Team physicians representing professional sports organizations face a complex set of challenges relating to medical liability, litigation, and external pressures. Their patient population includes high-profile athletes performing for big business. Every patient comes with a coach, teammates, management, and fans—and each has an agenda. Every medical decision could potentially end up at the center of media scrutiny.

Sports medicine physicians often face a dilemma shaped by the different sets of pressures from athletes and team affiliates. The goal of a team physician is to foster the long-term health and well-being of the athletes with full recovery from musculoskeletal injuries and related surgeries. The goal of the athletes and team management is often performance-based, with monetary implications and a focus on returning to play as soon as possible.

These competing goals can quickly breed tensions in the physician-patient relationship. Adding to the complexity is the litigious environment of sports medicine. Disagreements about best practices and clinical judgments can cost team physicians millions of dollars in malpractice awards.

Responsibilities of the team physician
The AAOS Information Statement on Team Physician Definition, Qualifications, and Responsibilities defines the role of a team physician as follows: The team physician should possess special proficiency in the prevention and care of musculoskeletal injuries and medical conditions encountered in sports. The team physician integrates medical expertise with medical consultants, certified and/or licensed athletic trainers, and other allied health care professionals (athletic care network). The team physician is ultimately responsible for the clearance to participate and the return-to-play decision.

Physicians must also educate athletes about their injuries, treatment plans, and the risks associated with returning to play. Informed consent must be received from the athlete before initiating any treatment plan. Orthopaedic surgeons who serve as team physicians must be comfortable consulting a different specialist when necessary; for example, a consultation with a neurologist for a severe concussion or a cardiologist for evaluation of a potentially dangerous arrhythmia or cardiomyopathy may be needed.

Athlete vs. physician
Many medical malpractice lawsuits in professional sport involve athletes accusing team physicians of negligent conduct. For an athlete to claim a physician has displayed negligent conduct, the following four elements of the legal term “negligence” must be demonstrated:

• Duty of care—The physician being sued has a legal duty to care for and make medical decisions relating to the injured athlete. This is often proven by contractual accountability.
• Breach of duty—The physician has deviated from the standard of care, defined in this situation as the reasonable practices of other professional-level team physicians. This could refer to inappropriate treatment, lack of treatment, fraudulent concealment of medical information, or inappropriate timing of medical clearance. Physicians cannot, however, be liable for withholding clearance if participation would pose an unacceptable risk to the athlete, based on the standard of care.
• Causation—A relationship must exist between the breach of duty and the injury sustained by the plaintiff.
• Damage to the injured party—The legal definition of damage is broad, and can refer to physical pain, mental suffering, and/or loss of earning capacity for a professional athlete. Compensatory damages are those intended to reimburse the plaintiff for the injury, suffering, or loss.

Release of health information
The laws about protected health information do not change in the context of professional athletics. The Health Insurance Portability and Accountability Act of 1996 is the primary governing act for all patient privacy issues. Despite media badgering, patient information may only be released to those parties that the athlete designates with written consent. Team physicians are at risk for legal ramifications if they release information about the status of a patient’s injury or details about a surgery to coaches or the media without the patient’s consent.

The importance of documentation
Effective medical documentation is, of course, essential for legal and professional requirements, but it’s also important for personal protection against potential malpractice lawsuits. Thorough documentation of all patient encounters, medical treatment, communication, and interventions can greatly reduce the chances of litigation against a team doctor.

It is crucial for team physicians to document what decisions they made and why they made those decisions. If a decision is not consistent with the standard of care, it is vital to document why that practice was not employed in that specific case, with a detailed explanation of the apparent contraindications to the standard of care. It should be made evident that the athlete’s best interest, from a health and safety standpoint, is being taken into consideration with every decision a team physician makes.

A unique challenge for team physicians is documenting on-field injuries. Physicians must act quickly in the event of an injury during a practice or game, where the typical office setting is replaced by turf, a hardwood floor, or ice. An effective solution to this challenge is the use of a handheld recorder to quickly dictate events, thereby allowing the physician to later enter the dictation accurately and completely into a medical record.

Bridging the gap
Professional athletes differ from high school level and amateur athletes in that their sport is not only their passion, but also their livelihood. Their salaries and careers depend on their performance and playtime. Professional athletes who are injured must carefully consider the advice of their team physicians and balance those recommendations with their own short- and long-term life goals.

In this sense, athletes are no different than any other musculoskeletal patients. The key for the treating physician is to focus on an essential motif in the practice of quality medicine: effective communication. Team physicians who establish successful rapport with their athletes and who maintain open lines of communication about all things related to injuries, treatment plans, surgeries, rehabilitation, and realistic timelines are more likely to have satisfied patients, and satisfied patients are less likely to sue their physicians for malpractice.

Orthopaedic team physicians must communicate the need for proper interventions in securing the healthy future of athletic careers and functional status after retirement. Athletes and physicians must work together to meet their shared goals of safety, well-being, long-term health, and a complete-as-possible return to play.

Aloiya R. Earl is a third-year medical student at the University of Toledo College of Medicine. She can be reached at aearl2@rockets.utoledo.edu

David H. Sohn, JD, MD, is assistant professor of orthopaedic surgery and chief of the shoulder and sports medicine division at the University of Toledo Medical Center. He is also head team orthopaedic physician for the University of Toledo Football.

Editor’s Note: Articles labeled Orthopaedic Risk Manager (ORM) are presented by the Medical Liability Committee under the direction of David H. Sohn, JD, MD, ORM editor.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

Email your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

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