COMPETING INTERESTS
The team doctor’s dual loyalty problem
Groveb/iStock
by Roger Collier, CMAJ

JANUARY 10, 2017

His teammates knew something was wrong. Sure, he had played in pain before. There was perhaps no other catcher in baseball as tough, mentally or physically. But this was different. The sunken eyes, the dark circles — he looked like a raccoon. It was obvious to everyone that he was in agony, that his body was breaking down. Lay off for a while, someone suggested. They all knew, however, that the advice would be ignored.

 

He wasn’t the type of player who took games off. Sometimes you had to suffer to succeed; pain was part of the process. That’s how he saw it. That’s how he was raised. It was a “staunch, quiet, archconservative, play-with-an-arrow-in-your-heart type of thing,” according to one of his teammates. Besides, their archrivals, the New York Yankees, were threatening to steal their position atop the American League East. Rest could wait.

So when he broke a rib after crashing into the stands while tracking a foul ball, he played on. And when he injured his right elbow after changing his throwing motion because of the pain in his ribs, he played on. He played on, in fact, until the season was over, despite his ever-dwindling production. He then spent the offseason doing pretty much nothing, the pain in his elbow so intense that even lifting his arm was a chore.

Later, reflecting on that season, he expressed regret. He had been wrong. He should have taken two weeks off after breaking the rib. But he wasn’t the only one in the wrong — at least, that’s how he came to see it. The team physician also shared blame. He recalled the doctor saying, after assessing the broken rib, “Well, you can’t hurt yourself any more than what’s already been done.” If he wanted to play, the doctor told him, go right ahead.

“If you’re an athlete in this game, you have to protect your own interests, and you have to protect your body and your family. If one doctor is a doctor for 15 guys, who’s paying this guy?”
Chris Bosh, professional basketball player (New York Times, Sept. 26, 2016)

“I think he could have been a little more informative. He could have indicated what the cause and effect could really be,” the player later said. “I think he should have indicated the problems that could arise.”

This story, told in the pages of Sports Illustrated, is not uncommon in team athletics, especially in the high-pressure, billion-dollar world of professional sports, where losing is very bad for business. And it highlights the difficult position in which team physicians often find themselves. Ideally, a team doctor, like any other physician, would be concerned only with the health of the patient. But a team doctor has a dual loyalty problem. Decisions made by physicians on the field can have a direct impact on a sports franchise’s success.

“While team physicians treat the players, they are paid by the owners. And although there are some excellent doctors and some enlightened owners, built into the relationship is an inherent conflict of interest,” noted the article. “Whose interests do the doctors have at heart — that of the owner, who wants the player out there on the field, or that of the player, who in certain circumstances probably shouldn’t be out there?

Here’s another interesting tidbit about that article: it was written in 1979. The baseball player described in the piece is Carlton Fisk, then a catcher with the Boston Red Sox. Today, nearly 40 years later, you might think that the dual loyalty problem of the team doctor has been solved, that policies have been adopted to remove the inherent conflicts of interest in providing health care for professional athletes. But if the response of a major American sports league to a recent study on this topic is any indication, some people in professional sports don’t think the problem even exists.

Serega/iStock

RECOGNIZING THE CONFLICT

The National Football League (NFL) is the most popular sports league in the United States, and it didn’t take kindly to the suggestion that the way it administers health care to its players may be flawed. But that was one finding of “The Football Players Health Study at Harvard University,” a nearly-500-page report released in November 2016. According to the report, the dual obligations of a team doctor, to players and ownership, creates legal and ethical quandaries that can threaten player health.

“Even if some medical staff are sometimes able to successfully manage this conflict, and even if certain players have expressed their satisfaction with the care they receive, the inherent nature of the conflict means there is always an underlying possibility of substandard care — and of damaged trust in the doctor-patient relationship as players wonder whose interests the medical staff is advancing in any given scenario,” said Holly Lynch and Glen Cohen of the Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard Law School.

According to Lynch and Cohen, both coauthors of the Harvard study, competing interests are prevalent in all areas of medicine, but systems are put in place to address them. In organ donation, for example, there would be an inherent conflict if the same doctors declaring a donor’s death were also responsible for the care of a possible recipient. That is why separate medical teams exist for donors and recipients. The Harvard football study suggests that the NFL take a similar approach.

“Once the conflict is recognized, we have offered one recommendation to resolve it — namely, to separate the medical staff responsible for treating players and the medical staff responsible for helping clubs make their business decisions,” said Lynch and Cohen. “Because there would be only one group of medical professionals responsible for caring for players, there would be no concern about treatment errors. However, there may be other possible solutions. The key thing, though, is to start by recognizing the conflict itself.”

