Playing Doctor: Of Games and Medicine
Notes from a Family Meeting, Vol. 3, No. 5
“Creatinine 2.3 yesterday, now 1.7 after fluids.”
“Diuresis goal of net negative 1 liter.”
“Adenocarcinoma. Clean margins.”
Many, if not most, of the goals in medicine are very concrete and clear. There’s a problem, some tools (including a clinician’s own abilities), and an environment to bring them together for a solution. It’s not easy, per se, but when you’ve got the right training, it can be straightforward.
There are areas where the path is overgrown with all kinds of existential flora. Consider a more complex situation, in which a patient is struggling with substance abuse and recurrent hospitalizations for exacerbations of various chronic medical issues. Their goals vary from day to day, some of which are at odds at with the goals their clinicians might have for them. One goal is probably to get them through the hospitalization safely, but given the recurrent nature of the problem, that isn’t the only goal. It might not even be the most important. It’s not really evident where patient and clinician can find the right path.
All of these scenarios are very serious. This is not a game.
Or is it?
Playing Games
We typically think of games as fun and inconsequential. The clinical encounter, on the other hand, is anything but. Sure, there are a treasure trove of things clinicians might enjoy about the clinical encounter (e.g., compassion satisfaction, intellectual problem solving, relationship building, meaning-making), but you wouldn’t describe the clinical encounter as “fun” in the same ways that chess, soccer, or Super Mario are fun.
But don’t be deceived. Games are really important in and of themselves, and they teach us lessons, as coaches like to preach, on and off the field. They can even change us in unexpected ways, altering what we expect from and what we do in non-game scenarios.
C. Thi Nguyen, in Games: Agency as Art, writes:
“A game tells us to take up a particular goal. It designates abilities for us to use in pursuing that goal. It packages all that up with a set of obstacles, crafted to fit those goals and abilities. A game uses all these elements to sculpt a form of activity. And when we play games, we take on an alternate form of agency. We take on new goals and accept different sets of abilities. … Goals, ability, and environment: these are the means by which games designers practice their art.”
By doing this, we can “try on” different agencies when we play games, an amazing opportunity for people who are typically bound to the day-to-day realities of their own life. “Painting lets us record sights, music lets us record sounds, stories let us record narratives, and games let us record agencies.” In this way, games are a unique form of art in which we get to participate.
I think Nguyen’s perspective offers some helpful insights about the clinical encounter. This doesn’t mean I’m making light of the serious work we clinicians do, or that I believe clinicians have selfish motives in caring for patients. I’m not lowering medicine to the status of a game. Rather, because Nguyen elevates the importance and seriousness of games, I believe it then makes the comparison more obvious. Here are a few tentative thoughts and some connections I’ve considered between games and medicine.
Playing Doctor
Games provide a “motivational inversion” of ordinary life. “In ordinary practical life, we usually take the means for the sake of the ends. But in games, we can take up an end for the sake of the means.” While the vast majority of people enter medicine with altruistic motives (they’re taking up the means for the sake of the end), how they decide where in medicine to practice largely depends on their own preferences, like how much they enjoy the day-to-day work of a particular specialty. At that stage, then, trainees really do “take up an end for the sake of means.” They enjoy operating on the brain and spine, for example, and so they accept all the relevant goals associated with neurosurgery for the sake of getting to do neurosurgery. How easily someone can switch between these two ways of working: pursuing ends for the sake of means, and means for the sake of ends, isn’t at all straightforward, and may resolve in some of what I’m about to describe.
Striving play has different goals and purposes. Nguyen differentiates achievement play (playing for the sake of winning) from striving play (playing the sake of enjoying the struggle). He describes it this way:
“When I play a party game with my friends, my goal is to win, but my purpose is to have fun. The way to have fun is to try, during the game, to win. But I don’t really care if I win or not - not in any lasting way. I have to chase the goal of winning to fulfill my purpose, but I don’t actually need to win in order to have fun. Winning, in this case, is rather incidental to my true purpose. In fact, if I start up a game of Charades for the sake of having a little fun, but I am so aggressive and competitive that I make everybody else miserable, then I may have succeeded in achieving the goals of the care, but I have failed entirely in my purpose.”
