PLAYING HURT—THE DOCTORS' DILEMMA

The team physician: is his paramount concern the health of the athlete or is it the welfare of the club?

Bill Lee began to see in late August of 1978 what the pain was doing to Carlton Fisk. These, of course, were not ordinary times in Boston. The Red Sox were coming to the turn for home in the race for the American League East. They had been fighting off injuries along the way, and, although they were still in the lead, they were beginning to show signs of strain. Behind them the Yankees were in second place and running. Fisk, playing in agony, was catching every day. Lee, who now pitches for Montreal, urged him to lay off.

"Ah," Fisk would tell him, "I can do one more."

And one more...and one more....

"I looked into his eyes," Lee says. "He looked like a raccoon. You could see he was playing in pain and it was just sapping his body. His eyes were sunk back in his head, with dark rings around them. I told him not to play. Some guys like days off, some guys don't. Some guys like to gut it out. Some guys have to have governors on them. Fisk is a guy you've got to put a governor on. He's just going out there because of his puritanical upbringing—you know, staunch, quiet, archconservative, play-with-an-arrow-in-your-heart type of thing."

Late in July, a month in which he batted .365, Fisk had broken a rib when he crashed into the stands going for a pop foul. A New Englander imbued with the ethic that one must endure pain and suffering to achieve success, Fisk played on, despite great discomfort. He maintains that no one told him not to—not Manager Don Zimmer (who has a metal plate in his head from a beaning), not Haywood Sullivan, the club's owner and general manager, not Dr. Arthur Pappas, the team physician. Pappas, determining that Fisk could continue playing without additional risk of injury, left the decision to play up to him. "I was never one to make an excuse," Fisk says. "I wasn't about to let a little pain and agony stop me from playing."

And so on he played, game after game. In the process of adjusting his throwing to compensate for the pain in the ribs, Fisk injured his right elbow. Nonetheless, he hung in as the Red Sox floundered through the stretch.

Never did Zimmer tell him to take a day off. "He came up to me a couple of times," Fisk says. "It was never, 'I want to give you a day off.' It was always, 'You're all right, aren't you?' Or 'You can play, can't you?' Or, 'You don't need a day off, do you?' "

"We were fighting for the pennant and he wanted to play," Zimmer says. "The doctor told him if he could stand the pain, it wouldn't hurt to play." And: "He never stopped throwing good."

Today, Fisk is paying for playing the last six weeks of the 1978 season. Following a winter of worry and idleness—worry that his arm wouldn't come back and idleness enforced by the pain in the arm—following a spring in which he could barely throw, Fisk has recently come off the Boston disabled list. "I don't know who should shoulder the responsibility," he says. "Seeing as I was the one who made the decision, you could blame me. But I think the situation was pretty obvious last year, me throwing three-hoppers into centerfield and hitting only one home run the last six weeks of the season. As a player, they know what I can do and what I had been doing, which wasn't a heck of a lot. I feel as though it's up to the medical advice whether you play or not. When I broke my rib, I should have had two weeks off. But the doctor said, 'Well, you can't hurt yourself any more than what's already been done.' The reason I hurt my elbow is I was favoring my ribs when I threw. I think he could have been a little more informative. He could have indicated what the cause and effect could really be. I think he should have indicated the problems that could arise."

Fisk's reflections address an issue that has become increasingly prominent in sports in the past year: the role of team doctors, and especially the question of where their loyalties lie. While team physicians treat the players, they are paid by the owners. And although there are some excellent doctors and some enlightened owners, built into the relationship is an inherent conflict of interest. Whose interest do the doctors have at heart—that of the owner, who wants players out there on the field, or that of the player, who in certain circumstances probably shouldn't be out there? Ideally, the doctor serves the interest of the player-patient exclusively, just as if he had walked into his office off the street, and in practice no doubt many team doctors do so. Evidently others do not. Team physicians work for men of varying temperament, from those inclined to demand and meddle to those who choose to stay aloof. The conflicts the doctors endure are multifarious, some of them self-imposed.

The case of Carlton Fisk wasn't the first, or the most dramatic. Nor was it the only one to prompt questions about playing hurt, playing with the aid of drugs and winning at all costs. So explosive and sensitive is the issue that several professional athletes wouldn't comment for the record about medical practices on their teams, including two prominent football players who feared reprisals in the form of trades or being placed on waivers.

