The professional poker player Annie Duke, in various articles and podcasts, answers the question about whether life is more similar to chess or poker. She makes the point that in poker there is a large element of chance. No matter how good a player you are, some of the cards remain face down, and what is hidden there can make all the difference. In chess there are some uncertainties, but in general, if you make better moves than your opponent you will win. Poker has no such assurance; you can play well and still lose. However, playing well over time will shift your probabilities and make you more likely to win. So if you want to improve your poker skills, you can’t just look at outcomes, you have to look at your process. Life, she says, is much more like poker than chess – there are unpredictable components and even the best strategy can end up with negative outcomes.
With this framework in mind, we can ask the same thing about healthcare – is it more like poker or chess?
We try to do the best job, but even if every doctor followed internationally accepted guidelines, bad outcomes would occur. No treatment is 100% effective, no test is 100% accurate. It doesn’t take much analysis to realize that – just as in poker – the desirability of the outcome does not always reflect the quality of the process. And, just as in poker, if we really want to know how we’re doing, we can’t only analyze the losing hands. But do we follow this advice in healthcare?
Unfortunately, we do the opposite. We look closely at bad outcomes; the worse the outcome, the harder we look and the more we want to find blame. Even if we appropriately focus on the process and not individual blame, we still tend to examine only those processes leading to the bad outcome. We have “morbidity and mortality” meetings, not “everything went as expected” meetings. If a doctor hasn’t had any adverse outcomes, quality programs usually overlook them; near misses and sloppy work are accepted until something bad happens. In other words, we act as if there are few uncertainties and outcomes can be controlled.
We not only make these assumptions in reviewing individuals, we do the same thing at higher levels of healthcare delivery. If the practice of a single doctor involves a lot of chance, it’s even more true when you multiply those differences by the size of a department, hospital, or system. And yet, we set operational, financial, and quality outcome goals for managers and expect them to meet them. We punish the ones who don’t make their numbers and promote those that do. We forget that some of the cards were face down, and out of their control.
Annie Duke teaches these lessons about poker and life:
- Look at the process, not the outcomes
- Don’t be too hard on a bad outcome – there was probably an element of bad luck involved
- Don’t be too proud about a good outcome – respect the role that luck plays in everything
They apply just as well to what we do in healthcare.
What happens if we ignore these lessons? What if instead of rewarding effort, consistency, and dedication, we blame the individual for outcomes that depend heavily on chance?
This creates uncertainly in the workplace, and people don’t like uncertainty. They’ll do whatever it takes to regain a sense of control. We might call it “gaming the system,” or even “cheating”. They might see it as doing what they need to to succeed in their jobs. It’s in these settings that we see surgeons avoiding high risk patients, nurses hiding their errors, and managers neglecting to document failures rather than risk punishment. Their numbers look good, but everyone knows it’s not real.
Of course, healthcare is more serious than any game, but we can learn a lot by using games as models. We shouldn’t pretend we’re playing chess and focus only on better thinking. We need the mindset of a poker player, learning to understand, embrace, and quantify the unknown. Only then can we create a winning strategy.