Medical Malpractice and Preparticipation Sports Physicals

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

Experts agree that the preparticipation physical examination (PPE), or sports physical, is best conducted by the young athlete’s primary care practitioner in the office setting. However, procrastination on the part of parents, lack of a primary care home, or financial constraints often lead 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 sports season.

Practitioners will often volunteer or be asked to participate in mass screening events. Practitioners may see it as an opportunity to provide a community service, already have a relationship with the school, or view it as a marketing tool for a growing practice. While these are all understandable motivators, practitioners 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 will help you reduce the liability risks associated with PPEs.

Practitioner-Patient Relationship

Depending on the legal venue, a court may hold that conducting a PPE creates a practitioner-patient relationship with the same legal duties as that of an established private practice patient. To limit this risk, consider the following strategies, communicated in writing:

• Explain to the patient and the parents or legal guardian the nature and scope of the practitioner-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.

History and Physical Exam

Nearly all state 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 exams are performed may be problematic. A complaint of negligence may be made if there is a perception that an exam was inadequate and 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 American Academy of Pediatrics Preparticipation Physical Evaluation Monograph, 5th edition, is an excellent resource for finding the currently recommended PPE form. 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 health history items for fear of being disqualified from participation.
• Refer any athlete with a suspected cardiac abnormality to a cardiologist for further evaluation and clearance for participation. See the current guidelines by the American College of Cardiology/American Heart Association.
• Consider including documentation of cognitive issues (such as learning 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 performs baseline neuropsychological assessments, these results should be reviewed prior to full release to participation.

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 practitioner, contact the practitioner to facilitate the evaluation and ensure appropriate follow-up.