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Marco AP. Bulletin 2015;97: 335–337

The author, a Professor of Anesthesiology from Wright State University, begins his essay by giving an overview of game theory. How should a committed carnivore 'game' when they dine with a vegan? If the meat eater is adamant on eating at a restaurant that serves only, for example 1.2kg Tomahawk steaks, 'instead of insisting on the big win', the outcome for both carnivore and vegan is optimised 'cooperative behaviour' by choosing an eating house that serves meat as well as black-bean burgers.

This paper then describes four positions in game theory and how they can be applied to health care. The first is the 'prisoner's dilemma'; in this described version, two prisoners are arrested for a petty felony, but are suspected of a more serious crime. They are kept in solitary confinement. Although the police have evidence only for the minor offense, if each prisoner keeps silent, they face only a short jail sentence. Instead they 'game'/'defect' and testify against the other. In return they expect a lighter sentence. But as each attests against the other, both end up with a harsher sentence. When applied to a health care setting, if a surgeon wants to add a patient to their list, the surgeon may 'defect' by misleading the team about the time needed to complete the operation. As a consequence the team may then disengage. On the other hand if the operating team 'defects', this may result in disciplinary action against them. If both surgeon and operating team 'defect', the outcomes for all, and most importantly the patient, are detrimental.

The second example is the 'tragedy of the commons'. Just as there are short-term gains for a herder when sheep are added to their flock, then there are also gains for a health care team when they insist on additional equipment or more staff. But in the long term, the quality of the pastures become depleted. Health care resources are finite; the unit is closed or strategic development for health care is compromised.

The third position explores 'cheating'; in small groups, 'reputation balances the urge to cheat, but as players become more numerous, reputation is less important and the prospective gain from cheating becomes larger'. This has parallels with the Mid Staffordshire NHS Foundation Trust debacle.

Asymmetrical information and how this plays into game theory, is particularly relevant for a dentist as some of their activities are 'discretionary surgical procedures', such as dental cosmesis. As an example, 'Top-notch surgeons might be willing to perform a procedure for $12,000, whereas a so-so surgeon would be willing to take $6,000.' But if the patient ('consumer') cannot discern between the outcome for a high- or low-quality surgeon, they will pay the lower price. As a consequence, fewer top-quality surgeons will carry out the procedure and in the long term, fewer total providers. Asymmetrical information squeezes out high quality surgery and when considering products, those that are superior.