Bibliographical noteFunding Information:
BAGGISH AARON L. 1 COLE BRIAN J. 2 GLADDEN L. BRUCE 3 HUTCHINSON MARK R. 4 PUTUKIAN MARGOT 5 STOVITZ STEVEN D. 6 BEST THOMAS M. 7 1 Cardiovascular Performance Program, Cardiology Division, Massachusetts General Hospital, Boston, MA; 2 Departments of Orthopedics and Surgery, Rush University Medical Center, Chicago, IL; 3 School of Kinesiology, Auburn University, Auburn, AL; 4 Sports Medicine Services, Department of Orthopedics, University of Illinois at Chicago, Chicago, IL; 5 University Health Services, Athletic Medicine, Princeton University, Princeton, NJ; 6 University of Minnesota, Department of Family Medicine and Community Health, Minneapolis, MN; and 7 Miami Sports Medicine Institute, Departments of Orthopedics, Biomedical Engineering, Kinesiology, University of Miami, Coral Gables, FL Address for correspondence: Aaron L. Baggish, M.D., F.A.C.C., F.A.C.S.M., Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114; E-mail: email@example.com . Submitted for publication December 2018. Accepted for publication December 2018. 3 2019 51 3 393 394 Copyright © 2019 by the American College of Sports Medicine 2019 Contemporary publication of scientific data mandates the disclosure of potential or perceived conflicts of interest (COI) and comprehensive standards for this process have been delineated. The International Committee of Medical Journal Editor’s policy states that “Financial relationships (such as employment, consultancies, stock ownership or options, honoraria, patents, and paid expert testimony) are the most easily identifiable COI and the most likely to undermine the credibility of the journal, the authors, and science itself. However, conflicts can occur for other reasons, such as personal relationships or rivalries, academic competition, and intellectual beliefs” ( 1 ). In practice, individual journals develop specific criteria regarding the disclosure of COI and present these requirements to authors during the article submission process. Medicine & Science in Sports & Exercise ® instructions state, “Authors must state all possible conflicts of interest in the manuscript, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest” ( 2 ). The clinical responsibilities, administrative duties, and ethical challenges faced by sports medicine physicians have been clearly delineated ( 3,4 ). Team physicians often find themselves with obligations to third parties beyond the athlete patient ( 5,6 ). In addition, team physicians and other members of the “sports medicine team” are most familiar with the key areas of scientific uncertainty relevant to their athletes and are thus optimally positioned to initiate, implement, and report relevant research. The paradigm in which a member of the sports medicine team identifies a scientific question and then applies a formal research structure to answer that question is well established and of tremendous value to the field. This process is typically driven by a desire to improve clinical care of the patient-athlete rather than for deliberate self-gain. Sports medicine clinician scientists are well versed and generally forthcoming in their disclosure of the well-established COI including research funding support, relationships with industry, stock ownership, and relevant patents. However, to our knowledge, the degree to which simply being a team physician or official clinical team affiliate constitutes a potential COI during the publication of related scientific articles has yet to be critically examined. Members of the “sports medicine team” are compensated for their work in a variety of forms. Remuneration for team physicians and team subspecialists ranges from full time employment to alternative incentives including tickets for games or permission to use team affiliation for marketing or alignment purposes. It must be emphasized that caring for competitive athletes, particularly at elite levels of sport, is demanding work that requires clinical expertise, involves the assumption of considerable responsibility, and lends to an element of public scrutiny. Thus, fair market value is an important consideration and clinicians who engage in these efforts should be appropriately compensated. Nonetheless, when clinical compensation and closely related scientific endeavors coexist, consideration of COI disclosure is prudent. The primary question, similar to other commonly disclosed relationships, is whether the nature of the obligations and responsibilities of being a team physician also require full disclosure in the realm of peer-reviewed publications or their equivalent? Several potential scenarios may shed light on the question at hand. Consider a cardiovascular specialist who is employed by a team or league to oversee preparticipation screening. This individual, well versed in the controversial nature of preparticipation cardiovascular screening, not only conducts the screening but also analyzes the data to determine efficacy and cost efficiency. If a corollary peer-reviewed article is subsequently published demonstrating the benefits of screening, might a team or league be more likely to renew this clinician’s annual contract or perhaps increase compensation based on a enhanced belief of the importance of the cardiovascular specialist? As an alternative scenario, consider an orthopedic team surgeon who is continually striving to improve the durability of a particular joint reconstructive surgery. Working