Ladies and gentlemen, please welcome your moderators, I want to welcome you here to our session, Risky Business, Keep Your Legal Briefs On. We'll have a couple of presentations by Eric McCarty and Chris Amad. So I'll introduce Eric McCarty from the University of Colorado. His talk is entitled, Team Physician Considerations of the New Frontier of Amateur and Collegiate Athletics. Eric? Thank you, Riley, and a pleasure to be here. I appreciate the opportunity. This is a great topic, and I thank you and all the audience that's here. Now, I'm waiting for my first slides. I can't see them. Are they up? Okay. There we go. Anyway, thank you for the program committee. You guys are doing a fantastic job, too. Allison and John, thank you. Thank you very much. Speaker, disclosure. So college athletics in 2024, what are we dealing with? I mean, it's a changed environment. NIL, transfer portal, social media, mental health, malpractice. So a lot has changed since the 1950s. A lot has changed since the 1980s when I was playing in those old uniforms. And a lot has changed even since the 2010s. 2021, things changed incredibly in college athletics. The transfer portal's rules changed. So before that, an athlete had to sit out a year if they transferred. In 2021, they could play immediately. And look at the change in the numbers of transfers that occurred from the years of 2018-19 to 21, 22, 23. I'm dealing with it in a big-time way. Coach Prime, who I absolutely love and endear with, this year, we had 41 transfers in, 44 transfers out. From a few years ago, we hardly have anybody left on that team that was there. So I'm dealing with this in real life. So it is changing college sports. But also what is changing college sports is name, image, and likeness. So about the same time as the transfer portal was this deal that the athletes are getting paid, which had been going on all the time in the SEC. But now everybody can do it. So, you know, you like college football? You like football? What's the difference? It's a lot of money out there, right? With that, there's increased mental health issues. So now we're dealing with that, too. Social media also contributes to that. The pressures from social media. You know, this is it. These kids are like, am I liked? Am I not liked? People making these bad comments. I mean, it is a big deal. And now these malpractice suits are trickling in, just like in the pros. So we're facing this, right? It's being written about. We have new challenges for injured athletes. Tony Romeo in North Pace today, what he said was a thorough understanding of current and future NIL negotiations is needed to effectively navigate the evolving responsibilities and liabilities of collegiate and high school sports. It's changed. So what approach should we take to protect the players and protect ourselves? Alright, a number of principles here. We need to maintain medical ethics and professionalism. We need to focus on patient-centered care. Always do what is right. Prioritize the athlete's health and well-being. Ensuring that the medical decisions are made in their best interest. In their best interest. We, as physicians, have to have independent medical judgment. We must prioritize the health and well-being of the athletes over any external pressures, right? No coaches, no agents, no NIL-related interests. That's principle one. We have to have skilled communication in principle two. We need to listen. We need to listen to the athlete, what they're telling us, and how they're telling us it. We have to have clear and transparent communication. We need to provide clear, concise, honest information about the athlete's injury. We need to have the outline of the treatment options, the prognosis and expected recovery timeline. Very important for these athletes. And we need to involve everyone in the decision-making process, especially at the collegiate level. The athlete, the ATC, the coach, the family. And now we got family advisors, which basically are agents. And we didn't used to have that. We need to have an open discussion with the athletic trainers, the coaches, the management administrators, on what are the policies and what's the return to play on an athlete. Principle three, diligent documentation. We need to have detailed records. Maintain thorough and accurate documentation of all the interactions, treatments, and advice given to athletes so they can't come back to you and say, well, you never told me that, doc. You never said that. We need to document. We need to do that. Informed consent is principle number four. We need to educate and fully inform the risk benefits and alternatives and also document it. And need to have this written down, ensure that the athlete signed these informed consents. And we need to manage external pressures, right? We need to be an advocate for athletes. We need to advocate for them, ensuring that their medical needs are not compromised by the external pressures from NIL deals, agents, or sponsors. And we need to help with boundaries. We need to establish clear boundaries to prevent the undue influence from these non-medical stakeholders. Mental health is a huge issue. So this is principle number six. Consider this. Be aware of this. Recognize and address mental health issues which might be exacerbated by the pressures of NIL and or social media. So we need to know this and we need to refer when appropriate. And then we need to have education on the legal aspects and awareness of what that is. Stay informed about changes in the law and regulations related to NIL and how they might impact medical practice and liability. And then engage in continuous professional development to stay current with practices in sports medicine legal considerations. In principle eight, we all need to have risk management. So understand the protocols and guidelines and adhere to evidence based approach to how we treat our athletes. And then number nine, insurance coverage. Make sure you got adequate coverage. Look at that. Make sure. Ensure that the malpractice insurance coverage is sufficient and specifically addresses the unique risks that we have associated caring for these collegiate athletes or even high school now in the NIL era. And make sure you understand the policies and regularly review and update insurance policies to reflect changes in this environment that we're in. And lastly, in principle 10, be present and aware. The transfer portal challenge is huge. Have awareness of the players coming in and players coming out. And it's been hard. With 40 coming in and 40 going out, it is hard. But I have to understand. I have to understand what are we bringing in? What kind of injuries do they have? What is happening with these players? And have a presence so they know who you are. So the first time that they get hurt is not the first time they see you. So how can AOSSM help? A few last slides. Educational programs and continuing medical education. Perhaps providing resources and toolkits. Mental health support and resources. Athlete and parent