And welcome to what I hope to be a very informative and helpful session. We're going to spend the next 55 minutes or so interacting with our illustrious panel. But when I start, before I introduce them, I want to remind you all to go to your mobile phone apps and send us text questions that you feel are appropriate and helpful. This is a conglomeration of superstar medical people that deal with professional athletes on a very high level. I'm going to introduce you going from your left to right. First is Brad Nelson. He's the past president of the NHL Team Physician Association. He currently is associate professor of orthopedics at the University of Minnesota where he did his residency. He successfully completed a sports medicine fellowship, I think under Bob Sierra at West Point and served on active duty for 15 years in the U.S. Army. Sitting next to Brad is Margo Patoukian. She is chief medical officer of Major League Soccer. She's currently director of the athletic medicine and head team physician at Princeton University. Among many other accolades, she was past president of the AMSSM and currently serves as team physician for the U.S. Women's National Soccer Team. Next is Gary Green, who's CMO of Major League Baseball. He is currently research director of the league and has been instrumental in several rule changes that have improved the health and safety of all major league players. Next to him is Dr. Alan Sills, who's chief medical officer of the NFL. Dr. Sills is also professor of neurological surgery and orthopedic surgery here in Nashville University at Vanderbilt in Nashville. He earned his basic science degree in engineering at Mississippi State and did his medical and postgraduate training at John Hopkins. And last but certainly not least is John Fiore, sitting on the end. John is CMO of the NBA and currently is chief of primary care sports medicine at HSS in New York. He also was former president, like Margo, of the AMSSM and has coauthored several recent articles regarding COVID-19 and professional sports. So I've created a list of what I think will be interesting questions, some of which have been submitted by the panel in anticipation of promoting a very thoughtful and interactive discussion. We're going to start off with COVID, a topic that has obviously been on the minds and hearts of many of us over the past 15 months. So we're going to start off here with Brad. So Brad, COVID is one of the biggest controversies during your tenure, during everyone's tenure here. I'd like to start off with you, but ask each panelist to briefly give their perspective on the challenges they had to overcome this year in order to play their season. Yeah, thanks, Pete. I think the panel will agree that COVID was a significant issue, primarily because we didn't know much about it and everything adapted very quickly. I think one of the specific challenges with hockey is that it's a close contact sport played indoors, and in professional hockey, it's played in two countries. And so we dealt with both the American and Canadian health systems as we tried to kind of fit the game into their rules. Mario, if you have anything to add. Sure. So for us, I mean, we were, if you think back in terms of when sports shut down, it was early March and we were two weeks into our season. And I think the NHL was about to go to playoffs, as was the NBA. And you guys were about to go to your cactus season, right? So for us, it was really a challenge because initially it was just dealing with what are we doing? How are we going to provide education? Are we going to be able to get our season in? And then we quickly moved to really wanting to have the season be completed. And so we made the decision to have a tournament in the bubble down in Florida. We were first to do that. And that wasn't without its challenges. And I'll let these guys talk about some of the testing issues that came up and other issues related to indoor versus outdoor as you and John had to deal with. But for us, we're an outdoor sport. We really started this phased approach to return to play. And in early May, started individual training in our sites. And then late May, started group training with six people in a pod. And then finally allowed full return to play with testing prior to that, just before the bubble. And then we were able to go down into the bubble. And biggest lesson learned for us was that we didn't quarantine long enough. And so we ended up having two teams that within the first week of arriving to Orlando had outbreaks. So we had 22 teams, 22 individuals test positive in our isolation area in our hotel in Florida. And subsequently no positive tests after July 10th. We were down there from June 28th until August 11th. So we literally had 20 positive tests within the first week. And then no positive tests after that. So I think we sort of learned that the bubble worked. And we were very successful in pulling off 54 matches down in that environment. And then after the bubble, we ended up actually going to having two divisions, and a post-season, and a tournament. And really were successful in terms of being able to complete our season. I think... I think... Let's try and keep the answers to a couple of minutes, because we've got a whole list of questions to go through. Yeah, I think the thing that we learned was obviously that this was bigger than sports. And so when MLB, we first hit COVID, we were obviously in spring training. So our big challenge was when we resumed is we realized very quickly that we couldn't play in a bubble the way some of our other colleagues had. Because there just was not a place that had that many outdoor stadiums that we could play in outside of Florida and Arizona. And I don't think anybody was too thrilled with playing in the middle of the summer in those places. So one of the... I guess the challenge that we talked about was testing. Because it was very clear at that point in 2020 that there was not enough testing nationally. And we did not want to take away from the general population. So we took our drug testing lab in Salt Lake City, which was out of business because there was no sports drug testing being done. And they were converted into a virology lab. And the other big thing that we did is instead of... Those of you I know have had the nasopharyngeal tests, how uncomfortable that was. Well, we realized if we had to test people every day or every other day, that that was not going to be very acceptable to the players. So we worked on saliva testing. And we worked with a group out of Rutgers. And we were able to do saliva testing, which turned out to be convenient. And it turned out to be very acceptable and very accurate. And so we were able to do 200,000 tests in 2020 with about a 0.05% positive rate. And we ended up being able to play 900 games in 2020. We only missed two games. And we went 58 days without a positive until the very well-publicized last game of the World Series. So what we learned was we could play outdoors outside of a bubble. And I think that was helpful. And just the last thing is we had to deal with 30 different public health people. And that became a big challenge because every venue, every state and local authority had their own particular things that we had to deal with. Yeah, Pete, I would just quickly play off of Gary's last comment. I think one of the biggest challenges that maybe people didn't realize was just that, dealing with all these different public health authorities. You know, we have 32 different NFL teams that are in 30 different cities. And we literally have 30 different public health agencies, actually more than that, because the state levels would get involved also. And so I think sometimes people would say, well, why is the NFL doing this or that? That