During Fisk's ordeal last August, Bill Walton rose up and demanded to be traded from the Portland Trail Blazers. Walton accused the Blazers of misusing four pain-modifying drugs in treating him and suggested that the injection of one of them, Xylocaine, led to the fracture of a bone in his left foot during a playoff game against Seattle. Earlier that season, in another game against Seattle, Blazer Forward Bob Gross had suffered a devastating fracture of the left ankle after it had been numbed by three shots of Marcaine, a local anesthetic.

Doug Collins, the 76ers' star guard, suggested at a press conference in February that the team misled him as to the nature of an injury in order to keep him playing. The team doctor told Collins it was an inflammation of soft tissue in the left ankle. The general manager, Pat Williams, was quoted as saying that Collins had a low pain threshold. Collins went to another doctor, who diagnosed a fractured bone spur that required surgery. Further medical opinion confirmed this diagnosis. Collins received an apology from Williams, and the physicians involved in the case said there had been an honest difference of medical opinion on the need for surgery. Surgery was performed, and Collins was out for nearly eight weeks. After resuming play he suffered a stress fracture in the arch of the same foot and missed the rest of the season and the playoffs.

Shortly after the Collins incident, two former team doctors of the New York Yankees accused club officials of meddling in the team's medical affairs. But it was the Walton affair that really brought to public notice the doctor-athlete dilemma.

Walton, who recently signed with the San Diego Clippers, says he learned valuable lessons from his experience. "The thing that athletes hear most is, 'It won't get any worse, it won't get any worse,' " he says. "They keep trying to tell you it's O.K. to play. You hear time and time again that you can't hurt it any worse. Somebody's got to come to you at some point and say, 'Hey, why don't you think about being champion next year.' Athletes are so competitive. They're so intent on being out there. We grow up our whole lives believing we should be out there. All of a sudden you can't and you don't know why. You hope like heck that somebody can do something to help you out. We learn to trust doctors. Sometimes we shouldn't."

For Pappas, the Red Sox' physician, the conflict is even more explicit. Pappas not only works for the owners but he is also one of them, having just under 4% of the team. "I haven't found this to be a problem at all," he says. Fisk is aware of Pappas' dual role, an unusual situation in professional sports and one that other team doctors have said they would avoid. Yet Fisk and Lee are quick to point out that Pappas, an orthopedic surgeon, is more suited than his predecessor to serve the needs of a baseball team. "He was a urologist," Lee says of the Sox' previous doctor.

"In that respect he [Dr. Pappas] is more qualified for the position," says Fisk. "In the same breath you can say he's got a vested interest in the team and he's going to want to get you back out there. I guess that's part of his job whether he had a vested interest or not. He'd be wanting to get you better, but not with the players' interest at heart. He'd want to get you better for the team."

That he didn't discourage Fisk from playing, Pappas says, had nothing to do with the pennant race. Even if the team had been in the cellar, he says, he would have left the determination up to Fisk. "I still think it's his decision," Pappas says. "It's not that he was making himself any worse. I don't think he's done himself any major permanent damage by playing. I asked him if he'd like to take time off and he said no, he'd rather play. We discussed the injury, and he felt that as long as he was able to participate, contribute to the team, that he would elect to continue playing. Frequently it's the pain that makes the decision as to whether someone is ready to return or not. They're not going to play until I feel, by examination, they're not going to do themselves any permanent harm."

"I don't think I have any resentment, but I'm very wary," Fisk says. "I don't have much trust in one man's opinion—not a specific one, anyone.

"I don't think I ever played where every movement, every upper-body movement, dictated that type of discomfort. When I wasn't actually moving, it was throbbing; every time I moved, the pain was sharp. They gave me anti-inflammatory drugs and, with that and the broken ribs, I wasn't able to sleep at night. They gave me something to go to sleep, and then I couldn't get up the next day—round and round."

When team doctors testify in injury grievance proceedings there is no question where their loyalties lie. Dick Berthelsen, the counsel for the National Football League Players' Association, has handled 67 such cases. In 39, the arbitrator found the club liable to some degree. "In every injury grievance I've ever been involved in," Berthelsen says, "the team doctor has been a witness for the club and in opposition to the player. So in every case you've got that question: is the doctor strictly the agent of the club, or does he have any kind of professional relationship with the player? Obviously, by testifying on behalf of the club against the player, you have a different situation than you normally do when a doctor is talking about his patient."

