Adamek, Dariusz

Folia Neuropathologica

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Jagiellonian Univeristy Repository

Folia Neuropathologica 2005; 43/3 191Neuropathological diagnosis of tumour and bridge card game.Some personal remarks and considerations (Letter to the Editor) Dariusz AdamekDepartment of Neuropathology, Institute of Neurology, Jagiellonian University Medical CollegeFolia Neuropathol 2005; 43 (3): 191-192Letter to the EditorThe process of making neuropathological diagnosisbased on a tissue sample taken by a neurosurgeon maybe envisaged as a kind of “bidding” resembling verymuch the one in the bridge card game. What makesboth seemingly incomparable processes in factconceptually very much close to each other? I will try toexplain but first, though bridge is rather a populargame, I would like to present just the basic featuresand rules of the game in a simplified way to make mypoint and this text comprehensible to those that do notknow the game. Bridge is the card game where twopairs of players are competing (each pair is a team).Two members of each pair sit at opposite sides ofa square table. To win the game, the pair has to collecta predefined number of points (100). The first phase ofthe game after each new deal of cards is called“bidding”. During bidding, which is a form of anauction, the players, seeing only the cards of their own,in a formalized way of symbolic communication (socalled a bidding system) try to achieve the bestpossible (optimal) “bid” in relation to the value (or“power”) of the cards they have received in a particulardeal. The final “bid” ('the contract') that is the result ofbidding, denotes the number of tricks a given pair ofplayers hopes to win. The next phase is a play theoutcome of which clears whether the bid was trulyoptimal, or in other words, whether the number oftricks matches the level of the contract achieved in thebidding phase. I hope that this somewhat oversimplifieddescription of the bridge card game will suffice tounderstand my thesis that bridge andneuropathological diagnosis of tumour have lots incommon if one makes an assumption that making theneuropathological diagnosis is a form of a bidding andthe following course of disease is a kind of “play” thatmay prove or (sometimes unfortunately) disprove our“bid”, i.e. the diagnosis. It turns out that analogiesbetween the formal conditions and rules of reasoningand the conduct in both so incomparable activities asa card game and the tumour diagnosing aresurprisingly significant. Firstly: Like in bridge, the neuropathologist “plays ina pair”. It is first of all a pair with a neurosurgeon. Inthis pair (also like in bridge) each of them does not seeeach other’s cards. In the case of a neurosurgeon “thevalue of the cards” or more appropriately (according tothe bridge jargon) “of a hand” is the operation field andeverything that is the result of direct “in situ”inspection and also the result of other examinations(including the symptoms and history of disease,neuroimaging, biochemical data etc). “The hand” of theneuropathologist in turn is the macroscopical and firstof all microscopical picture of a sample. In some cases,“the value” or “power” of a “hand” of theneuropathologist is so strong (when histology yieldsunequivocal characteristic features of a particular typeof tumour) that as if “the level of the contract” (thediagnosis) is practically obvious even without anyknowledge of the partner’s “hand”. It is though (like inbridge) rather a rare situation and a state-of-art“bidding” (mutual exchange of information betweenthe neurosurgeon and the neuropathologist) isnecessary to achieve “a higher contract” i.e. the moreprecise diagnosis. Secondly: Also like in bridge, a communicationbetween the neurosurgeon and the neuropathologist isusually not direct and straightforward (unfortunately)but by the use of quite a “conventional” exchange ofnotes. On the contrary, the physical distance betweenthem is usually much longer than in the real bridge gameand instead of a nice “green table” they are separatedsometimes by many walls and sometimes they are evenmany kilometres apart. One may say also that a kind ofFolia Neuropathologica 2005; 43/3 192Dariusz Adamek“a common language” (a name of the one of severalbidding “conventions” in bridge) is a must in relationsbetween the neurosurgeon and the neuropathologist.