education. Advocacy and guidance. So providing guidance on navigating these complexities on what we do and provide some advocate for policies and guidelines so that we can support the health and well-being of the athlete. And then professional networks. Which is why much of us are here at this meeting. Facilitate networking opportunities for collegiate team physicians to share knowledge, experiences and best practices. And then establish mentorship for these young surgeons that are coming up and facing this. New as a team surgeon. As a team physician orthopedic surgeon. So they can get some experience and provide some legal and ethical support, legal resources, ethical guidelines so that we can face this. And then task forces perhaps. This will help too to help navigate these various areas particularly injury prevention, rehab and the impact of NIL. So in summary in the current climate of NIL, team physicians must be vigilant in managing their malpractice ability by maintaining high standards of care through documentation and clear communication. And by prioritizing the health and well-being of athletes and navigating the complexities of NIL with transparency and integrity physicians can mitigate the risk and provide optimal care. And by providing comprehensive support through education, resources, advocacy and networking, the AOSSM can empower the collegiate team physician to deliver the highest standard of care to their athletes. Thank you. Fantastic talk, Eric. A ton has changed in college sports. Our next speaker is Chris Amad. You all know him. He's from Columbia University. He's a team physician for the New York Yankees. He's going to give us some strategies in the management, the current management of the professional athlete in 2024. Chris. Thank you so much. I think we're all beginning to question our roles as team physicians in the setting of this risky climate. I think it's important to recognize the setting of this risky climate. I'm going to have zero disclosures related to this. I'm going to assume some of you know what these numbers are. These are the millions of dollars in these extraordinary salaries that are being paid out. These contracts are enormous. These are the top earners in Major League Baseball, and it is true in the NFL, and it's true in the NBA. These contracts and these salaries are just astronomical. Our athletes, they're employees of the club, and they get injured. They're getting injured every day. That's why we have a job. They are work-related injuries, and the work-related injuries have a financial impact. We looked at this in 2019 and looked at what the cost is of a player who sustains an injury to their UCL and needs reconstruction. You can see it's on the hundreds of millions of dollars, and even in 2024, with data that's not even full yet, the total payroll is $4 billion in Major League Baseball, and the total that's getting paid in salary for players who are not playing because of injury is over $1 billion, and as you know, the UCL of the elbow is one of the culprits. At the same time that these players are getting these massive contracts, there's pressure on them, and if you are familiar with career length in the NFL, it is not what we would want. It's short. It's less than four years, and many of them have financial issues after their playing career. This is amazing. Rookies who played in Major League Baseball in the 2000s, they had an average lifespan of seven years. More recently, that lifespan is decreased in half. They're lasting almost less than three years of professional careers. Let's think about the exposure that we're dealing with. The number of players on the Yankees is more than you think. Within the whole system, there is close to 300 players. We're talking about all the Minor League players, and they're all over the country, and there's a responsibility that goes all the way up to the head team physician. Also, the responsibility of managing the other medical providers, the other staffers, the neurologists, they all kind of fall under our responsibility, and it's not the surgical risk that is really what we're dealing with. It's the non-surgical risk. This is my first patient I had to evaluate as the Yankees team physician. We don't just take care of the players, we take care of the families. Day one on the job, I got asked to see not the manager's son, but the manager's son's friend, who got hurt the day before at his house on the monkey bars, and they wanted me to help treat him. Then there's all the staff and the employees that come and seek your advice, so it gets enormous. In the world of baseball, there's this problem where we do elbow surgery, and this nerve makes me not sleep at night sometimes. This nerve, as it turns out, is one of the most litigated issues in all of health, regardless if you play professional sports when it comes to the elbow. We deal with some risk escalators. Risk escalators, particularly in sports that require you to play every day or train every day, means they're at risk of getting hurt every day. Then there's a question on us at all times. Players don't feel good all the time. They play with some level of soreness and pain, and it's on us to know when that soreness is a problem or it's an issue. These players are receiving treatments constantly. We talked about, Eric mentioned about documentation well, and some of our athletes, they're documented very well because it's in the media. It's on TV, and the injuries get analyzed by the public. I did this. I looked it up. I never do it on purpose, but in preparation for this moment right now, I looked up things on the internet. This is what gets written. Okay, we know why people sue. They sue. They create a lawsuit for reasons that they feel that they were not treated appropriately. We know all about it, non-operative, operative, complications, and things like that, but we have this issue of return to play, and how we return them to play safely is under a lot of scrutiny, and of course, if there's a deviation of standard, but this is a very gray and loose area, and our diagnosis is a challenge. Sometimes I took care of New York City Football Club for six years while they played at Yankee Stadium. We don't have time. Right before the game, a trainer might say, can you take a look at this? We got 60 seconds before they're running out. We don't have the tools. We don't have MRIs at the stadium, and there's some issues of conflict, and what I mean by conflict, there's all kinds of them, but many players do not want to disclose how symptomatic they are because they want to keep playing, and then it turns out to be that we're the ones who are absorbing that risk when players don't get to help us. We get asked to do this all the time. I'm sure while you're here, you're looking at MRIs all the time. You never get to talk or examine the patient, but you're asked to give a recommendation by looking at an image. Eric mentioned the documentation, and sometimes it'll be like this. Can you take a look at his finger right before the game? And it seems