Using Nguyen’s language (which is different from what I’ve developed in this newsletter), a goal of medicine would be to, say, improve the patient’s renal function, and the purpose is to help them be healthier. The goal needs to serve the purpose, and in fact, the purpose is best achieved through the goal (at least, insofar as we’re talking about medical intervention).
We run into a problem when clinicians replace the purpose with the goal: improving the renal function becomes divorced from any broader understanding of how this is serving their patient’s health. Clinicians might declare “victory” when they’ve improved the surrogate marker of their particular disease or organ, but they’ve actually been playing a different “game” than one that benefits their patient. This maybe has happened because they’ve taken on an end for the sake of the means - they’re more enamored with the techniques of their work and the ends supplied by those techniques (“metrics”), than the more nebulous, harder-to-measure state of health of their patient which originally piqued their altruism.
Games simplify the existential hellscape of real life.1 It’s worth quoting Nguyen at length here to capture this idea:
“In ordinary life, we have to struggle to deal with whatever the world throws at us, with whatever means we happen to have lying around. In ordinary life, the form of our struggle is usually forced on us by an indifferent and arbitrary world. In games, on the other hand, the form of our practical engagement is intentionally and creatively configured by the game’s designers. In ordinary life, we have to desperately fit ourselves to the practical demands of the world. In games, we can engineer the world of the game, and the agency we will occupy, to fit us and our desires. Struggles in games can be carefully shaped in order to be interesting, fun, or even beautiful for the struggler.”
…
Games can offer us a clarifying balm against the vast, complicated, ever-shifting social world of pluralistic values, and an existential balm against our internal sense that our values are slippery and unclear. In games, values are clear, well-delineated, and typically uniform among all agents.
…
In games, the problems can be right-sized for our capacities; our in-game selves can be right-sized for the problems; and the arrangement of self and world can make solving the problems pleasurable, satisfying, interesting, and beautiful.”
The landscape of illness is fraught with complications. These aren’t just physical risks, but values are, as Nguyen describes it, slippery and difficult to compare with one another. What is the right thing to do anyway? It’s not readily apparent and often not in any textbook. We have to make epistemic leaps from what we know of the medical literature to the unique patient before us. We may not be able to reconcile our hopes with those of our patients, no matter how much we tell ourselves that we’re “respecting autonomy.”
There’s solace to be had in having a goal (e.g., filtering the blood in the absence of intrinsic renal function) and the tool to address it (e.g., dialysis). You can use that tool to situate renal function in the broader context of a patient’s health - a complicated endeavor to be sure! - or you could enjoy using the tool to simply do what the tool is technical designed to do: balance electrolytes, remove volume, etc.
Sometimes we make up goals. Hopefully it’s something that’s easier to measure but still links to patients’ health (surrogate endpoints in research, for example), but often it’s just so we can see that our intervention has an impact on something because impacts on the patient’s health are hard to discern over the timescale that is acceptable to us. Or maybe our intervention doesn’t actually help, but the goals we make up hide that to simplify matters.
This value clarity is a major trait of games. By “value clarity,” Nguyen means that, first, the applicability of values in games are obvious. There’s no question what you supposed value in chess and how you supposed to pursue that. This is unlike real life, where we may not know exactly how and when to intervene, stop, speak, remain silent, move forward, and back away.
Second, in games, values are commensurate. The best example of this is point scoring. Two teams playing against one another are scoring points, and a point for one team means the same thing as a point for the other team. That’s not how it works in real life (though we’ll talk about metrics in a moment). How can you compare living longer without legs against preserving your legs but not living as long? Attempting to reconcile non-commensurate values can induce an existential crisis which often resolves in a decision but may not resolve the turmoil within the spirit.
Third, in games, values are rankable. Everyone knows who the winner of a point scoring game is - or else the rules of the game allow for a tie, but even a tie acknowledges rankability. Again, I’ll address metrics in a moment, but otherwise, real life values aren’t easily rankable: which is better, courage or wisdom? Strength or intelligence? How can I compare my “success” as a father against another father’s?
