Ethical, Legal and Financial Issues in Sports Medicine

1. Military Sports Medicine Fellowship Ethical, Legal and Financial Issuesin Sports Medicine “Every Warrior an Athlete” Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship USUHS

2. ObjectivesWe will… • Discuss some ethical concerns and situations • Review legal requirements and implications in Sports Medicine • Review financial options in being Team Physician

3. Ethical Issues for Team Physicians • No universally accepted code of ethics exists for Sports Medicine • EXAMPLE: International Sports Medicine Federation guidelines: • Always make the athlete the priority • Never do harm • Never impose your authority in a way that impinges on the individual right of the athlete to make his/her own decisions • Probably too simplistic, but useful

4. Questions that should guide you: • Will my decision or activity be… • …to the credit of benefit of the athlete? • …to the credit or benefit of the sport? • …to the credit or benefit of my profession? If all answers are “YES”, have no fear!

5. Case Study You are trying to establish your Sports Medicine practice in your community. You are approached about possibly being event physician for a World Extreme Cagefighting (mixed martial arts) fight night coming to town in a couple months. You love the sport, but your colleague has some concerns. He says, “If you cover that sport, you’re just encouraging those guys to cause further injury and maybe risking death.”

6. Ethics of Covering Dangerous Sports • Dangerous sports: Collision sports, combatives, extreme sports, etc. • Two lines of thought: • Medical coverage condones and facilitates risk • Physician partly responsible for the risk • Medical coverage limits unnecessary risk • Athlete knowingly assumes responsibility for the risk and would compete regardless of doc’s presence

7. Case Study 24 yo professional football team’s star running back was recently diagnosed with tarsal navicular stress fracture. He has pain with running, is concerned about making sure he heals OK, but really wants to continue playing. The division championship game is this Sunday. Coach really needs him, but you and the Head ATC are not so hot about his playing. The team owner comes to the training room and tells the player he’s counting on him to have a big game. He pulls you aside and asks what the medical situation is. You inform him that this fracture has a significant complication rate, and any continued stress could lead to a worse injury, perhaps needing surgery. The owner tells you to keep that part quiet from the player and still have him play.

8. Informed Consent and Autonomy • Must provide athlete with accurate and complete information • Athlete has autonomy in decision making • Encourage discussion with others • Coach, ATC, parents, GM, etc. • Comprehension may be difficult in the heat of competition • Athlete always wants to play

9. Case Study Scenario 1: A player on your high school soccer team has had a very painful apophysitis in the off-season at the AIIS of his kicking leg. He doesn’t have pain running but can only kick about 80% of his usual power due to pain. He’s a starter, but his back up is nearly as good as he is and could probably play better right now. The athlete is begging you to let him start and not to tell the coach, because he doesn’t want to get benched. He say it’s illegal to tell the coach anything about his medical condition. He knows about that “HIRPA” law, and he’ll tell his mom’s lawyer if you let anyone know.

10. Privacy Issues • Athletes still protected by HIPAA law • Athletes must understand balancing rights with needs/goals of the team • Media creates unusual pressure to disclose medical information • Use great caution dealing with media

11. HIPAA and Athletes • School athletes also covered by Federal Educational Rights and Privacy Act (FERPA) • Employed team physicians • may release health info w/o consent to school officials who need to know • May not disclose info to the media w/o signed consent • If physician NOT employed—falls under HIPAA • Obtain athletes’ permission before sharing health info • May restrict play though • Professional athletes • Health info is part of employment record and doesn’t fall under HIPAA regulation • May share information with team officials

12. Emergencies and HIPAA • On-field emergencies may not fall under HIPAA • May discuss return-to-play decisions with coach/ATC as part of emergency eval and tx

13. Case Study You are the Team Physician for a local High School football team. You have lived in this community for a while and feel at home here. The community knows you as the team’s doc and you are well respected. You occasionally get comments about “keep the team healthy, Doc!” from your friends who are avid fans. In fact, you are one of the team’s biggest fans too. You get very emotional on the sidelines, similar to the coach. The team really appreciates your enthusiasm The team is behind by 5 points with only a few minutes to go in the game, when the quarterback gets sacked and sustains a Grade III AC sprain. He’s in a lot of pain but wants to go back out. Coach wants him back in.

14. Uniqueness of the Physician-Athlete Relationship • Physician must understand the physical and mental demands of the sport • Avoid “fanhood” clouding your judgment • Recognize athletes’ tendency to pressure you toward certain decisions • Always put athlete’s safety above all else • Support goals of the team if it doesn’t violate athlete safety

15. AMA Code of Medical Ethics • “The professional responsibility of the physician who serves in a medical capacity at an athletic contest or sporting event is to protect the health and safety of the contestants. The desire of spectators, promoters of the event or even the injured athlete that he or she should not be removed from the contest should not be controlling. The physician’s judgment should be governed only by medical considerations.”

16. Athlete? Team/Military unit? Both? Athlete > Team Loyalties of Team Physician

17. Cast Study You are caring for a world-class wrestler who is competing in the USA Wrestling National Championship finals. He sustained a grade II AC joint sprain the day prior. It hurts a lot but he can function at about 90%. He’s asking for a shot prior to the match to get him through.

18. Short-term Gain vs. Long-Term Risk • Analgesics • Risks of masking pain for short-term gain • Benefits to athlete (not team) are paramount • Injections • Same considerations • Return to play decisions • Pressures from coach, player, teammates • Physician ego/success may create bias • In all: Informed Consent is critical • Athlete’s autonomy to make decisions

19. Case Study You are caring for a club hockey team. One of the players asks you what you know about steroids. You inquire a little and find out that he’s been injecting himself with them for a couple months and liking the results. He feels more power with shots on goal—and you gotta admit, he’s on a hot streak. No one is going to test for the substance.