so inconsequential, but then all of a sudden, it could be massive consequence for some of these little, can you just take a look at it? And then when you don't really document it well and you didn't really do a full, complete evaluation, you're putting yourself at risk. And then there's some issues with trust. We don't get to spend a lot of time with players. We talked about how players come and go. We get to meet them, hopefully in spring training and other times where there's not so much pressure to play, but there's some issues of conflict that maybe the doctor is working for the organization and maybe doesn't have the player's interest in risk. It has to do with contracts in my world. There's a typical contract where I scan and they're saying, we're going to pay this guy a lot of money. Tell us if you think he's going to get hurt and last. And if I give the recommendation that his ligament's not attached right on his elbow and he may not last five years before he needs an operation, that contract may not be executed or worse, the contract gets reduced in the amount of dollars to the player and then he joins the team and then he looks at me funny for the rest of his time because I cost him tens of millions of dollars. And then there's the diagnosis and treatment that we deal with. Had a player come in. He had a sore shoulder. We're in September. He's a starting pitcher. His exam, he's a little bit weak. We said, you're going to start again in five days. If you took and missed a start and got some recovery time, you would be better and you'd be better and more effective going into the playoffs. That's what I said to the player. Player came in the next day, cursed me out in my office. I had no idea what happened, but I went and spoke to the trainers and it turns out his contract had incentives built in it and for him to miss that start cost him a couple of million dollars. There's a perception that I think is missed in some of these athletes and with agents. I asked an agent one time after taking care of one of their players, it was a fun exercise, how much he thought we got paid for an operation like a Tommy John. The answer was, it's got to be at least $50,000. We get paid workman's comp rates. These are much less than the players that we take care of in our own private practices. It's so much less and the players don't understand that. They think that we're getting so well compensated. I think we have to have a discussion about malpractice insurance at some point and I'm not an expert in this area, but if you take care of these players, you should know what your malpractice coverage is. If you don't, that is a serious mistake. Know what your malpractice issues are. There's something about this asymmetric risk because we don't have enough coverage. It's impossible to have enough coverage for the amount of dollars that these players are making right now. This has been a sticking point. If someone can explain what this term means to me, help me, because it's really hard to understand. This has been a contract issue between institution of the team and the institution that managed the malpractice. This basically says who's going to deal with something if it goes wrong? Goes wrong like this. If I happen to bump into a player and knock him down on the way into the stadium and he gets hurt and he can't play and I bumped into him and they think I bumped into him with some fault, I am liable for what happens to that player financially. I got to assume that responsibility so our institutions won't get over that indemnification so I actually do not have a contract for what I do. How do we deal with this? Eric, I knew he was going to tell us how to do it. I just have a few other thoughts. The biggest resource I have in protection is the athletic trainers and having a great relationship with them is one, but they document and they develop trust with the players and they endorse you in such a way that my relationship with the players is always boosted because of our athletic training staff. There's some leadership that can help, and that's from the organization from TopDown, and it's from other organizations like this. And if you have a chance to read this statement in full, do it, but it's basically making it publicly aware that we are assuming risks that is not feasible and sustainable. There's something about asset protection. If you've ever been involved in something where they can take money from you and assets from you, there are ways to protect your assets. I would encourage you to look into that. And I'm gonna finish with just some personal reflections. I'm gonna get a little vulnerable. This is July 22nd, 2013. Alex Rodriguez is on a rehab assignment, got hurt, he's playing some games. Major League team's on the road, so he's at a minor league game. I'm at a barbecue. I'm at a barbecue with residents, and we're actually playing soccer as part of the barbecue. I get called that he needs an MRI, he hurt his quad. I go to the stadium, we get an MRI scan. It's a Saturday. For some reason, there are paparazzi outside the hospital. How would they even know that he's getting an MRI scan? Then that MRI scan got reviewed by an outside doctor, not of our choosing, I didn't even know about it. That doctor went on the media and said he does not have a quad strain. Well, I reported he does. That was a month earlier. Then August 5th, Major League Baseball announces that he's involved in a scandal, and there's gonna be a suspension. A few days later, this comes out. He's preparing it. I get to read this in the media. He's preparing it, and then it comes out, full blast in the news. It's on all the papers. And so he was having issues with the team and with Major League Baseball and with me, and that was August 20th, 2013, and then it really happened. It wasn't just being talked about. So I get filed with a lawsuit, and then several months later, he did drop the lawsuit, and you can imagine all the reasons why I'm very open about talking about it at this point, but it doesn't end there. He's actually still my player on the team, and I gotta take care of him, and when he showed up to spring training the following season, he made a public statement, and he apologized to everybody publicly except to me, and then the media wrote about it, and he actually didn't even take his physical with me the appropriate day, so they made it like there was a big scandal between him and I. Anyway, thank you for allowing me to share some of this experience with you, and I look forward to a interesting discussion. Wow, Chris, that was really, really interesting to hear from your perspective. We can certainly talk about that a little bit more, but just an unbelievable thing to have to go through. So I'm inviting up to this stage Dr. Robin West, who's gonna co-moderate a panel. We're gonna hopefully do this panel in somewhat of a conversational format. The purpose is not for us to interview you, but to get each of your perspectives on the current state of affairs in both collegiate, professional, and