Wednesday, December 16, 2009

The renowned neurosurgeon vs. Don Cherry

Dr. Charles Tator is a Toronto neurosurgeon who has treated many young people for concussions and spinal injuries. He's not just a doctor: he's an active medical research scientist with an impressive resume. He's also the founder of "Think First," a program that attempts to help prevent of concussions and spinal injuries by promoting the use of safe practices and proper equipment.

On Saturday, at a conference in Regina, Dr. Tator argued that hockey is too aggressive. He said that players are taking too many hits to the head, and that concussions are more frequent than they should be. He said NHL players used to have "respect for their own safety and respect for the safety of their opponents," but not any more.

That probably wouldn't have made the news, except that Tator went on to blame Don Cherry for contributing to the problem. Cherry, a plain-spoken (and often controversial) commentator on "Hockey Night In Canada," advocates an agressive style of hockey, and has created a series of "Rock 'Em Sock 'Em" videos that prominently feature NHL fights and spectacular checks.

"I think [Cherry] is a negative influence because he promotes aggressive hockey," Tator said.

I'm on Don Cherry's side. I think Tator is out of line.

The reason is: this is not a medical question. The general effects of concussions and spinal injuries are not expert or specialized knowledge: we all understand what it means to have a concussion, or to be paralyzed. We read about these kinds of injuries in the sports pages all the time, about Tim Tebow, or Brett and Eric Lindros, or Kevin Everett, or any number of other players. We laymen understand that less aggressive play will lead to fewer injuries.

We laymen understand other parts of the issue as well. We know that we could eliminate hockey injuries completely if we eliminated hockey. If that's too extreme, we know we could eliminate a very large proportion of serious injuries by banning bodychecking, where every NHL game is as contact-free as the All-Star game. There are lots of other ways we could reduce injuries, too. We could make the puck a little softer -- that might have prevented Trent McCleary's frightening injury. We could force goalies to wear a Kevlar neck brace (which would have saved Clint Malarchuk from his near-death experience), limiting their mobility but increasing their safety.

That's not a question of medical expertise. It's a question of tradeoffs. It's a question of, how much injury are we willing to put up with while keeping the quality of game where we think it should be? Or, put another way: how much are we willing to lose in the quality of or interest in the game in order to save a certain number of injuries per year?

It would be nice if there were no tradeoff at all, and, indeed, some people might say that banning aggressive play will make the game *better*, not worse. But if that were the case, the NHL would have done it already, and there would be no controversy. There are already rules banning many dangerous practices, rules that have a very strong consensus of approval in and out of the game. In any case, even in the unlikely event that Tator believes that there is absolutely no cost to implementing his view of what should be allowed in the NHL, that's an opinion about hockey, not about medicine.

Which is my argument, in one sentence: the issue is about hockey, not about medicine. Is there any reason to believe that Dr. Tator's opinion about what's good for hockey is more valid than Don Cherry's? Absolutely not. Certainly, Dr. Tator might have expertise on what kind of hits cause what kind of injuries. But in terms of whether the tradeoff is desirable, and what the rules of hockey should be ... well, on that score, there is a strong argument to be made that Tator is biased, much more biased than Cherry.

If you're Dr. Tator, what is your experience with spinal injuries? Pretty direct. You see many, many victims of sports injuries, some of whom are very badly hurt. Every day, you see their despair and their pain, and you identify with them, and try to help them as best you can. Sometimes, there's nothing you can do. You, and the victim, constantly reflect on what could have been. If only the opposition had been a little more careful; if only the game hadn't gotten just a little too chippy in the third period; if only the players had played in a non-contact league. Then, everything would have been fine.

It's easy to understand why victims and doctors are so concerned with averting as many future injuries as possible, and why some of them, like Tator, start organizations to promote education and prevention. Every day they see the costs, intimately and emotionally. We, the fans, do not. We may feel bad for Kevin Everett and Eric Lindros, but we quickly forget and move on. Dr. Tator cannot do so quite as easily.

But what about the benefits? Dr. Tator doesn't see them nearly as much as he sees the costs. There are literally millions of North Americans who play hockey, without incident. There are millions of us who watch hockey, and many of us see aggressive play as one of the fundamental characteristics of what makes the game great. Suppose reducing body contact will save 20 injuries a year, but reduce fan interest by 5%. Do the benefits outweigh the risks? Dr. Tator will have to deal with some of the 20 injuries, but won't be one of the 5% who lose a little bit of interest in the game.

