Doctors, a new study reports, may find themselves making better diagnoses and improving patient outcomes if they adopt the risk assessment techniques found in another high-stakes activity: poker.
For all the certainty medical science has gained over the years, there is still an alarming amount of guesswork to be done, and some of those guesses are more wild than educated. Full and clear access to patient files does little to inform physicians about how to judge the risk of disease when symptoms appear — if they ever do. And according to the new study, conducted by researchers at St. Michael's Hospital in Toronto, physicians may fall into the same traps as the general public. One solution, as the team sees it, is automating the assessment of risk.
"Sadly, more research has gone into how decision are made when people gamble or buy a car than it has to discovering how doctors make complex decisions," said Dr. Gustavo Saposnik, lead author and director of the hospital’s Stroke Research Unit, in a statement. Saposnik and his colleagues focused their research on a protein involved in the breakdown of blood clots, known as tPA (tissue plasminogen activator). How much tPA to give stroke victims, and when, is frequently miscalculated, Saposnik points out, putting people in danger over a simple err in judgment.
Stroke is especially concerning because the worldwide population is aging, and among other risk factors such as high blood pressure and heart failure, stroke risk becomes more prevalent with age. Data from the United Nations shows that over the last 50 years, stroke rates have tripled. And in another 50, they’ll triple again. Developing a more standardized way to handle stroke care, free from bias or hasty judgment, could turn the current school of thought on its head.
Raising The Stakes
Intriguingly, the researchers turn to poker — with its endless stream of betting, folding, and going “all in” — to inform their prescription for stroke care. Professional poker players typically rely on sheer probability to gauge whether the cards they hold offer a reasonable chance at winning. Certain hands offer low risk, while others, according to the risk tables, are immediate folds. And despite the stakes being markedly different, the team notes that there are interesting similarities.
“For example,” they wrote, “medical information is imperfect because clinicians in the emergency room may not be fully aware of all existing comorbidities, patients’ preferences, or advanced directives.” Likewise, poker players aren’t clued in to the cards in their opponents’ hands or what community cards will be dealt. Because of these unknowns, players routinely make use of what they can rely on: statistics.
Saposnik explains that clinicians have their own version of risk tables, which have been shown in prior research to significantly improve their estimates. But as Saposnik points out, risk tables — in both poker and in medicine — aren’t sufficient. Humans are notoriously poor at estimating outcomes on their own, especially when we operate with limited information. “In complex situations,” Saposnik told Medical Daily, “when there is a high probability of a poor outcome, a thorough discussion between physicians and the family is needed to discuss therapeutic options, risks, and established goals of care.”
The factors influencing these decisions aren’t always well-defined. The team offers a concrete example: a 79-year-old man scoring an 18 on the National Institute of Health Stroke Scale, which puts him in the “moderate to severe stroke” category. While a clinician may be tempted to offer intravenous tPA, “thorough assessment of subsequent relevant factors (eg, patient was living in a nursing home, history of severe dementia requiring assistance for all activities of daily living, and poor collateral flow) may affect the final decision.”
Ultimately, the choice of how much tPA to give a patient, if any, depends on the doctor’s thorough assessment of risk balanced with the patient’s and his or her family’s preferences. More invasive treatment may reduce a patient’s quality of life, while still extending longevity. Going all-in for a high-risk/high-reward treatment could be the best option, but if the family chooses to fold, clinicians must decide if they’ll be laying down a winning hand.
Source: Saposnik G, Johnston C. Decision Making in Acute Stroke Care: Learning From Neuroeconomics, Neuromarketing, and Poker Players. Stroke. 2014.