doesn't make sense. Those decisions are never made in isolation. Not that we could all sit around and make those decisions and enact them, but you've got to, you know, consider the expert medical advice, consider the input of the Players Association and the union and their perspective, and then the public health authorities. And we were dealing with that on a state, local, state, and federal level. So I think that's something that made it challenging for all of us because there was a wide variety of, you know, standards coming from those organizations. John? Well, I think, you know, there's so much to talk about, but I would say, you know, back in, you know, March, March 11th, and, you know, walking out of the NBA offices at 2 a.m. to now is just incredibly different. But I would say that our main goal was to make sure that if we were going to be able to play, that we had to make sure that our players were as safe or safer playing basketball than they would be in their communities. And we all like to practice evidence-based medicine. Well, there wasn't any evidence. We were talking to people all over the world and Australia and European soccer, trying to get as much information as we can. We, as like all of us, we had consultants that we worked with, but there was a big evidence gap and that made it very challenging, I would say. And perhaps the biggest challenge was not understanding completely what was going to happen from a cardiac standpoint. All the data we had prior to beginning our season in 2020 in the bubble came from hospitalized patients where there was a very high rate of cardiac issues. And so that was a major concern. And then we worked very closely with our teams, our team physicians, and the Players' Association. It was probably one of the most rewarding collaborative experiences that I can, I don't think I'll ever participate in. Many, many hours talking with our colleagues at the Players' Association. And, you know, I'll stop there, but I think in the end we had some policies and procedures in place that we had to continually adapt almost week to week. But again, I think it was the collaboration and communication that in large part led to success. All right, along those same lines, let's get a rapid response to this single question. How do you deal with players who refuse to get vaccinated? John? Yeah, so we, you know, we considered different options. We never proposed that to require that players would have to get vaccinated. And I think at that time, everything was still, you know, we were in season, we were just starting the season. And so there was a lot to be learned about the vaccines. So we created some policies and procedures that accounted for that. And we had a series of educational sessions with the players and the teams. And then I think what happened was a combination of, you know, hearing these educational sessions and then learning over time that the vaccine now being millions and millions of people is pretty safe. And then hearing from players who had gotten COVID who had struggled with it and continued to struggle with it after they got back to play. I think that made an impact. And so, you know, now we're almost finished the season, but, you know, the vast majority, more than 80% of the players are vaccinated. Yeah, I would say education and incentives. That's it. Working education. And education, by the way, is very much one-on-one, you know, trusted messengers. We can create all the PowerPoint slides we want to, all the great handouts, but it's really having a trusted messenger who can speak to questions and do those sessions. And then incentives, you know, the things that vaccinated people are going to be able to do, players that others will not. So if they're not vaccinated, are they given a separate protocol? That's right. So our unvaccinated players will continue to be tested daily. They have to wear masks in the facility. They have to practice social distancing. They can be out as a high-risk close contact, and basically they're in 2020 mode for all intents and purposes. If you're vaccinated, it's a whole other world. No mask, no distancing. You can get out, do social things. You're not out as a high-risk close contact. And just to echo that, when we talk to the players, the first thing they asked is, well, what do we get if we get vaccinated? Players are very goal-oriented. And so we really create a lot of incentives, a lot of carrots for them to get vaccinated. And we've been very successful. Twenty-five of our 30 teams are more than 85% vaccinated. And overall, all of the players of the league were well over 85%. So we feel like it's been very successful in that regard. And similar to Alan, those players who are vaccinated don't have to get tested. They don't have to wear masks. And those who are unvaccinated have more protocols to deal with. What about staff, like equipment managers and associate co-coaches and things like that that travel? One of the things that we all collaborate on is different tiers, so Tier 1, 2, and 3. So all the people who interact with the players are considered Tier 1 with the players. And we've had over 85% of our Tier 1 people vaccinated for quite some time now. Yeah, so I would only add that I think what's unique for MLS is we have such an international group. We have 73 countries in terms of our players. So a lot of the individuals that didn't want to have vaccinations, we really tried to get them to get education from either their peers or from other players. And I think the other thing that I would, the point I'd make is that the reason that these incentives are there is evidence-based. I mean, there is such a clear disparity between how people that are vaccinated should be treated versus those that aren't. Okay. Yeah, and I think it's the same in the NHL, a combination of education and incentive. There's not a mandate, and there's not a mandate right now with staff or people working in the arena. It's just encouragement and incentives. All right, we're moving ahead to performance-enhancing drugs. So this is a question. Let's start off with, let's see, let's start off with John on the end. Why have some professional sports organizations that you represent here adopted their own policies of performance-enhancement drugs and not signed on to those organizations that oversee a more international aspect of Olympic sports, such as the World Anti-Doping Agency? So our league does observe a lot of the WADA regulations, particularly related to performance-enhancing drugs and also with respect to IV fluids. We have a very strict policy regarding IV fluid administration. So for the large part, you know, we do at the NBA adapt that. Now, I think everything, as everyone here will tell you, everything's collectively bargained. So you can't just unilaterally adapt the WADA whole, you know, line of list. You've got to go through it literally line by line with the PA. So everything's a negotiation, but in large effect, we pretty much follow the WADA rules with a couple of exceptions. I think you can defer to me. Okay, I'll take that. So for, you know, for those of you who are sports fans, you may have noticed that baseball had a little bit of a steroid issue in the 80s and 90s. And so that was the reason I was actually brought on to work with MLB, was to develop a program. And, you know, the commissioner at the time and current commissioner Rob Manfred were very, very strident that they wanted to change the culture of baseball. And we've been able to do that. And there was a lot, to answer your question, Peter, there were a lot of people who felt that we, I was one of those people who was sat in those interminable congressional hearings for hours and hours. And there were a lot of people that thought that we should be signed