Being a Doctor and Playing Poker – The Overlap

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Dr. Kelly McMasters, a surgical oncologist, graciously allowed us to republish the commencement address he delivered to the University of Louisville School of Medicine Class of 2017. His words of wisdom resonated far beyond the typical platitudes pushed onto graduates. Further, his personal experience as a father of an ill child delivered unasked-for-insights that, when practiced, can make all doctors even better. Heads up: it’s longer than our typical blog post. But, it’s worth the entire read. Make time to read it from top to bottom…

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It is my great honor to give the commencement address for the UofL SOM class of 2017.  Twenty-eight years ago, I graduated from medical school, and I remember the overwhelming sense of pride and accomplishment in finishing medical school, the relief of never having to study the Krebs cycle again, the excitement of moving to a different city in a different state far from home to begin residency training, of having to start fresh to develop a whole new set of friends and colleagues, the thrill of finally becoming a real doctor balanced against the anxiety and fear of that solemn responsibility — of the knowledge that my decisions and actions could save lives, and my mistakes could cost them.  I remember that tangled mass of emotions like it was yesterday.  But what I do not remember at all, I assure you, is who the commencement speaker was at my graduation, or what he or she said.  I’m holding all of you to a higher standard.

Each year at my house, we host a party for the new interns.  Faculty and residents generally attend, drink a couple beers, eat too much food, and help the new interns celebrate the last few hours of their freedom before starting a challenging 5 to 8 year general surgery residency program.  As tradition would have it for the past dozen years, the new interns all volunteer to participate in a (mandatory) low-stakes poker game — Texas Hold ‘em.

Why do we ask the new interns to play in a poker game just before they take their first night on call, when they will hold the fate of patients in their hands, when their thoughts and deeds could mean the difference between life and death?  Shouldn’t they be studying anatomy or the Krebs cycle or something important?  Perhaps there are many hidden lessons to be learned from this simple game of poker.

In poker, there are only 3 possible actions — 3 possible choices:  check (do nothing), bet (or raise, which is just betting more than the player before you), or fold — check, bet, or fold, those are your only options.  It would seem that the person with the best poker hand should always win.  Ahhh, but if that were true, poker would just be a game of chance.  In fact, the person with the best hand frequently loses, because it is much more important how well you play the cards you are dealt than how good your cards actually are. The most dramatic moment of a game of Texas Hold ‘em is when the player pushes all of his chips to the center of the table, betting all of his remaining money, and goes “all in.”  At this moment, the player going “all in” realizes that there is no turning back, that she is committed to action that likely will result in either doubling her money (at least), or losing it all.

What is the point of this poker game, you might be asking yourselves?  All of human interaction is a negotiation of sorts — for resources, attention, recognition, prestige, status, power, and even love.  The three basic choices–check, bet, or fold — are fundamentally synonymous with all of the important decisions you will ever make, and form the basis for all human interaction.  Perhaps I’m overanalyzing the cosmic significance of a poker game, since I only get to play once a year with interns, but here goes:

Poker Lesson #1.  You win more pots by betting than by checking, and you never win if you fold.

Sometimes it is better to decide upon a course of action and pursue it, even if the end result is unsatisfactory.  It is frequently said that: “More harm is done by a timid surgeon than a bold one.”  Surgeons are also often said to be “frequently wrong but never in doubt.”  Action usually trumps inaction, and no decision is frequently worse than the wrong decision.  The same holds true of many of the other decisions you will make in life and in your career.  Be bold, be decisive, and never quit as long as you have a chip and a chair, or your patient has a pulse and a blood pressure.

Poker Lesson #2.  You have to play the cards you are dealt. 

You don’t get to choose what cards you are dealt any more than you get to choose who your patients are, what their comorbidities are, or who their families are.   You don’t get to choose the circumstances and obstacles that come your way.  Sometimes you are dealt a losing hand that you can win. Sometimes you are dealt a winning hand that you lose.  Play the cards you are dealt, and decide when it’s time to check, bet, or fold.  If you always fold when you are dealt 10-2 offsuit — that is, if you can’t sometimes find a way to turn bad circumstances into opportunity — you will have a difficult time in your career and in your personal life.

Poker Lesson #3.  You never win if you fold, but sometimes it’s better to live to play another hand.

Decisions in life to go “all in” should be made judiciously — you have to be prepared to lose it all.  Choose your battles carefully, don’t wage war on too many fronts, and don’t fight battles you can’t win.  When facing difficult situations, I often ask myself:  “is this the hill I want to die on?”  Sometimes strategic inaction is better than action, although this is an acquired skill for surgeons.

