Athletic Physicals and Liability

[EMDoc0411]

This issue came up last night as I was doing volunteer sports physicals for a youth football team at the request of a friend who is the coach. First off, nothing was ready and I had to sit there and waste alot of my time. Next, one of the parents started to flip out when I requested two chairs; one for the volunteer nurse taking BP's and one for the patient. At that point, I almost walked out and left. Lastly, what is the liability if I miss something in these less than ideal conditions (outside, crowds of people) and one of these kids later collapses and dies on the field. I am liable for this kid for an undefined period of time. Is it worth taking on this liability as a service to the community? Has anyone ever gotten burned in a similar situation? My wife thinks we have worked too hard to take this kind of a chance. I think I agree.

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[Arcan57]

It's risky, and the chance you'll find a potentially fatal disease process that you can detect in those circumstances is low. That being said, young healthy kids dying suddenly is really rare. But if it happens you'll be coughing up a lot of cash, which depending on your malpractice may or may not be covered.

 

[dmitrinyr]

I understand that you're trying to help the community and your friend, but this is very risky as you are obviously liable for the clearance of the athlete to compete. Especially given the conditions that you've described. In reality, pediatric clinic/primary care docs do these all the time but they also have the pleasure of being in a nice, quiet exam room with lots of time to take a good H/P, ROS, family hx and while being covered by their malpractice insurance. Most of these patients will have no history, no symptoms, no family history and a perfectly benign physical exam. If this is done in an exam room, you can document all of this and state that pt is in good health, can participate in athletic activity and has very low risk of morbidity and mortality. At most, you might be able to pick up a faint murmur on p/e and/or + family hx/sibling hx of collapse while playing sports/exertion and/or other s/s with exertion that will require other tests (ecg, echo, cardio eval, etc.). It's hard to hear a murmur in a noisy area with limited time and lots of people around. If you miss something, the lawyer can always say... "well you are trained and a licensed doctor, why didn't you pic up that murmur? Johnny could be alive today if you did! Why didn't you use better judgement and examine pt in a quieter setting?" This has lots of risk with very low reward.

 

[EMDrMoe]

This issue came up last night as I was doing volunteer sports physicals for a youth football team at the request of a friend who is the coach. First off, nothing was ready and I had to sit there and waste alot of my time. Next, one of the parents started to flip out when I requested two chairs; one for the volunteer nurse taking BP's and one for the patient. At that point, I almost walked out and left. Lastly, what is the liability if I miss something in these less than ideal conditions (outside, crowds of people) and one of these kids later collapses and dies on the field. I am liable for this kid for an undefined period of time. Is it worth taking on this liability as a service to the community? Has anyone ever gotten burned in a similar situation? My wife thinks we have worked too hard to take this kind of a chance. I think I agree.

Are the replies to this topic by anyone with legal background or just speculation?

 

[Stitch]

During my (peds) residency, we routinely went out and did a ton of sports physicals for the local high schools and middle schools. It made a lot of money for the program, but I felt very uncomfortable doing it. I also had a very low threshold to 'fail' kids and send them to their PCP for rechecking and clearance. This pissed a lot of people off, not suprisingly.

Now that I am done, I can assure you I will never volunteer in such a capacity again. The people (as you appreciated) just want their paper signed quickly. They don't care about you. But I can promise if something happened, they'd turn around and point the finger at you.

If this is something you want to do, I would talk to your malpractice carrier and make sure you are covered. It may also be worth talking to risk management, just to be sure. And if ANYTHING is even slightly out of whack, don't sign the paper.

 

[Substance]

Our society over-values athletics.

I'd never take part in this because it is completely incongruent with my belief that education should be more emphasized in society. As it stands, athletics get most of the focus in pre-secondary education. Who cares if a student understands basic reading and writing if he can break a few records in track?!

Right now a guy who can throw a ball really fast is worth far more than the guy who might cure cancer. That's ******ed. Just stupid.

That being said, athletics is the seen as the only avenue out of destitution for really really poor kids with stupid parents. If you miss something, and their little "ghetto promise" may never make it into the NFL anymore, you can be sure they'll sue you for the millions they thought their kid would have made for them. Idiots.

 

[shopsteward]

Presumably there are a couple of risks that the medical check is meant to cover: a player gets injured and the argument is that they should not have been playing because they were physically unfit to do so or a player has a medical condition that manifests while playing and which should have been found by a medical check. So someone doing a volunteer medical is looking out for an appropriate level of physical fitness and no evidence of underlying medical conditions which make playing inappropriate. (The level of expertise required of the volunteer, legally speaking, is the same as if they were being paid to carry out the medical.)