closely with team athletes, she or he identifies a novel surgical technique that appears to reduce the rate of relapse ligamentous failure and appropriately publishes this experience. In the eyes of team ownership, this already valuable member of the franchise now further establishes his or her importance and is amply rewarded at the time of contract renewal. In both cases, personal gain occurred as an unintended result of the scientific process. However, the fact that personal gain occurred as a result of scientific pursuit and peer-reviewed publication cannot be dismissed and as stipulated by the International Committee of Medical Journal Editor, “ perceptions of conflict of interest are as important as actual conflicts of interest.” In other potential scenarios, it is possible that the personal gain could be less than benevolent and the conflict more critical. For example, if an employed team physician chose to study the impact of concussions in elite athletes, it is possible that the outcomes of the research could have a negative effect on the employer organization leading to a direct conflict of interest and pressure to manipulate the research outcome. We are unaware of any mainstream sports medicine or closely related subspecialty journal (or national organization that requires conflict declarations at national meetings) that mandates the reporting of team physician or team subspecialist responsibilities at the time of article submission. Accordingly, best practice standards, which might enhance the reader’s ability to interpret the study findings, do not exist. This editorial was not conceived to imply prior culpability or unethical conduct within our professional community. Rather, this effort was undertaken to stimulate discussion about best scientific practices. Members of the sports medicine team are crucial to the health and wellbeing of competitive athletes and deserve proper remuneration for their time, expertise, and sacrifice. In parallel, the field of sports medicine will be optimized if these women and men in the trenches ask scientific questions and address them with rigor and precision. These parallel agendas are not necessarily at odds with one another and can be powerfully synergistic. However, the ultimate success of this synergy depends upon its scientific credibility and the public trust it garners, both of which are reliant on the disclosure of COI. Ultimately the exact mechanism and guidelines regarding clear declaration of COI will vary from journal to journal and across organizations. However, there must be a balance between full, fair, and effective declaration of potential conflict that assures the integrity of the research and allows the readership to make its own conclusions as to the relevance of this conflict. We believe that further discussions and potential policy changes about the declaration of team physician and team consultant responsibilities during the publication and presentation of scientific data are warranted. In the interim, it would be wise for those among us who simultaneously care for and study athletes to reveal this in a transparent and responsible fashion. Dr. Baggish has received funding from the National Institutes of Health/National Heart, Lung, and Blood Institute, the National Football Players Association, the American Heart Association, the American Society of Echocardiography and receives compensation for his role as team cardiologist from US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. Dr. Best has received funding from the National Institutes of Health and the National Science Foundation and receives compensation for his role as team physician for the University of Miami Department of Intercollegiate Athletics and the Miami Marlins. Dr. Cole has received research support from Aesculap/B. Braun; IP royalties, research support and paid consulting for Arthrex, Inc, other support from Athletico, IP royalties from Elsevier Publishing, other support from JRF Ortho, research support from the National Institutes of Health, publishing royalties from Operative Techniques in Sports Medicine, stock or stock options in Ossio, stock or stock options, research support, and paid consulting from Regentis, other support from Smith & Nephew, and research support as well as paid consulting from Zimmer. He is the head team physician for the Chicago Bulls and co-team physician for the Chicago White Sox and Chicago Dogs baseball teams. Dr. Gladden has received funding from the National Institutes of Health and the National Science Foundation and is Editor-in-Chief of Medicine & Science in Sports & Exercise ®. Dr. Hutchinson serves as Professor of Orthopedics and Sports Medicine and Head Team Physician at the University of Illinois at Chicago where he has not received direct compensation for those roles but does bill patients clinically and for surgical procedures. Dr. Hutchinson has also served in uncompensated roles for the United States Olympic Committee, the WNBA, and various national governing bodies. Dr. Putukian has received research funding from the National Collegiate Athletics Association (NCAA) & Department of Defense and receives compensation for her role as Chief Medical Officer for Major League Soccer. She receives compensation for her role as Director of Athletic Medicine and Head Team Physician for Princeton University. Dr. Stovitz is a team physician for the University of Minnesota’s Athletics Department and for USA Volleyball.