You are the team physician for an NBA basketball team. On the morning of an important playoff game, an EKG of a star player, Mr. P, shows findings suspicious for hypertrophic cardiomyopathy (HCM). Mr. P is an otherwise healthy, fit, professional athlete.
The playoff game that night is the most important of Mr. P’s career. When you inform the coach that you are thinking of restricting Mr. P’s participation, he threatens to fire you. Later that day you receive a phone call from the owner of the team threatening a lawsuit should you restrict Mr. P’s ability to play. Mr. P states that he will be playing in the game “if it’s the last thing I do.”
Which of the following is the most appropriate next step?
- Consult with a psychiatrist to have Mr. P committed
- Call the police and have Mr. P arrested
- Allow Mr. P to play against medical advice
- Educate Mr. P about the risks of HCM
- Schedule a repeat EKG for the following morning
The primary responsibility of a team physician is to protect the patient’s health. The most appropriate way to protect Mr. P’s health, while also preserving his autonomy, is to educate him about the risks of HCM and persuade him to voluntarily withdraw from the game.
The demands of the coach, the owner, or the patient himself must not sway the physician’s professional judgment regarding medically necessary action. In this case, given Mr. P’s HCM, playing basketball could be an immediate threat to his life. He should not play until he can be evaluated further. The most appropriate way to restrict Mr. P’s participation in the game would be to educate him about the risks of HCM in an attempt to have him voluntarily withdrawal from the game in order to protect his own life.
Maron discusses the diagnostic strategies and screening implications in distinguishing HCM from the physiological remodeling of an athlete’s heart. Screening healthy general athlete populations may raise suspicion for HCM, and ultimately lead to definitive diagnosis. However, there is controversy regarding the most effective and practical strategy for the screening of athletes. European investigators promote routine 12-lead ECGs. This differs from customary practice in the US which is limited to history and physical examinations.
Illustration A shows the breakdown in causes of sudden cardiac death in young athletes.