JOHN SHUFELDT, MD, JD, MBA, FACEP
Full disclosure: I was not always the smooth, confident provider I hope I am today. No, there was a time when I would say or do things while practicing medicine that would shine a bright light upon my medical inexperience, naiveté, or general ignorance.
To wit, the emergency medicine residents where I trained were pressed into servitude twice yearly to go out to the local high schools and perform sports physicals. On one particular day, I was wading through dozens of budding high school student athletes when I happened upon a young woman whom I believe was around 16. She was next in line for her preparticipation physical. As I recall, her particular sport was cheerleading.
Generally speaking, the women had it easier; their physicals consisted ofa brief head and neck exam, listening to their heart and lungs, acursory abdominal exam, and checking to see if their spine was straight. If they could walk and communicate, their neuro exam was judged to be normal. It was basically the “fog-a-mirror-while-preserving-their-modesty exam.” Typically, the dress du jour was gym shorts and a tank top. The men had it a bit hard- er. They received all of the above plus an inguinal hernia exam. While I was “examining” this young lady, I could not help notice that she had petechiae (red and purple spots caused by bro- ken capillaries) all over her neck and upper chest and on the top of her breasts. She also had a few spots scattered on her abdomen. I went into “Mayo mode.” I was sure that because of my differential diagnostic acumen, I was going to save her young life. I started inquiring about bruising, heavy menses, medication use, recent viral illnesses, mono, syphilis—you name it. Finally, she said, “Doctor, why all the questions? I’m a cheerleader!” I explained in my most Marcus Welby-like voice, “I am concerned about those spots—the obvious petechial lesions—on your neck, chest, and abdomen.” To which she replied, “You mean these?” She pointed to her rash. “They’re hickeys, you idiot!”
Perfunctory Exams No Longer
Back in the day, sports physicals were no-brainers; no one was too concerned about and consequently did not pay much attention to possible red flags. We operated in the ignorance-is- bliss days of “what could these healthy-appearing teenagers possibly have wrong with them?”
Those days are over. We are now keenly aware—or should be—that undiagnosed, critical conditions (now and back then) can kill a student athlete.
A frequently used marketing tactic for both new and well- ensconced urgent care centers is to market sports and back-to- school physicals to the communities they serve. While this is a solid marketing tool, the medical/legal risks may actually out- weigh the return on investment in increased patient volume and revenue that preparticipation physicals can generate. This is particularly true if these physicals are treated with anything less than utmost care and diligence.
The most glaring example of the necessity for diligence in the preparticipation physical is case of the Loyola Marymount University basketball star Hank Gathers, who collapsed and died during a game in 1990. The cause of death was determined to be secondary to idiopathic cardiomyopathy, which was previously undiagnosed. A $32.5 million claim was filed against 11 defendants, including Mr. Gathers’ physicians. The suit was eventually settled for $1 million in 1992.1,2
The goal of a preparticipation physical is to identify serious conditions that may preclude athletic participation. Perceived or real inadequacy of this exam can lead to litigation when a student athlete is felled by a condition that could have possibly been diagnosed during the physical. Although a number of serious conditions could surface on the playing field, cardiomyopathy is particularly concerning inasmuch as it is the leading cause of death in young athletes, followed by coronary artery anomalies and increased cardiac mass not meeting the diagnostic criteria for hypertrophic cardiomyopathy.3
Despite this, cardiac abnormalities are still rare. The incidence of cardiac-related death of young athletes is one in 217,000 to 300,000 deaths, which equates to approximately 10 deaths per year in the US.4,5
Historically preparticipation physicals were performed by the family physician or by a team physician. Today, urgent care providers perform a significant number of these exams, which are often tightly scheduled on certain days or between certain times. The assembly line nature of the enterprise may further augment the perception of the inadequacy of the examination should tragedy later strike. Also, the very nature of the en- counter (loud, busy environment) can make detecting subtle clues even more challenging. In one study, 501 college athletes were screened with an ECG and medical history.6 Of these 90 were selected for an echo. Ultimately, none were disqualified from participation in school sports. This study illuminates the “needle in the haystack” epidemiology of the conditions that we absolutely need to detect.
In 2005, 23-year-old Thomas Herrion, an offensive lineman (6’3” tall, 310 pounds) for the San Francisco 49ers, dropped dead of a myocardial infarction.7 This young athlete had repeatedly sailed through all his collegiate and professional screen- ing exams, yet his autopsy revealed long-standing heart dis- ease. This case further illustrates the lack of effectiveness of the preparticipation exam and led one author to conclude that “although the conduction of the preparticipation exams is considered medically and legally necessary and benevolent by many, the actual utility of at least the cardiovascular component, specifically in terms of screening for lethal conditions, is questionable from an epidemiological standpoint.”8
The AHA Weighs In
Despite this, the American Heart Association (AHA) recom- mends an adequate screening exam be performed on compet itive athletes by trained professionals.9 At present, however, there is no consensus regarding what constitutes an appropriate preparticipation screening history and physical. In a study looking at the preparticipation forms used by 193 high schools, only 32 of them included all three components deemed necessary by the American Academy of Pediatrics: cardiovascular symptoms, blood pressure, and family history.10
To complicate matters, providers have been sued for deeming an athlete ineligible for participation. Although, to my knowledge, none of these suits have been successful, denying eligibility to the next budding NBA star may cause some grief. I know what you are thinking; “Other than that, Mrs. Lincoln, how was the play?” Actually, it is not all bad. It is simply an area in which providers may need to be more cautious than they have been historically.
Preparticipation exams are an integral part of the services we provide in urgent care medicine. These exams should be per- formed with diligence adequate to detect cardiac anomalies. n
References
- Isaacs Conflicts of interest for team physicians: a retrospective in light of Gath- ers v Loyola Marymount. Alb LJ Sci & Tech. 1992;2:147-174.
- Maron Sudden death in young athletes. Lessons from the Hank Gathers affair. N Engl J Med. 1993;329:55-57.
- Maron BJ, Epstein SE, Roberts Causes of sudden death in competitive athlet- ics. J Am Coll Cardiol. 1986;7:204-214.
- Maron BJ, Gohman TE, Aeppli Prevalence of sudden cardiac death during com- petitive sports activities in Minnesota high school athletics. J Am Coll Cardiol. 1998;32:1881-1884.
- Van Camp DA, Bloor CM, Mueller FO, et Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995;27:641-647.
- Maron BJ, Bodison SA, Wesley YE, et Results of screening a large group of in- tercollegiate competitive athletes for cardiovascular disease. J Am Coll Cardiol. 1987;10(6):1214-1221.
- 49ners offensive lineman Herrion dies at 23. ESPN.com news services. Available at: http://sports.espn.go.com/nfl/news/story?id=2139454. Accessed Au- gust 10, 2011.
- Wen Preparticipation cardiovascular screening of young athletes: an epidemi- ologic perspective. Phys Sportsmed. 2004;32(6):23-30.
- Maron BJ, Thompson PD, Ackerman MJ, et Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation. 2007;115:1643-1655. Gomez JE, Lantry Br, Saathoff KN. Current use of adequate preparticipation history forms for heart disease screening of high school athletes. Arch Pediatr Adolesc Med.1999;153:723-726.