also in high school and other levels of athletics. So our panel is Dr. Riley Williams from the Hospital for Special Surgery, team position for the Brooklyn Nets. Dr. Lyle Kane from the Andrew Sports Medicine Institute in Birmingham, team position for the University of Alabama. Chris Ahmad, who just finished giving us a talk, he's team position for the Yankees. And Dr. Eric McCarty from CU right here, and team doc for Coach Prime and the Colorado Buffaloes. So I welcome the panel up. Robin, I'll invite some comments. Great, thank you. Thanks for joining us. So there's been a really changing landscape in sports medicines we've been talking about over the past couple years, with increased risk potentials and with the team positions. So not only are we managing the care of the athletes, but we're also dealing with the NIL deals that Eric was talking about, the transfer portal, and increased liability with the salaries and potential earnings of these players that continue to rise. These risks no longer just affect the professional team positions, but they also affect our high school team positions and collegiate team positions. So as Steve talked about, we're gonna ask some pretty vulnerable questions and talk about some vulnerable issues for all of us. So Chris, I'm gonna start with you. So several team positions at the collegiate and professional level have changed the way they do consent forms. They've worked either with private attorneys or institutional attorneys. Some have made some really strict changes, as far as location of the venue, statute of limitations, or the capitation amount, when they have their players sign these consents. Others have more limited restrictions, and others have not even changed their consents at all, because they're afraid that they're gonna actually lose these players if they make them sign these consents. So I'm curious about, have you changed your consents and the way you do it, and how and why? Yeah, what a great question. So I have not changed the actual paperwork of consent, but the whole consent process is a little bit different for me. And what do I mean by that? One, if it's a player issue, and we're talking about some magnitude of treatment, let's just say surgery, it won't just be me in the room and the athlete. It'll be someone on the team side, there'll be a trainer in the room, and there'll be somebody additional from my office in the room. And in the documentation, those people were in the room with me, and they witnessed the entire encounter. And there'll be documentation on all their questions were answered. They were asked several times if they had any further questions. There was support for second opinions and things of that nature. But the paperwork, I don't feel, is what's going to really protect us. And I've never had, say, enough support or willingness on the legal side to help with this. And sometimes if it makes it too, say, scary for the player, it actually incites it more than it helps it. Raleigh, how about you? We've added some riders to our consents at HSS for all professional athletes. It's not an aggressive rider, it just acknowledges that there is a dissonance between typical coverage standards and what a typical patient in HSS would be. The professional team physicians at HSS are indemnified. We're self-insured, so we've never had an episode where someone had their personal assets attached and whatnot, but no substantive change. There are no specifics in numbers, but I'd say one out of every 10 athletes catch it. And then we just have a frank conversation about what it means to take care of them and the risk that we bear as physicians. Lyle, how about you? Yeah, I think it's a great point. We looked at it for two different aspects. One is the college situation. When you're taking care of a university system, the university attorneys were very hesitant to allow us to change the consent for the college players for two reasons. One is that their student athletes are not professionals currently, and so there was concern that the athletes would perceive a different type of care by having to sign away some of their rights as a patient. And so the university wouldn't allow us to do that. On the NFL side and some of the other professional sports, we looked into having different riders and things attached for second opinions because we see a lot of second opinion MRI scans and things where we don't actually see the player, which is somewhat disconcerting, but a pretty common process. And so as we went down that road with a lot of the groups after the big settlement or the big judgment back in Philadelphia, some of the players' associations pushed back and told the players not to sign those consents. So I think it's, in my mind, we're kind of left hanging in some ways at both fronts. And I think our best protection, like Chris mentioned, is really how we disclose and how we talk with the athletes about any injury and any surgery to try to shield our liability, but we're still there. We're still probably hanging on a limb more than we want to be. Eric, have you changed anything? We haven't changed anything in the informed consent, but I think what we've done is just better awareness of documentation. Like Chris had mentioned, make sure that the documentation is very good. What you've done, what you've said, and what was presented. I like Chris's idea, I have not done that, stating in your note who's present, what parties were present, but typically when we're seeing somebody, there's gonna be several of us in there, the athletic trainer, myself, maybe a trainee such as a fellow. So a lot of themes here. So people witnessing consent, so it's not a one versus one conversation. I wanna dive a little bit more into the college side of things. Eric, you brought up a lot in your talk on the impact of both NIL and the transfer portal, and certainly in Colorado, it sounds like you've been vastly impacted by the transfer portal situation. We'll definitely get to that. But the NIL, for me at the University of Virginia, and for you guys, I'm sure, is something that I think we're still trying to wrap our head around. Like what really is it? You know, is this considered real earnings? You know, are these athletes, is this a contract? So Lyle, we'll start with you. Talk a little bit about your experience with, you know, now the presence of the NIL at a place like Alabama, and how it's maybe impacted both your interactions with the players, how you treat them, and frankly, your overall level of comfort being a team doctor at that level. Yeah, it's a great point. I guess my first kind of thought process is it's a real mess right now, for a lot of reasons. You know, I think the transient nature of transfer portal, the money that's being thrown at players to come to different programs, I think you really have to treat college athletes now, and even some high school athletes, almost like a pro. So the same discussions, thought process, advisors, agents, you know, it used to be in college, we had the kids for three or four