My coauthors and I would like to thank Drs. Marcus, Barnes, and Amendola for reading our editorial in Clinical Orthopaedics and Related Research® , and for their letter, which continues an important dialogue about the professional responsibilities of orthopaedic surgeons who work with American football teams.
Two important meta-questions underlie most of the concerns raised by Dr. Marcus and colleagues: (1) Whether the withdrawal of orthopaedic surgeons from sideline coverage (and other relationships with football teams) constitutes a form of patient abandonment, and (2) more generally, whether a recreational activity is too dangerous for us to validate it with our professional presence.
As I have noted  in response to an earlier letter that raised some similar concerns , our editorial does not recommend withholding care from injured football players. There is no question that that physicians and surgeons have a professional obligation to care for the sick and injured regardless of how they became sick or injured—whether they are smokers, soldiers, or football players. We must continue to meet that obligation. It is the right thing to do.
But we can care for injured football players without supporting and promoting the activity that injured them. We no more neglect our Hippocratic oaths by withdrawing our sideline support for football than we neglect those oaths by not being present at the scene of motor-vehicle accidents, or, indeed, by not being present on the sidelines of every sporting event where an injury might occur. Deciding not to provide sideline coverage at football games is no Hippocratic delinquency.
Precisely because we cannot be present everywhere, we must choose where to appear, and we should make that choice thoughtfully. This raises the second meta-question: Are some recreational activities so dangerous that they do not deserve our support? I believe the answer is yes, and because of that, I believe that our presence on the sidelines of professional football games does more to denigrate our Hippocratic commitments than would our absence. A conservative estimate suggests that 8% of professional football players will develop both pathologically evident and clinically symptomatic chronic traumatic encephalopathy (CTE) [4, 6]. More than a quarter of those with “mild” CTE in the recent JAMA died by suicide . If an 8% chance of developing a life-threatening condition from playing a game isn’t enough to cause us to step back, what would be enough? This risk might be easier to accept if we knew a solution was imminent. But no such solution is on the horizon; in fact, we have no idea whether our advocacy to “improve the rules, equipment, and care of athletes to make this popular sport safer for athletes” as proposed by Dr. Marcus and colleagues will succeed. Testing that bit of speculation will require running an experiment on another generation of young men’s brains. This should make us very uneasy. Physicians usually recommend avoiding potentially lethal exposures where possible, and I am not sure why are shying away from recommending that here.
The best thing we can do for the health of professional football players is to stop the game. Since that decision is not in our immediate control, the next-best choice would be to let the National Football League get its sideline coverage from others. This would force the league, the players (and the lawyers who might represent them in litigation beyond the billion-dollar CTE settlement already made ), and any healthcare professionals who might step in to answer the question “Why are those who know the most about this game’s effects on the human body walking away?”
Finally, the letter-writers were troubled because the editorial pointed out that collegiate and professional sideline coverage also financially benefits the surgeons, practices, and departments providing it. Dr. Marcus and colleagues note: “Most orthopaedic surgeons care for athletes and teams without any marketing agreements and, in many cases, without any compensation for their work.” This may well be true. But that portion of the editorial plainly pertained to collegiate and professional football teams. I would be astonished if any official NFL team physicians provide their services without a contract that includes a marketing component, and I doubt whether any department covering big-time college football would miss the lucrative opportunity to highlight this relationship as part of its approach to practice promotion. Importantly, nowhere did the editorial state or imply, as suggested by the letter writers that “orthopaedic surgeons are taking care of athletes purely as an advertising or marketing ploy or only for financial gain,” and I don’t believe this is true. I agree with Dr. Marcus and colleagues that the primary motivation behind these relationships is love for the game, and these providers’ deep concern for the athletes who play it. All the same, there is no question that money, sometimes big money, is a part of the equation at the elite levels of this sport.
Again, we thank Drs. Marcus, Barnes, and Amendola for reading the editorial, and helping to extend this important conversation by writing their letter.
2. Leopold SS. Reply to the Letter to the Editor: Editorial: Do orthopaedic surgeons belong on the sidelines at American football games? Clin Orthop Relat Res. [Published online ahead of print October 12, 2017]. DOI: .
3. Leopold SS, Dobbs MB, Gebhardt MC, Gioe TJ, Rimnac CM, Wongworawat MD. Editorial: Do orthopaedic surgeons belong on the sidelines at American football games? Clin Orthop Relat Res. [Published online ahead of print September 5, 2017]. DOI: .
4. Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML, Solomon TM, Nowinski CJ, McHale L, Cormier KA, Kubilus CA, Martin BM, Murphy L, Baugh CM, Montenigro PH, Chaisson CE, Tripodis Y, Kowall NW, Weuve J, McClean MD, Cantu RC, Goldstein LE, Katz DI, Stern RA, Stein TD, McKee AC. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017;318:360–370.
5. Rodeo SA, Taylor SA, Kinderknecht JJ, Warren RF. Letter to the Editor: Editorial: Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games? Clin Orthop Relat Res. [Published online ahead of print October 12, 2017]. DOI: .