Baseball and medicine

Saturday, July 4, 2009

Late innings of a close ballgame. One out with runners at second and third, a power hitter coming to the plate but the guy on deck has a higher batting average. The manager walks to the mound. Decision time. Pitch to the hitter or intentionally walk him to load the bases and potentially set up a double play. And does the pitcher have enough left to throw strikes or is it time to bring in a reliever.

Baseball and medicine may seem like an odd couple but the two are closely linked when it comes to decision making. Managers and physicians balance risk and reward to offer the best strategy for a given situation. It all comes down to numbers and while past performance does not guarantee future results, decisions are influenced by history.

The national pastime of baseball relies upon statistics and probabilities to help decide upon strategy. Fans understand that a .350 hitter will get on base more frequently than one below the Mendoza line (a batting average less than .200). They know that a 95 mph fastball is harder to hit than one travelling at 85mph. Managers take player performance and situation into account when deciding what they would like to see happen on the field. Decisions happen with each pitch: when to put in a relief pitcher, when to bunt or steal, or when to shade the outfielders to the right or left. Good managers understand the numbers while great managers add intuition gained from their own experience to help with decision making.

Medical decision making replicates what happens on the diamond. The physician needs to interpret information obtained from the history and physical to be able to order the appropriate tests and then those tests will help direct the decision for treatment. Sometimes the answers are easy but the numbers are hard and sometimes it’s the other way round.

A stroke is a devastating disease. When an artery to the brain is blocked, that part of the brain stops working and the clock starts ticking. Depending upon the technology available there is only 3-6 hours to inject a clot busting drug to try to restore blood supply to the brain and get it working again. The diagnosis is pretty easy to make if a patient presents with any combination of confusion, loss of speech or vision, weakness of one side of the body. The question is whether they qualify for clot busting drugs. Blood pressure needs to be controlled, blood tests need to be done and a CT scan of the head needs to make certain that there is no bleeding or tumor in the brain. Only then can TPA, the clot busting drug, can be considered. The numbers are harder. The treatment will reverse a stroke 33% of the time, but may cause bleeding in the brain in 6% of patients.

Time is of the essence in heart attacks as well, when the heart loses its blood supply because a blood vessel becomes narrow or clots off. In cardiac catherization, a cardiologist can snake a small catheter or tube into the artery and use balloons and stents to blood supply. Instead of hours, time is measured in minutes and the goal is to get the blood vessel open within 60 minutes of the patient presenting to the hospital door. Heart cath success rates run greater than 95% while complications happen less than 1% of the time.

The risk reward decision making doesn’t have to be life or death. Every day, doctors decide which antibiotic to choose hoping to choose one that will be effective against the bacteria and yet minimize the potential for side effect. There are decision strategies with birth control methods, high blood pressure control, diabetes and immunizations. Every medical treatment comes with its own set of benefits and liabilities.

Baseball and medicine also share replays and hindsight. Did the manager make the right call; did the doctor suggest the right treatment. If it were just numbers, then computers would be substituting players and ordering medicines. Intuition and experience transforms science into art and art can be critiqued.

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