There’s a danger here for those practicing medicine:
“If we expect value clarity, we may be drawn to those social milieus and institutions that present values as artificially clear. … We might start to expect our value systems to be applicable, easily commensurately, and rankable - and so avoid the use of subtler value systems. In other words, we will be drawn to systems institutions, social practices, and activities that closely resemble games, and we may be tempted to adjust our own goals to make our lives more closely resemble game play.”
I’m not knocking on interventional sub-specialties. I’m only drawing attention to the pitfall of gamification that exists for all of medicine, and certainly for sub-specialties where value clarity is more imminently possible (e.g., change a number, complete a surgery, stent a lumen, etc.). “Games,” Nguyen writes, “threaten us with a fantasy of moral clarity.” It’s not straightforward in real life, if we’re really going to behold suffering and strive for health.
Games are aesthetically pleasing. Games are fun of course, but there’s something deeper: “There is a natural aesthetic pleasure to working through a difficult math proof; chess seems designed, at least in part, to concentrate and refine that pleasure for its own sake. In ordinary practical life, we catch momentary glimpses, when we are lucky, of harmony between our abilities and our tasks. But often, there is no such harmony. Our abilities fall far short of the tasks; or, the tasks are horribly dull.”
Value clarity also plays a role here: “Value clarity boosts our experiences of functional beauty, because the functional beauty of an action is clearer when the actions’ goals are also clearer.”
So both ability-task harmony and value clarity lend themselves to a pleasurable experience that may, in the end, distract clinicians from pursuing the more elusive goal of their patient’s actual health. We just don’t get the same visceral reward when we’re trying to navigate the choppy waters of chronic illness on a starless night - unless! Unless we pull in some game-like elements to give us the feedback we need to harmonize our abilities to tasks, and to clarify values.
Games provide easy measures of success and failure. Now, this isn’t the case for all games (e.g., make believe), but for many games, you either win or lose based on, say, a score, or accomplishing a task (e.g., capture the flag). There’s not a lot like this in real life, but we try to recreate it by using metrics. We don’t know how to measure the quality of someone’s hospitalization in toto, for example, but we can measure things like length of stay, complications, etc. Nguyen writes:
“Metrics, after all, look a lot like points. They offer some of the pleasures of games when we pursue them wholeheartedly. And if we are too eager to recapture the pleasures of games in ordinary life, we may be excessively drawn to using such simplified measures in our practical reasoning. We could be drawn to redefine our notion of success in the newly clear terms specified by those metrics, in order to get more game-likel pleasures from our work.”
Again, don’t get me wrong: we’re not making up metrics in medicine just to replicate the same fun we might have playing a game. But metrics are tempting to use because they simplify things in ways akin to a game. They’re also easily transported around a bureaucracy that struggles to see narrative but can easily handle numbers. And before long, the tail wags the dog: we stop asking questions about health, and focus solely on the metric.
Changing the Rules of the Game
Since hearing about Nguyen’s perspective on games, it’s hard for me to un-see the gamification of real life: from social media all the way into the clinical encounter. Given the winds of our current cultural moment, it’s hard for me to hope for any change for the better. I certainly don’t think the answer is to get rid of games. They’re too important, prevalent, and embedded in our traditions.
Maybe there’s something to be said for just dragging the issue out into the light. If the clinical encounter has been gamified, to one degree or another, or is at risk of being gamified, in what ways is that helpful or harmful? In what ways does that help clinicians serve their patients’ health, or does it hinder them?
If the depth of the clinical encounter and the experience of human illness exceeds the “game” of medical intervention, can we have eyes to see that greater depth? A few thoughts on how we might refine our vision:
Recognize and honor health as the end of medicine.
Foster language to describe what we see and feel. We might not achieve value clarity, but we can clarify our thinking and speaking. Margaret Walker wrote this counsel to ethics consultants, but it applies to anyone who might find them entangled in an ethical situation:
“A narrative picture of moral understanding doesn’t spurn general rules or broad ideals, but it doesn’t treat them as major premises in moral deductions. It treats them as markers of the moral relevance of certain features of stories…; as guidelines to the typical moral weight of certain acts or outcomes…; as necessary shared points of departure….; and (with any luck) as continuing shareable points of reference … and reinterpretation … that lead to a morally intelligible resolution. So narratives in moral thinking come before, during, and after moral generalities.”
