By Michael E. Raynor
In the wake of one helluva tumble skiing in Lake Tahoe that left me with a ruptured ACL (knee ligament) and a long road back to my former semi-athletic self, I continue to try to make lemonade by looking for connections between my rehabilitation and the challenges that face managers.
Safely back at home in Mississauga, a city of about 800,000, about 20 km. west of Toronto, I began to think seriously about the road to recovery.
As you will have inferred from the location of my hometown, I live in Ontario. The implication of that on my healthcare options compared to what one might experience in the United States are worth mentioning. Canada, and Ontario in particular, has chosen to focus on relatively equitable access and quality through a much more socialized model than in the United States. As a consequence, there can often be material wait times for some procedures, especially non-critical ones. And repairing an ACL rupture is decidedly non-critical; in fact, for many people, especially middle-aged men like me (there, I said it!) the injury is not repaired at all.
I began by feeding myself into the system with a visit to my family doctor. She saw me the day I called to make the appointment, and confirmed the diagnosis made by the clinic in Tahoe, where the ACL was blown. She ordered the MRI that would give the orthopedic surgeon the detail needed to assess the required surgical repair, and asked to which surgeon I wanted to be referred.
A common misconception about Canadian health-care in general is that you can’t choose your doctor. I was free to make my own inquiries and request a referral to any surgeon I liked (provided, of course, they were in Ontario—but any American will appreciate the concept of “in network”). I had already been given a number of very promising leads by some of my friends “in the business.” Thanks to consulting work in the medical-devices sector, I got the name of a surgeon who tested out the latest devices and was renowned for repairing complex, multi-ligament injuries—my ACL would be a cake-walk. And thanks to a friend who had been the doctor for the Canadian ski team, I got the names of a network of leading sports surgeons who had seen and repaired much more severe injuries on people who then returned to far more demanding pursuits. Online communities with patient ratings provided confirmation, when I needed it, that these folks were top-notch and I’d be in good hands (literally). I made what I felt was the best choice I could, my doctor submitted the necessary referrals, and I felt I was on my way.
Then came two rather unpleasant doses of reality. It would be at least two weeks before the hospital would simply provide me with a date for the MRI scan; it would likely be four to six weeks longer until the scan itself. Worse, no surgeon would see me for a consult until I had an MRI, and the surgeon I had chosen had up to a two-month wait time for a consult and a further six- to eight-month wait for the surgery itself. Add it all up, and I could be looking at up to a year before I went under the knife, followed by another eight to twelve months of post-surgery rehab. I was suddenly looking at almost two years before I was back to normal.
I’m not exaggerating when I say that almost put me into sub-clinical depression.
Deciding to do what I could to move things along, I asked a buddy of mine to drive me to an MRI clinic in Buffalo that my wife had found online, where, with a day’s notice and for $450, I could leave that afternoon with a CD in my hand and a radiologist’s report the next business day. That moved things up a little, since now I could get in line for a consult and ultimately surgery, but it was cold comfort to think that my year-long wait was now only ten-and-a-half months.
I shared my sense of despair with the physical therapist who was helping me deal with the immediate aftermath of the acute trauma of the fall. He’s part of a sports-medicine clinic that has a general practitioner on staff, and the good doctor happened to be in the clinic that day. That physician referred me to a surgeon that hadn’t come up in my searches, one who specialized in sports injuries.
As it turned out, all this happened on the day of the Canada-Sweden gold-medal hockey game at the Sochi Olympics, which meant that the surgeon could see me that afternoon, as most of his patients had canceled or simply not shown up so that they could root for the boys in red-and-white.
Since I was more concerned about setting my knee to right than evincing my patriotism, I jumped at the chance. Ninety minutes later, my Buffalo MRI and I were on the examining table.
It gets better. This surgeon had an open surgical slot nine days later. I was hardly five weeks post-injury—barely enough time for the major swelling to abate to the point that surgery was recommended. What had started out looking like a horror story defined by soul-crushing waiting had turned into a level of responsiveness that was essentially world class.