Admittedly, my poker analogies were really just a way of easing into the more difficult part of this commencement address, which is entitled:  “Reflections from the Other Side.” I neglected to say:  from the other side of what?  I’m fairly sure you didn’t expect me to talk about reflections from the other side of the poker table.  And no, I haven’t seen the light at the end of the tunnel, nor have I had a glimpse at what is on the other side of this life.  Nevertheless, I certainly have had some time to reflect on what is important in this one — especially on what is important to being a good doctor and decent person.  I make no claim to be either. The only thing I claim is that at least I have had a few years longer than you to consider these issues, in the hope that I can learn from them.

So here are the lessons I want to highlight for you today:

When walking the tightrope, don’t lose your balance.

I am a surgical oncologist — I operate on patients with cancer for a living.  I have spent my entire adult life either training to be a cancer surgeon or being one.  Surgical Oncologists focus on doing whatever it takes to cut out cancer.  We excise, resect, ablate, and otherwise extirpate cancer.  Surgery is still the most effective cancer therapy ever invented. We appreciate the help of our medical oncology and radiation oncology colleagues to help improve the odds of curing patients, but make no mistake — surgery is the primary treatment for most types of cancer.  Perhaps that will change in the future, and I certainly hope so.

Surgical oncologists focus intensively on doing what needs to be done to cut out the cancer. There is something innately gratifying in grappling with tumors and removing them with your bare hands (OK, maybe with a few instruments, and with gloved hands).  You get the point.  Surgical steel vs. tumor — the battle is on.  Many patients recover from surgery uneventfully and are cured of their cancer.  Occasionally, patients will die because of the operations we perform.  Not uncommonly, patients experience major complications and problems.  We sometimes take big risks to achieve big rewards.  Or sometimes we push “all in” and lose.

Before we see our cancer patients, we look at their x-rays.  We want to see pictures of the cancer and stare it down — take its measure.  We assess the patient’s comorbidities and risks of surgery.  At times, it can seem as if we are treating a cancer that just happens to have a person attached to it.  Physicians (even surgeons) are human.  We protect ourselves using primal defense mechanisms because no human being could withstand complete empathy with an entire office full of patients suffering from cancer.   No matter what specialty you are entering, you must resist the natural tendency to treat the disease and not the patient.

I remember when this realization first smacked me in the face.  I’m going to tell you a story that I have never told to anyone.  I was a surgical oncology fellow at MD Anderson Cancer Center in Houston.  The fellows thought we were like Tom Cruise in the movie Top Gun,  learning to be the biggest, baddest cancer surgeons in the country.  We bragged to each other about the complex, difficult cancer operations we performed.

I had performed a forequarter amputation on a patient with sarcoma.  Forequarter amputation is removing the entire arm and shoulder, in this case, part of the chest wall and rib cage as well.  Now that was just the kind of big, gruesome cancer operation I went there to learn how to do.

The patient was a 19-year-old young lady from Spain.  She didn’t speak English, and I didn’t speak Spanish.  She was beautiful in every way.  She had shimmering dark hair, striking perfect features, and piercing, soulful dark eyes.  She was immensely courageous, and prepared herself for this life-changing cancer operation with uncommon grace, dignity, and fortitude.

While making morning rounds on postoperative day #1, I examined the patient, checked her incisions, witnessed the mutilation we had caused, then looked into those dark eyes, and saw that the light in those eyes had dimmed — her soul was crushed.  Overcome with emotion, I exited quickly and walked to the nearest stairwell and sobbed piteously, having glimpsed into the eyes of this girl who spoke a different language but communicated so well.  I wept in anguish and disgust for what we had done to this young lady, knowing that we had little choice but to attempt to remove her limb to try to save her life.  I don’t know what became of her, but I think of her often.

At the time, I was ashamed of my stairwell breakdown.  Surgeons don’t cry.  Human beings do. These days, I would be ashamed if I hadn’t felt this emotion so strongly, and would be concerned if this no longer bothered me.

There is often a very fine line in medicine between benefit and harm.  No matter what field of medicine you practice, you will be faced with impossible choices.  You must decide when to check, bet, or fold.  You will make mistakes, and they will have serious and sometimes fatal consequences.   The mark of a physician’s character is in how he or she deals with his or her mistakes.  Own your mistakes, admit them, learn from them, and use them to become better.  You will lose your share of battles.  Soldier on, and continue to fight the good fight.

