Sample Question

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CASE:

You are the team physician for a local college baseball team and an employee of the college. You have been treating a 19-year-old starting left-handed pitcher with left supraspinatus tendonitis. He had presented with gradually increasing shoulder pain. Initial evaluation revealed positive signs for impingement, and you suspected underlying glenohumeral instability. After a period of rest, treatment with NSAIDs, and range of motion and strengthening exercise, range of motion is improved but not yet normal, and there is still residual pain 2 months after initial presentation. He has already missed the beginning of the season and is anxious to return to the starting rotation since he knows he is being scouted by professional teams. You have explained that you cannot authorize return to play until he is pain-free and has full range of motion. You know that doing so may lead to a full supraspinatus tear, but this is not certain. He indicated he does not wish to continue treatment and will tell the manager he is ready to play. He has not consented to your discussing his current medical condition with the manager or others.

STEM:

What should you do?

ANSWER CHOICES:

  • a. Since you are employed by the college, you must inform the manager.
  • b. Since he is a student, you may discuss the matter with his parents.
  • c. Advise him he will definitely suffer a full supraspinatus tear if he returns to play.
  • d. Clear him for return to play and do not discuss his condition with the manager.
  • e. Do not clear him to return to play, but do not discuss his condition with the manager.

    EXPLANATION

    A physician practicing in sports medicine may face a conflict of interest in that they owe a duty to the team as well as the patient-athlete (doctor-patient-team triad). Conflicts may also arise from various ethical principles. Here, while a duty is owed to the team, your decision should be based on the best medical interests of your patient (beneficence). Further, although you must respect the competent patient’s right to make their own healthcare decisions (autonomy), you cannot follow a course of action that you are reasonably certain will harm the patient (nonmaleficence). Finally, you must respect the patient’s right to healthcare information confidentiality. In this case, nonmaleficence supersedes autonomy regarding return to play. While the physician cannot force this patient to continue treatment, the physician cannot conscientiously clear him to return to play. The physician must, however, respect the patient’s right to healthcare information confidentiality and must not discuss it with the manager without the patient’s consent. The manager, however, may require the player to sign a waiver allowing you to discuss treatment with the manager.

    The patient’s right to healthcare information confidentiality be respected; you cannot discuss the patient’s healthcare with the manager without their consent.

    Despite being a student, this patient is of full age. As an adult, he has the right to withhold consent to divulge his healthcare information, even to his parents.

    Overstating the consequences of not following medical advice is dishonest and goes beyond the bounds of acceptable paternalism.

    Clearing him for return to play violates the ethical principle of nonmaleficence.

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    REFERENCES

    1. Tenforde AS and Fredericson M: Athlete return-to-play decisions in sports medicine. AMA J Ethics. 2015. 17:511-514.
    2. Thomopoulos S, Parks WC, Rifkin DB et al.: Mechanisms of tendon injury and repair. J Orthopaedic Res. 2015. 33:832-839.
    3. Sohn DH and Steiner B: Nonmaleficence in sports medicine. Virtual Mentor. 2014. 16:539-541.