Medical Ethics Don’t Make the Cut on Game Day

David Epstein, one of the more astute observers of issues surrounding sports medicine, did a question-and-answer session on the social-news site Reddit that’s worth a read. In it, the Sports Illustrated reporter (who will move to the news organization ProPublica in two weeks) discusses his new book, The Sports Gene: Inside the Science of Extraordinary Athletic Performance, which has been widely praised.

Here are a few takeaways from the interview that touch on NCAA-related medical issues:

Q. What policies would you like to see the NCAA put in place to improve the medical care of athletes? Do you think the NCAA is in a position to implement the changes you’d like to see? If not, who is?

A. I was just at a roundtable the other day with Dr. Brian Hainline, the first chief medical officer of the NCAA, and I asked him a few questions in that vein. We both agreed that the degree of influence that administrators and coaches in athletic departments have over sports-medicine personnel represents a widespread and troubling conflict. I really think that needs to change. [The Chronicle wrote about this issue last week.]

We see what happened in the NFL when the doctors are beholden to team officials and not to their patients, as is the case when you or I visit the doctor. I hope that Dr. Hainline will use his new position to push for that to change. I absolutely think that member institutions can make that change, but I think the biggest roadblock is the degree of control—whether explicit or implicit—that most colleges give to coaches in an effort to recruit them. It seems to me that management of sports medicine should be handed over to a college’s med school, not the athletic department, whenever possible.

Q. What do you think is the most ignored medical issue in sports today?

A. … The first thing that came to mind was the general dismissal of normal medical practices that occurs on an every-game basis in some sports. Why does “do no harm” go out the window just because it’s game day? For example: If a typical medical patient runs into a wall, a doctor won’t give him or her a painkiller to allow them to run into a wall again. Instead the doctor will say, “Don’t run into the wall again.”

So why, on the football field, is it OK for a doctor to help mask pain so that an athlete can go do something painful again? I understand why the athlete wants that in the heat of the moment, but shouldn’t it be a doctor’s ethical place to say, “If you’re in so much pain that you can’t run, I don’t want to mask that pain so you can hurt yourself even worse.”

If the athlete wants to continue, he or she should have to do so with full awareness of the body signals that are screaming “Stop!” On top of that, I’ve been with ex-athletes as they check into painkiller rehab—not pretty—and there is some evidence that frequent cortisone shots and the like can do real damage to ligaments in the long term. I just don’t understand why the ethical guidelines should change so radically for a doctor just because his team might lose. I can only conclude that the patient’s best health interest is not in mind. And that, to me, distorts the practice of medicine.

Q. What sport most needs people who know the science making the decisions?

A. Wow, that’s such a difficult question, and I think it depends on the goal. I think football clearly needs independent doctors and scientists managing injury and brain-trauma issues—urgently. Given the interviews I did for the end of Chapter 6 of my book, though, I’m convinced that soccer is losing many potentially outstanding athletes because the sport is simply not individualizing training appropriately. That’s a shame. It’s clear that all athletes should not be trained so similarly.

Q. What do you think about MMA [mixed martial arts] and the UFC’s [Ultimate Fighting Championship's] mandatory suspensions for concussions and other injuries while in the ring? In the UFC, athletes are suspended for three months with no contact during training until cleared by a doctor. It seems like in other sports, like football, that athletes can suffer a concussion and are often encouraged to come back the next week and participate in a potentially full-contact game without repercussions.

A. I think being extra-cautious in this department is the prudent thing to do, given how little we really know about recovery from concussion. It’s quite clear that it’s easier to suffer a second concussion before the first has healed, and that suffering a second concussion before the first has healed can be devastating. In younger people—whose myelin sheaths have not fully formed around neurons—a second concussion before a first has healed can actually, in rare instances, result in death. And some MMA fighters are young people.

In Chapter 15 of The Sports Gene, I write about a gene that causes some individuals to have more difficult recovering from brain injury. And we aren’t screening for that gene, so we don’t know who those individuals are. So I think it’s appropriate to be conservative for everyone as far as return-to-play.

Lastly, it’s abundantly clear that current return-to-play protocols are not entirely grounded in science. Sam Slobounov, [a professor of kinesiology] at Penn State, has shown that concussed players who pass the most widely used return-to-play test seven days after a concussion essentially always are still impaired, and that that impairment shows up if they are given more-difficult virtual-reality balance simulations. That means that the current return-to-play tests simply aren’t difficult enough to determine when an athlete is truly ready to return to play.

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