20. Doping in Sports • Team physician is bound to discourage use of banned substances • Do not provide them or encourage their use • Physician are bound by laws and regulations of sports governing bodies • May or may not be bound to disclose use • Caring for athletes who use banned substances—two thought camps: • Your care for them facilitates the use • Your care for them and education about risks may change their behavior

21. Professionals Against Doping in Sports (PADS) + & many others… =

22. Athletes’ Use of Supplements(not banned) • Difficulties: • Most have little to no benefit • Product safety isn’t guaranteed • Athletes may feel supplements enhance their health or performance • Physician role: set your own policy, e.g.: • support proper nutrition • encourage good training • educate on current scientific knowledge and legality • let athlete make decision

23. Case Study You are the Team Physician for Division I Basketball team. The star forward has had URI symptoms for about 24 hours, and the Coach is asking for you to give him a Z-Pak. He’s seen it work miracles in his other athletes— They all seem to get better within one day when the last team doc used to prescribe it. The team is leaving tomorrow for an away game over the weekend.

24. “Costs” of Sports Medicine Care • Creating two standards of care • Elite athlete standard • Often imposed by those w/o medical expertise • E.G. agent demands an MRI • Often dictated by needs of team, not usual principles such as cost, risk/benefit, prudent use of finite resources • Community standard • Discrepancy of standards can lead to misunderstanding • Prevention: educate athlete and team staff

25. Case Study You are the Team Physician for Eastern State University. One of the female soccer players has never needed your medical assistance but “needs” you nonetheless. She is flirtatious, complimentary of your achievements, and thinks you’re “hot.” Your are recently divorced and actively seeking a new partner. Scenario 2: same as above, except adult professional athlete, but under your medical care. Scenario 3: professional athlete, except not under your care.

26. Doctor-Patient Sexual Relationships • Unethical in the context of the doctor-patient relationship • Illegal in most states • Never justified, even if initiated by patient West Virginia Law: “Sexual contact that occurs concurrent with the physician-patient relationship constitutes sexual misconduct. Sexual or romantic interactions between physicians and patients detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician's objective judgment concerning the patient's health care, and ultimately may be detrimental to the patient's well-being.”

27. AMA Ethics Principles • A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. • A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. • A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

28. AMA Ethics Principles • A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. • A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. • A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

29. AMA Ethics Principles • A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. • A physician shall, while caring for a patient, regard responsibility to the patient as paramount. • A physician shall support access to medical care for all people.

30. Medico-Legal Considerations • State licensure • Local team: need local state’s licensure • Military team: any state’s licensure • Coverage during training: depends on MOU • Determine state’s sports medicine laws

31. Medico-Legal Considerations Virginia: “Any physician, surgeon or chiropractor licensed [in Virginia] who, in the absence of gross negligence or willful misconduct, renders emergency medical care or emergency treatment to a participant in an athletic event sponsored by a public, private or parochial elementary, middle or high school while acting without compensation as a team physician, shall not be liable for civil damages resulting from any act or omission related to such care or treatment.”

32. Medico-Legal Considerations • Maryland: “A physician [licensed in MD] who voluntarily and without compensation [not including reimbursement for actual expenses] provides services or performs duties as a physician for a [school] sports program…is not liable for any damages for any act or omission resulting from the providing of the services or the performing of the duties unless the act or omission constitutes willful or wanton misconduct, gross negligence, or intentionally tortious conduct. Applicability—this section shall apply only to treatment at the site of the sports program, treatment at any practice or training for the sports program, and treatment administered during transportation to or from the sports program, pactice, or training.”

33. Case Study You are already caring for a local high school under your local license and a generous state GoodSam law. The orthopedics doc that also cares for this team cares for a minor league team in the area and asks if you can help him out with them as well. You would love to but just need to check something first.

34. Medico-Legal Considerations • Malpractice insurance • Local team: check state laws and local insurance companies to determine needs • Military team: none needed • Check with military commander first • Check with local military legal advisor

35. Case Study: Financial Issues • 2000 season: Washington Redskins team physician is reported to have paid $500,000 for the privilege of being the official orthopedic surgeon for the team.

36. Financial Considerations for Team Physicians • Team Physicians are usually NOT paid • Numerous financial or reward arrangements are possible • Consider options in advance of providing coverage ≠

37. Types of Financial Arrangements • Gratis (work for free) • Non-monetary compensation • Fee for service • Salary positions • Physician pays team

38. Gratis • Most common • Clubs, high schools, small colleges, some pro • Advantages • Flexibility, less time commitment, no obligation • Sense of community service • Disadvantages • No compensation for time/expenses • Ambiguous role; could lead to liability • Can trend toward over-commitment (“yes”)

39. Non-monetary Compensation • Forms of compensation are unlimited: • Team apparel, parking passes, free tickets, VIP status, free travel to away games • Rights to market Team Physician status • Advantages • Some compensation, but w/o the complications of a monetary contract • Disadvantages • Benefits usually not equal in value to time • Examples • High schools, colleges, some pro’s

40. Fee for Service • Set amount agreed to for time spent • Per game, practice, season, etc. • Costs for your expenses, travel • Advantages • Might make a profit • Exclusive rights to marketing • Disadvantages • Difficult to predict actual cost to your of time away from practice/family

41. Salaried Positions • Full or part-time employment • Advantages: stable income • Disadvantages: hours may be excessive and interfere with personal life • Examples: some universities

42. Team Physician and Practice Advertising • Being Team Physician can draw more persons to a practice • Perceived as “better” doc • Pitfalls: • Bidding wars for rights as Team Physician • May lead to violation of athlete-physician trust • Fear of loss of market visibility could obstruct objective decision making • Tendency to please team vs protect athlete

43. Questions

44. Questions