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Ethical, Legal and Financial Issues in Sports Medicine


Military Sports Medicine Fellowship Every Warrior an Athlete Ethical, Legal and Financial Issues in Sports Medicine Kevin deWeber, MD, FAAFP – PowerPoint PPT presentation

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Title: Ethical, Legal and Financial Issues in Sports Medicine

Ethical, Legal and Financial Issues in Sports
Military Sports Medicine Fellowship
Every Warrior an Athlete
  • Kevin deWeber, MD, FAAFP
  • Director, Primary Care Sports Medicine Fellowship

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
  • 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
  • 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!

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,
youre 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 docs

Case Study
24 yo professional football teams 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 hes
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
  • Athlete has autonomy in decision making
  • Encourage discussion with others
  • Coach, ATC, parents, GM, etc.
  • Comprehension may be difficult in the heat of
  • 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
doesnt have pain running but can only kick
about 80 of his usual power due to pain. Hes
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 doesnt want to
get benched. He say its illegal to tell the
coach anything about his medical condition. He
knows about that HIRPA law, and hell tell his
moms 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
  • If physician NOT employedfalls under HIPAA
  • Obtain athletes permission before sharing health
  • May restrict play though
  • Professional athletes
  • Health info is part of employment record and
    doesnt 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 teams 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 teams 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. Hes 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 athletes safety above all else
  • Support goals of the team if it doesnt 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 physicians judgment should be
    governed only by medical considerations.

Loyalties of Team Physician
  • Athlete?
  • Team/Military unit?
  • Both?
  • Athlete gt 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. Hes 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
  • Athletes 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
hes been injecting himself with them for a
couple months and liking the results. He feels
more power with shots on goaland you gotta
admit, hes 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 substancestwo
    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 isnt 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
  • 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. Hes 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
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
  • 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
youre 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
  • 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
  • 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
  • A physician shall support access to medical care
    for all people.

Medico-Legal Considerations
  • State licensure
  • Local team need local states licensure
  • Military team any states licensure
  • Coverage during training depends on MOU
  • Determine states 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 programis 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. Applicabilitythis 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
  • 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

  • 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 pros

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
  • 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