on to WADA and to USADA. And we decided to go a different route. We hired a former Senator Mitchell to do an independent report, and we've adopted all of the recommendations. And people were skeptical that a league could police itself and change its culture. But we actually were able to do that. And I think we were able to do that for several reasons. One is we have the US minor leagues, where almost all the players come from. So we, those are not collectively bargained. Those are players not part of a union. And so we actually imposed a very strict anti-doping code there. And now as those players fed into the major leagues, this is part of their culture. And they adopted that and they've accepted it. And we've had a really big, good success. The other thing, as John pointed out, the law of the United States is that if you have a union, if players or workers are represented by a union, it has to be collectively bargained. A drug testing program has to be collectively bargained. So when we went to Congress and Congress was pointing their fingers at us and saying, change your, you know, you have to unilaterally put this in. You know, we said, well, you guys could change the law if you wanted to, and then we wouldn't have to do that. And obviously they didn't change the law on that. So we have to respect the laws of the United States to make sure that this is all collectively bargained. And that's what we've been able to do. But as John said, we use WADA-accredited labs. We use WADA very similar to the WADA-prohibited list. And we've been able to be very successful in reducing our performance-enhancing drug use to what I would argue is, you know, the best program in the world. You know, it sounds like just listening to you that you have already difficult jobs, all of you, but it becomes even more difficult having to deal with players associations, how much control they have on what can and cannot be done, and so forth. In general with that, I think that while we all have difficulties sometimes with our players associations, it's actually been very, very helpful to have them as a partner and represented. As you mentioned about COVID, you know, when we go to public health authorities and they would question some of our policies, we would say, well, this is collectively bargained. The union is on board with that. As John said, they have their own experts. And that had a lot of weight in terms of convincing public health authorities to move forward. Okay. So, moving on to the topic of concussions. And Alan, I'm going to start with you. How were your concussion protocols developed? And associated with that, the independent concussion evaluation program, in other words, the independent neurologist, appears to be successful. How difficult was it to be accepted by existing team physicians at the time? Yeah, well, first of all, I'd have to make one small edit and say most of our independent concussion doctors are neurosurgeons and not neurologists, so you can understand that distinction. But, you know, we've really had a process, if you look back over the last 10 years, Pete, that has certainly been a major change. And we have a committee, a head, neck, and spine committee, experts in the field who have written that protocol and have modified it based on the data, what it's showing us, what works and what doesn't. And that protocol has evolved, as you mentioned, to having independent doctors on the sideline, also spotters in the booth. I was one of the first group of those independent doctors on the sideline. I worked here. Certainly I would say at the start, we were not welcomed with open arms and doughnuts and banners, only because people thought, hey, who wants to have somebody? It's like having someone come in our operating room, right? Who wants to have someone come in the OR and look over your shoulder and decide if you're doing a good job or not? But I think what we evolved to was an understanding that, look, we can be better together. It's an extra set of eyes. It's an extra set of ears. And that really changed over the course of a couple of years, and we've seen that now to be a very collaborative process. Our team physicians work great together with those consultants, and the consultants have become an integral part of that. So I think it has been a success story. It's been accepted by the players, and the players have been an important partner. The Players Association, they participate in writing those protocols. And I like to say that really our current players have sort of grown up with a concussion protocol. You know, they've had it since they were in high school, they had it in college, so now they expect it. And so the idea that a player's going to resist being examined or not cooperate, we've just seen that go down substantially because they understand who we're doing, what we're doing, and why we're doing it on their behalf. So it has been, I think, a success story, and I think it's something that can be translated to other levels of play. You might not have spotters in the booth, et cetera, but the idea of having a focus protocol of giving every player the exact same exam, you know, done in a systematic way, I think those are broad lessons that apply to every level of sport, and not just football. Along the, or aside from that, at the, as these rule changes have been going on over the past six, eight years, at the Combine, have you noticed any lessened issues of concussions of college kids that are presenting themselves at the Combine? In other words, have the rule changes at the college level had a beneficial effect on players as they get evaluated at the Combine? Yeah, I don't think there's any doubt the rule changes have had a very beneficial effect, not just on concussions, but on total head impacts. Now, I don't have exact data that I can point to you to say that, but I think that's our gestalt feeling of everyone that's examining, and make no mistake about it, think back 10 years ago. Remember that on ESPN there was a show jacked up, with the best hits of the week, and you saw all these helmet-to-helmet hits, and it was loud rock music, and everybody said, yeah, great hit. Now, when you show that video at a meeting or conference, everybody goes, ugh, I don't want to see that. There's been a real cultural change, I think, in what's an acceptable hit, and what's a good hit, and what it looks like. So, I think that is progress, and it is trickling to all levels of play. Has the media that televise these things, are they sort of coached up as to, well, you really shouldn't be showing that five times? Yeah, we spend a lot of time with our media partners. So, one of the things I do before every season is we meet with all the crews, all the announcers on all the networks, and we go through our concussion protocol. We talk about what we're doing, how we're doing, why we're doing it, and we talk about the rules changes. And I would say they have been very good partners, and very good advocates for that, and I think that is important. But, you know, it starts at the top. We all know that in our leagues, young athletes look to pro athletes. They're gonna model their behavior, and so, as they see our game changing, you do see it coming down to other levels of play, which is certainly a positive step forward. So, we're gonna talk about performance metrics. You know, in today's digital age, and ultra-sophisticated electronics, the use of performance metrics as an outcome of injury management has become more and more common. Let's start off with Margo. Have you adopted those, have you adopted those changing environment where now you have all these metrics of work, and load, and things like that to your safety rules or protocol? It's a great question. I think, you know, for soccer, that