MEDicine
We Measure the Goal Against
A survey landed in my inbox recently from a physiatrist — a physician focused on conservative spine treatment. Fifteen or twenty questions, all variations of the same thing:
Did pain prevent you from working?
Did pain interfere with recreational activities?
Did pain limit your enjoyment of life?
I answered honestly. And then I sat with what interested me about it.
The survey was well-designed for what it was measuring — outcomes, the moments when something had already interrupted what I wanted to do. Every question pointed to the failure event. To the goal against.
It wasn’t asking the wrong questions. It was asking complete ones for its purpose.
What stayed with me was a different question entirely — one the survey wasn’t designed to ask.
What about the moment before?
Hesitation is where a system first announces that it is asking more than it should
The Signal Before the Breakdown
In hockey, you can watch this problem play out in real time.
The goal against isn’t where the breakdown started. It started earlier — with a player who hesitated when they should have acted, a half-second pause before a pass that narrowed the margin just enough for everything else to go wrong. The goal is simply where a longer sequence ran out of room.
Coaches who diagnose only at the moment of failure are looking too late. The more revealing signal is hesitation — not the missed assignment, but the pause before it. Not the turnover, but the moment a player stopped acting on expectation and started acting on doubt.
Hesitation is where a system first announces that it is asking more than it should.
The spine survey had no questions about hesitation. It never asked: where do you pause before attempting something physical that used to feel automatic? What do you check before committing? What have you stopped trying — not because it caused pain, but because you weren’t sure the attempt was survivable?
Those questions would find the signal earlier. They would also find something the outcome questions may be missing.
A Question Worth Asking
The survey treated work, recreation, household tasks, and enjoyment of life as four containers for the same variable — pain interference. That may be intentional. The physician may already be accounting for what each domain means to the patient, and using the survey as one instrument among several.
But if the instrument is the primary lens, it’s worth asking whether the nature of what someone is trying to do — and what that particular kind of action requires of them — is as diagnostic as whether they accomplished it.
Consider: a patient who has stopped running is experiencing something different from a patient who has stopped doing yard work. Not just a different activity — a different relationship between themselves and the system they’re operating within. What the body needs to provide, what margin is required, what a mistake costs — these differ depending on what the person is reaching toward and why.
If those differences carry diagnostic weight, an instrument that collapses them may be losing information that would actually guide the work.
That’s not a critique. It’s an opening.
Where This Leads
In any system where people must act — and where hesitation carries consequences — the most productive diagnostic question is rarely about the failure itself.
It’s about what the system made feel risky in the moment before.
What would have had to be true for the hesitation to disappear? What kind of confidence was the system failing to produce — and for what kind of action?
Those questions don’t find the problem later. They find it earlier — at the moment the system first began asking more than it should.
Earlier is where the most useful work happens. On the ice, in the clinic, and in most of the complex systems people depend on every day.