In any situation of risk there are two considerations: how likely is it that an adverse event will occur, and how bad could it be if it does? If we are talking American football the risks on both counts seem greater than if it's soccer. But any claim on any adverse event is a problem, even if it has no merit or can successfully be defended, because of the costs and emotional/time investment in defending it.

The first line of responsibility for the safety of the players lies with the organiser of the team. That organiser should have their own insurance, and the player would claim against that insurance. The insurance should provide cover for the people working for the organiser, but I wouldn't bet on the insurance automatically applying to a volunteer until I'd been through the small print.

A volunteer could be in the firing line if the organiser doesn't have any/enough/appropriate insurance, in which case the player (or the player's representatives) would go after the next available person, who would be the volunteer. Also, even if the organiser is insured, the player might bring action against the volunteer as well in order to increase their chances of winning, and the organiser's insurance company would probably join the volunteer as a defendant in order to spread the cost of losing.

In future, if asked for help in this way, it would be a good idea to ask about the organiser's insurance. If they don't have any, walk away. If they do, then make sure (in writing) that you are covered by it. You are doing the insurance company a favour by weeding out potential claims, and doing the organiser a favour by enabling them to have valid insurance at a lower price. So the cost of ensuring that you are covered by the insurance should be pretty low, and should be covered by the organiser.

Edited to add: no legal responsibility arises in relation to any action taken in reliance on the contents of this anonymous internet post.

 

[deleted109597]

Don't do it.
Even if they are normal on your exam, if they take a zyrtec-d and have torsades, you're on the hook. Their primary care provider should clear them for sports, and if they don't have one, they need one.

Think of it as the same if a kid comes in with a concussion. Dad says "when can he play again". My answer is always the same. When his doctor or the neurologist I'm giving you follow up with says so. It explicitly says it on the discharge instructions. There was a kid here who died from second impact, and a local EMS guy had cleared him previously. Guess who is getting hammered by that lawsuit?

 

[EMDoc0411]

Thanks for all of the input. While I trully like to contribute to the community in a volunteer capacity, I have to think about the future of myself and my family. I'll just have to focus my volunteering in different directions.

 

[Stitch]

Think of it as the same if a kid comes in with a concussion. Dad says "when can he play again". My answer is always the same. When his doctor or the neurologist I'm giving you follow up with says so. It explicitly says it on the discharge instructions. There was a kid here who died from second impact, and a local EMS guy had cleared him previously. Guess who is getting hammered by that lawsuit?

Ouch. Totally agree with you here though. I send them to sports med or neurology and document that I advised to rest, sit out and not do anything active until cleared.

Our society over-values athletics.

I'd never take part in this because it is completely incongruent with my belief that education should be more emphasized in society. As it stands, athletics get most of the focus in pre-secondary education. Who cares if a student understands basic reading and writing if he can break a few records in track?!

Right now a guy who can throw a ball really fast is worth far more than the guy who might cure cancer. That's ******ed. Just stupid.

Totally agree in most respects here, but also keep in mind that athletics, especially school related may be the only way some of these kids have to exercise. Many of my patients live in areas where it's not safe to ride your bike or go to the playground. School sports, though overemphasized may be their only place to safe participate in outdoor activity. In light of the current American obesity trend, we should encourage kids to get out and play something.

 

[Doctor Bob]

I've seen some of these semi-impromptu sports physicals done and one issue I have with them is that the doc listens to their heart and lungs asks a bunch of questions, maybe looks in the ears and then signs the form and moves them down to the next step in the conveyor belt.

One of the more important parts of a sports physical, the hernia check, is so often ignored and really isn't an exam that's easily done in a group setting. If you're somewhere that you can't do a hernia exam then you shouldn't be doing sports physicals.

Maybe I'm just groin-o-centric.

 

[jwk]

Send 'em to the local DNP at CVS/Walgreens/Publix/etc. for their $29.95 no appointment necessary sports physical.

 

[edmadison]

I am a former general pediatrician (now in fellowship). I have done hundreds of sports physicals and I am very comfortable doing them. Frankly, the physical examination is almost useless (in terms of physical findings which would impact sports participation). For the PE, the most value is the BP and BMI. The really important part of it is the history. I have seen some pretty questionable sports participation forms. Some may fulfill the requirement of the athletic organization, but they certainly don't meet the standard of care. My father, an OB/GYN used to do physicals for my boy scout troop. In retrosepct, I am stunned at how little he actually did before signing the form. Of course that was a different time.