is actually an evolving field, and certainly in European soccer, they're following those metrics quite often, and oftentimes, you know, putting it up on a dashboard, and using that as it relates to trying to figure out what's the interplay between injury. And I think we're a little bit, you know, trying to play catch-up in some ways to try to sort of see how those performance metrics actually do affect load and affect injury. So, you know, we're certainly looking at it, although I can't imagine that we're ahead of some of the other leagues in terms of looking. I think the NBA is further along in terms of some of the- Yeah, that's a good point. That's a great question. So, you know, I think if you look at the history of this, and I think Tim Gabbitt's here, but Maurizio Fanchini in Italy, and Alan McCall, who is a multi-global person, you look at the history of this, you know, the idea being that if you can use wearables, you'll be able to measure load, and monitor load, and moderate it so that you can try to prevent injury. And, you know, I think what's happened is that the data doesn't support that. We have not seen that happen in European soccer. We looked at our own rest policies and things like that. The last three years, teams are resting more, yet injuries seemingly are climbing. So we're not seeing that cause and effect relationship, and I think, you know, what we're learning is that you can't use that to predict injury. The other part of it isn't, like, again, go back to collective bargaining. Teams use this in training now, but we have to collectively bargain the use of wearables during games. And in order to do that, that is a massive lift. We work very closely with our players association. I think Ashish Bedi is here today, and we actually have a wearables committee. We contracted with a lab in Germany to independently test about a dozen different manufactured devices to measure their reproducibility and precision, because that really impacts the player. You know, if you're gonna use it for measurement at a team level, teams will use that information to determine, is that player declining as they get older? Is their speed up and down the court? Is their vertical? You know, all those quickness factors. Are they declining, and do we wanna reoffer him a contract, or are we gonna trade him? So those things are very important, as you can imagine, so it's very important for us to have good evidence base, you know, to try to make sense of it. I'll just add two quick points, Pete. One, I would actually disagree with John. We need a little controversy, right, to get the panel going. We've actually seen in the NFL that there has been injury correlation, particularly for soft tissue injuries early in training camp with some of the load metrics and the work metrics. Now we're just getting into that work, but I think there's definitely something there, and I think we're seeing that how we start that first two weeks in training camp has a huge impact, not only on injuries in that period of time, but really on injuries even throughout the season. The second point I was gonna make is something I'm really passionate about, Pete, and I think it's something we, as a sports medicine community, have to take hold of, and that is the issue of who sort of owns sports science, or what is sports science, right? Teams have now these sports scientists, and they're a variety of backgrounds. Sometimes they're kinesiologists, sometimes they're PhD analysts, sometimes they're team managers, physios, whatever, and they're gathering a lot of data, and I think there's still an unfortunate tendency to think of that data as sort of secret sauce. It's the proprietary thing that we have, that we do different, that makes us an advantage over your team or your team, and I think that's really a flawed way of thinking about it because if we're ever gonna understand, if there really is a relevance of some of this data to injury prediction and injury reduction, we have to pool that data, and so we've been making a major effort with our clubs to say, look, as one club, you can collect that data for 10 years. You're never gonna have enough observation power to really associate it with injury, but if we pool our resources together, 32 clubs or 30 clubs, now we can really begin to understand. So my plea, Pete, is I think we as team physicians, we have to get even more educated about what those parameters are, what can be collected, what types of data, what systems, and I think we have to really work collaboratively with the sports scientists, however they're defined, to correlate that with injury and to look at that as not just performance data like coaching, but it's really injury prediction and injury reduction opportunity there, and that's gonna require some ongoing education and dialogue. And Alan, if I can just piggyback onto yours is I think you make really good points, and it sometimes puts up the larger issue of where do these sports scientists fall in the organizational structure of the team because every team thinks they have the best answer to this and they know better, but I think for all of us, our experience is the ones that work better is when it's integrated and when the team physician really becomes the leader of that team and it becomes part of the medical part, and I think there's been a fracturing of that that's led to, unfortunately, the team physician is not having as much control over that, and I think the organizations that I've seen in my years that work best is when it's integrated and the team physician is kind of the captain of the ship and kind of oversees that. And just to echo, John, I think we have disagreements with our unions sometimes, but I think they're sometimes right to be skeptical of how this data is used. Players, for example, in baseball may have a incentive in their contract for a certain number of innings pitched per season, and if all of a sudden you decide that their one level is too high and you're gonna shut them down for the season, that could have implications on that player. So I think that the players, we have to work closely with them to make sure that they feel comfortable with this new technology. Yeah, I think in the NHL, about four years ago, we actually changed the term from head team physician to medical director, and that medical director has to be an MD or a DO, and they are captain of the ship. It sounds easy, it's not. As everybody knows, the sports performance folks kind of get in the mix, but I do think the most successful programs are when the team physician, the medical director's engaged in leading that program. Yeah, I would almost add the same thing, which is we have the club medical officer, chief medical officer for each club, and we actually rename one of our, we have vetted positions, we have certain positions that have to be in place, and one of them is the head strength and conditioning and performance specialist. And we specifically didn't say coach, we said specialist, and we had that as a vetted position for that reason. Okay, so, I mean, there are a lot of people in the audience that are devoted researchers, and I think we all agree that collective data that you have access to, either in your individual organizations or collectively in terms of more than one organization, is extremely valuable. So here's the question. How does a legitimate researcher get access to this wealth of data that you have, number one? And number two, how much influence does the respective players association play in allowing you to release that data to somebody, let's say, here and wants to do some legitimate research? Can I start? I can start. So, MLB, we have a research committee that reviews all the requests for research, and anybody can put in a proposal and have