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A Risk/Tolerance Approach to the Preparticipation Examination

Levy, David MD*,†; Delaney, J. Scott MDCM‡,§

Clinical Journal of Sport Medicine: July 2012 - Volume 22 - Issue 4 - p 309–310
doi: 10.1097/JSM.0b013e318257d799
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*Department of Family Medicine and Internal Medicine (PMR), McMaster University, Hamilton, Ontario, Canada

Dr. Daniel Levy Memorial Sports Injuries Clinic, Hamilton, Ontario, Canada

Department of Emergency Medicine, McGill University Health Centre, Montreal, Quebec, Canada

§McGill Sport Medicine Clinic, Montreal, Quebec, Canada.

Corresponding Author: David Levy, MD, 810 King Street East, Hamilton, ON L8M 1A9, Canada (

Dr Levy is the Medicine Director of the Hamilton Tiger-Cats Football Club of the Canadian Football League, the Toronto Rock of the National Lacrosse League, and consultant for the Hamilton Bulldogs of the American Hockey League. Dr Delaney works as a consultant for the Montreal Alouettes Football Club of the Canadian Football League, Montreal Impact Soccer Club in Major League Soccer, and Cirque du Soleil.

Received November 1, 2011

Accepted March 28, 2012

Hippocrates once wrote, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” This dictum is well known to physicians and most often we are able to practice this simple medical commandment free from outside influence when assessing and treating patients. The sport medicine physician who works with elite athletes and professional teams, however, may be affected by influences other than the athlete's best interests. Whether these influences are financial, professional, or personal, there are a multitude of outside pressures that may knowingly or unknowingly affect a team physician's behavior and decision-making process.

Financially, there may be incentives for the physician to maintain his or her affiliation with certain athletes or organizations. Team physicians often receive a salary from the organization or individual athlete. In the United States, many physician groups or health centers pay to provide care for professional clubs, presumably, at least in part, to help promote and advertise in an effort to increase their public profile and ultimately patient volume. As such, a loss of association with the team or athlete can have a negative impact on revenue for the individual physician or physician group. Professionally, an association with high-level athletes can translate into speaking engagements, travel, involvement with funded research, and selection to different committees. Personally, a degree of public prominence may evolve for the physician involved with elite and professional athletes. In this age of 24-hours-a-day sports coverage, it is not uncommon for a physician to be seen on the sidelines with the team during television coverage, have his or her name mentioned in the print and electronic media, or be referred to by name on sports talk radio.

The recent resignations of the co-chairs of the National Football League's committee on mild traumatic brain injury have focused attention on the possibility of outside influences affecting physician's behavior. The resignations occurred after the National Football League Players Association expressed concerns that one of the co-chairs was too biased to lead the research and policy group on brain injury.1 Some athletes may believe that team physicians are more loyal to the organization than to the individual athlete. In an era when many sport medicine physicians patrol the sidelines, dressed in team clothing similar to coaches and ancillary staff, we should be aware that our appearance may undermine the view of the physician as an impartial party, one whose primary goal is to care for the injured athlete.

Ideally, all patient-related assessments and decisions occur in a vacuum, with the patient's best interests as the sole motivation. Realistically, this is not always possible because physicians are human and susceptible to outside influences. One need only to examine the effects of the pharmaceutical industry on some physician's behavior and prescribing practices to realize just how easily influenced we can be.2,3 Perhaps, it is time for us to take a step back and deliberately untangle ourselves from at least one aspect where bias and influence can affect our decision-making process: the preparticipation examination. Physicians associated with professional teams and athletes are likely aware that there is probably no more crucial interface between the player, team management, and the medical staff than that which occurs when decisions are made at the preparticipation examination. We are not merely viewed as a doctor about to conduct a preparticipation examination, but to a professional athlete, we are now seen as the gatekeeper between the player and his or her ability to pursue a livelihood. If we identify physical problems that may affect performance or predispose to more serious medical issues, then we, in their eyes, can potentially end their careers—quite suddenly with the stroke of a pen.

For many professional players, sport is their means to financial security. This is especially true for those athletes who have only partially completed a university education. Sport is often the best avenue, with their education and skill set, to earn a relatively lucrative living, doing something they love, and often working/playing only a portion of the year. Saying, “you've failed your physical” to just such an athlete is an ending, a door closed, and a real concern for their future financial security.

While absolute contraindications to play will always exist, there very often is a “gray area,” where a professional athlete with non—life-threatening musculoskeletal problems is permitted to play, often dictated by their perceived importance to the team. Frequently, these decisions are made after discussions between the physicians and management. We, as physicians, learn to understand that management decisions at this level are influenced by many factors, including individual contracts and league rules regarding when players can be released. Quite often, team management is understandably willing to tolerate a higher level of risk with an athlete to aid in achieving their own agendas. These decisions should rightfully be made by management and should be transparent to all the involved parties.

In an attempt to come to terms with the position into which “pass/fail” judgments put the medical staff and to remove physicians from being directly involved in “gray area” decisions, our group uses a different preparticipation assessment classification. Our system removes absolute responsibility from the medical staff in most cases while rendering the decision-making process more transparent. This classification system was developed to help the players and management understand how we rate an athlete's physical ability to compete and contribute to the team all season.

Our approach is one of risk/tolerance involving all concerned parties. After a thorough physical examination and close scrutiny of the individual player's history, the medical staff assesses the level of risk that a player will be unable to perform or safely compete both initially and over the course of an entire season. The medical staff then sorts the players into 1 of 4 classifications based on our assessment of risk.

  1. Class 1: Healthy—low risk
  2. Class 2: Some health concerns—moderate risk
  3. Class 3: Significant concerns—great degree of risk
  4. Class 4: Risk too great from MEDICAL point of view

There are always cases where, for medical reasons, a player must not be allowed to participate in a contact sport, such as professional football (Class 4). With this classification system, in cases in which an absolute contraindication does not exist, the medical staff is not “passing” or “failing” an athlete. We are just sharing our risk assessment with management and with the player. It is then the management's ultimate task (owner/president/team manager/head coach/assistant coaching staff) to decide on their level of tolerance of each player's assessed risk.

The scenario may unfold where a particular player has the skills that the team needs, and management may have a much higher tolerance for the risk that he or she may not complete the season, knowing that their contribution, while healthy, is paramount to the team's success. Also, knowing ahead of time that a player is at “high risk,” management may try to find a suitable backup player for that position. In this way, they are forewarned and prepared for any eventualities.

A player needs to know our concerns with their health status. This is of vital importance for their own safety and aids them in the decisions they make regarding continued participation in sport. If a player has an injury or condition that can be reaggravated and/or worsened in a high impact sport, they need to be made aware of the risk that they are accepting by continuing to expose themselves to the inherent perils of the sport.

If all parties are made aware of the classification system and the “risk/tolerance” decision-making process, then it is truly a transparent system, which can serve to inform and to help everyone involved. This process can be used for preparticipation examinations with any willing team, regardless of the sport. As physicians, using this system, we are able to remove ourselves in most cases from the absolute responsibility of having to decide a player's professional and financial future when many other factors besides the athlete's health and physical status are involved in the decision process. In this way, we can conduct ourselves in a manner that is “for the good of my patient, according to my ability and my judgment,” with no intention of doing harm to anyone.

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1. Fendrich H. Ira Casson, David Viano Resign: NFL Concussion Experts Were Under Attack. 2009.
2. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283:373–380.
3. Campbell EG. Doctors and drug companies—scrutinizing influential relationships. N Engl J Med. 2007;357:1796–1797.
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