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The Lottery Tickets

Packer, Clifford D. MD

doi: 10.1097/ACM.0000000000000320
Teaching and Learning Moments

Dr. Packer is attending physician, Louis Stokes Cleveland VA Medical Center, and associate professor of medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio; e-mail:

One of my patients is a 64-year-old Vietnam vet who has battled his schizophrenia to a draw. He lives alone in his own apartment, manages his own finances, and generally seems to be doing pretty well. He sees me every six months, takes his medications every day, and his blood pressure is well controlled. He cultivates a Gumby-style afro of which he is quite proud, as I learned when I asked him to take his shirt off for his exam.

“Doc, do you mind if I leave it around my neck? I don’t want to mess up my hair. I spent a lot of time this morning getting it right.”

As I examined him, shirt around his neck, I asked about his activity level: “So how much walking do you do?”

“Well, every morning I get up and walk two blocks to the store and back to buy a lottery ticket.”

“Oh, so you walk about four blocks in the morning,” I said.

“Yes, and then around noon I walk back to the store.”

“Why do you go back again?” I asked.

“To buy another lottery ticket.”

“Well, that’s four more blocks,” I said. “I suppose that’s a good thing.”

“And then in the afternoon I go back and buy another lottery ticket. Sometimes I win a little bit.”

“So you walk to the store three times a day, and each time you buy a lottery ticket?” I continued.

“Well, actually, I go back one more time in the evening and buy another ticket.” He beamed at me. “I get four a day. Four chances to win. It keeps me going all day. Last week I won 20 dollars!”

“You do quite a bit of walking to get those four lottery tickets,” I commented.

He smiled as he slipped his arms back into the shirt. “I suppose so.”

“Well, great. I’ll see you in six months.”

As he walked away I thought for a moment about his life, and the profound power of ritual in all of our lives. I understood perfectly why he made four trips, instead of just picking up four lottery tickets each morning—four chances to let the anticipation build, four purposeful strolls, four pleasant cash transactions (with man or machine, I did not ask), and four daily aliquots of the distilled ecstasy of random chance as he scratched off each ticket back in the safety of his apartment. What billionaire has more pleasures and luxuries in his life than this man? I felt a pang of envy at the simplicity and symmetry of his routine, and I wondered what other rituals he had devised.

Then I thought again about a problem that had vexed me for years. Of the many schizophrenic smokers in my VA practice, over a period of 16 years, not a single one had been able to quit. Now I knew why. For them, smoking was more than a habit or addiction—it was a survival routine, a repeating and reliable link to physical reality. The lottery tickets were a healthier version of the same thing. I began to ask my patients more questions about their daily routines and found an amazing array of rituals that included a man who jogged every day at 4:47 for exactly 26 minutes, a talented artist who painted only carnival mummers, and dozens of others who ate, drank, exercised, worked, or slept—lived, in short—according to a variety of inflexible and often irrational rules.

To understand and treat our patients, we must know their habits, rituals, and routines. Diet, exercise, medication compliance, and recovery from addiction all depend on the careful adaptation of new routines to fit with existing rituals. If our treatment plans clash with deeply rooted behaviors, the treatment will fail. After all, if our lives are “nasty, brutish, and short,” as the philosopher Thomas Hobbes put it, we must have ritual and habit to console us.

Clifford D. Packer, MD

Dr. Packer is attending physician, Louis Stokes Cleveland VA Medical Center, and associate professor of medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio; e-mail:

© 2014 by the Association of American Medical Colleges