THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 1 - JANUARY 99
New Team Doc Group Combines Educational, Business Goals
A number of physicians who care for professional athletes have formed a new sports medicine group, the Association of Professional Team Physicians (PTP). The organization is something of a new breed: a hybrid of professional association and private business concern, dedicated to improving care for active people, educating patients about sports medicine, and developing and evaluating sports medicine products.
In polished marketing publications, PTP is forthright about citing its members' prestigious connection with pro sports. For example, a stylish four-color brochure introduces the group by saying, "PTP is a coalesced group of physicians who treat the world's greatest athletes," and boasts that PTP has "best of class specialists in every US and several Canadian metropolitan regions." And the group is not reluctant to make money from its product review and development programs, as its background materials make clear.
A New Organizational Concept
Founded in 1996, PTP is the brainchild of Norman Scott, MD, an orthopedist and head team physician for the New York Knicks, says Dean Howes, chief executive officer of PTP. He says Scott sought a more efficient way to meet his patients' growing demand for sports medicine information. Howes says PTP's goal is to work with commercial partners to carry sports medicine information to consumers.
According to background materials provided by PTP, the group is a private corporation headed by a full-time business staff with offices in New York City and Orange, California. Each team physician on the 97-person "board of fellows" has the option to invest in PTP. A seven-physician advisory board serves as an executive body and makes such decisions as whether to distribute a portion of company revenues to the fellows or devote it to charity or research, as it did in 1998 with a $40,000 contribution.
The board consists of physicians from US and Canadian professional sports teams as well as physicians who work with elite groups such as the Professional Golf Association, the Ladies Professional Golf Association, US Soccer, and the New York City Ballet. Howes says PTP is currently inviting college and high school team physicians to join the PTP "community." The centerpiece of the PTP community, he says, will be an interactive Web site that will be launched in early 1999.
According to PTP, 71% of its members are orthopedic surgeons, 18% internists, 7% family practice physicians, and 4% other specialists. The board of fellows includes 26 physicians from National Basketball Association teams, 17 from Major League Baseball, 11 from the National Hockey League, 9 from the Women's National Basketball Association, 3 from Major League Soccer, and 3 from the National Football League.
It's not easy to pigeonhole PTP. According to background materials provided by the group, its wide-ranging areas of emphasis include:
Getting the Word Out
Howes says PTP is meant to supplement, not duplicate, established sports medicine groups. Traditional sports medicine organizations focus on the sharing of academic information between physicians, whereas PTP focuses on physician-to-patient communication. "PTP gives this relationship a business interface to make it happen at the pace of business and industry," he says. "Most physicians are still a little hesitant about this."
William E. Straw, MD, a PTP fellow (San Jose Sharks) and family physician in Los Altos, California, says that team physicians' experiences speaking with the media about pro athletes' injuries give them an appreciation of the power of the media. "Collectively we can have a bigger voice that may be able to address public health issues such as concussions or heat illness," Straw says. "We're not smarter than other doctors, but we're more identifiable."
The media link that PTP provides between team doctors and journalists is a useful benefit for members, says Straw. For example, when a team doctor cannot comment on an athlete's knee injury because of confidentiality or restrictions from team owners, another PTP member with knee injury expertise can provide journalists with comments.
Preston M. Wolin, MD, PTP member (Chicago Fire of Major League Soccer) and orthopedic surgeon in Chicago, says that though most sports leagues have their own team physician groups, "We need to have easier cross-links to talk across all of the constituencies." For example, he says the groin injury protocols used by soccer team physicians would be extremely helpful for pro hockey team physicians to know about.
Adopting a Business Model
Thomas Mayer, MD, MBA, an independent healthcare consultant based in Huntington Beach, California, says that though he doesn't endorse the idea of physicians "branding" their specialty, he understands that current trends create a fertile environment for the PTP concept. "The recent trend is to look at healthcare as a business, so now other business concepts are intruding—marketing, branding, and endorsements," he says. "You can't condemn doctors when they do things business does." Mayer is executive director of managed care education for Healthcare Advancement, a California-based nonprofit foundation.
In healthcare, prices and reimbursements are going down, and physicians' incomes are stagnant, says Mayer. "When markets are constrained, people develop little niches that they can be successful in." PTP has a unique niche, and it will probably be successful, he adds. "Team physicians have the recognition; they're taking care of a high-priced commodity. In the patients' eyes, it's a powerful marketing tool."
