This next talk, a lot of this is my opinion, but so that's part of the format of this conference is that it's importance on the discussion after these talks. So please encourage you to be interactive afterwards. When we look at the situation with what I find are challenges in terms of players, unions, or agents and medical legal issues, I kind of break it into what are challenges and what are the nightmares. And over my 23 years, not just with the Niners, but I worked as team physician for the Warriors, for San Jose Earthquakes, for the San Francisco Giants, as well as for Stanford basketball and football and soccer. So I have kind of a broad exposure to it, and I can tell you that these issues are all the same throughout all of these. I used to, when I first used to give this talk, I'd talk about the difference between professional and D1 college issues in this realm, and it's really narrow. There really isn't much difference anymore. So what are the challenges? Well, it's all about trust. None of us would want to do this job if we don't have the trust of the athlete, and it's becoming increasingly difficult to attain and maintain that trust. Why? Kind of three different categories. One is the ethical challenges therein. There's probably some inherent conflict between the medical focus on health and the athlete's focus on performance. Second is we're dealing with unions and agents, and the third is the alternative care providers. How many of these people come in having their guy or gal that has treated them before? So let's start with the ethical challenges. You should be familiar with this Harvard study that was talking in 2016 about these ethical challenges in sports medicine, and their statement said that a club doctor cannot always hold the player's interest as paramount and at the same time abide by his or her obligations to the club. So their solution, replace team physicians with one physician who is a player's medical staff, exclusive loyalties to the player, probably appointed by the union, and another who's the club evaluation doctor with exclusive loyalties to the club. Well, right away you can see that there'd be significant challenges with this. I think just on a daily basis, if you have a club evaluation doctor doing free agent physicals and doing the combine evaluations of the college athletes and then have a separate person that's working in the games, sidelines with that person, not knowing the personality of the different players, there'd be a lot of conflict there. But this is their recommendation. The second recommendation they gave was a conflict of interest in terms of medical sponsorship. This one I agree a little more with. I do think it's not a good look to have a bidding war to be a team physician, and I know that that happens. The NFL's really worked hard to try to discourage this. In fact, in the 2004 CBA, there's mandates that there's a separate agreement with the medical sponsor and the treating physicians. For example, the 49ers, all our signage and official health co-partners, Dignity Health and the team physicians, myself at Stanford and my partner at West Coast SportsMed. And it doesn't mean that you can't have the team physician be also the official healthcare partner, but it's not good optics, and I don't think it's right to have that bidding war to be the team physician. The second is the agents and the union. From the get-go, as these players come in, unfortunately, many of them are told, don't trust the team physician. Get it right away, get another opinion. And not always, but that's some of the feedback that we get. In fact, in the CBA, it's the player's right to get a second opinion. So how do we battle this? Well, first of all, it's embrace it, don't challenge it. Soon as you try to say, oh no, you don't need to do that, that's gonna go sideways in a real hurry. Do good work. The three A's that I always preach to my residents and fellows in terms of affability, availability, and ability are really important. Do good work. You have to be available. We heard earlier about athletic trainers spending time doing modalities with people and them telling their life stories and creating that bond. You can't just waltz in and say, well, just because I'm a well-respected surgeon and my clinics are booked out for two months that I can just waltz in when I want and gain instant trust. It's just not the case. So you gotta be available and spend time and be affable. You wanna try to build the trust of the locker room. They all talk to each other. If you can get some key veteran support, that's critical. It really helps. I have a veteran recently says, no one's touching me but McAdams. They talk to the newer players. That's really helpful. I've been through the flip side as well where we've had a veteran that wasn't a fan of our medical care and made that vocal and you have to ride those out. But the more you can get the veterans involved, the better. They may leave, retire, get traded, and you start to work over it again. So it's a constant effort that you have to make to maintain that trust through being real with them. Finally, check your ego at the door. It's not, even though you feel that you're the best surgeon around, it doesn't help to say that you need to stay here and I'll do the surgery. They'll read right through that. So tell them what you can offer and be supportive of whatever decision they make. You're part of that process, part of the team that's gonna help get them better. Their goal is to get back on the field. Finally, the alternative care providers, their guy or gal that they have coming in, they need to go do stem cells. They need to do IV cocktails the night before the game. Many of them prior experience from college to professional. You know, when I was in college, I got amnio injections into my knee Friday night before a game or free agent to a new team. This isn't the way we used to do it in Minnesota. We'll hear that a lot. When I started out, people were going and getting stem cells in Germany for the COBE media piece. And then it was to England for a while for IV therapy. Now a lot of them go to Panama or other places. So you have to kind of ride that out. What's the solution? We'll have an open discussion with them about how marketing is often before the science with these entities. And that we look at the science and as long as it's not hurting you, maybe it's a reasonable alternative. But here's the things that we do know and here's what we don't know. Don't be condescending, don't live in that ivory tower where you say this is just, you're wasting your money, you're wasting