The orthopedist’s parable

Doug Samuelson

Mike, the OR/MS analyst, limped into the doctor’s exam room, put down his crutches and greeted the orthopedist – a doctor who specializes in problems of bones and muscular systems – with a pained but game smile. He handed the doctor the big brown envelope containing the X-rays of his injured foot. After some routine polite conversation, the doctor put the X-rays up on a lighted screen – and looked surprised. “I’ve seen this picture before,” he exclaimed. “Where did you get this done?”

Mike explained, “This injury happened last Saturday evening. Sunday I went to the emergency room of the hospital a few miles from my house that has a good reputation for handling traumatic injuries. They took the X-rays, diagnosed the partial fracture of that bone in my foot, put a compression bandage on it, as you see, and told me to find a good bone doctor. You’re highly recommended and near my office, so here I am.”

“Ah, that explains it. Your office is 20 miles from that hospital, so they probably thought you wouldn’t come to me,” the doctor said. “We usually don’t do conferences about a patient one of us is likely to treat. But we had an interesting argument about this injury.

“We have two options,” the doctor told him. “We can put a soft cast on this and have you gradually put more weight on it, as you can tolerate, and it will probably heal well. That little toe may end up curling under the others a bit, but you’ll end up with full use of that foot in about six weeks, and full recovery – full strength, no pain — in about a year or two, depending on how you rehab it. The other option is to put a metal pin in that bone to help straighten the bone. It will hurt more and for longer, there’s a small chance of some complications from the pin being there, and your functioning will end up about the same, but you won’t have the toe curling under. It will look better on the X-rays. Which do you think you’d choose?”

“That sounds obvious to me,” Mike replied. “Why would I want a pin in there if it doesn’t make my outcome better?” 

“That’s what I think, too,” the doctor affirmed, “but you’d be amazed how many patients insist that they want that ‘perfect’ X-ray. A few of us have been sued over this sort of thing. So we have to ask.”

“Amazing,” Mike marveled. “But, come to think of it, this helps to explain a problem I had at work a couple of years ago!

“I worked in a group of decision analysts,” he recounted, “that was part of a larger group supporting a big military activity. I can’t tell you much specifically about what we did, but your first guess would probably be pretty close. Much of the larger group’s function was what’s called geospatial analysis. That means making maps of where events have happened, where we think adversaries are, where we might go, where important resources are. Our smaller group is supposed to do the more high-powered math modeling tasks. But I had this idea of using simple models, combined with some geospatial methods, to help with planning some actions. The people I was helping liked it, the downrange people they were helping liked it, but my boss and his first-level client hated it! My boss told me, ‘We’re not paying someone with your advanced degree in O.R. to help put dots on maps. Lots of people can do that. You need to do something more complicated to demonstrate why they need your skills.’

“I pointed out,” Mike went on, “that the map-generating might not be that high-powered, but figuring out what to map required some analysis, and the combination of the two approaches was innovative. He wasn’t impressed. I didn’t understand why, but now maybe I do: They were more interested in looking good, by some criteria somebody got excited about, than in actually solving the client’s problems! Maybe the company I worked for was thinking that impressing our clients with how clever we were was most important. Sounds like the same sort of situation, doesn’t it?”

“It does,” the doctor agreed. “Or, to take another example, did you ever see the movie, ‘White Men Can’t Jump?’ ”

“Yeah,” Mike recalled, “a long time ago.”

“Well,” the doctor continued, “there’s this scene when the white guy is telling the black guy, ‘Your problem is that you always have to look cool. That’s the most important thing. For someone like me, winning is most important, and I’m willing to look uncool to do it. And that’s why guys like me keep beating guys like you.’ Remember that?”

Mike shrugged. “I’m not sure.”

“Well, you see the point, though, right?” the doctor asked. “Concentrate on always looking good, by some definition – maybe using the techniques some committee decided were the best grounded in some theory, or the method that looks most impressive because it’s the hardest, or maybe always following some process somebody decided was the best one, without much evidence – and you can mess up your chances of getting good results. It may sound strange at first, but it’s true more often than you think; you sometimes have to choose between looking good to the uninformed and solving the problem!”

Doug Samuelson ( is president and chief scientist of InfoLogix, Inc., in Annandale, Va., and senior operations research analyst with Group W, in Triangle, Va.