Primum Non Nocere

1. Primum Non Nocere Ethics In Sports Medicine Where Do You Stand? Danielle Mitchell, MD University of Tennessee College of Medicine Erlanger Health Systems Primary Care Sports Medicine SEATA Conference March 2013

2. Objectives • Discuss • Traditional Patient Care Model • Sports Patient Care Model • Areas of Concern: • Autonomy of providers • Impacts of non-medical staff • Effects of Business Relationships • Who pays who? • Contracts? • Role of the NCAA? • Areas for improvement

3. Traditional Patient Care Model • Patient well being is primary goal • Patient presents to outpatient/inpatient medical facility • Patient sees Medical provider: • Physician • Physician assistant • Nurse Practioner • Associates of medical team help execute the medical plan under the supervision of a team leader (physician, physician assistant, nurse practioner)

4. Traditional Patient Care Model • Treatment of ailment is primary focus • The illness or injury “takes its course while treatment is provided”

5. Traditional Patient Care Model • Treatment of ailment is primary focus • Outside pressures/obligations that patient may worry about: • Return to health • Return to work • Return to family life • Return to recreational athletics **acceptance of letting the patient take time to heal**

6. Sports Patient Care Model • Is patient well being the primary goal? • Issues of athletes playing with injury • Rapid return to play • The pressure of being able to compete

7. Sports Patient Care Model • Patient presents to athletic trainer and/or coach as their first point of contact when illness or injury occurs • Are patients assessed by ATC? • Not always

8. Sports Patient Care Model • Are patients always assessed by ATC? • Do coaches and support staff give medical advice? • Ex: Prescribing (recommending supplements)

9. Sports Patient Care Model • Are patients always assessed by ATC? • Medical advice being given by medically naïve staff? • Ex: when to not be or be seen by doctor? • Are the goals of the non-medical staff the same as those of the medical staff? • How “invested” in the competition of sport is the medical staff member? **Words of caution: can a medical staff member heavily invested in your teams’ win/loss record jeopardize your medical judgment when it comes to return to play issues? • Example: what makes a good team physician?

10. Sports Patient Care Model • Ideally a patient presents to ATC • Initial “triage” of patient occurs • Issues around scope of practice • When is it appropriate for an ATC to refer the patient to see the team physician?

11. Sports Patient Care Model • Tennessee State Law Regarding Scope of Practice in Athletic Training: • Tenn. Code Ann. § 63-24-101 (2011) • 63-24-101. Chapter definitions. • (2) "Athletic trainer" means a person with specific qualifications as set forth in this chapter, who, upon the advice, consent and oral or written prescriptions or referrals of a physician licensed under this title, carries out the practice of prevention, recognition, evaluation, management, disposition, treatment, or rehabilitation of athletic injuries, and, in carrying out these functions the athletic trainer is authorized to use physical modalities, such as heat, light, sound, cold, electricity, or mechanical devices related to prevention, recognition, evaluation, management, disposition, rehabilitation, and treatment; an athletic trainer shall practice only in those areas in which such athletic trainer is competent by reason of training or experience that can be substantiated by records or other evidence found acceptable by the board in the exercise of the board's

12. Sports Patient Care Model • What is considered appropriate scope of practice for an ATC when the team physician is not present to supervise? • Examples: • Concussion clearance? • Suturing? • Fracture care? • Initial triage of injury vs prescription of treatment • Ex: knee pain

13. Sports Patient Care Model • Scope of practice of an ATC rests on the trust ESTABLISHED between the Team Physician and the ATC • ATC is practicing under the license of the team physician

14. Sports Patient Care Model • Scope of practice of an ATC rests on the trust ESTABLISHED between the Team Physician and the ATC • Time to establish trust • Turnover of ATC staff (also team physicians in some institutions) • Not having enough interaction • Team physicians who do not participate regularly in training room • How much do they really know about the skill of their medical team?

15. Sports Patient Care Model • Scope of practice of an ATC rests on the trust ESTABLISHED between the Team Physician and the ATC • Skill of the ATC • Skill of the team physician

16. Sports Patient Care Model • Is treatment of the medical concern really the primary focus? • Outside pressures/obligations: • Return to school • Return to sport • Return to family life • Where is return to HEALTH???

17. Sports Patient Care Model • Nuances of the Athletic Population • The nature of what a student athlete does predisposes them to an injury and illness • Schedules • Extremely demanding balance between school, sport, personal life • Risk of sport • Contact sports, heavy travel schedules, season of sport, etc • Evidence from Training Room Clinic • High number of patient visits for a small patient population

18. Sports Patient Care Model • The “business” of medicine • Do business contracts between entities affect patient care? • Common models • University owned model • Hospital contracted model • Hybrid model

19. Sports Patient Care Model • The University Model • University “owns” it’s health services • Employs all medical staff • Reporting structure: • ATC reports to whom? • Should coaches have a say about who is hired/fired within the medical team? • Should an ATC and/or team physician report to an athletic director?