We as physicians are forced to walk this tightrope on a regular basis.

So remember, when walking the tightrope, don’t lose your balance.

As many of you know, my son, Owen, died last year after a 5-year battle with leukemia.  When he was first diagnosed, I knew virtually nothing about leukemia.  I remembered nothing about it from medical school.  All I knew was that leukemia was one of those cowardly blood cancers that surgeons couldn’t cut out.

As far as I can tell, the strategy for treating childhood leukemias is to give every toxic drug that a child could possibly tolerate in the hope that the child is stronger than the cancer.  The treatment regimen was brutal.  Innumerable chemotherapy drugs that made his hair fall out multiple times over the years, made him sick and weak, prone to life-threatening infections that he dealt with multiple times, drug reactions, intrathecal chemotherapy injected into the spine on a regular basis, high-dose steroids that made him bloated and miserable.  The vicious cycle of apparent remission followed by relapse.  Many days and nights, every major holiday it seemed, spent in the hospital.  Bone marrow transplant that didn’t cure the cancer.  More chemotherapy, more toxicity, experimental therapy — eventually peace.

So yes, I’ve seen the other side — the other side of the patient’s room, looking out of the doorway instead of looking in.  I had never really been the patient before.  I had never been the family member before.  I had only been the doctor.

Here are some other lessons I learned from the other side of the patient’s room:

Any night on a flat surface is a good night.

My wife, Beth, and I have spent countless nights sleeping in a pediatric hospital room — well over 100, I have no idea how many.  We were confined to a hospital room or ICU room, often for weeks at a time.  I was one of those family members you have seen when making rounds in the morning darkness, in your way as you try to examine the patient — asleep in a chair, on the floor, in a cot, or every conceivable type of contraption that hospitals provide for family members to sleep on.  The chair-type things are impossible to sleep in, like sleeping in the center seat in the coach section of a red-eye flight.  I was the family member with crumpled clothing, uncombed hair, unwashed and unshaven in the morning.  You might have found me snoring ignobly, dead to the world.  When Owen needed me in the middle of the night, he often had to throw something at me to wake me up.  Fortunately, he kept throwable objects close by at all times.  More often, however, I would be waiting for you — residents and fellows — wanting to make sure that you had all the important information about Owen’s status since the prior day.  I always tried to be cordial, professional, or even friendly in these interactions with the health care team.  It was a lot easier to be congenial if I had gotten a couple of hours sleep on a flat surface.

Remember, family members are under an enormous amount of stress caring for their loved ones.  Sometimes the stress is too much, and they will seem accusatory, frustrated, angry, or full of contempt. They might become overwhelmed with emotion and need to find a stairwell. Don’t mistake their disheveled appearance, anxiety, fear, and questions and label them as “difficult patients” or “difficult families.”  They are concerned about their loved ones.  The louder and more agitated they get, the softer and calmer you must be.  You will be in their shoes some day.

And remember, any night on a flat surface is a good night.

An ounce of empathy is worth a thousand pounds of apathy.

For any of you who will enter the field pediatric oncology or be involved in treating children with cancer, you have my deep admiration.  As a surgical oncologist, I treat mostly old people with cancer.  That is child’s play compared to treating childhood cancer. Owen was fortunate to have wonderful doctors, almost without exception. Throughout the course of his disease, we experienced the difference between empathy and apathy.  It does not take much effort to express a little bit of empathy.  A little eye contact, smile, kind word or gesture is all it takes. It is immensely soothing to patients and their families. If you are looking at the chart, or these days typing into an electronic medical record, and not looking at the patient, you are making a big mistake. Patients and families can smell your apathy from a mile away.  On your worst days, when you have been up all night, and have given everything you have to give, you must still act professionally, even if sometimes it is just an act.  Sometimes you just might need to bluff.

Also, never forget that you are not on the front line in terms of the exchange of emotional energy.  Doctors make rounds, and have limited time with patients and families — often just a few minutes per day.  Doctors write orders, nurses care for patients.  Nurses know about empathy.  Respect that.

And remember, an ounce of empathy is worth a thousand pounds of apathy.

Sweat the small stuff.

At one point in his treatment, Owen developed a pneumothorax — a collapsed lung — requiring a chest tube.  This recurred a couple more times. Because of a persistent air leak, this last chest tube stayed in for a couple of weeks.  The new doctors in the audience understand that it is not pleasant to live with a chest tube.  Owen’s doctors responsible for this would check in periodically, but not every day, because he still had an air leak and the chest tube obviously needed to stay in.