Here is a good link discussing physicals which has the new AAP form. If you are going to do the physicals, I would insist on using this form:

http://brightfutures.aap.org/pdfs/Physical Examination_1.pdf

Here are a few more thoughts from a general pediatrician who is also an attorney.

1) We think of physicals as easy, but are you really skilled enough to be doing it? You may be missing some subtleties that the general pediatrician is going to pick up (such as my dad doing scout physicals). Are you thinking about Turners in that short girl? What about Marfans in the tall boy with glasses. Are you doing genital examinations and tanner staging the kids?

2) For many kids, this is the only time that they see the doctor in a given year. By given him or her a 5 minute physical, are we missing the only opportunity to follow this kid for preventative health issues? Are you assessing how they are doing at school? At home? HEADS examination for the adolescents?

3) What do you do if there is a positive result? Just refuse to sign the form and tell them to follow-up with the PCP? Do you put in a cards consult for a history of syncope? What if they go to the doc-in-the-box and get the NP to sign the form after you refused? What about meds? Will you just sign off or require further follow-up? Is the child's asthma really controlled?

4) Does your malpractice even cover you in this environment? One earlier poster suggested that the athletic organization's insurance cover you, but this won't work. A typical organizational liability policy won't cover professional services and there isn’t a written waiver in the world which will protect you from malpractice claims.

Specifically regarding the liability risk, I think there is a small but significant risk. Heart defects are uncommon, but not rare and we occasionally pick one up based on personal or family history. It only takes one missed HOCM to wipe you out financially. I just don’t see a big upside, it’s really not good for the kids from a medical standpoint and its not good for you.

BTW, the AAP recommends against the traditional cattle call sports physicals. Instead, it recommends annual comprehensive physical examinations.

Ed

 

[deleted6669]

here's a twist-
I volunteer at a free clinic a few times/mo.
one of the things we do there are sports physicals for kids who otherwise wouldn't ever get one as their parents make too much to get public assistance but not enough to afford insurance so they don't have pcp's. we are their pcp for all intents and purposes.. so basically if these kids don't get a free physical they will not be able to participate in school sports and will run a higher risk of becoming obese, etc
our state does provide malpractice(for free) for providers who volunteer at free clinics.
we have a standard form and check for murmurs, hernias, anemia, etc. we can also update vaccinations, etc
I probably do 3-4 of these every time I volunteer and have failed a few kids for murmurs that increase with squatting (pending u/s eval).

 

[EMDoc0411]

here's a twist-
I volunteer at a free clinic a few times/mo.
one of the things we do there are sports physicals for kids who otherwise wouldn't ever get one as their parents make too much to get public assistance but not enough to afford insurance so they don't have pcp's. we are their pcp for all intents and purposes.. so basically if these kids don't get a free physical they will not be able to participate in school sports and will run a higher risk of becoming obese, etc
our state does provide malpractice(for free) for providers who volunteer at free clinics.
we have a standard form and check for murmurs, hernias, anemia, etc. we can also update vaccinations, etc
I probably do 3-4 of these every time I volunteer and have failed a few kids for murmurs that increase with squatting (pending u/s eval).

Yeah, that's good and all, but as a PA, you are working under a physician's license. Not to be rude, but we've got a little more liability/risk involved.

 

[deleted6669]

Yeah, that's good and all, but as a PA, you are working under a physician's license. Not to be rude, but we've got a little more liability/risk involved.

There is a difference between "licensing" and "supervision".
I work under my own "license" but am indirectly "supervised" ( or in my state "sponsored" )by a physician.
if bad stuff happens we both get sued. I have just as much to lose for a bad outcome as you do.
I have seen pa's get fired and become unemployable due to a bad outcome from a lawsuit.

 

[NERDY]

here's a twist-
I volunteer at a free clinic a few times/mo.
one of the things we do there are sports physicals for kids who otherwise wouldn't ever get one as their parents make too much to get public assistance but not enough to afford insurance so they don't have pcp's. we are their pcp for all intents and purposes.. so basically if these kids don't get a free physical they will not be able to participate in school sports and will run a higher risk of becoming obese, etc
our state does provide malpractice(for free) for providers who volunteer at free clinics.
we have a standard form and check for murmurs, hernias, anemia, etc. we can also update vaccinations, etc
I probably do 3-4 of these every time I volunteer and have failed a few kids for murmurs that increase with squatting (pending u/s eval).

Since these kids don't have insurance, do they actually get the u/s?

 

[deleted6669]

Since these kids don't have insurance, do they actually get the u/s?

yup, we have u/s 1 day/week there.

 

[NERDY]

yup, we have u/s 1 day/week there.

That is great.