years, and you got to know them well, you knew them outside of injuries, you knew them before they got injured, you knew some of their family members for different reasons, especially if they were local to the area. In today's world, that personal connection's not there as much. And so I think you have to really treat every college athlete, and even some of the elite high school athletes, as a professional, the way that you deal with them. So similar to what Chris said, I'll make sure I talk to the family, I'll try to make sure I talk to the advisor, they can't call them agents now in college, but they're advisors, basically agents. And so I think involving everybody that's a stakeholder in these NIL situations is important, and when you think about a player's treatment, you know, it used to be trying to get them back for the next season, or for the rest of their college career, now you're thinking about the money they make, and their endorsement deals, or whatever they got their NIL for, how that affects their ability to earn that money. And so I think it's a very different mentality. I think there's a lot less connection with the players than there was, say, five years ago. But if you're used to dealing with professional athletes, you just kind of roll your brain into that scenario. It's really kind of a sad process in college right now. So that really wades right into the kind of impact of the transfer component. Eric, I don't know if you have additional comments, obviously you touched on this quite a bit, but Colorado's very well known recently for kind of the cascade in, cascade out of players. So Lyle talked about, you know, we're not getting to take care of these guys when they're freshmen and sophomores, and all the way through as much. So any tricks you've learned as far as kind of establishing rapport in a shorter period of time, or? You know, I mentioned it on that last principle number 10, that we really need to be aware of what's happening, you know, with our players. And of course, we're the extreme, but, you know, 40 in, 40 out. But you saw second was 30 in, 30 out. And so, you know, those are not insignificant numbers. We used to see one or two transfers a year, you know, maybe three or four, but it's really astounding what's happening. And so, you know, what I really am remiss with what's happening in college athletics, because there was a relationship, as Lyle mentioned, that you get this freshman, 17, 18 years old, you get to take care of them. By the time they're 22, they may have been there four or five years, and maybe they had a surgery or two, but you get to see them develop, and you develop a relationship. Now, you get somebody that's coming in as a graduate transfer, transfer portal, and you don't know them, and you don't know their history, and it's really a shame. So it's important to be aware of that, but also try to get yourself in front of them so that they meet you, they know you, so that when they do get hurt, that it's not the first time that they get hurt, is when they're on the field or in the training room. So the other thing I would like to introduce there, too, you guys get these transfers in, and we have transfers in and transfer out. This has happened to be quite a bit over the past few seasons, and they're coming in after having a surgery, or coming off of an injury, or you're taking care of them, and then they transfer, and so their follow-up is elsewhere. Any experiences that you would like to share? Lyle's chuckling, so hopefully he's got a couple, of how you, experiences recently that you've had with those types of scenarios. I certainly have had some. Yeah, that's a great point. This year, when Coach Saban retired, somewhat unexpectedly in January, we had a flow of transfer portal people go out, and a lot of them had just had surgery, because the season just ended, so a variety of things between ankles, and labrums, and everything else, and all of a sudden, I was hit up by all these different team doctors. I know, hey, tell me about this kid. What do you have, what did you do? Obviously, the kid's not coming back to see me, and so it really changes your relationship. Again, I did surgery on a player that I thought I was gonna be able to see two or three more years. Now, he's at a different university, and he's not gonna come back for follow-up. He's just gonna follow up with that team physician. So, very different relationship. There was another situation this past year, where early in the season, we had a defensive back that had a shoulder instability episode, just a subluxation. I had fixed his other shoulder two years ago, and he played the whole season with a couple of subluxations, but no major events, and did really well. So, our plan was, we talked to the family, we talked to the kid, he's gonna try to play the rest of the season, he's excited about it, and he calls back the next day and says, I wanna have this thing fixed. Now, I thought it was kind of odd, and then I find out later on, a month or two later, that he was planning on transferring, and didn't wanna waste a season of eligibility. So, I think the transfer portal not only changes your relationship with the patients, it also changes how they deal with injuries, because if they're not happy with their current position, they think they have a better opportunity somewhere else, they change the entire way they treat an injury. A minor injury becomes a major injury, and it's almost like having a work comp patient from a secondary gain standpoint. So, I think you have to be aware of all those things. The trainers are the best people to tell you that, because they know the background much better than we do as physicians. And so, I think you have to be aware that those things are going on, because it may change not only your follow-up, but the way that the patient acts after an injury. That's great. So, with the recent litigation cases in sports medicine, several team docs I've talked to have changed the way they've practiced. They've limited their care of professional athletes, and have really been focusing more on their high school athletes. In talking to one of the prominent team physicians, he said, you know, I can do five to six high school athletes ACL reconstructions when it takes me the same amount of time to do one professional athlete. Not the surgical time, right, but it's the time of talking to the agent, the family, the whole process. And so, they're like, you know what, I'm gonna start passing on some of these professional athletes, and really focus my practice and build my practice on the high school athletes. So, Riley, have you changed the way that you manage now, the professional side, because of this? No. I mean, listen, I'm of an age where the badge of honor was having these people come to you, and I acknowledge all the risks that are involved, but I stand on business with this. You just have to say I'm willing to accept what might happen. Now, I will differentiate. I'm lucky, my tertiary care practice with regards to a national following