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The Smartest Person is a popular Dutch television quiz show in which three contestants receive a few seconds to answer trivia questions. In one of the rounds, to answer the question, contestants must hit certain key words, for example, ‘Apartheid’, ‘Prison’, ‘Nobel Peace Prize’ and ‘South Africa’ for the question ‘What do you know about Nelson Mandela?’ Contestants who mention one of these key words, regardless of context, hear a rewarding ‘ting!’ and receive 20 extra seconds. The most efficient strategy to win is to mention the four key words without a linking sentence; answering with a complete and cogent sentence costs precious seconds. In fact, contestants can win even when they get the context wrong, for example: ‘Nelson Mandela is an Italian actor starring in a film about the Apartheid (ting!). He recently spent a night in Prison (ting!) after he egged the house of a Nobel Peace Prize winner (ting!) from Zimbabwe… Namibia… well, somewhere in South Africa (ting!)’.
The show is advertised as a ‘knowledge quiz with a wink’. The show’s ‘smartest person’ is not the most knowledgeable, but the one who knows how best to play the game.
Similar challenges affect performance measurement in healthcare. For example, consider the proportion of patients with 10-year cardiovascular risk >7.5% prescribed statins, as a measure of good preventive care. Or the proportion of patients with type 2 diabetes with haemoglobin A1c (HbA1c) levels <7.5%, as a measure of good diabetes care. Or the proportion of patients getting low-dose CT (LDCT) to screen for lung cancer who participated in shared decision making, as a measure of patient-centred care. These measures are set up to improve the quality of care for patients, but if you know how best to play this game, you would be rewarded for prescribing statins (ting!) to patients who …
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