Put me in, Doc: When doctors must say no to athletes

Favored by 17 points against the Southern Methodist University Mustangs, the No. 4-ranked Texas Christian University Horned Frogs found themselves unexpectedly trailing on Sept. 24, midway through the second quarter of a nationally televised game. Then star running back Ed Wesley was upended by SMU safety Chris Banjo.

That is when TCU's head physician, Samuel J. Haraldson, MD, sprang into action to evaluate Wesley, who was averaging 8.7 yards per carry for the season.

"He was knocked unconscious, and any loss of consciousness is automatically considered a concussion," said Dr. Haraldson, who oversees care for more than 400 student-athletes. "He had an unsteady gait and a few memory problems."

Due to a new policy adopted by the National Collegiate Athletic Assn., following in the footsteps of the National Football League, once Dr. Haraldson diagnosed Wesley with a concussion, he would not be allowed to return to play because of the increased risk that a second impact could lead to a major brain injury.

"Then five or six plays later, I literally was verbally accosted by the coach, screaming at me insanely at the top of his lungs that he doesn't think [Wesley] has a concussion and what right do I have to hold him out," Dr. Haraldson said.

Once TCU took control of the game, going on to win 41-24, TCU Coach Gary Patterson returned and "cast a pseudo-apology" for the outburst, Dr. Haraldson said.

Asked days after the game by ESPN Dallas about Wesley's condition, Patterson said the sophomore running back was fine. "As far as I'm concerned," the coach added, "he was fine 10 minutes after he got hurt."

Whether it is at the youth, high school, college or professional level, team physicians can face demands from coaches, athletes, parents or agents to return players to action prematurely. Media and political scrutiny of how teams and their medical professionals handle sports-related concussions, in light of emerging evidence demonstrating their long-term impact on athletes' brains, have only raised the stakes for team physicians.

More than a dozen states have enacted or are considering legislation on concussions. Many of the measures require immediate removal from play of any athlete suspected of having a concussion, education of coaches and parents about the dangers of concussions, and no return to play until a qualified health professional approves. Similar bills are pending in Congress.

Loyalty to the patient

Physicians who serve as team doctors or who consult for sports teams say they are guided by their commitment to put athletes' interests first.

"I try not to base my decision on how the coach is treating me," Dr. Haraldson said. "I go back to the way I was trained in medical school and residency and having the reassurance of knowing I'm doing the best thing for my patients. That's the only way I can do it."

The American Medical Association policy on sports medicine, last updated in June 1994, buttresses that ethical principle. "The desire of spectators, promoters of the event, or even the injured athlete that he or she not be removed from the contest should not be controlling," the policy says. "The physician's judgment should be governed only by medical considerations."

Physicians who serve as team doctors must withstand pressure from many sources, said Stephen L. Brotherton, MD, senior orthopedic consultant to TCU. He covered the SMU game and evaluated Wesley on the sidelines to ensure that he did not have a neck injury from the tackle that took him out of the game.

"All coaches say, 'Are you absolutely sure?' when you're going to hold a kid out," said Dr. Brotherton, who did not hear Patterson's conversation with Dr. Haraldson. "You deal with it. If you can't stand up for the kids, then don't be there. ... Patient safety trumps everything.

"You're not dealing with something that's going to lead to some long-term enmity," he added. "It's just what's going on during the game."

All physicians, not just those serving as team doctors, face demands from different quarters, Dr. Brotherton added. "If you want easy, don't be a doctor."

Some physicians thrive on the high-stakes environment of being team doctors.

"It's very ego-gratifying," said Brian J. Cole, MD, an orthopedic surgeon who is head team physician for the National Basketball Assn.'s Chicago Bulls. "I love sports, and I love basketball, and I love being in a position of making medical decisions and being challenged on it. I love the intellectual dialogue that goes into making these decisions.

"My job is to have [the team, coach and athlete] come to the same conclusions that I do, and if I can't do that, then I'm not doing my job," Dr. Cole said. "If I have to make a decision about return to play, I never make a decision that could put the athlete in harm's way."

At the professional level, players and their agents sometimes second-guess team physicians' motives, said Douglas B. McKeag, MD, part of the Indiana University Center for Sports Medicine and co-author of the 2007 reference book Primary Care Sports Medicine, published by the American College of Sports Medicine.