is largely NBA and some soccer. Not a lot of NFL, and there's an essential difference, as everyone knows, between a guaranteed NBA contract and a non-guaranteed, you know, employee-at-will NFL contract. So, I am much more circumspect and direct about liability with NFL players. I've lost a couple, but that's not my bailiwick. My bailiwick is 15-year-old, developmental project. He lives in Atlanta, plays AAU, tears his ACL. They know about me, so they come up. So, I deal with this issue of leaving, but it's planned. Like, we understand beforehand the entirety of care, and I'm all over it. So, it's laid out, it's planned. So, if there are deviations from that that I don't have direct knowledge about, we've already started talking about it, and so I think that does, when they see that you have a longitudinal plan, it mitigates the risk. So, I mean, for us, I think, as sports medicine physicians, I don't think it's realistic to try to amortize it or try to shy away from it. I mean, the reality is, and this is gonna sound terrible, but like, I'm really good at the stuff that I do, and my family says it to me, because I had a very high-profile lawsuit from a famous person who wasn't an athlete, and at that time, I really stepped back and thought about all the things you guys talked about, this asset protection, do I need additional coverage? And I sat with our attorneys, and I'm like, you know, should I be doing this? And they're like, listen, we value you, and we're gonna make it so that you're protected. And that was very reassuring, so I'm lucky, because I have backing like that. But again, you know, this is kind of the waters we live in, and just be aware. I think there's a big, big thing, we can talk about it with the non-guaranteed versus the guaranteed contract status. How about you, Chris? Have you changed anything? Are you still seeing the same number of professional athletes, or have you tried to limit that for this reason? Yeah, I think about it deeply, but I haven't done any formal changes to limit the amount of exposure risk, professional athletes that come in. It's more how do we manage that? But from a intellectual side, it is disturbing that there's so much risk and to hear of friends and colleagues who are going through situations that we don't have enough control over makes you, it's just less fulfilling. And so along those lines, even the smallest injuries now, we tend to have the situation reviewed by outside doctors because sometimes it's the small little things that turn into the big lawsuits and things like that. So it's not see less, but it's just do more to make sure it's documented well and that the players are happy with it. And along the lines with the, I'll just make one other comment. I'm sure everybody's doing this, but I spend a full day on Thursdays seeing patients from my computer screen. And it's a little bit awkward on the computer screen, but about 30% of my practice, maybe 40% are athletes who are not in proximity to me. They fly in, have the surgery, and they leave. And in order to not lose the touches with them, we do virtual visits. And what's cool about that is anybody can get on from anywhere. So a trainer, a parent, anybody. So we have a whole bunch of, it's like a regular Zoom call, allows us to document everything. And if there's issues, then we might act differently, get a player in. So it does help with this regional diversity issue. I'm gonna add something else. Yeah, Robert, I was gonna say, in my practice, we don't have any pro sports in Birmingham, really. But my mentor, Jim Andrews, who I kind of followed in practice, is a very coveted physician for second opinions by the NFL agents, particularly, but also Major League Baseball and some of the other sports. And so when Dr. Andrews retired back in December, a lot of those agents started calling me to do second opinions for different athletes. And I think we looked at what's our exposure, what's your risk, is it worthwhile to do it? And when you think about high school sports, when you cover a high school team, the athletic trainer for a high school wants a team physician that they are available, that they can call for a problem, that they'll pick up the phone. College is the same way. In professional sports, it's the agents. It's not the ATCs so much, it's the agents that wanna have somebody to talk to for their clients to have a second opinion. And so most of the second opinions through professional sports come not from the player or necessarily from the team physician for that team, they come through the agents. And so really, when you have a relationship with certain agents that cover certain sports, you almost feel obligated, just like an athletic trainer, to answer the phone, try to help them, try to answer their questions, not be too specific, because multiple times that it happens, you don't actually see the player, you just see the MRI or the study. And I think you really have to be careful about how you frame the situation, but I think we're valuable to those agents because all they want is somebody they trust to confirm the diagnosis. And that's an easy thing. Now, if the diagnosis is different, then you gotta talk to the player, the team physician, the agent, have to go through the whole process to make sure everybody's on the same page. But I think it's something I've looked at a lot in the last six months, and I think it's still valuable and I still do it, but you have to be careful about how you frame your answer to the agents. Just a follow-on comment. With regards to these remote, I'm always asked, oh, should I see someone locally? And that's the thing that gives me the willies. So all these actions, guys, always happen based on some other physician's comment. So as I've gotten older, I'm really trying to be really good about interacting and placing myself in the position, the treating physician who's the patient I'm seeing, and I'm super, super, super careful about how I talk. And I think the advice I would give, we need a lot less doctor on doctor crime because a lawsuit requires some physician to basically say that what you did was not correct. So my purview is, if I'm seeing your player, I'm like, everything's fine, everything was done correctly, and that's my purview. So if something looks amiss, I'm like, well, let me call him. And I think in this age of text messaging and emailing, the phone call is a lost art. I know you're at a busy clinic. I don't want to call, it's gonna take me 10 minutes. But for my purview, having been on the other end of it, it's the least I can do. And will, I believe, 99% of the time, mitigate any kind of potential action when these things arise. I agree, it's all about communication, right? And just making sure that it's open dialogue. And also, when a player comes and there's an issue or there's something that I see on x-ray, again, I always say, I wasn't there for the surgery. I don't know what was done, but I'll talk to your surgeon. And I will never say, never want to say something was done incorrectly or, right? Is