I don't play ice hockey, but I play ball hockey four times a week. Two weeks ago, one of our players got hit in the hand by a stick. His right index finger was broken in three places; he'll be unable to use it for a month. If you're a doctor, an indexfingerologist, and you see three of these broken fingers a day, wouldn't it be easy for you to get the idea that floor hockey is dangerous, and should be banned -- or at least that everyone should have to wear gloves? But we, the participants, just kept playing. We understand there's a risk of getting our finger broken, or worse, and we accept that risk. Floor hockey is fun, and the risk seems quite reasonable compared to the benefits. My life would be a lot less interesting without ball hockey -- it's my main source of recreation and exercise, and a good part of my social life. If the doctor sees only the thousand broken fingers, but not the millions of happy players who get all these benefits, while knowing about the danger and being willing to put up with it, isn't it the doctor who's seeing things the wrong way?

I recall a few years back, there was another chapter in the ongoing debate on whether motorcycle helmets should be compulsory. A doctor wrote something like: "if you don't think helmets should be mandatory, it's because you're not a doctor dealing with the victims every day. You should come to the emergency room and see how mangled these riders' heads are when their cranium hits the pavement. If you saw a few of these, you'd change your mind."

And that, frankly, is a bulls**t argument. You don't need to see the blood and guts to understand that the accident killed the victim, or turned him into a vegetable. You don't need to have a medical degree. You need to carefully weigh the risks and benefits, and come up with an argument. You need to study the issue. If helmets saved one life a year, it wouldn't be worth it: you could take all the money spent on helmets, use it to buy medical tests, and probably save hundreds of lives. On the other hand, if helmets saved a hundred thousand people a year, then, yeah, there's an argument for requiring them. But "blood and guts are disgusting and tragic, therefore helmets should be banned," is not a reasonable argument. It's an argument from a misguided person who thinks the fact that he treats the victims gives him a special moral insight into what risks society should tolerate and what risks it shouldn't.

To his credit, Dr. Tator doesn't make such an argument, but the idea is roughly the same. The argument has to be one of costs vs. benefits, and Dr. Tator's involvement with the victims, no matter how expert, charitable, and concerned, makes him likely to be *more* biased and *less* credibile in analyzing the issue. Of course, he could make an argument, with numbers and logic, to show us that he has used valid analysis to overcome the possibility of bias. If he's done that (and the press didn't report that he did), I'm absolutely willing to look at it.

Now, you could argue that for the NHL, the fans are biased just as much, in the other direction. After all, in ball hockey, the injury is mine. In the NHL, the injury is a stranger's. As a fan, I get all the benefits, the entertainment value of fights and bodychecks, and it's the players who pay the price. If I'm willing to criticize the doctor for overemphasizing the costs, shouldn't I also criticize myself for *underestimating* the cost?

Well, yes and no. From an economic standpoint, we fans *are* bearing the costs: more enthusiastic fans creates more revenue for the league, which means the players get paid more, and therefore compensated for the risks inherent in the kind of hockey we demand. On the other hand, Dr. Tator doesn't have to pay anything for his demand that hockey get less aggressive. He gets all the benefits, in terms of having to give bad news to fewer victims of spinal injuries, but pays a very small portion of the costs, being only one hockey fan out of millions (and perhaps not liking aggressive play in the first place).

But never mind that argument. Suppose we ignore that we fans are compensating the players for their preference, and we assume that we are so insulated from the reality of career-ending injuries that we're too biased against safety, and are demanding more than the "optimal" amount of hockey aggressiveness. Then we're biased one way, and Dr. Tator is biased the other way.

So it seems like, so far, everyone is biased. What we need is an opinion from someone not so far from the fans and the game, and someone not so far from the victims of injury. Someone who is intimately familiar with both the costs and the benefits.

That's Don Cherry, isn't it? Cherry may have strong (and sometimes controversial) political views, he is often politically incorrect, and it seems to me that he's disliked by many who don't like his blunt style and uneducated way of speaking. But in my (admittedly untested) opinion, he is one of the foremost experts on NHL hockey anywhere. He has a huge fan following, and, more importantly, inordinate respect from the players. He is not in favor of recklessness on the ice; he's spoken out many times against aspects of hockey he thinks are dangerous. For years, he's waged a campaign in favor of "no-touch" icing. Every year, he shows an video, quite unpleasant to watch, of injuries incurred by players chasing each other after an iced puck, and rants against the stupidity of the league for not changing the rule. He's been active in injury prevention in youth hockey, promoting the "STOP" program to help prevent hits from behind. I don't follow Cherry as much as some others, but I have never heard him condone dangerous play.