“Conventional” and laconic communication betweenthem may lead to disastrous misunderstandings... Thirdly: Again like in bridge, the neuropathologistand the neurosurgeon have to try to combine the valueof their both “hands” in the aim to reach the diagnosisas precise as possible which results in optimaldecisions as for the treatment. The problem is that veryfrequently, the neuropathologist receives much lessimportant information on the “power of theneurosurgeon’s hand” (when, for example, a lot ofcrucial information about the precise localization,relation of the tumour to particular anatomicalstructures, clinical symptoms and history of theailment, to name only a few, are missing). The result isthat it is much more difficult to achieve the “optimalcontract” (the proper diagnosis). Fourthly: One may say that the pairneurosurgeon-neuropathologist plays against anextremely vicious “pair” of enemies. Let’s try topersonificate and name them. It is first of all “Dr Death”playing in pair with other “doctors” or “advisors” like“Dr Routine”, “Dr Lazy”, “Dr Neglect”, “Dr Tiresome”, “DrHasty”, “Dr Hoity-Toity”, “Dr Botcher”, “Dr Wiseacre”,“Dr Bighead” and many others malicious “doctors” whoin fact may exist just inside us... Fifthly: The precision of a diagnosis may becompared to the level of contract in bridge which isthe result of bidding. Say, the diagnosis of “gliomaWHO grade III” may be an equivalent of a sort of “3 notrump” (3NT) i.e. the lowest but usually satisfactorycontract “making a game” because it is worth 100points with the least number of tricks that have to bewon. In case of a tumour, such a diagnosis (gliomagrade III), though not very precise, notwithstandingenables proper and effective further treatment anddecision-making may be also acceptable. Of course, inbridge we would prefer a higher contract, especiallywith “slam bonus”. For example, instead of “3-no-trumps”, 6 or 7 (“grand slam”) in any suit or NT ismuch better. Every neuropathologist knows that thematerial and the information at our disposal does notalways enable the “bonus” diagnosis (a high contractwith bonus points) especially in cases of a pathologicalrarity where the exact and true diagnosis is reallysomething like a “slam in spades”. Unfortunately,there are still worse situations when “the cards” donot allow any bid that “makes the game”, i.e. a specificand definite diagnosis. Even so, we try to bid: “the bestpossible contract” which means any diagnosis that atleast excludes something or gives some indications forfurther examinations and management. In bridge it issomething like, say, contract at the level of 2 or 3 indiamonds or in any other suit. It does not “make thegame” (it is worth less than 100 points) but at leastproceeds toward its completion. Sixthly: In spite of the optimal contract (i.e. properdiagnosis) the total result of the game (in other words,the result of the treatment) depends on many neverfully known or predictable factors which (in bridge) area precise distribution of cards and the way the rivalsplay. In a real “play against the death” the result as wewell know depends also on many not always controlledand predictable factors. Seventhly: As it is in bridge, the worst that mayhappen in the process of diagnosing of a tumour is “aslip-up” (so called “undertrick” in bridge) which wedislike most and by all means we would like and haveto avoid... There are still more analogies. For example, theway of bidding and the way of making and expressingthe diagnosis depends to some degree ona “temperament” of correspondingly a card playerand a neuropathologist but in both cases “thecourage” and “aggressiveness” (in bidding and inmaking the diagnosis) should be under control ofreason and experience. Of course, every analogy hassome limits beyond which it becomes either uselessor just ludicrous. I do hope I have not exceeded them. This “bridge-neuropathology” analogy may beregarded as a mere kind of intellectual pastime butI think it may be of some practical value because it mayhelp to realize more vividly the conditions andlimitations of our involvement in the struggle for thetrue diagnosis and hence for optimal and effectivetreatment of the patient. It emphasizes andillustratively explains the profound role of mutualunderstanding between the neuropathologist and theneurosurgeon and necessity for a close cooperationbetween them. It may also (hopefully) help to avoidpossible dangers very easily caused by theaforementioned “malicious doctors” who are alwaysready to act in every of us. P.S. Surely, everything that was written about thepair of “players” formed by the neuropathologist andthe neurosurgeon can be applied to the pair of just thepathologist and the surgeon (in other words, a verysimilar pair of medical professions but without the“neuro” prefix). 

Neuropathological diagnosis of tumour and bridge card game : some personal remarks and considerations (letter to the editor)

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Neuropathological diagnosis of tumour and bridge card game : some personal remarks and considerations (letter to the editor)

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