that what you're talking about? No, Riley, very well said. Sometimes the problem is us. As much as we want to talk about all the other frameworks that we work in, in the end, we need to be our own best advocates. Let's expand it a little bit. I'm gonna skip forward a little bit just because we're talking about some of the pro stuff and it's interesting. So it was reported recently that the Rothman Institute ended its long-term relationship with the Philadelphia Eagles. And I'm sure many of us, in fact, probably all of us have seen at least the reporting on at least largely what the reason behind that was. Do you think this is a sentinel thing? I mean, obviously, Rothman is the heavyweight player in Philadelphia and this is the Philadelphia Eagles. What's your guys' experiences within your own health systems? Is it worth it? Do you see this being a trend? Is there gonna be a time where it's gonna be hard for the teams to actually get support because of the liability risk? So why don't we actually start with Eric down there because you guys do college at a high level as well as your group takes care of a lot of the pro teams here locally. So curious to your comments on that. Yeah, I think, well, there's been suits going on for a while, right? In college and in the professional leagues, I think the amount of the suit is what's really upsetting and how it came about. The most recent one, but there's been a few recently that have come up and it seems to be a trend that I think there's many people involved with this and particularly the attorneys, maybe the agents, but maybe the players. And so it's getting to be more and more challenging. I think as you look at that, we need to protect ourselves. Obviously, one of the reasons that I put so many of those slides on there, how do we protect ourselves? And we've got to do it as a society too. And we've got to do it as group of physicians. Earlier today, the presence of many of the professional team physician societies, for example, the MLS, the NFL, NHL, got together and are going to start meeting to be able to discuss as collective group. You know, it's not just the baseball, it's just not the NHL, but it's all of us. And we all have our challenges, but if we come together collectively with AOSSM, that will be very empowering. And so we're looking at that type of thing to assist with that, but it takes, there's gonna be a lot of movement that has to take place for us to get to where the point, we're not looking over our shoulder all the time. Other comments, Chris? I think it's important, at least for me, in self-reflection, not to make my identity the Yankees team physician, because that's my only identity. I'm holding on to something where now we have risk that's overwhelming the threshold and the issues of consequence in this situation. So while I would, I feel honored and privileged to take care and be part of such a special, unique area and the people I get to interact with, if situation changes and gets worse, I'm preparing myself to manage it in different ways. And it's not just the, as my institution takes care of a lot of colleges, we have these marketing service agreements within these major franchises. So the Yankees changed their hospital marketing relationship to another hospital. I still stayed on as the team physician. That type of situation's happening at the college level. So now colleges put their marketing out to bid to other hospital systems, and it's pretty common that once the contract's up, it goes out to bid again. And so now we're getting different physicians who are asked to fill in roles very quickly because of a marketing agreement. So there's something that's impure about that from a take care of athletes standpoint. I think it's interesting, several years ago, our society put out a position statement on the ethics of the team physician and choosing team physician based on their ability and not based on a financial revenue source. And I think most teams, I would say athletic directors in college, professional GMs, even high school athletic directors don't have any idea that that's a position statement. It's not widely understood by the other side involved in this negotiation. And so I think we as a society need to make sure that that stays in the forefront by updating it or putting it out periodically. But I think as a society, as Eric's mentioned, I think we almost have to collectively bargain with the professional leagues, which we've never done. It's always been 1,000 individuals talking with different teams, different professional teams. I think at some point, it's gonna come to a point where we as a society of sports medicine physicians need to have a collective negotiating stance with all these professional leagues. And until that happens, we're all gonna be on an island. So a few months ago, a former team physician and director of athletic medicine at Penn State was awarded $5.25 million when the jury agreed that the head team coach had interfered with the medical decision-making. I think we've all experienced it, right, where we have coaches who are pushing us to get an athlete back to play. That's changed over the years, but after you see an injury on the field and the coach is pushing you to get that kid to play. So I'm curious, can you guys share some stories like that that you have and how do you handle these situations? You know, I read about that. I don't know the details. We don't know the details. All we see is what's in the paper, but I'm sure there's much more under the surface, right? And that's where it's really important with media, especially social media. All you hear are these things like what Chris showed, those headlines in those, I wouldn't even call them newspapers. I don't know what you'd call them, but the tabloids in New York, but that's what we hear. So there's more to the story. We don't know it all, but the idea that coaches are telling us how to practice medicine, I don't tell the coach what play to do, but I feel like it sometimes. But we have that conversation at the very beginning when I ever have a new coach come in, sit down with him and just have a very nice conversation. And I had a really great conversation with Deion Sanders, Coach Prime, just me, him, he and I one-on-one. And we talked about how we like to take care of the players, how we manage it. And I think those kinds of conversations are really important so we're all on the same page. And I think having that communication where I can get on and call him or text him. And he likes to FaceTime, so he FaceTimes me sometimes. But those are important. We gotta have that. And I think those one-on-ones, those times with those coaches are really important so that we can be on the same page as we're trying to take care of the athletes. They wanna win games, I do too, but I wanna do it in the right way. You know, and some coaches aren't like that, right? I mean, so I think we've all worked with some very difficult coaches who maybe are more pushy. And so really, who's the final decision maker? You