Team physician conflict: Balancing responsibilities to the patient and team

Team physicians at all levels — high school, college and professional — often face conflict, but the key to overcoming that conflict is following a specific moral compass that is no different than when taking care of any patient: First, do no harm.

“In many respects, the moral compass goes back to the Hippocratic Oath: It is the safety, well-being and present and future of the athlete,” Brian J. Cole, MD, MBA, professor in the department of orthopedics at Midwest Orthopedics at Rush, head team physician of the Chicago Bulls and co-team physician of the Chicago White Sox, told Orthopedics Today. “At the basic level, our obligations to a professional athlete are no different than any other active individual with orthopedic problems. Obviously, they are buried within a system that involves contracts, competition, agents, general managers and the media — and that has to be taken into consideration as well.”

Similarly, James Bradley, MD, clinical professor of orthopedics at University of Pittsburgh School of Medicine and head team physician of the Pittsburgh Steelers, follows a patient-centered moral compass. “It encompasses four things: your integrity, the trust of the athlete, your communication with the athlete and compassion,” he told Orthopedics Today.

While keeping grounded in the moral compass, team physicians have to deal with unique factors and pressures that attempt to influence their decision-making, according to Benjamin Shaffer, MD, orthopedic surgeon at Washington Orthopedics and Sports Medicine, associate professor of orthopedics at Georgetown, head team physician for the Washington Capitals and assistant team physician for the Washington Wizards.

“Athletes may have different demands, goals and abilities that exceed those of many patients we otherwise take care of,” Shaffer told Orthopedics Today. “Being a team physician, especially at a professional level, involves a fairly careful balancing act trying to satisfy all those different components that go into the decision-making process besides the fundamental premise, which is that you never lose sight of the fact that you are taking care of a patient.”

Potential pressures

Despite the perception, conflict does not always arise from payment as a team physician. Most physicians are typically not employees of the teams they serve, but are often consultants paid on a contractual basis, according to Cole. “The amount of money, in general, that physicians are paid to assume this responsibility is far less — at least in economic terms — than the time and resources utilized to cover a team,” he said.

In other situations, compensation by the team is provided to the organization where the physician is employed. For example, Richard D. Parker, MD, chairman and professor of the department of orthopedic surgery at the Cleveland Clinic Foundation, serves as team physician for the Cleveland Cavaliers through his employment at the Cleveland Clinic. He is not directly compensated by the Cavaliers. “Part of my job description is that I carry out the care of the Cleveland Cavaliers, but I am not directly conflicted by any income I derive by taking care of the team,” Parker told Orthopedics Today. “Of course, it can be perceived as a conflict, but it is important how you manage that conflict. You have to keep looking at your moral compass and make sure that you feel you are doing the right thing for the athlete.”

“The risk nowadays of lay scrutiny and public press is so high that I do not think there is any number where a physician would put his reputation at risk to do something outside of the standard of care, outside of the best interest of the player because of all the retribution that will come to him,” said Charles A. Bush-Joseph, MD, managing partner of Midwest Orthopedics at Rush, head team physician for the Chicago White Sox and professor of orthopedic surgery at Rush University Medical Center.

According to Bush-Joseph, conflict can arise in ways other than compensation, including pressure from the player and his agent and representatives, from the team management and ownership, and from the fans and media.

A player’s own desire to get back to play can often influence a team physician’s decision-making, according to Christopher Harner, MD, medical director of the University of Pittsburgh Medical Center for Sports Medicine, head team physician for the Pittsburgh Penguins and current American Orthopedic Society for Sports Medicine (AOSSM) president. “These are athletes and they want to compete,” he told Orthopedics Today. “If they are hurt, they will play with injuries. You as the team doctor need to decide when you can let someone safely back to play with some pain or if they are just not able to play.”

Most team physicians said that pressure from team management and ownership has been rare in their experience. “With rare exception, I have not been subjected to onerous pressures by management in making decisions regarding players’ welfare,” Shaffer said. “I have never personally experienced a conflict between the players’ welfare and the team’s agenda. Your goal has to be for the long term for the player, which inherently most of the time ought to be consistent with what is good for the team as well.”

“If the basic tenet of ‘the athlete and his safety always remain ahead of the organization’ is observed and practiced, then although there always is a potential for conflict, it can be minimized,” Cole said.

Medical decision-making

According to Harner, 95% of team physicians serve high school or college sports teams. At all levels of sports, “the same care is taken and the same decisions are made based on the right thing for the athletes,” he said.