access, but you have to realize that this injury surveillance data is these players' personal health information. And as a result, it is protected and it's collectively bargained. So, for example, on our research committee, we have a representative physician from the players association who reviews the proposals and we can decide whether or not that should be released because all of us get, I'm sure, requests all the time from people who wanting to use our data and we wanna make sure that data is used properly, that the players' identities are protected. For example, if you have a one injury of a left-handed 32-year-old player who gets hurt in the middle of the season, everybody's gonna know who that person is. And so we really have to make sure that the players' privacy is protected. And as far as MLB, our criteria for approving research is what impact it's gonna have on professional baseball. And then we also give priority to people who are affiliated with MLB teams. But even if you're not affiliated with an MLB team, we still consider that. And I would encourage anyone who wants to submit research to us to become partner with somebody who's either a minor or major league affiliate and then that would assist them in getting their research proposals approved. Alan, any secrets on how to get access to that? No, I was gonna answer to your second question, which is how much influence do the players' absolute veto power? Ultimately, they have veto power. Absolutely, so there's no research request that can be approved without Players Association endorsement of it. We have a similar process. Ours is probably twice as long and cumbersome as Gary's is. But we have a committee and there are a number of steps that have to go through. And the grants are probably twice as big as the ones that we award. But ultimately, Pete, the players have absolute power for the reasons that Gary articulated. So I wanna remind everybody that if they have interesting questions, if they'd like to text, to log into their mobile app, click on Game Changers Session, go to the poll position and type in the question. So we'll talk about organizational topics. So we'll go quickly down the line. How were each of you selected to be medical directors in your respective sports? Yeah, well, I'm sitting in for Winna Moese, who's the medical director for the NHL. And we've talked about this. I think for Winna, it's probably true for everybody on the panel. Winna started as a team physician. He took care of the Calgary Flames for quite some time and had an interest or an expertise in injury epidemiology. So I think for him, it was sort of this progression over time from team physician with an interest in injury epidemiology to helping the league out with special projects to eventually becoming their CMO. I didn't finish asking this. Who do you report to? And since we're talking about players associations, how much influence, if any, do they have in the selection process of who the chief medical director, chief medical officer is? Yeah. Okay, so I've been the CMO since 2018. Prior to that, I was a primary care consultant. I'm still a consultant. But I think I joined MLS in 2015 in that role. And I think, I mean, at the time, I was serving on the NFL's head and neck spine committee and as an internist and primary care sports medicine physician. And I think sort of the bandwidth in terms of mental health and cardiac and some of the team physician issues is what sort of brought them to asking me to consider being CMO. Prior to that, it's been Dr. Larry Lemack. And I think there's also, in terms of the union, I don't believe they played any role in choosing the prior CMO or myself. And what was your third? What was the third? Oh, who do I report to? I report to the deputy commissioner of the league. I think the way I got to be medical director, I think a van pulled up and they asked me if I wanted to see a puppy. I think that was what happened. But no, I was, in 2003, as I mentioned, MLB started their drug testing program. And my expertise is in, I worked in performance-enhancing drug research. And so they brought me on board there. And then we were very successful. So in 2010, they asked me to become medical director. And I report to the commissioner's office and to the commissioner and John Coyles, who's the vice president for health and safety and labor. And I'm not aware that the union had any impact into my selection on that. So it's been a really successful partnership and working closely with the league. And I think one of the roles of the medical director is to be able to advise the leagues on where their liabilities are in terms of medical issues. And ultimately, it's their decision as to what they decide to do. And they're the ones who are taking the risks in these things. But I think it's incumbent on the medical director to really inform them as to where they have liability and where they're particularly vulnerable on certain issues. Yeah, I started working with the NFL as a neurosideline consultant in 2013, and then became chief medical officer in 2017. Actually met with the union and their medical leadership in the interview process. So they did have a voice in that. And Dr. Tom Mayer is the chief medical officer for the NFL Players Association. So we work really closely together. We're constant communication. He serves on all our committees that we have and so forth. And I report to the guy that signs the footballs. You know, I was at the time, 2014 was when I started with the league. I was at that time at UCLA, a head team physician. The league reached out to me. They didn't have a chief medical officer at that time. And I think they may have posted a job for a couple years. I don't know the whole process, quite frankly. But they reached out to me and asked me if I'd be interested. And then there was a process that followed that. I report, you know, ultimately to Adam Silver. And my day-to-day is with a senior vice president. We have a whole group called Player Health in the NBA, which is expanding, growing. And, you know, what I've learned, as Gary mentioned, the NBA is often referred to as nothing but attorneys. And so it's a day-to-day process to learn all the legal implications. And some of them are quite nuanced. And as Gary said, part of your role is not just from sort of the pure medical side of it, but how to package things in sort of a legal way that maintains, you know, protects the league. And also, again, I want to point out that we work very closely with our Players Association leadership. Joe Rogowski is the lead on the Players Association side. And they're involved in, you know, almost all of the processes that we entertain day in and day out. All right, we're going to move on to nonsteroidals and IV fluids. And we're starting to get a lot of questions from the audience. So let's try and wrap up as quickly as we can some of these next topics. So are there standard rules for toroidal use, using it immediately prior to games? And if so, how do those rules get decided upon and or enforced? I can start. We have a policy on toroidal. Basically, it's not used unless it's used afterwards. It's not used pre-game. It wouldn't be used to sort of prevent any type of, you know, pain. So it's used and it's preferably used in its oral form. So, you know, just based on the onset of action. So we have a policy as it relates to avoiding the use of it pre-game. But a chronic injury or an injury that occurred during a week of practice, you can't give it pre-game? Correct. What about IV fluids now, switching? So same thing, IV fluids, we have a policy that basically states that you don't use IV fluids unless it's severe dehydration and they can't take out oral fluids or significant heat injury where they can't take in oral