The Paradox of Skill
Orthopedic Business Review
written by Will Kurtz, M.D.
November 14, 2020
The Paradox of Skill
Over time, the absolute skill level of participants increases, and the difference in skill level between participants narrows. In the past, skill was the largest determinant of outcomes. Now, luck plays a greater role in outcomes which makes it harder for one participant to dominate their field.
The Success Equation: Untangling Skill and Luck by Michael Mauboussin
Sports examples
In 1941, two things happened in baseball that will never be repeated. Ted William’s batted .406, and Joe Dimaggio hit in 56 consecutive games. There are many theories as to why the .406 and 56 consecutive games will never be repeated. Maybe the utilization of relief pitchers means today’s batters are hitting against better pitchers. Maybe games are played under the lights which makes it harder for batters to see the ball. Maybe, it is just statistics. If you compare the bell shaped curve of batting averages in 1941 to the bell shaped curve of today’s batting average, you would realize that today’s bell shape curve is much narrower than 80 years ago. Ted William’s .406 batting average was four standard deviations away from the mean in 1941. If a batter is four standard deviations from the mean today, they are batting .380 and not .406. For batters and pitchers, absolute skill has never been higher while the difference in skill between players has never been narrower. In other words, 80 years ago, skill was a larger detriment of differential outcomes and now luck plays a larger role. Since luck-based scenarios tends to “revert to the mean” faster than skill based scenarios, these exceptional accomplishments are unlikely to occur again. Money Ball is in part a manifestation of this narrowing of the skills bell curve. Many baseballs teams no longer overpay for that one superstar and take a more statistical approach to building a team.
The Success Equation: Untangling Skill and Luck by Michael Mauboussin
This narrowing of relative outcomes has occurred in most skilled sport. The gold medal winning marathon times depicted by the white line in this graph have decreased through the years. The gold medal marathon winner in 2012 ran 23 minutes faster than gold medal winner in 1932, but more impressive is the decrease in the differential between runners. The blue line represents the difference in time between the first place finisher and the 20th place finisher over the last 80 years. In 1932, this difference was 39 minutes and in 2012 it was 5 minutes.
Golf has seen the overall increase in skill level through the years, but the difference in skill level between the top players has become razor thin. Because the difference in skill level between players is smaller, luck plays a larger role than before. Today, more players win a smaller number of tournaments throughout their career because the competition is so fierce. Fewer players dominate golf for long periods of time, so players don’t accumulate as many life time wins as shown below.
Of the top ten golfers with the most PGA Major wins, Tiger Woods is the only player in the past 20 years with more than 5 Major wins.
Of the top 25 golfers of all time by tournament wins, Tiger Woods (82 wins), Phil Mickelson (44 wins) and Vijay Singh (34 wins) are the only players in the past 20 years with more than 24 tournament wins. Tiger is currently tied for first in all time tournament wins, so expect lots of fanfare the next time he is on the leader board.
A similar phenomenon has occurred in all skilled activities including swimming, rowing, running, and investment banking. The participants’ skill has improved, and the difference between the absolute best and the really great participants is razor thin. In fact, these sports are so competitive and the outcomes are so close that the judges now have to rely on more sophisticated timing equipment to determine who really won. On any given Sunday, anyone may win. If the game were replayed the following week, the outcome may be different because luck now plays a larger role than before. One exception to this rule seems to be team sports like college football where past victories help in the recruitment of future talented players creating an advantageous feedback loop that keeps the top teams at the top year over year.
The Paradox of Surgical Skill:
Surgical skills has also drastically improved over the last 50 years. Twenty years ago, surgeons could differentiate themselves from the other surgeons in their city by simply stating that they were fellowship trained and sub-specialized. Today, most surgeons in metropolitan areas are fellowship trained and sub-specialized. The difference in surgical skills of the best surgeon and 5th best surgeon in a city is less today than it was 30 years ago. If two fellowship trained, sub-specialized surgeons are operating at the same hospital, with the same implant and same robot, then they will likely have the same average outcomes. As the bell curve on surgical skill narrows through sub-specialization, patients can expect a similar outcome from any of the top 5 sub-specialized surgeons in any city. Other variables like the patients’ risk factors, patients’ engagement in the post operative treatment, and patients’ support network become a larger determinant of patients’ outcomes.
