Players' Doctors: The Roles Should Be Very Clear.

Years ago, one of us had the opportunity to talk with a starting guard in the National Basketball Association about his health care. The player, then a rookie, did not have his own personal doctor. Instead, he received his health care from the team doctor. This athlete was very well paid and could have received care anywhere he wished in the area. But he came from a very poor neighborhood. Growing up, he said, he had no health care other than hearing and eye tests done at his school and maybe (he was not sure) vaccinations given by the school nurse. The player said he now felt fine and trusted his team to look out for his health since they were paying him a lot of money and obviously wanted him on the court. While it might seem obvious that conflicts of role could arise for doctors working simultaneously for a team and for an athlete-wanting to please coaches, owners, and maybe fans while looking out for the athletes on the team-that is not how this young player saw things. He trusted his team and those who worked for them, and he figured that their interest in keeping him healthy overlapped nicely with his interest in staying healthy. As someone who did not get much access to health care as a child and had little need for it, he did not have concerns about conflicts of interest and second opinions foremost in his mind. But as is clear from a recent scandal involving the National Football League and concussion research, there are reasons for concern when athletes deal with health care workers paid by their teams.

Preventing Conflicts of Interest of NFL Team Physicians.

At least since the time of Hippocrates, the physician-patient relationship has been the paradigmatic ethical arrangement for the provision of medical care. Yet, a physician-patient relationship does not exist in every professional interaction involving physicians and individuals they examine or treat. There are several "third-party" relationships, mostly arising where the individual is not a patient and is merely being examined rather than treated, the individual does not select or pay the physician, and the physician's services are provided for the benefit of another party. Physicians who treat NFL players have a physician-patient relationship, but physicians who merely examine players to determine their health status have a third-party relationship. As described by Glenn Cohen et al., the problem is that typical NFL team doctors perform both functions, which leads to entrenched conflicts of interest. Although there are often disputes about treatment, the main point of contention between players and team physicians is the evaluation of injuries and the reporting of players' health status to coaches and other team personnel. Cohen et al. present several thoughtful recommendations that deserve serious consideration. Rather than focusing on their specific recommendations, however, I would like to explain the rationale for two essential reform principles: the need to sever the responsibilities of treatment and evaluation by team physicians and the need to limit the amount of player medical information disclosed to teams.

Being Right Isn't Always Enough: NFL Culture and Team Physicians' Conflict of Interest.

The job of being a sports team physician is difficult, regardless of the level, from high school to the National Football League. When a sports league receives the intensity of attention leveled at the NFL, though, a difficult occupation becomes even more challenging. Even for the NFL players themselves, players' best interests regarding health issues are often unclear. Football players are, as a lot, highly competitive individuals. They want to win, and they want to help the team win. It's a warrior culture, and respect is earned by playing hurt. Should the team physician respect a player's autonomy when this means allowing him to make choices that might lead to further personal harm, especially if the player's choices align with the preference of the coach and management? Or should the doctor set limits and balance the player's choices with a paternalistic set of constraints, perhaps in opposition to both the player's and the team's desires? Simplification of this web of conflicts of interest is the goal of the model proposed by Glenn Cohen, Holly Lynch, and Christopher Deubert. In my view, their proposal is very clever. As an idea, it meets the expectations its authors set, namely, to minimize the problem of conflict of interest in the delivery of health care services to NFL football players. The ethics of the proposal align well with certain moral goals, like treating the player's interests more fairly and treating the player's health as an end instead of as the means to an end. But will such a proposal ever make headway in the pressurized environment of the NFL?

Health Care for NFL Players: Upholding Physician Standards and Enhancing the Doctor-Patient Relationship.

Beginning my third year with the Kansas City Chiefs and being also a medical student at McGill University, I was at first a little reluctant to comment on Glenn Cohen et al.'s critique of the National Football League's structure involving player health and team doctors, but the opportunity to provide a perspective as both a football player and a medical student was too much to forgo. Because of my athletic and academic background, I am often asked what I think about injuries in professional sports and about the role of sports medicine physicians, and Cohen et al.'s article demands a thoughtful reaction. I want to suggest that the fundamental principles concerning the medical profession and the doctor-patient relationship provide additional arguments for some of the solutions that Cohen et al. discuss. The professional self-regulation that the proposed medical committee could provide and the reliance on a doctor who was not hired by the player's employer-the club-for a second opinion are both good ways to minimize conflicts of interest.