fluids or there's blood loss related to trauma. So it wouldn't be, we wouldn't be, we don't use IV fluids at halftime. And is this like the honors, is this the honor system or is there actually? No, they'd have to apply for a TUE based on, you know, the WADA implications. Anything, anybody has a different approach than that? I was going to only add to your last point. We actually have a prescription drug monitoring program now. So every drug that's given at the club is logged into the EMR and each club gets a report out on that. And the players union does get to see that as well. So we were able to track opioid use, iamtoradol use, all those things on a season basis. And I think the NFL has done a really good job. Matt Metabo did a really good review on iamtoradol. And I think that that's been adopted by the leagues that, you know, unless there's a, there has to be a medical indication for both the use of IV fluids and iamtoradol. So going back to Gary here in terms of risk management, does your league require a risk exposure liability clause that professional athletes must sign? Oh, if that's for you, is that for me? For me? No, we don't. I'm not aware of a risk liability policy that we have. Anybody? All right, return to play issues. Do you insist athletes sign a waiver release when they want to return to play against medical advice? That's not been a formal policy. I think what we do in those situations, when we have a situation where there's a materially elevated risk, particularly of catastrophic injury, those players are then referred to what we call a fitness to play committee. And there's one representative from the NBA, one from the Players Association, and an independent person. so those types of cases go to that committee and they're, you know, basically reviewed and a decision is made and that decision is binding as agreed upon by the league and the players association. We have a similar thing that if there's a disagreement between the team and the player in terms of return to play, we have a procedure for an independent evaluation that they submit to. Same with us. Okay. If you could change one rule in each of your sports to enhance player safety, what would it be? I think probably in the NHL, I think one equipment modification that we've looked at is adding shot blockers. Puck injuries in hockey are becoming more and more of a problem and we know that players wearing shot blockers have a significant decreased incidence of fractures, but today we haven't been able to mandate that. Again, it's collectively bargained and the equipment change is a collectively bargained thing and so we haven't been able to get that passed. I would say that, you know, about 2010-11, the NHL passed rule 48, which made head hits illegal and that rule change has probably had the most dramatic decrease in injuries in the game. So for us, hamstring injuries are actually the most common injury, but there's not much that we can do as it relates to rule changes and we're limited as it relates to concussion based on FIFA and the laws of the game. So probably the, you know, one of the things that we have been able to do is make changes in terms of having a player discipline committee and sanctions for egregious hits. That has been pretty helpful. And if we could change one thing, it would be to have a temporary substitute for concussion so that we could actually do an appropriate evaluation of a suspected concussion. Right now we're limited based on the rules of the game in terms of substitutes. And so unlike any other sport here, we're unable to really evaluate that player. We don't have a substitution either. Yeah, that's true. So you know, one thing I would disagree with Margot on that, we looked into that also because baseball also doesn't have a substitution rule, so we can't take somebody out and evaluate them. We actually considered trying to change that and allow for temporary substitution. We actually decided that we were better off without that. And one of the reasons is because part of it is we have 162 games. So if you take a player out, the nice thing is there's no pressure to put them back in the game. And if the player comes out and they turned out they don't have a concussion, there's no, the manager, the player is not lobbying to get back in the game. They're out and they're done. And so we like that. But in terms of the one thing I'd like to change, Peter, the thing that keeps me up at night the most is a potential pitcher serious injury from a line drive. And we've had several epidural hematomas from pitchers hit on the right or left temporal artery. And we had a minor league player recently, Tyler Zombro, who was luckily treated quite well at Duke and survived his injury. But that's the thing that keeps me up. And we actually worked very hard to develop a pitcher head protection device. And we had our first one that actually was worn in the major leagues by a player, Alex Torres. He was, it was kind of big. He was called Super Mario and he was teased. And the hat went to the Hall of Fame. Unfortunately, Alex didn't. And we then developed a carbon fiber one that's quite expensive, really lightweight. And we haven't been able to get a pitcher to wear it in the game yet. But that would be my hope that eventually we could get a pitcher head protection cap that's acceptable to the players to reduce the risk of potential catastrophic or death in a pitcher. And that's kind of what keeps me up at night now. So just follow, so you make a recommendation like that and it goes up the organizational chart. How does it, when does it become a rule? Yeah, again. How does it become a rule? Like the other, you know, my other colleagues have said, you know, all of that equipment changes have to be collectively bargained. And you know, the Players Association actually supported our most recent cap that we did. They actually were part of the development. And unfortunately, we couldn't get any of the players to wear it. And we haven't been able to mandate that at this point. Alan, a rule change? Yeah, I mean, head contact, continuing to reduce head contact is an easy and obvious one. But I'm actually going to go a little different direction and say the punt play is really squarely in our sights right now. The punt play is the most injurious play in our games. There are more injuries of all types on that play. The injury rate's quite a bit higher than any other play. So I think we're going to have to look at some fundamental modifications to that, the same way we did with kickoff a couple of years ago. Because the reengineering of the kickoff did have the intended effect of reducing injuries. But the punt play stands out right now as an injurious play. John? Yeah, I mean, I think people are familiar with what we're trying to do to reduce head contact with flagrant one and flagrant two fouls in the league. And you know, we're constantly evaluating how that's working. And I expect there will be continued modifications to that. You know, one of the things that when I very first started, we were confronted with Paul George who fractured his tibia when he landed very close to the base of the basket, the stanchion. And we moved that back further. There's a lot of contact, again, different than football and soccer. But there's a lot of contact collision in the lane and around the baseline. And I would expect that we'll continue to look at that area carefully to see what we can do to modify that space. A lot of the injuries that we see are landing, you know, landing on top of players. And then, of course, the, you know, the hits to the head, which, you know, we're trying to control with the flagrants. I think just to add here, the other thing is, you know, we all want sports to be safer. But the balance we have