According to the standard contract, NFL players arc entitled to their salary if, after passing their physical examinations, they become disabled while playing or practicing, even in the preseason. In all injury grievance proceedings, the player's claim is that he was cut from the team while still injured. Brian D. Monaghan, a San Diego attorney who has represented several players in such matters, is convinced that doctors are in cahoots with their teams to deny the players their money. The scenario, according to Monaghan, goes like this: the player is injured in the preseason after he has passed his physical. As the final cut approaches, he goes to the team doctor, "who will ostensibly examine the player to determine if he is ready to return to practice." The doctor passes him, tells him he is fit to play and asks him to sign a release. The player is then cut from the squad. Because the team has certified him ready to play, it now contends it has no financial obligation to him. This way the team is able to save thousands of dollars in salaries. After leaving camp, the player visits a private physician and discovers that he has clearly identifiable injuries, such as a herniated disk or torn ligaments.

Most team physicians are orthopedic surgeons, and they work in a stressful environment in which the object is to field players and win, and the patient is a well-conditioned, exceptionally motivated man who often wants to play—despite injuries and infirmities—more desperately than his owner, his coach and even his creditors want him to. If the doctors always seem to be on the owners' side in court and hearing rooms, few will confess to divided loyalties on the playing fields, where they claim that their first duty, their only real obligation, is to the patient. Yet their decisions are subject to a variety of pressures, not only from without but also from within, conflicting crosscurrents pushing them this way and that.

"It must be one of the most difficult of all medical roles," says Dr. Bruce Ogilvie, a clinical psychologist who has worked as a consultant with a number of pro teams during the past 25 years and was a co-founder, with Dr. Thomas Tutko, of the Institute of Athletic Motivation in San Jose, Calif. "You can't be a team physician without becoming a red-hot jock yourself," says Ogilvie. "I know for myself. My heart, soul and identification are with these players. The doctor is no different from me in that regard. But that places him in a very difficult position. He has to make judgments on readiness to play, medical treatment, diagnoses in situations of high stress—going down to the wire for the playoffs, going for the championship. In these situations he can't help but be torn."

Most team physicians bristle at any suggestion that a doctor might give advice that is injurious to a player. "That would be a reprehensible situation," says Dr. Robert Kerlan, the noted orthopedic surgeon and physician to four professional teams. "Certainly no doctor worth his salt would be associated with any program where his primary concern was not his patient, and the athlete is his patient."

If some team doctors are able to do as they please without interference, others claim to have been less fortunate. The Yankees are working on their third team physician in four years. "Team physicians are caught in a dichotomy, really," says Dr. Maurice Cowen, who held the post in 1977 and 1978. "They're under pressure by owners to do certain things, to get somebody back, and also under their own moral obligation to practice good medicine and take care of the player. And you sort of have to stave off the owner." The Yankees may be the most secretive, evasive team in pro sports in dispensing information about injuries. "I've been instructed by the Yankees, 'Don't tell the player what's wrong with him,' " says Cowen. He says he felt pressure from the front office on how to treat players. He would find a player unable to play and tell the manager. "The manager will say O.K. But then you'll get heck from the front office: 'Why can't he play? What's the matter with him? He's a faker. He always does this. He could play. He's just afraid.' "

The front office—owner George Steinbrenner and president Al Rosen—deny Cowen's allegation. But Dr. Edward Crane, Cowen's predecessor, says he generally agrees with Cowen's assessment of front-office meddling. He says he quit because he could no longer abide its policies, which he felt had reduced him to being an iodine-and-Band-Aid man.

It took Dr. Jay Malkoff only one 30-second experience to quit his job as team physician for the San Diego Sockers soccer team this spring. The Sockers were playing their second home game of the season against the champions of the North American Soccer League, the Cosmos. With 15 minutes left in the game, San Diego's Jean Willrich cracked heads with one of the Cosmos and went down. Malkoff went out to check him and found nothing serious; Willrich continued in the game. At the end of regulation play, with the score tied 1-1, Willrich came to the sideline complaining of a terrible pain in his cheek. Looking at him a second time, Malkoff diagnosed that his cheekbone was fractured. He had missed it the first time. "One cheekbone was dimpled in," Malkoff says.

