Medical Malpractice and Preparticipation Sports Physicals

Experts agree that the preparticipation physical examination (PPE), or sports physical, is best conducted by the young athlete’s primary care physician in the office setting. However, procrastination on the part of parents, lack of a medical home, or financial constraints often lead high school athletic directors and/or athletic trainers to arrange for the PPE to be done in a mass screening that typically involves multiple medical providers at the school or a local clinic a few weeks prior to the start of the fall sports season.

As summer ends, physicians will often volunteer or be asked to participate in these types of events. Physicians may see it as an opportunity to provide a community service, may already have a relationship with the school, or may view it as a marketing tool for a growing practice. While these are all understandable motivators, the physician should be aware that the medical/legal risks may outweigh the return on investment of increased community goodwill, patient volume, or revenue.

The following strategies may help you to reduce the liability risks associated with PPEs.

Physician-patient relationship: Depending on the legal venue, a court may hold that conducting a PPE creates a physician-patient relationship with the same legal duties as that of an established private practice patient. To limit this risk, consider doing the following, either verbally or by using a handout:

  • Explain to the patient and the parents or legal guardian the nature and scope of the physician-patient relationship.
  • Emphasize that the relationship is solely related to the examination for safe athletic participation and does not replace an annual well-child exam.
  • Ensure that the parent or legal guardian provides consent to evaluate the athlete.

The history and physical exam: Nearly all state high school athletic associations require a PPE for participation in interscholastic sports, while the requirements for club sports vary. The often quick and cursory manner in which an exam is performed may be problematic. If there is a perception that an exam was inadequate, a complaint of negligence can occur if it failed to uncover a medical condition.

The goal of the exam is to identify serious conditions that may prevent safe athletic participation. Conditions that may result in increased risk for sudden cardiac arrest are a particular concern. More recently, concussion risk and sequelae of traumatic brain injuries have received a great deal of attention, making an evaluation of cognitive function another important consideration. Strategies to reduce risk include the following:

  • Take a comprehensive personal and family medical history that includes a cardiovascular history with exercise-related symptoms and previous diagnoses. If your state does not have a required or recommended PPE form, the PPE Monograph is an excellent resource for finding the currently recommended PPE form.1 A parent or guardian must complete the history portion of the exam form and should, ideally, be present for the PPE to answer any questions or provide additional information.
  • Recognize that competitive athletes may not fully disclose symptoms or significant past history items for fear of being disqualified from participation.
  • Any athlete with a suspected cardiac abnormality should be further evaluated and cleared for participation by a cardiologist, using the Bethesda guidelines.2
  • Consider including documentation of cognitive issues, such as reading disabilities, decreased attention span, or questions related to history of cognitive problems, recent academic struggles, or neurological symptoms that parents might not think to mention. If the school or organization uses the ImPACT Test or other forms of baseline neuropsychological assessment, these results should be reviewed prior to full release to participation.

Ensuring appropriate follow-up and clearance: When referring an individual for specialty evaluation, make sure that the athlete and parent or guardian understand that the child has not been cleared for participation and that determining eligibility requires completing all follow-up consults and testing.

If the patient requires further evaluation and has a primary care provider, contact the provider to facilitate the evaluation and ensure appropriate follow-up.

 


References
1.Preparticipation physical evaluation. American Academy of Pediatrics. https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Pages/PPE.aspx. Accessed: July 19, 2015.

2.Maron BJ, Isner JM, McKenna WJ. 26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Task Force 3: hypertrophic cardiomyopathy, myocarditis and other myopericardial diseases and mitral valve prolapse. Med Sci Sports Exerc.1994;26 (10 Suppl):S261-267.
 


By Michael C. Koester, MD, ATC, Slocum Center for Orthopedic and Sports Medicine.


 

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J10257 8/15

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