preparticipation screening

Preparticipation Cardiovascular Screening: Toward a National Standard
David L. Herbert, JD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 3 - MARCH 97

In Brief: In the absence of a national requirement for cardiovascular screening of competitive high
school and college athletes, some physicians have been vulnerable to lawsuits in the wake of sudden
cardiac deaths in athletes. The American Heart Association recently recommended routine cardiovascular
screening for athletes and a specific screening protocol. To best serve the athletes and their
healthcare providers, the author suggests that national sports governing organizations should make
cardiovascular screening a national requirement in preparticipation evaluations.
When a high-profile professional or college athlete collapses on the basketball court, the press and
public understandably pay attention (1). Sudden cardiovascular-related collapse or death is dramatic
and shows the vulnerability of even the most fit among us. Less publicized but no less dramatic are
similar events that befall less well-known and seemingly healthy high school and college athletes (2).
Many believe that some of these tragedies could be avoided through universal cardiovascular screening
of athletes, but the nation's student-athletes and their medical providers still await a vehicle for
uniformly requiring such screening.
Ideally, every athlete with some latent but potentially fatal cardiovascular condition could be
identified and either treated or steered away from participation in competitive athletics or strenuous
recreational activity. Presently, however, reaching this goal seems unlikely, if not impossible. There
is currently no cost-effective battery of tests that identifies all, or even most, dangerous
cardiovascular conditions. Some in the medical profession, nevertheless, have wondered if more could be
done to help prevent cardiovascular-related tragedies. As a result of this concern, the American Heart
Association (AHA) appointed a panel of cardiovascular specialists, other experienced physicians, and a
legal expert to develop recommendations for preparticipation cardiovascular screening of competitive
high school and college athletes.

Recommendations Only...

In June 1996, the AHA panel published recommendations (3) calling for a "complete and careful personal
and family history and physical examination designed to identify (or raise suspicion of) those
cardiovascular lesions known to cause sudden death or disease progression in young athletes...in
organized high school (grades 9 through 12) and collegiate sports." The panel suggests screening every
2 years performed "by a healthcare worker with requisite training...to reliably obtain a detailed
cardiovascular history, perform a physical examination, and recognize heart disease." The panel also
calls for the development of "a national standard for preparticipation medical evaluations."
Although the panel's statement characterizes itself as "recommendations" and not a "requirement," it
has clear medicolegal significance that may not have been intended. The recommendations could be used
in litigation as a benchmark with which to compare and evaluate medical conduct. Through expert
testimony in medical malpractice cases, the statement could become rather strong evidentiary support
for a particular medical standard of care. Consequently, the AHA document, along with related
recommendations such as those of the 26th Bethesda Conference (4), is important for both patients and
physicians.

...Or a Medical Standard?

One statement in particular makes the AHA document akin to a standards statement. The recommendations
state, "Such cardiovascular screening is an obtainable objective and should be mandatory for all
athletes (3)." If a panel of medical experts appointed by a recognized medical association says that
cardiovascular screening of athletes should be mandatory, and is supported in this recommendation by
the American Academy of Pediatrics Section on Cardiology and by the board of trustees of the American
College of Cardiology, how can anyone effectively argue in a legal setting that such screening is not a
necessary part of the care that providers owe to patients?
Given this interpretation of this one sentence, providers conducting preparticipation physical
examinations of athletes should include the cardiovascular screening procedure suggested in the AHA's
recommendations. Failure to do so could result in a legal claim that a student's medical care fell
below expected standards. Thus, what may not have been intended by the statement's authors may well
become a result of its wording and publication.
Considering what could be at stake for a young athlete and the examining physician who uses some
protocol other than the AHA's recommendations, why wouldn't practitioners use the suggested
cardiovascular screening process as a matter of course, especially when the cost and effort in this
process are minimal? As the AHA consensus panel found (3), the failure to perform cardiovascular
screening may arise from the lack of uniform national requirements for screening athletes. While
several national medical organizations have jointly published guidelines for preparticipation physical
examinations of athletes (5), there is presently no way to ensure that these guidelines are followed in
the examinations of all high school and college athletes.

Needed: A National Standard

At the high school level, prerequisites to athletic participation are generally established through
school boards or districts in conjunction with state high school athletic associations. Given the
number of states and the thousands of school districts that set requirements for athletes, one can only
imagine the multitude of divergent preparticipation physical examination guidelines there may be.
Although there is a National Federation of State High School Associations (NFSHSA) that includes more
than 50 state high school athletic organizations, it has adopted no requirement for a standardized
preparticipation physical examination for high school athletes.
At the college level, the National Collegiate Athletic Association (NCAA) has published a statement
regarding preparticipation evaluations (6), but it provides only general recommendations regarding the
content of the evaluation process. The NCAA requires no specific examination protocols, preferring to
leave these in the hands of each member institution. The result is a diversity of procedures,
protocols, and requirements in colleges and universities.
If preparticipation screening recommendations are to benefit and cover all athletes and medical
providers, national umbrella organizations, like the NFSHSA and the NCAA, need to develop a system for
adopting and implementing statements such as the new AHA recommendations, so that the guidelines might
become a universal format for all preparticipation evaluations. Such a systematic approach would
protect athlete-patients by requiring adherence to a comprehensive, nationally derived standard of
care. It would also protect providers, who are increasingly held accountable to such a standard of care
anyway.

References

1. Herbert DL: Another professional basketball player dies. Sports Medicine Standards and Malpractice
Reporter 1993;5(2):17,19-20
2. Herbert DL: Two athletes die. Sports Medicine Standards and Malpractice Reporter 1995;7(1):12
3. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive
athletes: a statement for health professionals from the Sudden Death Committee (clinical cardiology)
and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart
Association. Circulation 1996;94(4):850-856
4. 26th Bethesda Conference: Recommendations for determining eligibility for competition in athletes
with cardiovascular abnormalities. Med Sci Sports Exer 1994;26(10 suppl):5223-5283
5. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for
Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of
Sports Medicine: Preparticipation Physical Evaluation, ed 2. Minneapolis, New York City, McGraw-Hill,
Inc, 1997
6. Benson M (ed): NCAA Sports Medicine Handbook. Overland Park, Kansas, NCAA, 1996
Mr Herbert is a senior partner at the law firm of Herbert and Benson and coeditor of The Sports
Medicine Standards and Malpractice Reporter, a publication of PRC Publishing, Inc, in Canton, Ohio. He
is an editorial board member of The Physician and Sportsmedicine. Address correspondence to David L.
Herbert, Herbert & Benson, Attorneys & Counsellors at Law, The Belpar Law Center, 4571 Stephen Circle,
NW, Canton, OH 44718-3629.