On the drive home from the surgeon’s office, cognitive dissonance began to set in. The surgeon I had originally chosen was affiliated with a prestigious teaching hospital, came highly recommended by my professional colleagues, and was well-reviewed by patients. Even though I was deeply dismayed by the pending wait, I had—almost subconsciously—equated that wait with superior quality. Without realizing it, I had begun to rationalize the delay as the price of a good outcome: The only thing worse than waiting would be a bad repair.
If this new surgeon was any good, how could it be that I could get an assessment right away—gold-medal game or not—and then get a surgical date within the fortnight? Sure, I had asked him how many knees he did a year (over two-hundred) and what types (almost exclusively sports injuries). Sure, I had looked him up, and his ratings were even higher than the original surgeon I had settled on. But I just couldn’t shake the notion that I was about to make a bad choice.
Thankfully, I realized that I had become the victim of at least two well-known cognitive biases. First, dissonance reduction had led me to turn the wait times associated with my initial choice from a bug into a feature. But that wait time was only in part a function of the first surgeon’s excellence. Just as his reputation impressed me and the associated wait time became an indicator of quality, it was surely impressive to others. This was a market where consumers lack the knowledge necessary to assess quality prior to consumption, and so his resulting backlog was surely also attributable in part to the backlog itself. After all, just as higher-priced wine can be in higher demand because it is higher priced rather than because of its superior taste, a surgeon you have to wait for can be in higher demand simply because you have to wait for him and not because of superior skills or systematically better outcomes.
Second, anchoring had led me to put the first surgeon on a bit of a pedestal: Changing my mind had come to demand a higher level of evidence than what would have been required to choose between the two surgeons in the first place. It was no longer a “fair fight” based on the available data. Instead, the second surgeon had now to displace the first one, and my preference was born not of a dispassionate analysis but rather the essentially random order in which I had considered the relative merits of each.
Making a conscious effort to acknowledge these biases allowed me to see alternative explanations. Ontario’s health care system isn’t perfect; find me one that is, and I’ll move there. It is subject to all manner of inefficiencies in how its internal market functions. I ended up finding a reputable and accomplished surgeon with availability because I talked to everyone I knew about my situation and kept looking even after I had nominally reached a conclusion. I know from subsequent conversations with others who have had ACL reconstructions that if you simply take a number and wait your turn you might get in right away and you might wait a long time. But if you’re willing to advocate for yourself and decide you won’t take “later” for an answer, it turns out that you can do significantly better, at least some of the time. In other words, the second surgeon’s availability wasn’t an indictment of his skills; it was an artifact of market inefficiency.
Letting go of the anchoring bias came next, largely through the passage of a day or two and the opportunity to reflect more objectively on what I learned about the second surgeon’s practice and the comments of his patients. In truth, there really wasn’t much to choose between the two—at least, not insofar as I could tell from the available data. I came to believe that in terms of relevant skills and experience, they were on the same level, especially with respect to my injury, which was about as garden-variety an ACL repair as you’re likely to find.
Since it’s my knee, I took the decision of which surgeon to use pretty seriously. I’ll guess that you take many of the management decisions you face pretty seriously, too. Coming to the right conclusion is tough enough under the most favorable conditions. How much more difficult does it become—and how much less likely are we to make the right decisions—when we are burdened by all manner of cognitive biases?
A ship at anchor is being held in place via an obvious and well understood mechanism. When it’s time to move on, the captain merely yells “anchors aweigh,” by which she means to have the anchor pulled up so the ship can set sail. Unfortunately, our mental anchors are not nearly so obvious, especially to those being immobilized or at least constrained by them. But we can nevertheless come to grips with our mental anchors, and with some effort, pull them up and move forward.
The surgery is behind me now, and so far, so good. I’ll never know if that first surgeon would have done a better job and if I should have waited. But I’m OK with that. I’ve had a salutary experience both from the perspective of improved knee function and psychological well-being: I’ll spend this summer rehabilitating my knee to full strength, not killing time until surgery in the late fall. And I’ve learned a valuable lesson: that we can make better decisions if we take into account the biases that would otherwise make our choices for us.
By the way, the prognosis is that I’ll be back to full speed by the fall, in plenty of time for ski season. (And if you think I’m missing the larger lesson of this injury, you just might be right.)