20. NO!

21. Sports Patient Care Model • Hospital Contracted Model • University “contracts” health care services to a hospital • All or part of medical team is employed by an outside health care institution • Example: • University pays hospital for medical services • Team physician employed by hospital • ATC’s employed by hospital

22. Sports Patient Care Model • Hybrid Model • University “contracts” some portions health care services • Part of medical team is employed by an outside health care institution • Example: • Team physician employed by hospital or internally • ATC’s employed by hospital or internally

23. Sports Patient Care Model • Issues with university and hybrid models • Medical staff reporting to non-medical administrators (i.e., an athletic director) • What happens when there are patient care issues? Dysfunction between the team physician and an ATC? Dysfunction between ATC’s? • Inappropriate care delivered by ATC? • Inappropriate care delivered by physician?

24. Sports Patient Care Model • Issues continued • The business relationship (“the contract”) can supersede patient care • Ethical issues when a health care institution “pays” to be the medical provider for a university? • Drug companies are not allowed to “buy off” physicians

25. Sports Patient Care Model • What is the role of the National Collegiate Athletic Association (NCAA)? • The NCAA created bylaws which define the roles and responsibilities of the university athletics program • Generally speaking, NCAA bylaws state the university will essentially protect the well being of the student athlete

26. Sports Patient Care Model • The role of the NCAA and bylaws continued: • Universities must adhere to these bylaws • The bylaws extend to cover medical standards and sometimes specific recommendations related to participation in each individually sponsored sport (see NCAA Sports Medicine Handbook)

27. Sports Patient Care Model • What happens when a bylaw is violated and a complaint is filed against a university? • The complaint becomes confidential • NCAA then chooses whether to proceed to investigate or not • No further information is released to the entity filing the complaint

28. Sports Patient Care Model • The role of the NCAA continued: • How much accountability really exists in the system? • How “bad” does it have to be for the NCAA takes action? • Penn State Tragedy • $60 million fine • Banned from postseason play including bowl games for four years • Vacate its 112 wins from 1998-2011 • Lost 10 initial scholarships — given to first-year NCAA athletes — for four years beginning in 2013-14 • Will drop its total number of scholarships from 85 to 65 for four years beginning in 2014-15 • Put on five years' probation • What happens when student athletes are harmed by people in a university and/or hospital system who are supposedly there to protect them?

29. Sports Patient Care Model • How many cases of harm caused to student athletes that are linked back to the university and/or medical team exist on public record? • Search results for phrase “NCAA athlete harmed medical” • “Should NCAA athletes be paid?” • Litany of articles on under-insured athletes harmed during participation in sport and then “stuck with the bill” • Very few hits directly related to search • Are NCAA athletes simply not being harmed? • Is this issue not being reported??

30. Sports Patient Care Model IT IS TIME FOR A NEW APPROACH

31. Sports Patient Care ModelA NEW APPROACH! • New Model of Care: • University training room clinics should be licensed and accredited by the NCAA and/or an outside neutral organization

32. Sports Patient Care ModelA NEW APPROACH! • Licensed and Accredited Athletic Training Medical Programs • Similar to what happens with physician training at the resident level • Must adhere to accreditation standards set forth

33. Sports Patient Care ModelA NEW APPROACH! • Licensed and Accredited Athletic Training Medical Programs • Accreditation standards created by AMSSM AND NATA AND NCAA • Must pass routine site visits • If quality standards are not being met then the site visit is not passed • If the site visit is not passed then the athletic training program is put on probation and/or shut down until the issues are addressed

34. Sports Patient Care ModelA NEW APPROACH! • New Model of Care Continued: • Athletic Trainers should be supervised by a designated team physician who is involved with the daily workings of the athletic training room • Team physician responsible for: • Defining and enforcing medical standards • Providing routine evaluations and official reviews for ATC’s

35. Sports Patient Care ModelA NEW APPROACH! • The medical team reporting structure: • ATC’s report to the head team physician • The head team physician reports to: • The chancellor of the University and/or medical director of university health services (if the health services are university owned) • The medical director of sports medicine and/or the chief medical officer of the hospital (if the health services are contracted) Medical personnel report only to medical personnel

36. Sports Patient Care Model • Distilling it down to the basics….. • Act with your patient’s health as the number one priority • Be of sound moral character

37. Do the right thing

38. THANK YOU