"He can't play anymore," Malkoff said to the Sockers' Austrian-born coach, Hubert Vogelsinger. "He's got a fractured cheekbone."

Vogelsinger said, "Do you have a Röntgen?" Röntgen is German parlance for X ray.

"I don't need one," Malkoff shot back. "I can see it's fractured."

Vogelsinger asked again, "Do you have a Röntgen?"

"If you look here," Malkoff said, pointing to the dimple, "you'll see why I don't need one."

"I don't see how you can make a judgment without a Röntgen" Vogelsinger said.

"Find yourself another doctor," Malkoff said, picked up his bag, and walked off the field and out of the stadium. "I can't work like that," he said later. His outburst had an effect—Willrich didn't return to the game. "One of the tragedies of most modern pro sport is that it's very shortsighted," says Tutko, who is a professor of psychology at San Jose State University and has worked as a writer and consultant in sports medicine for 17 years. "Its views are the immediate game, the immediate season. The physician's got to be able to take an awful lot of guff and rebuff, coercion, threats and innuendo from managers, coaches, owners and what-have-you because they want the players to play. It's a kind of meat market. Get the meat out on the field. They can't be concerned with two years from now. Right now is what they're concerned about. I'm not saying this is true of all owners and coaches, but the vast majority are in a situation where the immediate becomes important."

Tutko believes that, in the majority of cases, team physicians bow to pressures to bring ballplayers back. "There's always the feeling that in the off-season you can rest, or there's a day or two's rest after this game so you won't have to worry. The core of the player's feeling is, 'Well, I'm just another body, and they'll use my body until I can't play any longer, then they'll use another body.' "

One of the most vexing problems that team physicians say they face is the player himself, his unbridled willingness to play when hurt, to submit to the knife and the needle, to tough it out under pain and pressure. "I remember talking once to Charlie Krueger, a great All-Pro defensive tackle for the 49ers," says Ogilvie. "He was on the training table one day and the trainer was working on his newly repaired knee. His knees looked like they should be examples in an orthopedic hospital. I said to him, 'Charlie, how can you get out there with those legs and do what you do?' He looked me right in the eye and he said, 'Doc, I can't dishonor the way I feel about myself as a man.'

"There is almost a masochistic side to it. To master and handle their pain is a very self-enhancing, elevating, self-fulfilling experience, kind of getting involved in the ultimate measurements of their being, their worth."

To play is everything, for many the only thing. Sitting out with an injury is like being socially ostracized. "When you step out of that mainstream," says Bob Trumpy, who used to play tight end for the Cincinnati Bengals, "it's like you've been blackballed from the fraternity.

"We had a guy on this football team, Ken Dyer was his name," Trumpy continued. "He had a knee injury. He was out for two or three weeks and then came back and suffered a severe neck injury. Now, you talk about a tough decision for somebody to make. But it was Ken Dyer's choice to get back there on that football field. He knew he was an important part of our football team and there was nobody who was going to take him out of the lineup because he felt he was physically ready. He still walks a little mechanically and he can't run and he can play very little golf, but he's happy."

The problem, Kerlan says, is not the owner and front office. "It's when the player wants to play and we don't think he should," he says. "That's where we run into trouble." There is, for instance, the football player who wants another knee operation, even though he is cautioned that as a result he may have arthritis in years to come. "He says, 'Look, it's my knee. I have a whole life to live, I've got a family to support, I want to do this. It's the only thing I know how to do. I'm not an auditor, I'm not an attorney. I'm going to have to cash in right now because my whole future's on the line, my whole security. Now please, do anything you can. I want to play!' That's where our problem is."

If a player behaves otherwise, he is labeled a malingerer. The burden is always on him. It was on Walton last year. Wracked by conflict and doubt, but remembering how he'd been called a "faker" and an "idiot" during his problem-plagued early career, he agreed to the shot of Xylocaine.

"I think the point is that players themselves really have to have the courage to stand up and say, 'Hey, I'm injured,' " Walton says. "A year ago I didn't have that courage to say no. Fortunately, now I have that courage."

PHOTO ILLUSTRATION

San Diego Socker Jean Willrich has had his share of injuries; after one, his team doctor quit when the diagnosis of a fracture was questioned.

PHOTO

Fisk says he played out the '78 season with a broken rib because Dr. Pappas did not stop him.