 

“They will clear 30 people out within three minutes. You tell a normal doctor that… and they’re like, ‘No, there’s no doctor in the world who would do that.’ Well, there’s 32 doctors that I know that do it all around the NFL.”

retired professional football player Jeremy Newberry on the “assembly line for painkiller injections” in football locker rooms (CBC News, Mar. 12, 2015)

The NFL, however, doesn’t appear willing to make that start. As reported in The Washington Post, the league’s executive vice president of health and safety, Jeffrey Miller, sent a 33-page response to the Harvard researchers, calling their proposed changes unrealistic, untenable and impractical. The NFL said having two medical teams would add unnecessary complications, and took issue with the recommendation that doctors treating players communicate with teams only by written reports, suggesting it “would lead to confusion, errors and ultimately failure … particularly with respect to complex medical situations.” Miller also wrote that the study “cites no evidence that a conflict of interest actually exists.”

But to researchers in sports ethics, that conflict is a given. “Obviously, considerations about long-term health and the interests of the team collide,” said Samantha Brennan, a philosophy professor at Western University who teaches a course on sports ethics. “I can’t imagine how hard it would be to be a team doctor for a football team given all that we know now about the long-term head-injury risks.”

It’s apparent that the NFL has a profound misunderstanding of what a conflict of interest entails and why it needs to be managed, according to Bradley Partridge, a senior research fellow with the Caboolture Hospital Research Development Unit in Queensland, Australia. Partridge has written about this issue with respect to the two most-popular sports in Australia, rugby and Australian Rules football, including a paper in Bioethical Inquiry called “Dazed and Confused: Sports Medicine, Conflicts of Interest, and Concussion Management.”

“The relevant question is not whether a team doctor’s professional judgement has ever been biased, but whether the conflicting roles create the tendency for judgement to be less reliable than it could otherwise be,” said Partridge.

jtomason/iStock

ETHICAL OBLIGATIONS

Bruce Greenfield, an associate professor at the Emory University School of Medicine in Atlanta, has also studied the dual loyalty problem in sports and is coauthor of a review in Sports Health called “Ethical Issues in Sports Medicine.” Physicians don’t knowingly compromise their duty of work, says Greenfield, but they are human and therefore not immune to influence. To address this problem, team doctors should be made aware of their ethical obligations to patients, and there should be rules and regulations to guide conduct.

“At the very least, there should be in place some sort of independent watchdog to make certain that client/athlete rights are being respected, and that the physician is making decisions for his best interest, regardless of the needs and expectations of team management,” said Greenfield.

But full separation of doctors who treat players from coaches and owners, as recommended in the Harvard football study, may be a step too far, says Lynley Anderson, an associate professor of bioethics at the University of Otago in New Zealand. Anderson has studied elite athletes and teams in New Zealand, and is coauthor of a paper in International Review for the Sociology of Sport called “Competing loyalties in sports medicine: Threats to medical professionalism in elite, commercial sport.”

Sure, the relationship between a team doctor and a coach can be testy at times, but it can also be effective and based on mutual respect. Severing that relationship entirely could have unanticipated consequences.

“For example, the frequent interaction between health providers and coaches on an everyday basis may help educate the coach about medical matters and encourage them to have more realistic expectations when it comes to return-to-play decisions, and to keep the pressure off players” said Anderson.

“The opportunity for effective communications between a doctor and a coach or player that provides an understanding of the nuances associated with the delivery of care, recovery, and needs of the player may be lost if the coaches and health providers are limited in their ability to communicate.”

“The NHL team doctors and medical trainers worked for team owners and have been ordered to get players back on the ice. … They should have been looking out for the long-term health of players.”

hockey player agent Allan Walsh commenting on concussion lawsuit by former players against the National Hockey League (CTV News, Feb. 12, 2016)

There should be limits to that communication, however, according to the Team Physician Committee of the Canadian Academy of Sport and Exercise Medicine. Team doctors should maintain some degree of patient confidentiality. Owners and coaches need some feedback on injured players, of course, but that could be limited to general information and an estimate of recovery time.

Other best practices for managing the medical competing interests in teams sports include working with the team to create a return-to-play process and communicating it to athletes and coaches, letting players know they can seek a second medical opinion from an external doctor and following ethical principles when prescribing medication to athletes.

“Team physicians are sometimes pressured by the athletes, the coaches, agents, parents and club management to allow athletes to return to play too early when the athlete is a key player or the competition is of specific importance,” according to the committee. “The ethical team physician continues to apply best practices to their return-to-play decision-making.”

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