NFL Physicians: Committed to Excellence in Patient-Player Care.

The National Football League Physicians Society read with disappointment the article "A Proposal to Address NFL Club Doctors' Conflicts of Interest and to Promote Player Trust." In spite of the authors' suggestions, NFL physicians are accomplished medical professionals who abide by the highest ethical standards in providing treatment to all of their patients, including those who play in the NFL. It defies logic for the authors not to have engaged experienced and active NFL physicians from the very start of their effort to explore, challenge, and recommend significant alterations to the delivery of health care to NFL players. As troubling as this article is from so many perspectives, it does represent an opportunity for the NFLPS to set the record straight and call attention to the excellent quality of care NFL players receive. In addition, it represents an opportunity to expose the extraordinarily weak evidence presented in the article and to refute the baseless allegations that challenge the high ethical standards of NFL physicians. Contrary to solid scientific research that starts with a hypothesis based on theory, in this case, it seems quite apparent that the authors started with a predetermined conclusion and set out to justify it. Their premise was flawed, and they failed in their execution.

A Proposal to Address NFL Club Doctors' Conflicts of Interest and to Promote Player Trust.

How can we ensure that players in the National Football League receive excellent health care they can trust from providers who are as free from conflicts of interest as realistically possible? NFL players typically receive care from the club's own medical staff. Club doctors are clearly important stakeholders in player health. They diagnose and treat players for a variety of ailments, physical and mental, while making recommendations to the player concerning those ailments. At the same time, club doctors have obligations to the club, namely to inform and advise clubs about the health status of players. While players and clubs share an interest in player health-both of them want players to be healthy so they can play at peak performance-there are several areas where their interests can diverge, and the divergence presents legal and ethical challenges. The current structure forces club doctors to have obligations to two parties-the club and the player-and to make difficult judgments about when one party's interests must yield to another's. None of the three parties involved should prefer this conflicted approach. We propose to resolve the problem of dual loyalty by largely severing the club doctor's ties with the club and refashioning that role into one of singular loyalty to the player-patient. The main idea is to separate the roles of serving the player and serving the club and replace them with two distinct sets of medical professionals: the Players' Medical Staff (with exclusive loyalty to the player) and the Club Evaluation Doctor (with exclusive loyalty to the club). We begin by explaining the broad ethical principles that guide us and that help shape our recommendation. We then provide a description of the role of the club doctor in the current system. After explaining the concern about the current NFL player health care structure, we provide a recommendation for improving this structure. We then discuss how the club medical staff fits into the broader microenvironment affecting player health.

Lessons for the NFL from Workers' Compensation.

In the article "A Proposal to Address NFL Club Doctors' Conflicts of Interest and to Promote Player Trust," Glenn Cohen et al. write, "The [NFL's] current structure forces club doctors to have obligations to two parties-the club and the player-and to make difficult judgments about when one party's interests must yield to another's." I can understand why some might be suspicious about bias in the current NFL medical system, in which the club doctors have a professional duty to put their player-patients' best interests first yet are employed by clubs, which have a primary goal of winning football games. It is my opinion, however, that neither the club nor the player needs to be sacrificed. I base this opinion partly on my experience as an NFL player in the early 1980s, partly on several years as team physician for the Boston Red Sox, and partly on my twenty-three-years of experience as a physician with the Connecticut Workers' Compensation medical system, which supposes that physicians can be fair to both workers and employers.

The Dual Role of NFL Team Doctors.

Glenn Cohen, Holly Fernandez Lynch, and Christopher Deubert are right in their article "A Proposal to Address NFL Club Doctors' Conflicts of Interest and to Promote Player Trust" that the problem with the medical care rendered to National Football League players is not that the doctors are bad, but that the system in which they provide care is structured badly. We saw some of the problems this system causes last season in what happened to Case Kenum, a quarterback for the Los Angeles Rams who, despite having a possible concussion from a game injury, was allowed to continue to play, with a concussion spotter in the booth and coaches, teammates, seven game officials, and two full training staffs present. From my experience playing in the league from 1989 to 1999, I do not believe that you can eliminate the conflict of interest completely, but I think it can be limited to the point that it does not harm the player. As the structure is now, with the team paying the club doctor, it is impossible to put the players' health and well-being before the team's on-field priorities.