Ben Hoban is a GP in Exeter.
If there is one thing guaranteed to take the joy out of playing games, it is surely game theory, which analyses dispassionately the decisions we make while having fun. Perhaps that’s being a little hard on the theorists: after all, we play games not just for fun, but to model the world around us and familiarise ourselves with its rules, roles, and relationships.1 Ultimately, we can also learn a lot from games, just as the study of probability grew out of the monetisation of games of chance.2
The Prisoner’s Dilemma is a game which in all fairness, no one plays for fun, and which hopefully none of us will ever need to play in earnest. It has two criminals in the ‘nick‘ being interrogated separately in the hope that one will give the other up and hand the law a nice easy conviction. Both prisoners must decide whether to talk or keep their mouth shut, but in doing this, they must also take into account what the other is likely to do. If one blabs while the other keeps shtum, the one who talks is let off with a slap on the wrist, while their buddy goes away for a very long time. If they both keep quiet, their sentences will be limited, while if they both rat each other out, they’ll be locked up for longer, even if it’s not as long as it could be. Honour among thieves and all that, but in practice, both prisoners sing like canaries and get a decent stretch behind bars, even though they could have done better by looking out for each other and taking the chance that their partner in crime was doing the same. Game theory explains why this happens in terms of the choices available to them: whatever their partner does, both prisoners can always do better by squealing; mutual betrayal is the most rational move. Within game theory, this position is referred to as a Nash equilibrium, a hole in which the players become trapped by their need for certainty.3
In any medical consultation, one of the most important decisions the patient and their doctor must make is how much uncertainty to accept.
In any medical consultation, one of the most important decisions the patient and their doctor must make is how much uncertainty to accept. Patients generally understand that there aren’t any guarantees in healthcare, although they want to know that they’ve been taken seriously and given reasonable advice; on their side, most doctors want to help, even though they’re under pressure to keep things moving along as smoothly as possible. The choice they both face is not whether to betray each other, but whether to play a game that is concrete, predicated ‘bish-bash-bosh’ on tests, diagnoses and treatment, or one that is more nuanced, leaning into the story and trying to make sense of things, one step at a time.
Both players recognise that they have something to lose. The patient risks their health if something dangerous is missed, but also their time if they have to attend multiple appointments for investigations and specialist opinions. The doctor risks their time as well, and ultimately their own health and effectiveness, if their surgeries become filled with in-depth discussions and reviews on a regular basis. As a result, both end up being pushed towards a Nash equilibrium of risk-averse, transactional consultations, in which neither side benefits from playing a nuanced game without first being able to guarantee that the other is doing the same. Concrete game-play, a mutual leaning back and folding of the arms, is the most rational move.
The more rounds they play, however, the less sustainable this strategy becomes, because the actions that seemed expedient in earlier consultations give rise to unanticipated consequences later on: unnecessary attendances caused by heightened expectations; incidental findings of investigations that still need to be followed up; medications that cause side-effects; and further action requested by specialists following a referral. Sometimes it helps, but often, both doctor and patient simply feel as if they’re drowning in activity, which both sides come to resent the other for having caused, and neither feels able to change.4
In a single round of the prisoner’s dilemma, the best the players can do is compete against each other to minimise the risk to themselves. Playing repeatedly, however, changes this dynamic and establishes a new Nash equilibrium in which it becomes feasible to cooperate in order to optimise the outcome of the game instead. Knowing that they are going to keep playing together gives the prisoners a shared interest in the future, and every round in which their partner refuses to grass them up gives them greater confidence to do the same in the next.
…often, both doctor and patient simply feel as if they’re drowning in activity, which both sides come to resent the other for having caused, and neither feels able to change.
This change from a single-round to a multi-round game is also crucial in healthcare. Even straightforward clinical problems involve a degree of uncertainty, which a concrete strategy adopted in a single consultation can to some extent contain, but with which it can never engage more meaningfully.5 As the level of complexity rises, so do the patient’s and the doctor’s own shared interest in a manageable future, and so therefore does the importance of a more nuanced strategy applied consistently over repeated consultations. General practice, where uncertainty tends to be held, is often about the long game.
While it is true that we play games to have fun and to develop the skills that we apply more seriously in other parts of our lives, we might also observe that playing games together builds relationships, and that it is easier to play cooperatively with people we trust.6 It is becoming increasingly clear that effective healthcare depends at least as much on these more nuanced factors as on concrete, technical ones, and that the factors that promote them, such as personal continuity of care and face-to-face consultations, are therefore not merely desirable, but essential.7 Improving general practice is not simply a matter of doing more or creating more efficient structures and processes; on the contrary, it is often precisely these efforts that fragment care and trap us within a dysfunctional single-round Nash equilibrium.8 If we want to do better, we must adopt a different strategy in pursuit of a different equilibrium; we need to play a better game.
References
1. Kelly Clancy, Playing With Reality: How Games Shape Our World, Allen Lane, 2024
2. Leonard Mlodinow, The Drunkard’s Walk: How Randomness Rules Our Lives, Allen Lane, 2008
3. Moshe Hoffman & Erez Yoeli, Hidden Games: The Surprising Power of Game Theory to Explain Irrational Human Behaviour, Basic Books UK, 2022
4. Ian Beardsell, “What if”—Two words that are breaking emergency medicine BMJ 2025; 390 doi.org/10.1136/bmj.r2051
5. Paul K J Han, Uncertainty in Medicine: A Framework For Tolerance, Oxford University Press, 2021
6. Richard Baker, Louis S Levene, Emilie Couchman, Christopher Newby and George K Freeman, Factors influencing confidence and trust in health professionals: a cross-sectional study of English general practices, British Journal of General Practice 10 February 2026 doi.org/10.3399/BJGP.2025.0154
7. Mohammed Mustafa, Hassan Awan, Awadalla Youssef and Carolyn A Chew-Graham, Cultivating hope: reframing the ‘heart-sink’ consultation, British Journal of General Practice 2026; 76 (763): 54-55. doi.org/10.3399/BJGP.2025.0728
8. Jennifer Voorhees, Simon Bailey, Heather Waterman and Kath Checkland, A paradox of problems in accessing general practice: a qualitative participatory case study, British Journal of General Practice 2024; 74 (739): e104-e112. doi.org/10.3399/BJGP.2023.0276
Featured Photo by Harry Shelton on Unsplash