Team physicians often see medical issues other than orthopedic injuries, such as groin injuries and skin lesions. In all cases, the important decision-making factors include the type of injury, location of the injury, severity and the time of year in which the injury occurs — whether in the off-season, during the season, or during the play offs, for example. “It is a multifactorial process, but the overarching goal is returning the athlete back to play the sport safely,” Harner said.

The AOSSM has provided a consensus statement to guide team physicians in return-to-play decisions. The guidelines suggest team physicians have a return-to-play process in place and that the following criteria are confirmed before a player returns to the court or field: the status of anatomical and functional healing, recovery from acute illness and associated sequelae, and chronic injury or illness; that the athlete poses no undue risk to the safety of other participants; that restoration of sport-specific skills has occurred; psychosocial readiness of the player; and ability to perform safely with equipment modification, bracing and orthoses; and compliance with applicable federal, state, local, school and governing body regulations.

The AOSSM will release another consensus statement later this summer that will provide expectations of team physicians at all sports levels, according to Harner.

Gaining athletes’ trust

Team physicians often gain the trust of athletes with time and experience. However, according to Parker, questioning of the team physician is prevalent because of advertising and marketing around the arena and often because of agents’ and teammates’ opinions. “It is the human condition — it is common for there to be questions,” he said. “As a team physician, I am not insulted by that. I realize that is part of the rules of engagement.”

The NFL is a particularly demanding sport for team physicians because its players have non-guaranteed contracts, which often place team physicians under more scrutiny. “In systems where there are guaranteed contracts like in baseball and basketball, I do not think we have the same level of distrust,” Bush-Joseph told Orthopedics Today.

According to Matthew Matava, MD, co-chief of the sports medicine program at Washington University in St. Louis and head team physician for the St. Louis Rams, distrust among NFL players is often induced by the agents. “There is, unfortunately, a financial aspect to the NFL that the other three sports do not have,” Matava, who is also the NFL Team Physicians Association president and chair of the STOP Sports Injuries Outreach and Education Committee, told Orthopedics Today. “Many of us think it has to do with the lack of guaranteed contracts. The implications from agents are that if the doctors work for the team, then they are in cahoots with the team ownership as far as making decisions. The reality is that could not be farther from the truth.”

In fact, Matava said, in today’s medical-legal climate, a team would not be wise to have medical providers rush a player back to the field or court before they were completely rehabilitated. “General managers, coaches and even team owners have become much more medically sophisticated than they were several years ago out of necessity more than anything else,” Matava said. “Often, people ask me whether I feel pressure from teams to get players back on the field. The answer is absolutely no because of that reason.”

Transparency often goes a long way in establishing a trusting relationship with the players, according to Michael G. Ciccotti, MD, chief of sports medicine and director of the sports medicine fellowship program at the Rothman Institute and Thomas Jefferson University, head team physician for the Philadelphia Phillies and head team physician for St. Joseph’s University athletics. Ciccotti and his colleagues at Rothman conduct a regular anonymous player survey about the medical staff, in which they ask players about their medical care, as well as their feelings in terms of trust and comfort with the medical team.

“[Based on the survey at Rothman,] I would say we have a trusting relationship and a lot of it comes down to communicating with players when they have a specific injury,” Ciccotti said. “We talk to them about what the injury might mean, what kind of testing is appropriate, when that testing is obtained, what implications it has, whether they need nonoperative treatment or operative treatment, how long it will be before they are back to play — going through like you would with any patient. Communicating, giving them the opportunity to ask questions, being transparent and open goes a long way to generating a sense of trust.”

Shaffer added: “If you take good care of your athletes, if you are their advocate, you have a positive track record and you have developed relationships with them, I think there is a high level of trust.”

Second opinions

Most team physicians feel that second opinions on an operative or nonoperative decision for an injury are sometimes necessary, but not obligatory.

“I always encourage my athletes to get a second opinion in an objective and impartial way,” Cole said. “The second opinion is good for the athlete, the system and the physician to make sure we, frankly, do not miss anything and synthesize the best information available. The likelihood of achieving benefit from a second opinion is related to the complexity and severity of the clinical problem. This is clearly an area where all benefit by leaving one’s ego on the shelf in an effort to make the best decision in the interest of the athlete.”

Shaffer believes second opinions are appropriate when the patient’s condition is outside of the physician’s expertise, the outcome is unpredictable or there is controversy around the best treatment for the particular injury. Also, at times, second opinions may be sought when determining the timing or type of surgery. “In general, it is always reasonable to disclose to an athlete that they have no obligation to have surgery or to pursue a specific path,” he said.

“As a team physician, we need to check our egos at the door, and part of doing what is best for the player is to make sure he or she is comfortable with the treatment recommendations, and so we should embrace second opinions,” Parker said.

He suggested that physicians facilitate second opinions by suggesting appropriate physicians who have experience with the specific condition and type of athlete.

Contribution of a team physician

As a team physician, an orthopedic surgeon offers him or herself as an accessible, reliable resource who is available 24 hours a day, 7 days a week. They must be able to manage health care issues within their area of expertise and be willing to facilitate access to specialists in other areas, according to Cole. “It is not a one-doctor team, but it is a team of physicians typically, so I rely on many of my partners to assist in participation physicals, game coverage and managing injuries, whether surgical or nonsurgical,” he said. “We rely on primary care sports medicine, physical therapists and trainers.”

The team physician’s job goes beyond simple evaluation and care of players, according to Bush-Joseph. They also review the medical records of prospective players. “My colleagues and I have a level of expertise that the team relies on,” he said. “Our job is to assist the team in its medical functions and work with the team’s employed training staff. But still, at the end of the day, when it comes to patient interaction, we have a relationship that tries to push out all those outside influences.”

Team physicians also help to establish the team of athletic trainers, physical therapists, and strength and conditioning coaches to “help keep the healthy players healthy and help the injured players reduce the time away from participation,” Parker said. “It is a multifactorial and a multidimensional role. Game coverage is just a small part of it.”

According to Ciccotti, the entire medical team, including the training staff and medical staff, plays a vital role in the organization’s success. “The team’s various areas of expertise include identifying the most appropriate nutrition for these athletes to keep them well-nourished and able to perform at such a high level with extreme temperatures, extreme timing and psychological stress,” he said.

Injury prevention plays a large part in the team physician’s job as well. For example, Bush-Joseph said he works with the training staff, coach, and strength and conditioning coaches to establish off-season workout programs and rehabilitation programs. “At the end of the season, we sit down with each player, identify what conditions and problems they had during the course of the season, and help the training staff outline what we expect of them in the off-season so that the following spring, they are ready to play and perform at a peak level with a low risk for injury,” he said.

Implementing new technology is also relevant in injury prevention. According to Matava, the St. Louis Rams medical team recently incorporated a functional screen for flexibility that the training staff and strength and conditioning coaches can use to pinpoint areas of deficiency that could be causing injury.

The professional leagues are also proactive in examining prevention issues. The NHL and NFL have implemented rules for neuropsychiatric testing and return-to-play guidelines in concussion cases, according to Shaffer. “The NHL has also been aggressive in examining equipment and making modifications to make the game safer,” he said.

The NFL has a projected 2014 budget of $18.5 million for injury prevention measures, including studies, injury and safety panels, a cardiovascular committee, head and neck committee, and spine committee, among others, according to Bradley. “This is a staggering amount of money that the league uses to try to protect its players,” he said.

In the MLB, team physicians are involved in prevention research at a team level and at the league level, according to Ciccotti, who is the president of the MLB Team Physicians Association. “We have a structured research program that looks at the common types of injuries, when they occur, the conditions they occurred in, the time of year, the type of athlete, what type of player — whether a position player or a pitcher — what part of the game did it occur in, to try to maybe answer the question of how we can prevent these injuries,” he said.

The MLB Team Physicians Association currently has a research committee examining areas of high-risk or high-frequency injuries and, from that committee, has created subcommittees of team physicians to evaluate those specific injuries, which currently include concussion and injuries of the shoulder, hamstring, knee, hip and elbow, according to Ciccotti.

“Injuries are unfortunately a part of the game — they are never going to completely go away, but between treating methods, nutrition and equipment improvement, we think the rates of injuries are going to go down even further,” Matava said.

Training to become a team physician

Some aspects of a team physician’s job are beyond what most orthopedic surgeons handle every day, according to Cole. Basic intervention parameters, such as managing concussions, back injuries and high-energy musculoskeletal trauma, are unique to acute management of an athlete.

Shaffer emphasized that on-the-job training through a fellowship is the ideal pathway for those interested in becoming a team physician. “Interacting with the player and/or the agent, or the management and the trainer, and the subtleties in deciding how to proceed with clearance to play are on-the-job decisions,” he said.

Cole recommended AOSSM subspecialty certification. “A lot of the curriculum in sports medicine certification relates directly to the kinds of things we have to manage acutely,” he said. “Even as orthopedic surgeons, we need to know about eye injuries, neurologic injuries, head injuries — things we do not see walk in our office every day.”

Matava also said physicians should use the athletic trainers as educational outlets because they often have years of experience in the particular sport. “I will always have our fellows and our residents try to tap into the knowledge base of our athletic trainers,” he said.

The AOSSM, American College of Sports Medicine and individual organizations also offer opportunities for training. The AOSSM holds open meetings and workshops at the local, regional and national levels. Additionally, the AOSSM holds sports-specific meetings each year; for example, in 2014, the MLB and AOSSM are cosponsoring a meeting on the overhead-throwing athlete. Organizations like the Cleveland Clinic also hold local, regional and national meetings on team physician skills.

Being a team physician offers a unique opportunity and privilege, Parker said. “In the current climate of distrust and concern, you can be a successful advocate for the athlete and develop a good doctor–patient/athlete relationship that these players value,” he said. “You can save careers, and you can help people recover and get back to their careers. As much as there is a negative perception, being a team physician is an exciting area and it is a privilege to be one. It can be rewarding for the athlete and for the physician.” – by Tina DiMarcantonio

How can an orthopedic surgeon minimize the conflict of interest between care of the athlete and the responsibility to the team?

Planning can help avoid conflict

Conflict of interest is inevitable for team physicians. It occurs in many different ways for all of us, and the stakes get bigger and bigger as the level of competition increases. All of us are aware of the sinister ethical failures seen in television or movies — portrayals of team physicians injecting athletes without performing an informed consent and doing harm for the good of the team. We are less aware of the ethical dilemmas that happen every day and are usually present in less dramatic and more innocuous doses. These seemingly less dramatic conflicts are where we need to take a stand so we do not get into trouble with bigger issues; for example, ‘Should I finish my coffee or rush to the visitors’ locker room to close an opposing team member’s small laceration and get him back to play sooner?’ or ‘Should I tell our coaching staff about what I saw on the X-ray of an opposing team member?’ When money changes hands between the team and the physician, or between the team and the physician’s hospital or group in either direction, things can get even more complex.

Ethical conflict can be controlled, but it takes planning and work. If possible, a well-defined and broadcasted plan for specific injuries or situations can help to avoid conflict. For example, if everyone knows that any concussion results in pulling an athlete from play for the day with no exceptions, there is no longer pressure on the athlete to say he is ‘good to go,’ nor is there pressure on the doctor to say ‘it is probably OK’ for the athlete to return after reporting concussion symptoms.

Transparency and open discussion are also beneficial. Tell the athlete what you tell the coaches and management and be explicit. The 20/20 rule of thumb is also helpful. If you would be uncomfortable explaining your course of action in a news interview, plan what you will say before the interview. It is always better to consider a situation and be prepared to stick to your decision when you make the decision in the calm of your office. Making a decision with a high school crowd, a city or a nation watching can be troublesome. Communicate well, stick to your decisions, make them after considering all of the implications and be able to defend them to the athletes, parents and friends. As a result, you will sleep better and last longer as a team doctor.

Michael A. Terry, MD, is an associate professor in orthopedic surgery at Northwestern University Feinberg School of Medicine in Chicago. He is the head team physician for the Chicago Blackhawks, team physician for USA Volleyball and team physician for Northwestern University varsity athletics.
Disclosure: Terry is the head team physician for the Chicago Blackhawks, team physician for USA Volleyball and team physician for Northwestern University varsity athletics. He has no relevant financial disclosures.

Develop a bond of trust

I have made the answer to that question much easier than it may appear on the surface: I always do what is right for the player.

The team has an investment in the player. To rush the player back out onto the field appears on the surface to help the team, but it may lead to further injury, longer time out and ill will between all concerned. A bond of trust needs to be developed between the player, training staff, coaches and team management. If you treat the player as a patient, you will soon develop the level of trust you need for a successful outcome for all concerned.

The only time I act solely on behalf of the team is for clearance exams for trades or contracts. The responsibility to act on behalf of the team is understood by the player and the team. Once that player becomes a member of the team, I try to do what is right for the player just like I do what is right for my clinic patients. I do not change the professional standards I hold with my clinic patients when I provide team coverage.

A similarity may be seen in the relationship between performing independent medical evaluations and treating worker’s compensation patients: In the former situation, the physician is providing an evaluation and perhaps recommendations but not treatment, and in the latter, the physician is providing evaluation, recommendations and treatment. Of course, I have simplified this scenario. We know the many complexities associated with treatment of worker’s compensation patients as well as athletes.

My primary concern is that there is a high level of respect between players, physicians, trainers, coaches and team management to work together for a successful outcome of any injury. All of these important individuals must be part of any decision so that everyone understands the severity of the injury, timelines to recovery and impact of the injury on the player and the team.

Stephen E. Lemos, MD, PhD, is the president/chair of DMC Sports Medicine, chief of DMC Surgery Hospital, program director of the DMC Sports Medicine Fellowship and team physician for the Detroit Tigers and Detroit Pistons.
Disclosure: Lemos is the team physician for the Detroit Pistons and Detroit Tigers.