks, but if the pt. looks terrible, you are betting that the risk of the central line is far outweighed by the risk of doing nothing. And pts. who look great, the low risk but “possibility” of badness, generally are going to suffer at your hands when you put them through the “rule out testing” that goes through the entire differential dx and keeps them there for hours only to turn up with false positives.
    It would be great if our least likely to test attdgs always worked fasttrack, and those who order at least 2 CTs per pt. always worked critical. But it would be better if
    we all understood that if we never vary our natural tendencies with the situation at hand, then we will never get it right often enough to get to that final table.

    And that will hold us back and harm our pts. in the process.

    • Thanks for the comment Pik,
      Agree anything that makes you consider how you practice and what/if you should be changing your approach is great.
      Be a fun survey to see which doctors prefer different games ect.
      I know all the local medical physicians love bridge and the ED docs play poker.

  2. Great analogy. I’d add that the other similarity is that poker isn’t really a card game – the cards are merely the vehicle by which the mind games bluffing and art are expressed. Similarly, medicine isn’t really science, science is merely the vehicle through which the art is expressed.

    • Cheers for the comment Domhnall, Impressed at such depth of thought the day after St Paddys.
      At graduation our professor apologised that we had spent 6 years learning science and now we are starting to practice an art.

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