Another trend that may have helped spawn the PTP concept is the dramatic success of direct-to-consumer pharmaceutical advertising, Mayer says. Managed care organizations changed the relationship between pharmaceutical representatives and their physician "customers," he says. "Now pharmaceutical companies are directly marketing to patients. There's some thrust of that here with the PTP."
A PTP brochure urges consumers who are looking for excellent sports medicine products, "Just look for the PTP and Stardox icons!" But with the badly fumbled endorsement deal between the American Medical Association (AMA) and Sunbeam fresh in physicians' minds, some may question the appropriateness of any product endorsements by physician groups.
Some physician groups and other health organizations do have long-standing product endorsement arrangements. Examples include the American Medical Women's Association's endorsement of Nature Made vitamins, the American Cancer Society's relationship with the Florida Department of Citrus, and the American Dental Association's "Seal of Acceptance (1)." But unlike PTP, these groups are nonprofit organizations.
Where is the line between an ethical and unethical endorsement deal? The AMA crossed the line when it agreed to endorse Sunbeam products before evaluating them, says Howes. Several of the Sunbeam products got low rankings from consumer groups (2).
Mayer says the huge amounts of out-of-pocket money that patients are spending on healthcare products and alternative therapies are understandably tempting to many physicians. He says some physicians sell vitamins in their offices, and some dermatologists are selling an exclusive line of cosmetics. "Hopefully, the PTP is not just looking at money, but quality as well."
Straw says he understands that some physicians might be uncomfortable with PTP's commercial ties. "The antiendorsement sentiment fits in with a very strict purist view," he says "Endorsements themselves aren't bad. If you're careful, there's nothing wrong with them." Straw says PTP doesn't endorse companies, only certain products. "We help design products—products that fit in with our philosophy. We're careful; we solicit a wide range of opinions."
For ethical reasons, physicians long ago stopped filling prescriptions in their offices, says Mayer. The physician endorsement trend seems like "the first step of a slippery slide down the hill," he says. The public doesn't want to believe that doctors practice medicine to make money, he adds, but "the reality is that they practice medicine to support themselves."
High School Association Declines National PPE Form
The National Federation of State High School Associations (NFHS), while endorsing preparticipation exams as important, has declined to move toward establishing a national standard form for the exam. In explaining the decision, NFHS officials cited differences in local conditions and state laws and said member state associations have not asked the group to develop such a form.
In response to a recent report in The Journal of the American Medical Association (1) that criticized portions of the PPE forms that most states use, the NFHS sports medicine advisory committee discussed the idea of a national PPE standard at its meeting in mid October. According to an NFHS press release, the committee concluded that adopting a standardized form would not be practical because state laws and local conditions vary. Instead, the committee issued an advisory statement that was adopted a few weeks later by the NFHS board of directors.
The advisory statement stipulates that:
David W. Glover, MD, coauthor of the JAMA report that identified the PPE inadequacies, said he was disappointed that the sports medicine committee did not take a stronger stance by adopting a PPE form. "We've proven that the current system hasn't worked. I don't see this as a major step forward," says Glover, a family physician practicing in Warrensburg, Missouri, who has collaborated with the NFHS as a liaison from the Missouri State High School Activities Association and the American Medical Society for Sports Medicine. "What seems clear-cut medically has been bogged down bureaucratically," he says.
In a statement released to The Physician and Sportsmedicine, the NFSH counters that its powers are limited by the agenda set by the state associations and by the voluntary relationship between the NFSH and the state associations. "For good and valid reasons, our member state associations have not asked us to promulgate a standardized preparticipation form," says the NFSH.
In its statement, the group says PPE forms are useful tools and that it provides its members with access to bibliographies of forms. "State high school associations can use such information in conjunction with input from physicians, attorneys, and state healthcare regulators in the development of appropriate forms within their individual jurisdictions," the NFHS says. Officials also note that states vary in their health regulations and that risk factors can vary by locale.
The JAMA report that spurred suggestions for a national PPE form found that eight states had no approved PPE forms; among the states that did have forms, many lacked cardiac screening questions that are recommended by the American Heart Association (AHA). The report also highlighted discrepancies among the states regarding the medical qualifications of those authorized to perform the exams.
