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Emergency Medicineʼs Loserʼs Game

2006; Lippincott Williams & Wilkins; Volume: 28; Issue: 10 Linguagem: Inglês

10.1097/01.eem.0000294629.74467.3a

1552-3624

Mark C.D. Mitchell,

Organizational Management and Leadership

Everyone plays games. Casinos, sporting events, online poker, lotteries, video games, and bingo occupy the attention and dollars of huge numbers of Americans. But would you be surprised to know that you are playing a game every time you go to work? Once you acknowledge that, you need to ensure you are playing the right one. Thirty-one years ago, Charles D. Ellis wrote a seminal paper that was published in Financial Analysts Journal entitled “The Loser's Game.” The game to which he referred was money management, and in his six-page paper, he set about proving that this was indeed a loser's game. So what is a loser's game? Mr. Ellis refers to Simon Ramo, PhD, the son of Lithuianian immigrants who earned two doctorates by age 23 and is remembered as the father of the intercontinental ballistic missile and the founder of TRW. Dr. Ramo was also somewhat of a tennis buff who wrote a book on strategy entitled “Extraordinary Tennis for the Ordinary Tennis Player.” In it, he describes tennis as two different games depending on who is playing. One game, played by the elite who rarely make mistakes, involves winning the game by actually winning more points than your opponent. The vast majority of less skillful players, however, win their games by losing fewer points than their opponent. Dr. Ramo discovered that “in expert tennis about 80 percent of the points are won; in amateur tennis about 80 percent of the points are lost.” Mr. Ellis proved in his paper that money management in the 1960s had become a loser's game. Investing in the preceding decade was a winner's game. If you had money to invest, you could make more. This climate drew more people into the game, people who were intelligent and hard-working. Money managers became a much larger, better-educated group with better tools and research. The eventual result, according to Mr. Ellis, was that a manager who wanted his net returns to beat the market by 20 percent had to earn a gross return more than 40 percent over the market's, a pretty difficult thing to do. This was borne out by the fact that the median mutual fund's annual rate of return was only 5.4 percent in the 10 years preceding the 1975 publication of Mr. Ellis' paper, well below the S&P 500 Index. The success of the game had turned a winner's game into a loser's game, where now the only way to win was by not losing. How does this apply to emergency medicine? As in any endeavor, you must have a strategy if you are going to practice medicine. Is your strategy to play a winner's game or loser's game? Many people would pick the former. They want to see themselves as bold, innovative, swinging for the fence. This may have been true in the early days of emergency medicine. Who but the fearless would try to make a living in medicine by not having an office, not doing surgery, and not admitting patients to the hospital? We see physicians playing a winner's game on television when the iconoclastic physician (“Paging Dr. House!”), at great risk to himself and his patient, performs a procedure for the first time, saving the patient and redeeming himself while his colleagues look on in amazement. But in reality, most of us play the loser's game. We are plodding, methodical, and thorough. We play, and usually win, the game of emergency medicine not by winning points but by paying attention and not making mistakes. A case in point occurred to me recently. I saw an elderly patient who was brought to the emergency department by her daughter. The daughter said the patient had been less alert for several days and that she seemed to be worse in the late morning and late evening. She ambulated with a forward leaning gait, slurred her speech, and sometimes was almost unresponsive. I responded in my plodding, methodical way by ordering about a thousand dollars worth of lab tests and an even more expensive CT scan, all of which were normal. I consoled myself that at least I didn't miss a subacute subdural or silent MI. Among the mundane tasks I assigned myself was reviewing the patient's medication list where I found she was taking 100 mg of chlorpromazine twice a day (for hiccups!). This struck me as odd for a 67-year-old woman so I asked the daughter to go home and bring back all the patient's medications while we were compiling her database. When I reviewed the bottles, I found that the patient had been on chlorpromazine 10 mg BID until several days prior when she had received her new prescriptions for the first time from an online pharmacy. The daughter had thought the new pills were a lot larger but didn't worry about it, figuring the pharmacy knew what it was doing. So I admitted the patient, stopped the chlorpromazine, and she was much better the next day. I was a genius until the next puzzling case came in 10 minutes later, thanks to playing the loser's game. By performing tiresome tasks in a thorough manner, I avoided making a mistake and missing the diagnosis. Granted, this case does not deserve any accolades, and it wouldn't make a very good television script. But it is representative of what we do every day as emergency physicians. We try not to make mistakes. As Mr. Ellis pointed out in his article, in the early days of flight, pilots were better than the rest of us. They were brave, strong, intelligent, and without nerves. Today pilots are, like us, people just trying not to make any mistakes. Emergency medicine can be tedious. The general public doesn't realize this. When people find out what I do for a living, the usual response is, “I'll bet you've seen it all!” Well, we have seen it all. But most of the time, we see the same things over and over and over. The trick is not to be lulled to sleep by it. The writer David Foster Wallace made an intriguing commencement speech at Kenyon University in Gambier, OH, last year in which he pointed out that we all have a default setting in our brain that leads us to believe we're the center of the universe: “The freedom all to be lords of our tiny skull-sized kingdoms, alone at the center of creation.” The goal he sets is to free yourself from this default setting, especially when the world seems dreary and irksome. “The really important kind of freedom involves attention and awareness and discipline, and being able truly to care about other people and to sacrifice for them over and over in myriad petty, unsexy ways every day,” he said. I doubt that Mr. Wallace had emergency medicine in mind, but I think he nailed it. This is what we do, day in and day out. And we try to do it by paying attention and not making mistakes. In the end, our patients win when we don't lose. Continuing Medical Education in EMN In this and every issue, Emergency Medicine News offers two CME activities: 1) InFocus, the clinical evidence-based column written each month by James R. Roberts, MD, and 2) Learning to Live with the LLSA, a review of the American Board of Emergency Medicine's Lifelong Learning Self-Assessment reading list by Daniel K. Mullin, MD. Target Audience Statements: The InFocus CME activity in Emergency Medicine News is intended for emergency physicians with an interest in the diagnosis and treatment of various disease processes commonly seen in emergency departments, with special emphasis on evidence-based medicine. The Learning to Live with the LLSA CME activity in Emergency Medicine News is intended for emergency physicians with an interest in studying for the annual American Board of Emergency Medicine's Lifelong Learning and Self-Assessment examination. Accreditation Statement: Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide medical education to physicians. InFocus Credit Designation Statement: Lippincott Continuing Medical Education Institute, Inc., designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activities. Learning to Live with the LLSA Credit Designation Statement: Lippincott Continuing Medical Education Institute, Inc., designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activities.