to find is maintaining the integrity of the sport. You know, for example, in baseball, if we mandated that the pitchers can only throw 50 miles an hour, it would reduce the hit by pitch injuries. But that's obviously not within the spirit of the sport. So I think we always try and find a balance between maintaining the integrity of the sport while also trying to make it as safe as possible. Here's a question from the audience. So we'll go quickly down the line. Do you personally recommend that COVID vaccination be mandatory for players and personnel in your league? Yes. It's not going to happen, but yes. You know, I don't think so, no. You can't mandate it. You can educate and encourage, but. Okay. Yeah, I would agree. I don't think you can mandate that at this point. Yeah, ditto. As we mentioned, collective bargaining is not going to take us there. So I think it's a moot point for us. Agree. I don't think we'll be in a position mandating, but again, our policies and procedures will reflect their status. I'll pitch this one to you, Alan. With the value of sports contracts rapidly increasing, how can leagues partner with their physicians to mitigate liability risk to the individual physician? Are there any specific policies or procedures currently in place to address that? Yeah, I think it's a great question, and I do think it is something that we have to pay attention to. I think the contractual and the legal relationships between physicians and the clubs have obviously changed. I mean, you know, back 20 years ago, Pete, we all just kind of had a handshake, and we showed up, and we were the team doc. And so I think that we do have to be proactive about that now, and we have to address those concerns that you mentioned. But I think also there are pathways forward there, and part of the setup of our rules and our protocols and our collective bargaining agreements are to engender some protections for team physicians. So I think there are really more protections that might meet the eye because of the collectively bargained nature of a lot of these protocols. For example, the concussion protocol, COVID, et cetera. So I think that's something where it's a matter of the individual club physician partnering with the league. Because as John said, in New York, we employ a stable of several thousand attorneys that are happy to help with those issues, and so I think they can be a really good resource for team docs. And they make a lot of money, those lawyers. Yeah, you know, we've looked into that because we obviously want to keep the best and the brightest physicians possible taking care of our players, and I think that we have players who are at the top of their profession. We should have physicians at the top of their profession who take care of them as well, and we've been very concerned about the liability. We've actually looked into that, and part of it is, to be honest, it's hard to get all the physicians to agree on a single malpractice or liability. And so all the physicians have different contractual arrangements, and they come from different types of hospitals or organizations or in private practice. So that's been a little bit of a challenge to get a consensus on that. Does any of your organizations offer support for the enhanced malpractice liability that these team physicians need to carry? Not at this point. We've worked on it, but so far have not been able to come up with something that's acceptable to everyone. I think it's something that's critical. I think one of the things that we as a league, in collaboration with our players association, is our players need to have the best medical care. And you're asking an awful lot of team physicians, time commitment, expertise, navigating multiple communication levels with the players, their families, their agents, the coaches, and then you've got the liability. And so the last thing that we as a league want is to have highly experienced, committed team physicians begin to get weary of what they're dealing with. And we all have standards for what the credentials that are required. And it's really important to us, and I think to all of us, that we have the best physicians. And I think what you're talking about is an overlooked aspect of how we may not be able to maintain or continue to encourage highly qualified, experienced team physicians to be part of the league. So given the current notoriety with Carrie Richardson's proving positive for marijuana, is there anything being discussed in terms of rule changes regarding its use of detection? Well, I'll start. I mean, I think we've already adapted our policies over the last several years. Reflective of marijuana use, I think with the growing, you know, societal perception as well as the scientific data. But I think what we view as probably more important is the underlying potential mental health issues and wellness issues that that may reflect. And so over the last five years, we have really developed a much more enhanced program around the league. And so that's kind of the stance that we've taken. You want to take that? Go ahead. You know, one of the problems with, again, there are lots of drugs that are legal that are on the banned list. And you know, obviously we're looking at that. One of the problems with testing for cannabinoids is that it's very difficult to tell if this is recent or remote use. So part of the drug testing we're working on is trying to find ways to identify people who are acutely using, because obviously you want, it's going to interfere with hand-eye coordination and things and put players at risk if they're intoxicated at the time. So I think part of it is trying to determine, do better testing for what is acute use and what is remote use that may be just residual and not have much of an effect. Two quick points on that. One is collectively bargained, also like everything you've heard today. But secondly, Pete, we actually have an open RFP right now for a million dollars of grants to study particularly performance effects of cannabinoids and cannabis. Not so much acute, but even remote. Because I think that's an underappreciated area is, you know, what happens if somebody's used and 24, 48 hours later, how does that affect elite athlete performance? And so I'm really hopeful that we'll get some good high-quality research out of that, because we don't really have that data right now. All right, two more questions. Again, try and keep it somewhat short. What's the biggest need for future research in each of your respective sports? And if there's overlap, that's fine too. Yeah, I would say what COVID has shown is that there's significant potential in research done across all the leagues. So I think from my standpoint that, you know, having programs, you know, looking at hamstring injuries in soccer and baseball or, you know, concussions across the league, it will probably provide the most impactful data for safety. Yeah, I would agree. I think, you know, those are some of the biggest, bigger topics. And I think what we learned in our experience with COVID was how valuable that type of collaboration was when you looked at, you know, the cardiac complications of COVID. So, you know, we've, I've really enjoyed over the past year being included in some, you know, weekly calls that these guys started and extremely beneficial in terms of my role with MLS and being able to learn from their experiences and then being able to also, you know, collaborate moving forward with future research. Yeah, I think for baseball, it's obviously UCL injuries. You know, UCL has been called the most expensive part of anatomical aspect in sport. And we've done a lot of research in terms of trying to reduce UCL injuries. And in fact, we started a UCL registry with Dr. Chikadi and as well as