In the game of poker, zero sum game theory suggests that the sum of the amounts won by some players equals the combined losses of the others. So if one player wins big, then other players must lose big.
It struck me recently that it’s possible our healthcare system functions as if it were a zero sum game, too.
A number of my readers, for example, have observed that some men are openly expressing concern that the money and attention now being spent on raising awareness of women’s heart disease (which has started happening over the past decade), must mean less money in the pot to spend on them.
“I am sick of hearing the down trodden women were (sic) heart problems are concerned.”
Closer to home, one of the most memorable reviews of my book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017) came from a reader named Robert in Australia, who succinctly criticized it like this:
“A bit too much emphasis on how women are neglected when it comes to heart disease. Happily, for me and my fellow patients, my doctors, nurses and physios did everything by the book.”
(Thank you, Robert, by the way, for helping to prove my frickety-frackin’ point).
And here’s how I quoted Laura Haywood-Cory, who survived a heart attack at age 40, addressing male readers in her compelling essay “But What About the Men?“:
“Women with heart attack symptoms are less likely than men to receive life-saving clot-busting drugs, less likely to even receive simple treatments like an aspirin or nitro. Women survivors are less likely to be referred for cardiac rehab. Women have a 28% increased risk of dying compared to men within the first year after a heart attack (perhaps because of the fact that we’re less likely to get adequate treatment, as noted).
“It’s not ‘us versus them’ in that we women heart patients and advocates are now taking something away from male heart patients. What we’re striving for is EQUAL access to correct diagnoses and treatment.
“In order to do that, we have to address the current inequalities – you can’t change the fact that because you’re male, you’re automatically going to be treated differently if you complain of chest pain than a woman is going to be.
“In general, men don’t have to fight to be believed if they show up in a doctor’s office and say that they think they’re having a heart attack.
“We do. We have to. Every single day.
“We don’t want to take away the men’s piece of the pie (access to accurate diagnosis and correct treatment); we want to ensure that everyone has pie.
“And everyone wants pie, right?”
Yes, Laura, women certainly do want pie!
Consider also the inherent issues with funding cardiac rehabilitation programs for heart patients.
Here in Canada (a.k.a. “commie pinko land of socialized medicine”), our government-funded health care system pays tens (sometimes hundreds) of thousands of dollars for our cardiac diagnostic tests, emergency procedures, hospital stay, drugs and supplies while in the hospital, and lifelong follow-up with cardiologists, but it often will NOT pay for a proven program like supervised cardiac rehab, despite many studies that show paying for cardiac rehab now will actually save money down the road by improving our cardiac outcomes and helping to prevent expensive hospital re-admissions.
This rehab is ranked by every cardiology society worldwide as a Class I treatment for ALL eligible heart patients. That means the highest quality studies have shown that attending and completing a supervised program of cardiac rehab results in better longterm outcomes compared to heart patients who don’t attend.
In fact, completing a program of cardiac rehab can reduce risks of future cardiac events by up to 30%.
Not even taking statins every day for the rest of your natural life can guarantee that kind of improved cardiovascular outcome.
It’s almost as if our provincial Ministry of Health bean counters view cardiac rehab as a zero sum game while they scramble up excuses to deny reimbursement.
(In the U.S. healthcare system – a misnomer because, arguably, there IS no healthcare “system” – it’s a patchwork of coverage: some rehab programs are covered by Medicare or private health insurance, others are not, but even when they are, the patient co-pays can be prohibitively expensive, often cited as reasons that heart patients are unable to attend.)
So despite current research results and accepted treatment protocols, modern medicine does not yet fund rehabilitation programs to help prevent future cardiac event before they happen, the same the way it chooses to fund invasive procedures after the fact.
Similarly, within the traditional hierarchy of medicine(1), sociologists describe a dominant group holding power in a given society (doctors) being disturbed by those who have historically had little power to dare question that dominance (patients). Thus any gains for “patient engagement“ movements can be viewed with distrust and dismissal by traditionalists as a threat to their own status.
Sadly, we see evidence of this flawed zero sum theory in many other areas of life.
For example, here’s how the Harvard Business Review once described the zero sum concept that employers can embrace when it comes to work-life balance:
“Work versus personal life is a zero sum game. Most executives still believe that every time an employee’s personal interests ‘win,’ the organization pays the price at its bottom line. So they consign work-life issues to the human resources department, where the problems are often dealt with piecemeal.”
In education, a landmark study published in The Lancet asked if school children aged 12-16 would achieve better academic results at school if schools provided free healthy lunches.(2)
This may intuitively make sense, but the general zero sum game objection has long been a pervasive belief that if schools spend money on supporting nutritional health, it would mean less money to do what they’re really supposed to be doing, which is educating the kids.
Yet here’s what the researchers found out about those schools that did provide healthy lunches:
“Our findings did NOT support the zero sum game hypothesis. In fact, especially among more deprived schools, there was better attendance and academic goal attainment.”
In other words, one aspect doesn’t necessarily suffer because another aspect receives attention, time or money. Just the opposite, in fact.
But in other entrenched examples of this “win-lose” zero sum game, ranging from the white supremacist movement to equal pay for equal work, any step forward for some can be mistakenly perceived as a dangerous step backward for everyone else.
1. M. Mast. “Dominance and gender in the physician-patient interaction.” The Journal of Men’ s Health & Gender. 2004. 354-358.
2. S. Long et al, “Testing the zero-sum game hypothesis: an examination of school health policy and practice and inequalities in educational outcomes”, The Lancet. Volume 390, Supplement 3, November 2017, Page S60.
Cartoon: ©Bob and Tom Thaves
NOTE FROM CAROLYN: I wrote much more about misdiagnosis in women’s heart disease in Chapter 3 of my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 20% off the list price).
Q: Can anything be done to address the inevitable ‘win-lose’ outcomes of a zero sum game?
- This is NOT what a woman’s heart attack looks like
- Does your hospital have a Women’s Heart Clinic yet? If not, why not?
- The surprising reasons heart patients don’t go to cardiac rehab
- Do we need to change the name of cardiac rehab?
- Failure to refer: why are doctors ignoring cardiac rehab?
- ‘Women-only’ cardiac rehabilitation curbs depression for heart attack survivors
- Why aren’t women heart attack survivors showing up for cardiac rehab?
- Study: “91% discharged from hospital without care plan”
- Skin in the game: taking women’s cardiac misdiagnosis seriously
- Fewer lights/sirens when a woman heart patient is in the ambulance
- Same heart attack, same misdiagnosis – but one big difference