by Carolyn Thomas ♥ @HeartSisters
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.
Or, as one man (who had joined the WomenHeart online support community – a support group for, ahem! – women living with heart disease!) protested:
“I am sick of hearing the down trodden women were (sic) heart problems are concerned.”
Another example: 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 events 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 trying to raise awareness of women’s heart disease in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
♥
Q: Can anything be done to address the inevitable ‘win-lose’ outcomes of a zero sum game?
See also:
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
Heart Sisters 
Lots of useful information here. Thanks for sharing.
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I do hope that my previous comment can be kept private – did not stop to think it would be posted. Thank you!
And I should have guessed you already know about Dr. Victor Montori’s Patient Revolution!
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Hello Cynthia, not to worry: you left me a message via my “Contact” page which is a good way to reach me without making a message public. Thanks for getting in touch, and for your kind words about my blog.
I agree with you, by the way: we need to KEEP EXERCISING after a cardiac diagnosis. I like your goal (30 minutes per day, for 5 days at least). That schedule can scare the freshly-diagnosed off at first, until it becomes clear that we do feel much better with such a plan than we could ever feel sitting around feeling scared about what has just happened.
Thanks for recommending Dr. Sandeep Jauhar’s book, The Heart, A History. Haven’t read it yet but have read some great reviews so far. Thanks very much for getting in touch.
PS I love, love, LOVE Dr. Montori’s book, Why We Revolt. I am very proud to say that I have had the wonderful opportunity to meet Dr. Montori in person while at Mayo Clinic, and to also have a signed copy of his book!
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I live in a community that boasts over a 25% senior population. Plans for many new seniors’ facilities are in the works to make the Comox Valley the benchmark in senior life. We have a brand new hospital with state-of-the-art patient care.
But…there is not one cardiologist in the community. There are 9 internal medicine doctors who take cardiology referrals and must liaise with cardiologists in Victoria – a 3 hour drive away.
I’m finding out that you have to be such a persistent personal advocate for my heart issues that it sometimes seems overwhelming. I had a heart attack and stent surgery 6 months ago and absolutely no referral or opinion was ever given by any of the physicians for cardiac rehab. I get most of my information online.
Thank you Heart Sisters for being there for me.
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Hello my sister Vancouver Islander! Your experience (no cardiac rehab referral) is unfortunately common, especially in rural communities or even cities that happen to be far away from the nearest heart hospital.
Yet with nine IM docs in the Valley (NINE!!) – it would be wonderful if at least one of them knew enough about the proven longterm benefits of cardiac rehabilitation to both heart patients AND the healthcare system that they would decide to launch a pilot program in your area.
Here in Victoria, except for the Royal Jubilee Hospital-based rehab program for high risk heart failure patients with complex needs, all “Take Heart” rehab programs are community-based.
You don’t need a board certified cardiologist to sit and watch you on the exercise bike! You do need a kinesiologist, a cardiac nurse or other trained healthcare provider to supervise heart patients during their programs, but those programs can and do take place at local community centres. Also, FYI, here’s a link to a journal abstract on this interesting “virtual” cardiac rehab study from Simon Fraser University prof Dr. Scott Lear. As he says: “More than 90% of us have Internet access, opening up opportunities for patient communication while bridging geographic distance. This has led to the development of ‘virtual’ cardiac rehabiltation that can be remotely conducted, reaching patients in their homes and communities, using a range of technologies such as telephone, Internet, text messaging, and smartphones.”
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I think you described the problem well …. it is a matter of perception … an actual expectation that one person winning causes the other to lose.
In a win-win, there must be an integration of ideas and cooperation as well as an expectation that both can win.
So why do men have this expectation about funding women’s heart disease issues stealing money from their own?
It is a fundamental problem that a large portion of men, consciously or unconsciously, feel that women are not as valuable or important as men. It is an animal trait of dominance that persists even in our advanced civilization.
Progress is being made… More women in positions of power, boards of directors, researchers, government agencies will gradually cause this to fade out. In the meantime remember “Knowledge is Power” – those of us who are in the position of being a patient can be knowledgeable about our needs and know if they are not being met, we can seek another health care provider….at least here in America I can.
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Such important points, Jill. An “expectation that both can win” is really the key to preventing a zero sum game, isn’t it?
I was reminded while writing this blog post that people who hear good news about another but cannot feel truly happy for that person are also exhibiting that unfortunate ‘animal dominance’ that comes when another person’s good fortune is somehow interpreted as an imminent threat to one’s own.
I’d like to believe that things are improving (and in some circles this is undoubtedly true!) yet we have a ways to go yet…
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Two cardio rehabs turned me down … cardio dr sent me to one, where the only patients there working out – were men – and where I was turned down, heart surgeon sent me to another, where I was turned down. Female dr head of the second cardio rehab clinic couldn’t get past the fact that I’d been in a three day-induced coma when my heart repeatedly failed immediately after the surgery was completed.
Also, I use a walker and that seemed to play a role in both refusals, but neither clinic heads ask me if I’d be able to do their exercises, they didn’t even explain them to me.
PS: Both people who interviewed me were woman, the head dr in one, the specialist in the other. I had ten blocked arteries because over the years, since my early 40’s, no dr believed my symptoms were my heart and offered Prozac. Only four of the ten could be repaired.
My surgery was April 2009, I was 69. I’m still living with the remaining six blocked arteries and this month – I’m 79. I believe rehab would have helped me be more mobile today, and I did have another heart attack after uterine cancer surgery in 2016, another surgery I survived, altho am more homebound than before.
MEN RULE – even when female medical pros make the decisions.
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Thanks for sharing your unique perspective, Michelle. My goodness, you are the poster child for not being taken seriously (offered Prozac for years for TEN blocked arteries?!?) And the beauty of cardiac rehab programs is that they can be customized to suit the physical abilities of each participant, even for people who use walkers to help them get around. If geriatric patients can sign up for chair aerobics and chair yoga, then 69 year old heart patients with walkers can do cardiac rehab!
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Just a note about Cardiac Rehab for USA heart sisters on medicare….About 5-6 years ago Dr Dean Ornish compiled all of the research results, including his own, that show how intensive cardiac rehab decreases hospital admissions and improves wellness and survival. He presented them to our Medicare board. So Medicare now not only covers regular cardiac rehab, which they have for a while but they cover “ Intensive Cardiac Rehab” This program, designed by Dr Ornish meets 4 hrs twice a week for 13 weeks. Each 4hr session has 1 hr of monitored exercise, 1 hr of nutrition and we eat a meal together, 1 hr of stress management and meditation, and 1 hr of group support. Rehabilitation is NOT just about exercise …. All 4 aspects work together for success.
Most cardiologists haven’t even heard of this type of rehab. I had to tell my cardiologist about it and ask him to refer me.
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Thanks for sharing this info about the Ornish intensive cardiac rehab, Jill. The Pritikin program is similar (providing 72 sessions instead of the usual 36). These programs sound like every heart patient’s ideal rehab format! Medicare funding would cover about 15% of US citizens qualifying for medicare.
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