Should the NFL overhaul its medical system? Why the Harvard study has it right.

Last Thursday morning I was seeing a patient for a second opinion. His injury had a very long history and, as I reached in my white coat pocket to grab something to take notes, I realized that I didn’t have a pen. In 2008, the state senate of Massachusetts voted unanimously to ban all gifts to doctors from pharmaceutical companies, becoming the first state ever to ban the practice. Legislators cited influence on doctors’ prescribing practices and therefore increase in healthcare costs. Branded pens and Post-it notes were just the tip of the iceberg, however. Pharmaceutical companies recognized that fact and, in 2009, preemptively agreed to a voluntary nationwide moratorium on branded gift-giving. That meant no more Viagra pens and mugs and prompted the only natural question “What the hell am I going to give my uncles for Christmas now?”

The fact is, free t-shirts, pens, plastic knee models, notepads and meals influence the way that doctors make decisions. Doctors are understandably defensive when this is even suggested. In medical school, we all take the Hippocratic oath, pledging our commitment to our patients and swearing never to let anything interfere with that relationship or cause harm to our patients. It may sound touchy-feely and plenty of patients make comments about how all doctors really want is money, but I can promise you that as a whole we take this oath incredibly seriously and anything that questions our commitment to our patients as number one is like a punch to the gut.

Eric Campbell, Ph.D., a professor at Harvard Medical School who has studied doctor bias points out, “The key is realizing [pharmaceutical companies] do things for a reason,” he said. “Drug companies are there to sell drugs.” He has an excellent sports example of bias. What if, in the World Series, referees were allowed to accept a free meal from the American League team but not the National League team. Would fans be okay with that? No. “If we wouldn’t accept it in our referees,” he said, “why would we accept it in our doctors?”

How can we extrapolate this to the report released by Harvard researchers this week calling for a complete rebuild of the NFL’s current player healthcare structure? The report is part of the much larger Football Players Health Study at Harvard University Business School and it recommends that, to remove excessive doctor bias currently caused by doctors being employed by the team rather than the player, the NFL should change who player physicians report to.

Seems reasonable, right? Players would be diagnosed and managed by a doctor who is employed by the NFLPA and NFL as a whole and would therefore theoretically be free from pressures exerted by the team, trying to get the player back on the field as quickly as possible, possibly faster than they should. Unfortunately, in practice, this could be a lot trickier. I’m not an NFL team physician, never have been, but I can imagine that in practice, changing the way team physicians are employed could be challenging.

This is the current NFL player medical care structure, nicely outlined by the Harvard study:

nflteamdocresponsibilities

Numbers 1 and 2 on the NFL physician’s list of responsibilities, player healthcare and guidance to players on when to return to the field, could easily be transferred over to a non-team physician. However, interactions with the team, consulting with the team to help them to make decisions on when players are ready to return, how they might be limited when they return, and which players should be hired and fired as a result of their injuries as outlined in responsibilities #3-5 in the above chart would be much more difficult.

As a result, the study recommends that a second physician be employed by individual teams to act as a liaison between the independent player physician and the team to assist with advising the team on player decisions.

recommendednflchanges

This chart gives me a headache. It’s redundant. And is it really going to result in better player medical care? Ex NFL team doc David Chao @profootballdoc thinks not.

What the Harvard study doesn’t take into account enough is the fact that players have enormous bias. According to the NFL Players Association, the average career length is about 3.3 years. The NFL spins the data a bit differently. They claim that the average career is about 6 years – for players who make a club’s opening day roster in their rookie season. Either way, a professional football player in the NFL has a very small window in which to make enough money to support his family, lifestyle, or both.

Boston Globe staff writer Ben Volin writes “If the researchers truly believe that a conflict of interest is preventing players from receiving the best medical care, the answer is simple, and doesn’t take two years of research or 76 recommendations to identify — give the players guaranteed contracts. If the money is guaranteed, then players won’t have to worry about rushing back to the field.”

I agree with you, Ben. Players need guaranteed salaries. I think that players are hurting themselves more than any team doctor bias likely is. NFL player bias is no different than a patient who won’t let me put them in a cast because they have to work in a restaurant kitchen to support their family. It’s understandable and excusable. Player bias could certainly be quelled by guaranteeing players money regardless of injury or gameday status.

However, just because player bias exists, it does not mean that the system of NFL player healthcare should remain status quo. Teams simply should NOT employ player physicians. It is an unintentionally corrupt system in which club physicians’ loyalty and relationship with the team could and mostly likely does impact return to play and player employment decisions. It will be difficult to streamline a better, player-centric healthcare system in the NFL, but that does not mean it can’t or shouldn’t be done. The NFL, a league whose revenue is projected to surpass 16 million dollars in 2016, owes it to its players to make their health a true number one priority.

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