Jerry L. Diehl, NFHS assistant director, has said that if the group adopts a standardized PPE form, enforcement would be difficult because federation membership is voluntary and the NFHS does not have a role in state association governance. (See "Study Critiques Cardiac Screening of Athletes: Time for a National Standard?" September 1998, page 15.)
The push for a national standard will continue despite the setback, Glover says. "I still feel they [the NFHS] are the logical choice [to set up a standard]. But we may have to change our angle," he says. Glover urges physicians to continue pushing for the adoption of state PPE forms that include the AHA's 13-point PPE cardiac exam (2). He also suggests that the multispecialty PPE monograph (3) should be revised to incorporate all 13 of the AHA's recommendations (it currently covers 10). "If you're following the monograph, that's pretty good—but it's not perfect," Glover says.
A Lifesaving Ticket Surcharge?
About 25 defibrillators and 50 trained staff should be enough to cover a major sports venue, according to study coauthor Ann Peberdy, MD, assistant professor of medicine and chairperson of the resuscitation team at the Medical College of Virginia Hospital in Richmond. The authors assumed that each AED would cost about $3,000 and would be usable for 10 years.
The number of people who suffer cardiac arrests at sports events is unknown. "High-tension excitement associated with big-time athletics creates a fertile environment for these deadly attacks," Peberdy said, adding that annual attendance at sports events in the US totals 120 million. Traffic congestion around sports arenas often delays paramedics, Peberdy said. "That's where on-site defibrillation can make a huge difference at minuscule cost, yet many sports venues have delayed purchasing AEDs because officials believe the cost is far higher than it actually is."
US Olympians Clear Asthma Hurdle
In a press release from the University of Iowa College of Medicine, study coauthor John Weiler, MD, professor of internal medicine, said, "This study tells young athletes that asthma should not prevent them from competing in sports or even having the goal to win an Olympic medal." The study appeared in the November 16 issue of The Journal of Allergy and Clinical Immunology.
News About Sudden Death in Athletes
Sudden death occurs in about 1 in 200,000 high school athletes per year, according to a report published by Barry J. Maron, MD, and colleagues in the Journal of the American College of Cardiology. They report that of 651,695 Minnesota 10th-, 11th-, and 12th-graders who competed in sports between 1985-86 and 1996-97, three suffered sudden cardiac death. The authors noted that the findings may not be precisely representative of the nation because 95% of the athletes in the study were white.
Physicians should have a high index of suspicion for a coronary artery abnormality that originates from the wrong aortic sinus when athletes have cardiac symptoms such as exertional syncope or chest pain, according to a study presented at the American Heart Association annual meeting in November by Maron and a research group from Italy. To determine the clinical profile of the cardiac condition, Maron and his colleagues analyzed two large registries of US and Italian athletes who died suddenly after 1979. Twenty- eight deaths were attributed to a coronary artery that branched from the wrong side of the aorta. The group concluded that electrocardiography is unlikely to reveal the condition. The study abstract appears in the October 27, 1998, issue of Circulation.
Laser Pointer Pranks: A Danger to Athletes?
Press reports in various places have told of spectators who aimed laser pointers at athletes. For example, a fan was ejected from a New Jersey Nets basketball game last winter for such a stunt, according to an Associated Press article on the Web site of Philidelphia Newspapers Inc. And a number of school districts across the country have banned the pointers from schools, according to the online edition of the New York Daily News.
Are the beams just an annoyance, or is there a real risk of eye injury? Bruce M. Zagelbaum, MD, an ophthalmologist at North Shore University Hospital in Manhasset, New York, says the devices can cause retinal damage when directed at the eye for 10 seconds or longer.
"There have been two documented cases of eye injuries from laser pointers, and it is inevitable that many will follow," Zagelbaum says. Neither case involved an athlete. In one instance, an 11-year-old Phoenix girl had temporary vision loss after staring at the beam several times for several seconds each. In Delaware, a 13-year-old girl reported a burning sensation and temporary decreased vision after staring at the beam for about 10 seconds.
Zagelbaum says the American Academy of Ophthalmology cautions that laser beams are hazardous and should be kept away from children.