your time, you're a fool to do that because that's not gonna be helpful for you maintaining their trust. So those are the challenges. They're all surmountable. And I think that are something that you have to put time into, but if when done effectively can really be very rewarding. What about the nightmare? Well, that's lawsuits. And the rest of these slides are all public information. So I'm not talking out of school, but the point of this is basically to have this discussion and talk about what kind of initiatives we need to make. The elephant in the room is the recent one that came out last month, press, that was the 43.5 million verdict against a team physician hospital group as well as an operating surgeon. What was scary about this one is that the negligence involved misdiagnosis of a torn meniscus from repairing a PCL per the media. Former teammates testified that everyone recovers from this type of injury. And the expert testimony, while the defendants had three of the best thought, thinkers, three of the best thinkers in the AOSSM and experience in the NFL, the defendant had an expert orthopedic trauma doc for hire. So that's what's very concerning. It's a landmark case in the view of the NFL Physician Society, which we're not gonna go down lightly with this in what we see go to happen. This is different than leaving a sponge in somebody's abdomen. This was clinical judgment versus negligence. And it involved not only the treating physician, but also the team, I'm sorry, not only the treating physician, but also the team physician follow-up. We heard earlier about how great it is that Dr. Voos can pick up the phone and talk to somebody else about a certain unusual injury and talk to the colleagues. Well, that's gonna go by the wayside real quick. I can't just call somebody else, all of a sudden their notes in the chart, they're liable as well. So you're gonna see people really clamping down on these curbside consults, which is really unfortunate. There's gonna be the fear of copycat claims. This is not a new issue. I think this one is poignant because of the issues I just talked about. But there are some things that we're brewing, and this is kind of what brought it to a head recently and why we're trying to make a change. Other things that we're brewing, we've seen in the press, this one with the physician being sued about over really a pain block that was done that affected the nerves afterwards. It's not just orthopedics. It's also gonna be in the medical realm. This is one that involved a MRSA problem. And this one is very interesting. This is one that involved a ruling against a physician that the underlying part basically says the patient woke up in a pool of blood two feet in diameter before a preseason game, which he played three quarters and had to be taken to the hospital afterwards. And this is very damaging to that physician. And then two weeks later, another report came out saying this was all thrown out. The judge threw it out. It had no merit to it. This doesn't really help us as the physicians when our names are already smeared out there, the physical, the emotional anguish that we can go through. It's not just in the NFL. It also happens in other sports, MLS soccer for tibial nailing. They got infected and then we see it in baseball as well. What are my recommendations? Well, first of all, acknowledge that it may happen. Every attorney I've talked to says the only way that you can completely prevent this from happening is get out of the business. Just stop doing what you're doing. And some people, unfortunately, are gonna do that and we're gonna lose some really great, great physicians. Second, don't take it personally. Understand the motivation of the players. We heard earlier about the average career length, about that 3.3 year length. 78% are bankrupt or under financial stress within two years of retirement. It's not all about the dislike you. It's the situation they may be in. Understand your legal protection. I can't stress this enough. I've had many discussions with Stanford and their attorneys to figure out where I'm covered, where I'm not covered. And everything is so different within states as well as within states. So know your situation. We all know in our training about document, document, document, but this is just have to be incredibly ultra type A about how you document in these situations. If you're gonna inject an AC joint before a game and you maybe forget to do it, you should be up at night worrying about that and get up and just dictate it and be done. You have to document everything you do. And finally, it's risk mitigation strategies. This is a challenge. There's no easy solutions. A few areas, three main areas that are being looked at. Statutory caps can be helpful for the non-economic loss. Really not as helpful for these situations with high profile players because it does not cover loss of potential future earnings. It cannot put a cap on economic loss and that's where that worries a lot of us. The second is some type of patient contract. If I'm gonna operate on you, if you sue me, there's a cap to the amount you can sue me if it's to your insurance limit. That's being looked at. The Stanford attorneys kind of laughed at me for bringing this up. It would never fly in California, I'm told. And I'm told that through different attorneys in California. But certain states, it may fly. So you wanna look at your state to see if this can be done. You could also discuss in that contract, you're gonna select a form. If you do sue me, you have to sue me within this region and not in a different area that may be more malpractice friendly. And finally, employment status, workers' compensation. There's a few physicians within the NFL that do function as a team employee and get some protection under workers' comp. I have mixed feelings about this. I think that that can be a little more of a challenge. Maybe I'm wrong in gaining and maintaining a trust of an athlete. I like to be seen as separate from the team as best as possible. In conclusion, I think this is rewarding and fun as a career. There's also the aggravating and negative energy that we just talked about. But I can tell you that I wouldn't change a thing. As I look back, even with all of these things I sometimes have stressed about, it's the people, it's the athletic trainers, the colleague physicians, the players, the coaches, strength and conditioning, management, everybody, those relationships over the time. And I wouldn't change a thing for it. So thank you. Thank you.

team physicians

trust

ethical challenges

lawsuits

recommendations