know, is it the athletic trainer or is it you? Who makes that final decision? Yeah, so, you know, University of Alabama football, we would never push anybody to play, right? Coach Saban, never. No, you know, he actually, Coach Saban, probably of all the coaches in college football, you would think would be the most aggressive about pushing the limits. He was actually the opposite. He was really good about, you know, listening to us, listening to the physicians about return-to-play issues. We did have a situation, though, this past spring in a different sport, not football, at the University of Alabama, where one of the coaches from one of the sports had a lot of international athletes on the team and was pushing them to play through things behind our back and was actually guiding treatment, would send the player in saying, I want a PRP injection, but he's gotta be at an event in six days, things that were not medically reasonable. And so the way we addressed it is, the athletic director, who's, you know, his boss, we, the medical staff, the athletic training staff for that sport, and our director of athletic training all put basically all of our thoughts together, met with the athletic director, voiced our concerns. He then went to the coach and said, look, here's the concerns on the medical side where you're gonna have some liability as a coach if something goes south here, and was able to flip that situation around. So I think, you know, using your administrative resources at the college level is really important. The AD, the last thing he wanted to do was be in the middle of a medical versus coach situation, but it was a bad situation and he handled it. So, you know, I think you have to, if you have that as a team physician, high school, college, or pro, you know, you have to use your administrative side, your AD, your GM, to help manage that. It can't be you against the coach. All right, so we're getting close to time here. So I think maybe a question that I'd like to throw out here that's a little bit less targeted, but kind of allows you guys to use your vast years of experience, as well as your kind of, you know, where you are right now with this. So, you know, this is, if you look out here, we have all our membership here and, you know, you guys take care of very high level athletes, professional, collegiate level. But, you know, given the current landscape in sports medicine and the management of quote, elite athletes, this term seems to apply more and more to athletes based on their perception, that of society, their parents, other people. So, you know, a lot of, I mean, you guys have touched on this in some of your responses. A lot of these people we're seeing have this viewpoint of where they're gonna go with their career. So basically what I'm asking is, can you give our membership some advice on how to approach these athletes in a broader sense, especially the younger people in our field? You know, what principles do you lean on and have remained steadfast despite, you know, the times and kind of what's going on around us? So maybe, Riley, maybe some comments on that. Yeah, this'll be brief. Eric touched on it. I understand that when I have somebody like that, whether they're in high school, college, it's gonna take more time. So it happens outside of a normal clinic time because it's gonna be an hour, you know. It's an explanation, what's your diagnosis? Do you understand the remedy? Do you understand how much it's gonna take? Do I have to call anybody? You come back, oh, do you know what your diagnosis is? That's just my habit. And so those appointments happen at the beginning of clinic or an off day or at the end of clinic. So that's probably number one. We've looked at this. The biggest determinant if you're gonna get sued or not is like, what is your communication line with the patient and the stakeholders? So it's incumbent upon me, and that's my big effort, is I wanna create some connection between myself and the player. And I'm at a point now where if I don't feel that connection then sometimes I'll pass. Lyle. Yeah, you know, it's interesting. I think the professionalism of amateur sports that's happened over the past 20 years or whatever it is, where kids specialize early, they have all these private instruction, I think there's unrealistic expectations in general. But I can't think of an athlete in the last few years that I've seen probably from 12 on that doesn't think they're elite or their family doesn't think they're elite. And so, you know, I think the same kind of mentality you have with a college player or professional player, you kind of have to dumb it down a little bit, but you have to realize that no matter how good this kid is, he and his family think he has a future. And so you have to kind of, you have to temper anything you say about their outcome and future to their expectations. And oftentimes in my mind, what happens is you fix whatever their problem is, they get back to some level, and then mother nature takes over. They either have the genetic ability to play major league baseball or they don't. And you just wanna make sure that they don't feel like you're the one that kept them out of it. You wanna make sure that you did the best you can and meet their expectations, but you really can't, I don't think there's any way to convince a parent or a kid that they're not elite. I think that comes down to the rest of their sport, convincing them that, but through competition. Chris. What I get most uncomfortable with is the time when you need to lean in the most. So basically, if you're having a difficult time with a player, either they're unhappy with you, that's the time not to disengage. That's when you have to engage more. And I mentioned a player that lost a few million dollars who missed the start. I now take care of his kids. And so sometimes when you think the relationship is going wrong, that's a time when it's actually an opportunity to flip it and make it a great relationship with that patient. So lean in when it feels uncomfortable. Eric, some final words of wisdom. You heard my comments earlier with the slide, so I won't, we got just a few seconds left, but we love what we do and we want to continue doing that. So we need to basically look at what we all said today and continue to be ethical, be professional in what we do and try to protect ourselves in what we do, how we do. All right, great. So amazing comments. So we're out of time here. I want to thank Robin and I want to thank our panelists for all their thoughts, as well as kind of just being so open and sharing their experiences with all of us. So thank you very much to everybody. And we'll move on with the next session. Thank you. Thank you. Thanks.

Stephen F. Brockmeier, MD

Riley J. Williams III, MD

Eric C. McCarty, MD

Chris Ahmad, MD

E. Lyle Cain, MD

Christopher C. Kaeding, MD

Robin V. West, MD

team physicians

college athletics

NIL deals

mental health

risk management

medical ethics

asset protection

legal documentation

sports medicine