One does this by sustaining a “wide and critical” conversation with relevant terms of moral assessment. You do this by, say, reading fiction and non-fiction, and talking to people outside of your tribe.
Develop skills to address the real needs of your patients. These are, of course, technical skills - how to prescribe a medication or dialysis, for example. They are also the harder to define skills that proceed from virtue - like listening with compassion, recommending with wisdom, or advocating with courage. How you go about doing this is a topic for another day, but in doing this, the encounter becomes more meaningful even if it doesn’t meet the aesthetic criteria of a game that Nguyen describes.
And with that: play on!
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
A survey with some interesting results, chief among them the belief that, at least for these intensivists, assisted suicide and euthanasia (ASE) hasn’t changed the practice of end-of-life care in the ICU. The obvious implication is that these are distinct ways of practicing medicine, and a portion of the survey about the principle of double effect gets at that: most clinicians are careful in how they understand their intention to use opioids when someone is dying. However, one point the authors don’t set before their respondents is the possibility that care in the ICU, particularly around withholding and withdrawing life-sustaining therapies (WLST), has already become so much like ASE in terms of intent that there wasn’t much left to change with the advent of ASE. Specifically, if a clinician’s intention is for a patient to die with WLST, or to use death as a means to assuage suffering, then there is little difference between that intention and the intention guiding ASE. Culturally, then, ICU care practices at the end-of-life pave the way for the acceptance of ASE later on.
“Medically assisted deaths could save millions in healthcare spending”
The researcher interviewed sounds resigned that this is just how reality is in Canada now: we must take cost into account. He admits that these data aren’t meant to promote the practice of assisted suicide and euthanasia, which remains a “personal decision” of each individual. But with this kind of money at stake, how could cost not become a consideration in each person’s individual deliberations? Is this what proponents of these practices wanted? Are they satisfied, knowing that Canada’s health system will save a lot of money now that the euthanized no longer will receive expensive care?
An absolutely tragic story told by a girl who died from a condition that should have been caught early and treated. As the mother tells us, physician arrogance, miscommunication, and bias resulted in overlooking the signs of her daughter’s worsening condition until it was too late. Certainly lessons for any clinician can be learned from this story, but first we need to allow ourselves to lament the tragedy. This should not have happened, and both the mother and (presumably) the daughter didn’t feel cared for by clinicians who were supposed to care.
Lydia Dugdale laments the fact that modern medicine appears without an end, that is, without a telos or objective purpose. She uses the idiosyncratic oaths produced by many medical schools as evidence that people are just committing themselves to whatever they individually think is good, which degrades the tradition of medicine as a communal profession. Maybe if we returned to the Hippocratic oath? I have low expectations for that improving the state of affairs in medicine. White coat ceremonies are abundant in medical training, full of inspirational speeches. So, too, with graduations. But this pomp and circumstance, along with the words, fail to resist the far more powerful hidden curriculum.
This is a helpful companion to the older article “Rehabbed to Death.” Both seek to clarify what both clinicians and patients are hoping for by pursuing rehabilitation in a skilled nursing facility. We need to improve our communication (particularly around prognostication) so that patients and families make better decisions about this big move. And it is a big move - those of us who work in the hospital every day don’t give it a second thought, but we’re asking people to move someone for a few weeks and endure the food, the staff (sorry, the quality of staff has suffered in COVID times), the separation from family, and the routine. As Shi et al. indicate, it’s not guaranteed that older adults will all recover during their stay in a SNF. Let’s be careful when considering its use, just like we would prescribing a new medication for an older adult.
Closing Thoughts
“Medicine often reflects who we are, what we want, and what we fear.”
Stanley Hauerwas, God, Medicine, and Suffering
I think this was a quote/paraphrase from Nguyen’s interview with Ezra Klein rather than from his book, but it captures the idea really well.