Preparation essential when handling ethical conflicts on the playing field

When athletes need treatment for concussions or other injuries in sports, the player, team or coach may oppose the judgment of the physician. How can these controversies best be resolved?

Reply: Although the basic ethical principles are not new, the case of the injured athlete returning to play has drawn renewed interest lately, and physicians occasionally find themselves in a swirl of controversy. The archetype of this conflict is the college or professional football player with a concussion. The collision that causes a concussion, for example, can look just like a "good hit" that draws admiration from the crowd. The athlete frequently recovers quickly enough that untrained observers speculate he or she is uninjured. Before studies on late effects of concussions and "second-blow syndrome," even the recommended medical treatment was much more casual.

The physician who rules this athlete ineligible to return almost always will meet resistance, either from the coach, who sees an alert and conversant athlete, or from the athlete, who by nature is competitive and tough. The physician may be employed by the team or its university, and that position can be threatened if the disqualification seems unnecessary. The physician may be conflicted, especially during a crucial game. The decision is as much ethical as medical -- can he or she allow a player to assume additional risk for the sake of the team?

Fortunately, the ethics of this are well-established and draw from both defining principles in the AMA Code of Medical Ethics (especially Principle 8), and from specific policies. Opinion 3.05 states that physicians employed by nonphysicians "must give precedence to their ethical obligation to act in the patient's best interest ... even if that puts the physician at odds with the employer/supervisor."

Opinion 3.06 is even more specific: "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 ... should not be controlling. The physician's judgment should be governed only by medical considerations."

Thus, from the viewpoint of the AMA Code of Medical Ethics, there is no substantial ethical dilemma. A physician cannot allow an individual to assume an increased risk of injury no matter what -- even if the player requests it.

Therefore, the question is how the doctor can make his or her clinical (and ethical) decision stick while incurring a minimal amount of disfavor. It does the health of the team no good if the physician's actions result in the doctor being replaced by a less sound, more ethically compliant provider, so conflict avoidance and conflict resolution are important skills.

First, make the decision on evidence-based criteria. Second, prepare for how these decisions will be carried out. As a friend says, "If the first time you think about this is when it happens, you're already in trouble."

In higher-profile games there is often more than one physician available. Have that doctor support the eligibility decision. The concussed athlete also needs his or her cervical spine cleared. If the orthopedist watches the generalist do a concussion check while he or she clears the athlete's neck, he or she can back up the colleague on the disqualification. Or if an athletic trainer is present, he or she may support the decision.

Athletes and coaches will be much more likely to accept a disqualification from a physician with whom they are familiar. So be available to the team at less-stressful times and get to know the players. It is absolutely necessary to have thick skin. The coach's reaction should not cause a physician to waver, nor should the physician be offended.

Ethical and clinical decisions on the playing field are not made in the same environment as that in which academic ethical policies are created. The resulting difficulty in implementation is inherent and unavoidable, however, and the individual who has no tolerance for controversy will serve both himself and the athlete poorly. Preparation and professionalism are absolute necessities.

Stephen L. Brotherton, MD, associate team orthopedic physician, adjunct faculty, Texas Christian University, Fort Worth, Texas; practices at Texas Healthcare Orthopedics

Reply: Think the win-at-all-costs mentality is only for the pros and big-time college athletes? Think again -- it can be found even in elementary school athletics. As a youth sports physician, you need to be ready for it.

At first glance, it might seem as though team physicians wouldn't face much pressure or controversy in youth and high school sports. In reality, team physicians face ethical dilemmas at all levels of sport and even when treating the youngest athletes.

Many doctors become team physicians to give back to the community, often serving their local high school, perhaps the school their children attended, or a youth sports organization filled with athletes who have seen the team physician for years in a primary care setting. It is important that this personal connection to the high school or youth teams does not interfere with objective medical decisions.

Being perceived as unbiased is important. Doctors do not travel with many youth teams, so the home-team physician may be called upon to assess injured visiting team players and make return-to-play decisions. If the doctor on the sidelines is jumping and cheering like a fan, it may make the opposing coaches more likely to question the medical decision-making process and authority of that physician.

Often problems arise in youth sports when the wishes of the athlete, parents or coaches take precedence over the welfare of the athlete. Adolescents feel invincible. They also want to be the tough hero who plays through an injury. Children and adolescents cannot be expected to comprehend the full ramifications of their actions after an injury. An objective team physician must understand and explain the potential long-term risks of returning to play after an injury to help counter the perceived short-term benefits to the team.

Many of these ethical issues can be easily resolved with appropriate communication. Team physicians should hold regular meetings with the school and coaching staff to establish an open line of communication. At these meetings, the physician should discuss the underlying principles of treatment and return-to-play expectations so all parties are well-informed. Good communication establishes a common respect among coaches, parents and the team physician. This may reduce the risk of arguments with coaches on the sideline and doctor-shopping by parents.

The team physician should have complete professional autonomy over all medical decisions. Physician spectators should not be allowed to come from the stands to clear athletes to return to play. These physicians often are acting more like fans and may not have the clinical experience to make consistent, safe decisions about sports injuries and concussions.

Finally, team physicians need to advocate for the athlete. It is best to evaluate the injured athlete in a private area. If the athlete doubts his or her ability to return to play, that athlete should be kept out, and the team physician can take pressure off the athlete by informing the coach that the athlete is not cleared to return. Athletes are unlikely to verbalize these fears in the presence of a coach.

Being a team physician is a wonderful and rewarding experience. Establishing free and open communication between yourself and coaches and advocating for the welfare of the young athlete is critical.

Kevin D. Walter, MD, assistant professor, Depts. of Orthopaedics and Pediatrics, Medical College of Wisconsin; program director, Pediatric & Adolescent Primary Care Sports Medicine, Children's Hospital of Wisconsin; member, Children's Specialty Group