"In the pro ranks, players have to protect their careers," said Dr. McKeag, who has consulted for the NFL's New York Giants and Indianapolis Colts. "What they're finding out now is that -- whoops -- by going back and being valiant and playing hurt, maybe that was not good for their careers. Many team physicians are seen as an agent of the franchise, fairly or unfairly."

A study in the Journal of Neuropathology & Experimental Neurology in July 2009 reviewed 48 cases of chronic traumatic encephalopathy and found progressive, degenerative brain disease in retired football players and wrestlers who had repeated head trauma such as concussions. The NFL now requires that any player with a concussion receive a consultation from an independent consulting neurologist, not the team physician.

Even so, physicians sometimes get heat directly from players.

Dallas Cowboys tight end Jason Witten was diagnosed with a concussion after ricocheting between two defenders during the fourth quarter of a Sept. 19 game. The Dallas Morning News reported that Witten was "noticeably upset on the sidelines" when the team's doctors told him he would not be allowed to return to the game.

That the Cowboys' doctors were able to resist a player's demands in the spotlight could help other team physicians do the same, said Howard Derman, MD, the team neurologist and concussion expert for the Houston Texans.

"Once you see that someone stands their ground, it makes it easier the next time," said Dr. Derman, co-director of the Concussion Center at Methodist Hospital's Neurological Institute in Houston. "It is very difficult in the heat of the game, a close game, when someone gets injured, to make the call that they can't go back in."

Just a week earlier, Philadelphia Eagles' linebacker Stewart Bradley rose unsteadily after a play in the first half, then stumbled back to the turf. Less than four minutes later, he returned to the game, with his concussion being diagnosed at halftime.

"Even with these safety net [rules], it still fails," said Sarah Fields, PhD, associate professor in the sport humanities program at The Ohio State University. "There is a lot of pressure on athletes at every level to return to play."

Requiring an independent neurological consultation "helps to limit the possible appearance of impropriety," Fields said. "I have no doubt there are a number of very competent, ethical team doctors doing what's in the best interests of the athlete, but sometimes it's hard for outsiders to necessarily believe that."

Some physicians who specialize in sports medicine seek an even greater level of independence -- emotional distance.

Anthony G. Alessi, MD, a Connecticut neurologist who works as a ringside physician, tries to avoid rooting for the boxers he cares for.

"I don't want to know if this could be a guy's last fight or if his mother's on her deathbed, because that might change my decision," said Dr. Alessi, chair-elect of the American Academy of Neurology's Sports Neurology Section. "When I go in the corner at the break of the round, I have to decide whether they can continue to fight or not. I don't really want to know about them."

Dr. Alessi said he thinks personal feelings someday might skew his medical decision-making. "There are two principal ways of dying in sports -- from neurological or cardiological causes. Those are the stakes we're dealing with here."

Young athletes' big dreams

For physicians fortunate enough to be in a situation where the organization and its coaches are deferential to their medical expertise, even the youngest athletes can pose a challenge. At the college, high school and youth sports levels, these patients may deny postconcussion symptoms such as headaches to get clearance to play, said Kevin Walter, MD.

"It happens, and the problem is not overblown," said Dr. Walter, a former team physician for high school and college teams in Madison, Wis., who now is program director for pediatric and adolescent primary care sports medicine at the Children's Hospital of Wisconsin in Milwaukee.

"A lot of people see professional sports as a kind of meal ticket," he said. " 'Oh, I can get the scholarship and live that pro lifestyle,' but most people do not come anywhere near even getting college money. I hear it all the time [from parents] that their kid is one of the tops and looked at for scholarships. ... There are some parents and kids that just can't come to grips with an injury."

Dr. Walter, who co-wrote a September 2010 Pediatrics article on proper care of sports-related concussions in children and teenagers, said the key to preventing any deception or mistrust is to develop a rapport before injury strikes.

"If you build that relationship, the coaches may not be happy, and the family may not be happy, but they have enough of a basis to respect you and trust you to do the right thing for the kid," he said. "It's not the right thing for a high school to win this game if it means putting a kid at risk."