Dr. Ahmad. And we're working on ways to identify risk factors for UCLs and how we can reduce the injuries. Because right now, about 25% of players in the major leagues have had at least one UCL reconstruction. So, for us, that's the biggest, you know, there's probably a billion dollars of lost salary on the injured list every year from UCL injuries. Low extremity soft tissue. And we come at that from the concept of injury burden. You know, we've really transformed from just counting how many injuries do we have to looking at time loss. And when we look at that graph of what causes players to miss the most time, hamstring injuries by far and away lead that graph. That keeps players off the field more than any other injury, which is surprising to a lot of people. But that's the highest burden injury. And so, we're really trying to take that graph of the highest burden injuries and use that to prioritize our research. Yeah, that's absolutely right. I mean, we look at our injury data year in and year out. And, you know, people think about ACLs. And, of course, that's a high individual impact. But there's about four or five a year across the whole league. Hamstrings, gastroc strains, lower spine, chronic spine injuries. I mean, these are the things that really take players not only off the court, but it affects their long-term, too. And I think what we're really looking at is injury prevention, which I think is what we're all talking about, is injury prevention and how do we create injury prevention programs that, you know, aren't sort of seen as, well, I'm not going to do that because my guy, my performance guy doesn't want to do it. How do we get those things implemented? And for us, you know, we've got a lot of young players coming in who already have a laundry list of injuries. And we're at a league. We're looking at how we can impact youth basketball and youth sport to try to keep kids healthy so that they can progress in their careers. And when they do get to one of our leagues, we're not already trying to manage significant chronic injuries. And a lot of our star players just, you know, they have a hard time, you know, lasting in the league because of preexisting injuries. So we're really looking at that. And I would only add that, you know, the second step of this is the knowledge translation because, you know, I mentioned before, hamstring is our biggest issue. And Bert Mandelbaum, I'm not sure if he's here, but he's done a tremendous amount of work with Holly Silvers in MLS to actually do a lot of work as it relates to what could be beneficial in terms of preventing. But being able to translate that knowledge to our clubs, to our medical staffs, and get away from what Alan was alluding to earlier where it's like, well, no, no, no, we have our own gig. Like, we know what we're doing. But not sort of being able to learn from, you know, the collective work that actually has already been done. To your state of curiosity, how often do you five people actually get together and maybe by yourselves and discuss things like this? Well, I guess I've been the medical director the longest. So, you know, previous to COVID, John and I would meet with Winn and Moissa and we would meet occasionally at meetings. But with COVID, we initiated a meeting in like last March because we realized we all had very similar challenges. Even though our sports are very different and have different demands, our challenge was the same of getting back on the field or on the court or the ice. And so we started meeting about in last March, about once a week. And we've once, sometimes twice a week. And what we found was sometimes the information changed during the course of our meeting. And so we've continued that and been able to collaborate. And I think we had we produced two papers this last year that came out of it. And in order to get five leagues to collaborate on a paper and their players association to sign off and the lawyers to sign off on the papers, I think that was the biggest challenge of all that I think I'm most proud of our work together this year. So here's the final question. Other than sitting here answering my silly questions, what's the most difficult part of your job? Start here. Yeah, I think it's hard for me to speak with when I think, and I'll let these come. My experience as being a team physician in the NHL and dealing with a chief medical officer has kind of been, you know, the docs have taken care of these teams for a really long time. And they're used to the kind of doing things a certain way and to have a chief medical officer come in and try to institute some uniform policies. It's been probably a little challenging for him. Yeah, for me, I think it's been, you know, sort of making the jump from being a team physician at a collegiate level my entire career. And then all of a sudden trying to apply that and being an advocate for athletic trainers and advocate for team physicians. And then all of a sudden making the jump to professionals where all of a sudden, you know, you're trying to say, this is what I think is in the best interest of the players. But there's this, you know, professional league and business and politics that, you know, supersede and sometimes overrule your medical decision making. I think the hardest thing is just patience and trying to get a large organization to make changes. You know, we instituted the home plate collision rule in 2014 and it probably took two years once we had the data to show that this was going to reduce concussions significantly in order to get all the parties on board. And so I think that's the hardest thing is just understanding and just being focused that you have a goal and you just need to keep at that goal and keep chipping away and eventually, you know, you'll get there. But that's probably been the hardest thing. Yeah, I would just amplify that. Learning about collective bargaining and what labor relations, you know, I didn't have any courses in that in my residency. And I think the other thing as a surgeon, we're used to doing things, right? We make a decision, we do it, or we write an order in the hospital and it happens. It doesn't happen that way here. This is much more like making a law in Congress. You've got to propose something and negotiate and ratify and compromise. And so learning that process and developing that patience that Gary spoke of is certainly different. John? Yeah, I would say that's exactly been my experience. I've been a head team physician at a major division one university. There's often a ton of communication involved, but this is a completely different situation even coming from that setting. You know, it's sometimes the most frustrating, but in the end, often the most rewarding because a lot of times the product that is delivered is much better than you initially thought it was going to be because of all the interaction, because of the collaboration. And so it's a little, the patience and being consistent. And then I think the other thing that comes in for all of us is we'll be working on some project that's been in progress for a year or two, and then something comes and all of a sudden we've got another issue to deal with and that gets pushed back and you have to keep coming back to it. So again, it's frustrating, but in the end, it's really rewarding because we're able to potentially have a favorable impact on a lot of people. Well, I'm going to close it with that. I'd just like to thank the panel for being very patient and interactive, and I hope the audience will appreciate all the information they shared with you as well. So thank you very much.

player safety

COVID-19 pandemic

protocols

vaccination

concussion protocols

head injuries

data collection

painkillers

rule changes

professional athletes