Listed As Probable

Article raises dissenting opinion to sickle cell trait testing

A recent article in the San Francisco Chronicle questions the necessity of testing NCAA athletes for sickle cell trait and claims such a policy could also lead to discrimination against minority players.

A quote related to the first point:

...in several cases where athletes with the trait died, doctors found evidence of "sickling" in their blood cells. Vichinsky and other doctors say researchers don't know if the sickling was brought on by intense exercise and played a role in their deaths, or if the blood cells took on the sickle shape after death.

But there are studies that have shown that those with sickle cell trait  "are marked by biological and clinical differences in comparison with subjects with normal Hb". I would also add that the clinical presentation of those with presumed sickle associated collapse (exhaustion early in an intense workout) seems to be different than that of heat stroke (elevated core temperature, often dehydration, after exercise of a longer duration) indicating that they are distinct entities.

And the second point:

Some doctors and ethicists said it's easy to imagine some coaches easing up on athletes with sickle cell trait, especially since there has already been a lawsuit.

"The idea is coaches are supposed to work out an individual plan with that athlete, but unconsciously you can imagine they're going to be worried about their liability," said Marsha Treadwell, who works with patients at Children's Hospital's sickle cell center. "Those athletes are not going to get the same conditioning."

I'd argue that we probably have no choice. They absolutely shouldn't be pushed as hard because doing so puts this type of athlete at risk.

Now I am always sensitive to the notion, as is raised in the article, that we should have to prove a condition is risky or an intervention is effective before it is mandated. The sudden cardiac death screening debate is an excellent comparison. I haven't seen evidence to convince me that it is worthwhile to screen all athletes with an EKG or echocardiogram. Sickle cell trait and sudden death faces the same challenge when it comes to ressearch - deaths are rare so it takes huge numbers and lots of time in order to see if you've made a difference. As I've mentioned before, I think the decision to go ahead with sickle cell testing is easier than cardiac screening issues because A) the test is already done on everyone B) there is no gray area with the test, either you have the trait or you don't  C) those indentified with the condition do not have to be restricted from play, just educated.

I do think it is reasonable to study whether or not such screening engenders any feelings of discrimination among athlete populations. If testing is offered to all ethnic groups - as it should since sickel cell trait affects other groups besides those of African descent - and all involved are educated adequately on the nature of the condition and how to prevent complications then I would think we can avoid any ethical quandries.

 

Trust Me, I'm A Sports Doctor

Most of us in the health care field like to think we hold the moral high ground, healing the sick, helping the downtrodden, making society better, and all that, especially when compared to other professionals (cough, swindling lawyers, cough).

When our brethren are arrested it certainly must be for noble purposes like peaceful protest over health care reform. Upon further review however, medicine has produced a surprising number of sociopaths (serial killers Harold Shipman, Michael Swango, H. H. Holmes, the alleged Craig's List killer, and possible terrorists). That Ted Bundy was apparently accepted to law school doesn't come close to balancing the doctors vs. lawyers score sheet. Probably doesn't help that we are more likely to attract those with a god complex or a fascination with death. At least our oath is cooler and far more famous than their oath...but I'll admit 'the bar' is tough to beat.

As a whole, very few doctors run afoul of the law. The DEA reports that < 0.01% of registered physicians are arrested each year (the curious can look at those cases here). Based on this recent report from the Florida Bar it looks like the proportions of doctors and lawyers who have their privileges revoked by their respective boards in the state is roughly similar.

The DEA's investigation into Dr. Pedro Bosch, the physician who reportedly prescribed Manny Ramirez his hCG, raises the question are sports medicine providers at higher risk for unethical behavior? Other publicized examples include the cavalier use of human growth hormone by Richard Rydze, former team physician for the Pittsburgh Steelers and Richard Shortt who provided HGH and testosterone to former Carolina Panthers.

A small 2005 study of sports medicine physicians in New Zealand found that their main ethical concerns were privacy issues and how doctors fit into the sports hierarchy where they can feel responsible not only to their patients but coaches and management. A recent Boston Globe article also emphasized the challenge of maintaining patient confidentiality.

At his 15th Harvard reunion this past weekend, (Dr. Peter) Asnis was eager to catch up with buddies he hadn't seen in years. But what classmates really wanted to dish about were the Bruins, as well as the Red Sox and Patriots, all teams cared for by his Mass. General practice.

"I didn't answer any of the questions about the athletes, so they were generally short conversations," Asnis said.

I'd echo those comments and add that the smaller the town sometimes the more frequent the questions are about the local sports stars.

There may also be a real or perceived pressure to push the envelope of normal practice in order to gain and then maintain the prized status of team physician. Excitement, prestige, gear, trips, exposure, and access to the inner circle are all heady benefits of working with high profile teams and/or athletes. In a similar fashion perhaps access to this celebrity culture influenced the decisions made by Michael Jackson's personal physician. The first step to keeping perspective is to remember that it isn't who you treat but how you treat that makes you a good physician.

Professionalism has become a point of emphasis in medical schools in recent years, especially after a study showed that physicians with disciplinary problems usually demonstrate concerning behaviors during their training years. Professionalism is one of the 6 core competencies the ACGME mandates that all medical trainees demonstrate before graduating residency and fellowship and sports medicine is no exception. At Wake Forest we have woven in ethical debates and case studies into our teaching sessions in order to address this educational need but the real difficulty is how to then prove that our graduates possess this nebulous virtue. Professionalism report cards and paying close attention to disciplinary issues are basic steps in this direction.