Good morning. Welcome to Plenary Session 3. This is the last but certainly not the least of our plenary sessions. It will be moderated by Jerry Grant and Shelly Timmons. We're going to start today with the Theodore Kersey lecturer, which will be given by, the lecture will be given by Gary Green, who is a board-certified physician of both internal medicine and sports medicine. And he's a fellow in the American College of Physicians and the American College of Sports Medicine. He currently serves as medical director, research director, and consultant on anabolic steroids for Major League Baseball. He's a clinical professor in the UCLA School of Medicine in the Division of Sports Medicine. He's been a team physician for Intercollegiate Athletics since 1986, and currently serves as head team physician for Pepperdine University. Dr. Green was a member of the NCAA's Committee on Competitive Safeguards and Medical Aspects of Sport, and chaired the NCAA Committee on Drug Testing and Drug Education for five years. His career has been devoted to improving the health and safety of athletes at all levels. He's active in research in areas of performance-enhancing drugs in athletes, as well as concussions and reducing injuries in baseball. So it's my pleasure to welcome Dr. Gary Green. Thank you very much, Alex, for that really nice, little bit long introduction, but thank you very much. So I'm not really sure why Alex asked me to give this talk. I wasn't really sure why he wanted me. I'm not a neurosurgeon or even a neurologist. But I thought I was really honored to be given the Curzi lecture of such a distinguished scientist and physician. So, how do we go back here? Sorry. There we go. So, of course, when I got this, I thought, well, maybe something about Dr. Curzi inspired Alex to give me this lecture. So I went to the most authoritative place to do my research. I went to Google and looked up Dr. Curzi to think maybe there was something in his background that would help me figure out what to talk about. So I looked up, and it turns out Dr. Curzi practiced at UCLA, and I practiced at UCLA. So I figured, you know, I better dig a little deeper. That didn't seem like enough of a connection. Well, Dr. Curzi introduced the microscope to neurosurgery, and that was his big contribution, and it turned out that I used a microscope in medical school. But, again, I didn't quite think that that was enough for the lecture, so I kept digging, and it turns out that Dr. Curzi made his breakthrough in 1957, and I was born in 1957. So, again, the connection got a little deeper, and then Dr. Curzi helped develop the Ben Casey TV show, and, in fact, they think that the character of Ben Casey was based on Dr. Curzi, and then it turned out that I had actually watched that TV show. But, again, it did not seem like that was enough of a connection, and then digging a little deeper, Dr. Curzi had a very strong interest in addition to neurosurgery and medical ethics, and so I said, okay, finally, something that I can decide to talk about here to honor the memory of Dr. Curzi. So I was going to talk about some ethical issues in sports medicine, the role of the physician in sports medicine, or how to make sports safer without altering the essence of the sport and eliminating it completely. So the first question that a lot of people ask is, what is sports medicine? Well, there's a lot of things that go into sports medicine. A lot of it is watching games and waiting for injuries, and, fortunately, I like watching sports, and so I cover a lot of games, and you wait for injuries to happen. The other thing that we do a lot of is pre-participation exams to make sure that athletes are safe before they participate, and when I rode crew at the University of Pennsylvania in 1975, this was our pre-participation exam. Eight of us were led into a room all at once. We were told to drop our shorts, and then a medical resident, actually a female medical resident, walked up and down the line, said, turn your head and cough, signed our forms, and then we were off on our way, never examining any shoulders, knees, or even listening to our hearts or lungs. So sports medicine has come a long way in the last 40 years. But sports medicine is really the understanding of the pathophysiology of injuries and illnesses, and then coming into the interaction between those injuries and the demands of the sport or activity, and the difference in sports medicine is a physician's job isn't done until the patient returns to their previous level of activity. And does anybody know who this is? This is one of the most famous left arms in all of sports. Does anybody know who this is? Well, this is Tommy John, who was the first case for having, and became known as the Tommy John surgery, replacing the ulnar collateral ligament. And Dr. Jobe, who did the surgery, Tommy John could have lived his whole life without an ulnar collateral injury, but he wouldn't have been able to