Uncynical Wednesday: The Gambler

In Monday’s post, I mentioned that I won a bet among five physicians for guessing a patient’s CD4 count. It occurred to me that I should say a word about it, but thought it was off-topic and, to be honest, wasn’t sure if anyone would think it needed explanation. Apparently, it did.

Here’s the deal: physicians bet about everything. CD4 counts are perhaps our more benign wagers. Before a biopsy is back, we put our chips on adeno versus squamous carcinoma. We play our cards on whether someone is having acute coronary syndrome or indigestion. We lay odds on someone having a pulmonary embolism versus being a hysterical whiner.

When physicians make such bets, it’s not idle gamesmanship; physician bets are about testing clinical acumen.

I listen to someone’s chest and bet with my interns about the specifics we’ll see on chest x-ray. When they lose, I have them go back and listen again. Sometimes, my intern will win and I’ll go of my own accord—and dishonor—and listen again.

I even place bets with myself. I look at a jaundiced patient’s eyes and estimate their bilirubin. I’ll look at the pink under a tongue and guess a patient’s hemoglobin. I’m at the point now where I am trying to estimate combined hemoglobin and bilirubin. When they both hit seven, white people turn a most curious shade of chiffon.

So why bet? Why enter pools? Labs aren’t always available. At my hospital, CD4 counts are only run on weekday mornings. That’s assuming we have an HIV diagnosis established, which takes three or four days. As a patient’s CD4 count changes, the antibiotics I choose change. The bugs that cause their illness change. The way they will respond to treatment changes. By wagering, we’re keeping tally of our ability to assess a patient’s needs.

More importantly, lab errors occur. By predicting what the lab values should be, I’m able to spot errors. When other physicians have been ready to transfuse a patient, I’ve had blood counts repeated and found the severity of the anemia was a lab error. I can think of eight patients who I’ve spared the risks of a blood transfusion in the past four months—to say nothing of the blood that was saved for a patient who actually needed it.

Betting is an effective way for physicians to keep us improving ourselves. I lost a bet to a surgeon this weekend, blaming his mismanagement of a patient’s IV fluids for an electrolyte abnormality. I wrote a consult telling him to change the fluids to fix the problem. Turned out, I was wrong. We later discovered that the patient was secreting inappropriate antidiuretic hormone. I’m not likely to make the same mistake again.

Physicians are, all day, betting. Betting on your diagnosis, gambling that their intervention will make you well. While our wagers make a game of our very serious job, they remind us that something is on the line.

Different attendings have different wager amounts. The standing bet for one oncologist is always a Can of Diet Pepsi. A certain intensive care physician always bets One Shiny Penny. These physicians are so good that they almost never lose, but I’ve never seen a can or coin change hands.

When physicians are constantly testing their acumen, they get so good that they can start setting up the treatment right along with ordering the diagnostic studies. Their patients start getting better that much faster—or, when appropriate, are made comfortable that much sooner. Since its Wednesday, I won’t mind the cheese of saying that it’s their patients who are the winners.

And if you’re gonna play the game, boy, you gotta learn to play it right.