It turned out that the air leak wasn’t from Owen’s lung.  It was a leak from the tubing connections.  The chest tube stayed in for much longer than necessary because of inattention to detail.  I was very angry with myself for not figuring this out sooner.  But I was just the parent.  I shouldn’t have to figure it out.

The moral of this story is that the little things matter.  Meticulous attention to every detail of patient care, every test, every X-ray, and actually performing a history and physical examination.  As we frequently see in Surgery Morbidity and Mortality Conference, there is no procedure so trivial, no detail so small, that it can’t make a big difference in patient outcomes.  During my training, I got in the surgical habit of making rounds early in the morning every day.  Many people no longer do this.  It is a routine, an act of discipline that gets my day off to a good start — to make sure my patients are OK and deal with any problems they may have before anything else happens that day.  See your patients every day.  Develop good habits.  When you are on your way home, and you get that nagging feeling that you should have gone back to check on that patient one more time, turn around and go see the patient.  When you are on call and the nurse calls you about a patient, and the easy thing is to give a verbal order and go back to sleep, get up and go see the patient.

And remember, sweat the small stuff, because it makes a difference.  If you can’t handle the small stuff, you will not be prepared for the big stuff.

Don’t avoid the hard conversations.

I have taken care of cancer patients my entire life.  I tell my patients with serious cancers that I will follow them until I die.  We develop a long-term relationship.  Many are cured by surgery.  Some are not.   When the cancer recurs, they usually come back to see me to ask my advice about treatment.  I tell them that if it gets to the point that further treatment (chemotherapy) is not going to help, I will tell them.  When it gets to that point, I do tell them.  Part of my job — often the most difficult, but the most rewarding part — is to ease patients to the other side with dignity.

You would be amazed how often no other doctor is willing to have this conversation with the patient.   Hope is a precious thing for patients to cling to, but false hope is just that — false.  Learn the difference. It shouldn’t be so hard for physicians to tell the truth.  Patients and their families want to hear the truth, and they are eternally grateful to you for telling it.  You don’t have to bludgeon people with bad news; learning to deliver bad news with compassion requires some practice.  I was never ready to hear the truth about Owen, but I’m grateful to have had a doctor who could tell it.

So remember, don’t avoid the hard conversations.

Aim small, miss small.

Each of you is about to embark on an exciting journey to define the purpose of your life.  You have studied long and hard, have prevailed against many obstacles, and have demonstrated exceptional tenacity and determination to accomplish the goal of graduating from medical school.

And now, all of that is meaningless.

What I mean by this is that it doesn’t matter where you grew up, where you went to college, where you went to medical school, or whether you were at the top or the bottom of your medical school class.  From here on, the slate is wiped clean.  You will be on equal footing with all of your fellow residents.  You have equal opportunity to excel, to be mediocre, or to fail.

Residency is hard.  Life is hard.  But none of you has chosen an easy path, and all of you understand the value of self-sacrifice to achieve your goals.

It is easy to get lost in the crowd and never aspire to be anything but average — to be just good enough.  Each of you is capable of achieving great things in your chosen specialty — of making a lasting difference in your community, your region, your country, your world.  Most people will tell you to aim high. But if you aim high and miss your target, you fail.  I would say:  aim small, miss small.  That means, if you focus intensively on your target, even if you miss the target, you get close enough to be successful. Set big goals, but focus on small targets.

Excellence is the result of discipline, study, hard work, practice, and the drive to become the best.  You have come too far to just become an average doctor.  You now have the opportunity to make a difference.  Don’t squander it.

Good enough is not good enough.  Aim small, miss small.

I confess that even though I have seen the other side, I need constant reminders to try to apply these lessons in my own life.  So I will take no offense if — many years from now, or even just a couple of hours from now — you have no recollection of this address or who gave it. But maybe, just maybe, you will hold onto a few bits and pieces of this commencement address, and, despite all of the pressures of medical practice and complexities of your personal lives, will remember why you went to medical school in the first place, and what it means to be a good doctor.  Remain mindful of what is on the other side.

It has been my great honor to deliver this commencement address.  I played for you the cards I was dealt.  I showed you my hand.  Now you must decide how to play yours.  I wish each of you success and happiness in your personal and professional lives.

Kelly M. McMasters is the Ben A. Reid, Sr., MD Professor and Chairman, the Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY.