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Team physicians must balance conflict of interest

Issue: July 2013

ByAnthony A. Romeo, MD

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As the Washington Redskins were competing in the 2012-2013 postseason for a chance to advance to their sixth Super Bowl, the entire organization and fan base was counting on the “once-in-a-generation” talent of their rookie quarterback, Robert Griffin III. During the infamous 2013 NFC Wildcard game, Robert Griffin III was returning from a knee injury — an injury he had been dealing with since week 14 of the season, which incidentally was in the same knee he had ACL reconstruction while in college.

James R. Andrews, MD, the Redskins’ team physician and arguably the most famous team physician of our profession, had previously outlined various treatment options for Griffin’s knee injury. Like any NFL quarterback in his first playoff, especially a rookie with his rare blend of talent and drive, Griffin wanted to play. Not wanting to jeopardize his opportunities, Griffin followed Dr. Andrews’ instructions for rehab carefully and was fitted for a state-of-the-art knee brace. When Jan. 6, 2013 arrived, he was ready. His coach and team rallied behind him and Dr. Andrews cleared him to play in the most important game of the season.

Anthony A. Romeo

Early in the first quarter during one of his patented athletic escapes to avoid a sack, Griffin planted on his leg and felt an instability event. He came off the field and tried his best to “walk it off.” He did not seek Dr. Andrews, and Dr. Andrews had not seen the injury as he was caring for other athletes. Shortly thereafter, Griffin went back out on the field – based on his own desire to play – and the rest of the story is well-documented. The most electrifying quarterback of the 2012-2013 National Football League (NFL) season had suffered a season-ending injury that subsequently was treated with revision surgical reconstruction to restore knee stability.

Conflicted decision-making

Looking to identify a provocative storyline depicting a rift between a star quarterback, his coach and his medical staff, the media went crazy. Did Coach Mike Shanahan make him go back out on the field? Did the medical staff miss something? Did Dr. Andrews make a mistake in clearing Griffin prior to full recovery thereby jeopardizing not only the current playoff game, but the perception of many future years of Redskins success with Griffin at quarterback? Inevitably, someone had to be conflicted in their decision-making in the days and minutes leading up to that fateful play.

As expected, some fingers were pointed at Dr. Andrews, a man who has become legendary among athletes, team physicians, agents and others for his ability to provide the highest level of sports medicine and team physician care for athletes of all levels. Why did this happen? Are conflict of interest concerns inseparable from the role of a team physician?

Moral code

Team physicians are physicians. We are guided by our upbringing, training and a moral code to care for our patients. We have taken the Hippocratic Oath that speaks to the fact that our foremost priority is to the health and well-being of our patient-athlete regardless of athletic ability. It also speaks to the effort to pursue professionalism at its highest level, as well as “first do no harm.” Further, we are motivated to provide the best care possible despite the incredible scrutiny we receive from interested “third parties” — family, friends, trainers, coaches, principles, owners, agents and malpractice lawyers.

The higher the level of the athlete means the higher the level of athlete compensation and greater stakes and scrutiny. In these situations, the effort team physicians and medical staff put forward to provide care is generally irreproachable. Our goal is to establish the correct diagnosis, work with the medical staff to protect and rehabilitate the injured athlete, and to restore athletes — essentially ultra-high functioning orthopedic patients — back to their full potential.

The basis of the conflict is the priorities of others who are not typically part of the patient-physician relationship. The most obvious addition to the patient-physician relationship is the “team.” The team priority is clear — to win. A team’s success is based on how many competitive events are won. It is incredibly important that sports medicine physicians remember their role and focus on medicine, not the sport. We are not professional coaches, scouts and owners. We are fans, and fans should let the professionals make decisions related to winning at sport.

Fortunately, most of the time the priorities of the team, player and physician are aligned. But, as with any human endeavor, not every decision is black and white. In fact, most of our medical decisions are based on low levels of scientific evidence gleaned from case series (level 4) and expert opinion (level 5). When opinion without strong scientific evidence is the basis of our decision, which happens every day in every physician’s office or operating room, there is room for another opinion, perspective and conflicted person to question the physician’s decisions. Therefore, inevitably, the basis of conflict is trust: who is most trustworthy to make decisions in the best interest of the athlete? How do we as physicians earn that trust?

Controversy and turmoil

The underpinnings of our proposed conflict of interest stem from many sources. However, individuals who have the most to gain from the controversy and turmoil these accusations create frequently include the media and often the athlete’s representation (agent, family or both). For the media, sensational accusations that can neither be proved nor completely disproved are tremendously attractive methods to garner public interest and readership. More controversy is better. Agents also have an undisclosed conflict of interest: control over their commodity — the athlete. As part of an agent-client relationship, a promise is made that “I will take care of everything for you.” Frequently, this involves directing their clients toward “the best medical care money can buy.”

Despite the local reputation and quality of care provided by the team physician and the limited medical knowledge of the agent representation, the agent may prefer to send the athlete to an out-of-town nationally known physician to best demonstrate their ability to pull connections. Ultimately, their goal may be to show the athlete he or she is getting the best physician in the United States, thereby supporting the agent’s role in complex decision-making in all aspects of the athlete’s life, creating additional trust and allowing for a more involved relationship, often with financially driven motives.

Even players’ unions, such as the NFL Players Association, can “fan the fire” of mistrust for personal interests. In early 2013, the representatives of the NFL Players Association released the following statements to the media:

1. Not enough is being done to protect those who make a living on the playing field; and
2. The results of an unpublished “health and safety survey” suggested that 78% of players polled do not trust team medical staffs. Only 43% of respondents rate team training staffs as “good.”

Let’s look at the study, analyze the methods and try to understand the results. Unfortunately, after three formal requests from Commissioner Roger Goodell’s office, the NFL Players Association answered by claiming the results stemmed from an “internal survey,” thereby eliminating the need to provide further information to the NFL. In response, Goodell emphasized what is absolutely true — our athletes receive the highest level of medical and surgical care from a system that caters to the athletes at almost all levels, providing care that is the best in the world. It is not perfect, but 78% of players do not trust the team medical staffs? Show the data because an informal survey at the NFL team physicians’ meeting of surgeons, trainers and other medical staff showed that most athletes — more than 80% — trust their medical staff. But the irony is we have been so successful that any deviation from return to full athletic abilities after injury is considered a “failure of treatment.” Despite setting appropriate expectations, we are victim of our own success at times.

Trust and quality of health care

What can be done to improve the trust of athletes and to continue to improve the quality of their health care? From a programmatic perspective, our major professional sports leagues have made substantial system-wide changes, including care for concussions (NFL, National Hockey League), sideline video review cameras (NFL) and the availability of state-of-the-art imaging, to name a few. Many changes have been derived from medical staff recommendations. The changes and newer proposals, such as a neutral chief safety officer, a formalized second opinion process, and other programs for safety and prevention will trickle down and affect the younger athletes. The revolution in concussion identification, assessment and management is a prime example of the power of our input.

In my opinion, research funding remains limited. The NFL signed a $27 billion television contract over 9 years. Less than 1% of that contract will go toward research. The NFL Players Association is even stingier. While their representatives complain about the medical care, there is no organized effort on their behalf to direct funds toward research that could improve player safety, health and longevity in their sports.

Our ‘duty’ as team physicians

To be effective clinicians, we must persuade our athletes, and the people who counsel them, that they can trust us with their care. We can look at the principles of persuasion as written by Aristotle, and summarized by the motto, “Ethos, Logos, Pathos.”

“Ethos” is about character. We must have a strong moral and ethical code to keep an athlete’s health at the center of our decision-making. “Logos” is about achieving and maintaining competence. We must stay current with methods of nonsurgical and surgical care, and we need to organize and maintain the competence of the entire medical team. For “Pathos,” we need to be passionate about the care we provide our athletes, with a conviction to do what is best for them, as well as maintain compassion for their human sirit.

Editor’s note

I am honored to be named as the new Chief Medical Editor of Orthopedics Today. Much of my professional career has been dedicated toward education, which I pursued with a passion for taking complex concepts and distilling them down to understandable and practical ideas. I will continue these efforts in my role with Orthopedics Today. I plan to present topics that effect orthopedic surgeons, not only today, but with an eye on the subjects that will guide and shape our future. In this world of expansive information, we will identify and deliver the most relevant and insightful written, spoken and digital communication for all members of the orthopedic community. I look forward to your comments and suggestions as we present this information in your hands each month through our printed publication with links to our web-based portal, Healio.com/Orthopedics, for further in-depth analysis and review.