Syndrome from Disney’s The Incredibles
Jason Lee, the voice of Syndrome in Disney’s The Incredibles, summed up this phenomenon when he said “and when everyone is super, no one will be.” The orthopedic equivalent is when every surgeon differentiates themselves as being a sub-specialist, then no one will be differentiated. Since surgeons can no longer claim to be the best just because they are fellowship trained, they attempt to differentiate themselves with other means.
The Paradox of implant design
Orthopedic implant design has dramatically improved over the past 50 years as well. Patient function, implant sizing, and implant longevity have increased for all implants. The difference in the quality of implants today is hardly noticeable. When one company has a successful implant, the other companies are typically “fast followers” with their own version of that technology (i.e. cross linked poly, reverse shoulders, robotics, etc.). In short, both surgeons and implant companies have a harder time differentiating or branding themselves on quality and expertise because the difference in quality and expertise is often indistinguishable between surgeons and implants.
If branding on a surgeon’s or implant company’s expertise is less effective and less differential than in the past, then how can someone differentiate themselves among their peers? In other words, how should you market a surgeon or surgical procedure in today’s world?
Brand through Stories
When a former patient refers their friends to their surgeon because he/she is the best surgeon in town, their friends may not understand “why” that surgeon is the best in town. In contrast, when a former patient refers their friends to their minimally invasive surgeon, their friends will rationalize that the surgeon is the best because he/she is a minimally invasive surgeon. The “minimally invasive” term is a place holder; you could easily insert “robotic” , “DAA”, “custom implant” or any other marketable term into that sentence. The most influential way for a surgeon (or implant company) to differentiate themselves from their peers requires former patients telling a story that explains the “why”.
The “why” needs to be something tangible. The best examples of the “why” should be noticeable and understandable to the patient. Many successful marketing concepts may or may not have clinical benefits but resonate with patients and are therefore successful. Patients often believe that making an incision in a different location or smaller (i.e. two incision hips, direct anterior, minimally invasive incision, Jiffy knee, etc.) might improve their outcomes. Since most patients can not conceptualize what occurs underneath the skin during a surgery, a successful differentiator is rarely a surgical technique. Surgeons might use a piece of technology that differentiates them from other surgeons (i.e. gender specific knee, robot, custom implants, etc.). However if your crazy uncle or kooky aunt can’t clearly explain the technology in one sentence, then the technology is not a differentiator. For instance, three or four companies make software and hardware that helps surgeons measure the leg length during hip replacements on intra-operative radiographs, but patients are not bragging to their friends about how their surgeon used these products because patients can not easily explain what the technology does. Surgical navigation never really took off with patients until companies called it “robotics” even though surgeons know the real value added by the robot is the positioning of the implants which has always been possible with navigation. Patients can’t explain navigation but can conceptualize what a robot is and does and therefore tell their friends how amazing their surgeon is because he/she uses a robot.
Successful implant marketing in the future should consider how the technology will be understood from the patients’ perspective and how willing a patient will be to incorporate that technology into their discussion about their surgeon’s expertise.
Joint Registries and Review Sites
Surgeons and implant companies try to differentiate themselves through independent validation. Australia and United Kingdom national joint replacement registries independently validate implant survival rates. Implant companies use that information to promote their implants, but implant survival rates and joint registry data are a relatively crude tool to prove or disprove a technology’s superiority.
Many HCPs invest resources in promoting their reputation through review sites like HealthGrades and Google. These sites are also a relatively crude tool or proxy for surgical skill. More sophisticated and accurate tools to judge the quality of a surgeon or implant will enter the market as data becomes less siloed and more aggregated.
Conclusion
Surgeons are still an important determinant of outcomes, but as information about best practices is more freely shared and technology improves, the importance of the person holding the knife will decrease. The knowledge about successful surgical techniques will move from just belonging to the most skilled surgeons to being incorporated into robotic and 3D planning systems and available to all surgeons. As a result, over the next 50 years, surgeons may become less important and more commoditized. Since the average surgeons practices for 30 - 35 years, this trend will not likely impact current surgeons, but might influence how surgeons and implant companies choose to market their services in the years to come.
Most marketing campaigns of surgeons, implants and surgical techniques predominately consider the surgeon’s perspective. The most successful orthopedic marketing campaigns (gender specific knee, robotics) have always considered the patient’s perspective first.
As more data flows into joint replacement registries and review sites, these independent reviewers will become more important in determining quality among surgeons and implants.
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