Cherry has been an NHL coach, and he's active in the league's social circles. He's certainly seen many of his player friends and acquaintances felled by injury, unlike most of us fans, which means that, like Dr. Tator, he has first-hand experience with the costs of aggressive play. But he knows the game, and he knows, intimately, the risks involved. He intuitively knows what types of "aggressive" play are risky, and which ones are not. He has opinions, probably as good as anyone's, with credentials as good as anyone's, on what types of aggression are good for the game, and which ones are not.

Intuition is no substitute for a well-formed argument, backed by evidence and logical argument and measurement of costs and benefits and risks. But if you asked me whose gut argument I would want to hear first, it would be Don Cherry's. It doesn't matter if you're one of Canada's foremost experts in spinal injury treatment and prevention, because the question is, what's the proper balance between aggressiveness and risk? That's a question of opinion, not of science.

Dr. Tator may well be right, that hockey is too aggressive and therefore too dangerous. But until he comes up with numbers and arguments and a way to measure the tradeoffs, I am less inclined, not more, to take his word for it simply on account of his profession.



At Wednesday, December 16, 2009 1:16:00 PM, Blogger Brian Burke said...

Great post. Best thing I've read in a while, even though I'm not familiar with the debate or the characters.

I detect some of Thomas Sowell's "Conflict of Visions" in there ( Experts/moral superiority/trade-offs /solutions/etc.) Phil, if you haven't read the book, you'd love it.

At Wednesday, December 16, 2009 1:24:00 PM, Blogger Phil Birnbaum said...

That's funny! I'm reading Sowell's latest book right now, the one on the housing crisis. I own a few of his others that I haven't got to yet.

At Wednesday, December 16, 2009 2:01:00 PM, Blogger edkupfer said...

That's Don Cherry, isn't it? Cherry may have strong (and sometimes controversial) political views, he is often politically incorrect, and it seems to me that he's disliked by many who don't like his blunt style and uneducated way of speaking.

By which you mean his xenophobia/racism.

I don't follow Cherry as much as some others, but I have never heard him condone dangerous play.

Except for fighting, of course.

At Wednesday, December 16, 2009 2:33:00 PM, Blogger Ron Rollins said...

In other news, baseball will outlaw bats and ball due to the danger of line drives, football will outlaw tackling, and the NBA will outlaw groupies.

Lets not get these athletes hurt in the pursuit of the sport.

At Wednesday, December 16, 2009 4:53:00 PM, Anonymous Andy B said...

"The general effects of concussions and spinal injuries are not expert or specialized knowledge: we all understand what it means to have a concussion, or to be paralyzed."

Dr. Yoder's argument can be glossed as "that's not true", and he's correct. Most of us have no actual experience of the cost (in quality of life) of concussions or paralysis; we know what they are intellectually but we drastically underrate them when we consult our own judgment. That seems like elementary psychology to me, I'm sure there's a name for that bias (but "proximity bias" is already taken and I'm out of time to google). Possibly it's also the case that Dr. Yoder himself overrates those costs, but that just means that we should discount his judgment as well as Mr. Cherry's and our own, not that we shouldn't discount Mr. Cherry's and our own.

The "hockey is violent, deal with it" argument is a non-starter. Dr. Yoder's claim is only about the current margin: right now, hockey is more violent than it needs to be in order to be entertaining. That's certainly true for me and I'm confident that it's true for the average fan as well. Possibly the All-Star Game is not violent enough, but again, that misses that point. The question is whether, *at the current margin*, we should be advocating (just advocating, not legislating!) more violent play or less violent play (or exactly the same amount of violent play). On that, Dr. Yoder is right that Mr. Cherry is doing a bad thing.

At Wednesday, December 16, 2009 9:56:00 PM, Blogger Brian Burke said...

Andy B-I'd concede you're probably right about Yoder being too sensitive to the risks and fans being too insensitive. Then why not leave it up to the players and their union?

Don't you think the players are appropriately sensitive to the risks? If the problem is as bad as it's made out, wouldn't they have friends and teammates who suffer? Wouldn't they and their wives lose sleep worrying?

The union could snap its fingers for enhanced safety rules without any cost to them. I doubt owners would demand monetary concessions in return.

My main point is that the real question isn't a medical one, or even a hockey one. It's a question of who gets to make the decision. I say the people at risk get to make it.

At Wednesday, December 16, 2009 11:39:00 PM, Anonymous Eddy Elfenbein said...

Very good post. Your argument also serves as a handy rebuttal to almost everything Malcolm Gladwell has written.

At Wednesday, December 16, 2009 11:54:00 PM, Blogger Phil Birnbaum said...

Thanks, Eddy! But I don't understand the Gladwell comment.

At Monday, December 21, 2009 8:49:00 PM, Anonymous Anonymous said...

You don't have a relevant argument. Just a vague statement that safe-guarding players will reduce viewing or game quality, somehow.


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