March 2012

Out on a limb: Game theory

Jordana Bieze Foster, Editor

There are plenty of reasons you might be thinking about seeing Moneyball. Maybe you’re wondering how anyone could have turned that book into a movie. Maybe you’re curious about how Angelina’s better half and the kid from Superbad ended up with Oscar nominations. Maybe you just need to forget about the snow on your lawn and try to get in the mood for Opening Day.

You probably aren’t imagining that seeing Moneyball will make you ponder shifting paradigms in lower extremity healthcare. But it just might.

A major theme of the movie is that a scientific approach to analyzing baseball players can make a team more successful than the time-honored tradition of assessing a player based on a scout’s observations and his professional expertise. The philosophical chasm between the stats geeks and the old guard is illustrated by the interactions between forward-thinking Oakland A’s general manager Billy Beane and the crusty collection of scouts who seem less interested in a player’s on-base percentage than in his physique. Beane makes a crack about how they’re not looking for Fabio, at which one grizzled scout explains to another that Fabio is a shortstop in Seattle.

It’s funny stuff, even if it’s almost certainly an exaggeration of just how out of touch conventional baseball scouts really are. But those scenes also effectively make the point that quantifying a problem can make it easier to solve than looking at it subjectively, even if that subjective assessment is based on years of experience.

That’s exactly the point that researcher Daan Bregman, PhD, makes in this month’s cover story (see “Finding a formula for the optimal AFO”). Using complex mathematical and anatomical modeling, Bregman and colleagues have calculated an optimal ankle foot orthosis stiffness corresponding to minimal energy costs for patients with drop foot. The idea is that science can take the guesswork out of determining which AFO stiffness will result in the most successful patient outcomes—guesswork that some say has no place in modern evidence-based medicine.

But Bregman acknowledges that his findings have limitations. The model’s assumptions fail to account for a number of variables, such as variations in neutral ankle angle and the mechanical properties of the AFO at the forefoot. And models, by definition, can’t account for unique characteristics of individual patients.

Even practitioners who live by statistics and evidence-based medicine know that the numbers can only take you so far. At some point, observations and professional expertise really do come into play.

Most scouts would say the same is true in baseball.

“Baseball isn’t just numbers, it’s not science,” scouting director Grady Fuson argues in the movie. “If it was then anybody could do what we’re doing, but they can’t because they don’t know what we know. They don’t have our experience and they don’t have our intuition.”

Sound familiar?

As with so many things, the real answer is a compromise between the two camps. In reality, most professional baseball teams are working to integrate statistical analysis with scouts’ expertise. This doesn’t happen in Moneyball, because the movie has a different creative agenda.

But it is happening in baseball. And it’s happening in lower extremity healthcare.

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