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					                Military Sports Medicine
                       Fellowship




               “Every Warrior an Athlete”



Ethical, Legal and
 Financial Issues
        in Sports Medicine
            Kevin deWeber, MD, FAAFP
Director, Primary Care Sports Medicine Fellowship
                     USUHS
                 Objectives
                  We will…

   Discuss some ethical concerns and
    situations
   Review legal requirements and
    implications in Sports Medicine
   Review financial options in being Team
    Physician
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
    Questions that should guide you:
    Will my decision or activity be…
    1.   …to the credit of benefit of the athlete?
    2.   …to the credit or benefit of the sport?
    3.   …to the credit or benefit of my profession?


If all answers are “YES”, have no fear!
                           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.”
                   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
                           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.
    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
                          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.
                 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
                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
         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
                           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.
           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
    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.”
Loyalties of Team Physician
        Athlete?
        Team/Military unit?
        Both?
        Athlete > Team
                         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.
               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
                          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.
                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
Professionals Against Doping in
        Sports (PADS)


              +            & many others…




     =
        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
                          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.
“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
                          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.
              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.”
           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.
           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.
           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.
          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
    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.”
 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.”
                            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.
    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
    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.
      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


                    ≠
    Types of Financial Arrangements
   Gratis (work for free)
   Non-monetary compensation
   Fee for service
   Salary positions
   Physician pays team
                           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”)
    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
                 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
           Salaried Positions
   Full or part-time employment
   Advantages: stable income
   Disadvantages: hours may be excessive
    and interfere with personal life
   Examples: some universities
        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
Questions
Questions

				
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