continue his profession. And it's the replacement of that ulnar collateral ligament that's allowed many pitchers to continue their career. Actually, Tommy John won more games after his surgery than he did before. So the job isn't really done until the athlete is back to their level. And some of the differences are, in a regular patient, when you see them, their first question is, how long can I be off work? And the athlete wants to know, how soon can I get back to play? The other difference is, in sports medicine, the doctor is usually paid by the team or the school, and not by the patient. So that can create some ethical dilemmas that I'll talk about in a minute. The other thing is, when you have a regular patient in regular medicine, you really can't talk to the employee supervisor. However, in sports medicine, we're always talking to coaches, general managers, the public. If you watch sports, you see a sideline reporter. If somebody goes down, there's a sideline reporter there to give you an immediate update as to what they did, when they're going to be back in the game. And that doesn't happen with regular patients. And then prevention is a big part of medicine. We do routine physicals. We do vaccinations. We're looking for ways to prevent illness and disease. In sports, it's really more about risk mitigation. It's often a doctor at a sporting event has been compared to a priest at a hanging, that you really can't do much until afterwards. And I often thought, when I was a team doctor for a football team, that I'd look around on the bus to the stadium and realize that in about four hours, about 10 percent of the players were going to be hurt, and several of them would be hurt seriously. And if I really wanted to practice good preventive medicine, I'd stop the bus right there. But unfortunately, they'd probably run me over if that happened. But you're really trying to reduce risk. You can't really eliminate it. And then we also have to deal with a lot of cliches in sports that athletes often tell us about, such as injuries are part of the game. You have to play hurt. Are you hurt or are you injured? Suck it up. Everyone is hurt this time of year. And then probably, and then I can't let my teammates down. I have to play hurt. And then probably the most famous one is from an English football soccer coach, Bill Shankly, who said, some people think football is a matter of life and death. I assure you it's much more important than that. So athletes tend to take their sports very seriously, as well as the public. And so these are things that you have to deal with. And then you have the image of the heroic athlete playing through pain. Those of you old enough to remember Willis Reed in 1970 limping out for Game 7 of the playoffs, or more recently Michael Jordan playing through a flu-like illness during a playoff game. And these are celebrated icons. But what's not different about sports medicine is the standard of care. There's no such thing as an athletic standard of care. Physicians are held to the same standards, whether you're treating an athlete or not. And so some of the excuses that have not held up in court are, well, we didn't have any more linebackers left. We had to play this guy. Or it was the last game of the season. It was the playoffs. Well, the coach said I could play. And the athlete said he wanted to go back in the game. None of those things are likely to help a sports medicine physician who is not practicing a good standard of care. In fact, if you rely on one of these, you're probably writing a check with a lot of zeros and commas. So what do we do? How do we manage these risks? Well, risk is inherent to most sports. And we have to decide what is the essence of a sport and which risks are acceptable and which ones aren't. And some examples, when I was on the NCAA committee, we had several, we had three wrestlers who died trying to cut weight before a match. So we had to change the rules of weight loss in wrestling. We had several catastrophic eye injuries in women's lacrosse, and that led to the use of protective eyewear in that sport now. And I'm going to talk a little bit about how we were able to influence the injury rates of home plate collisions in baseball, and I'll talk a little bit about performance enhancing drug use. And of course, I think everyone knows about the risks of concussions in football and what the media has covered that. So there are some ethical challenges to the team physician. One is that you could lose perspective. You feel like you're part of the team, and you're one of the guys, you're part of the team, and you lose your perspective on your role. And then there's a conflict. Are you serving the team that pays you, or are you serving the athlete who's your patient? There's also medical sponsorships. Many leagues allow what's called a medical sponsorship, where hospitals or private practice groups will bid to become the team physician for that particular team. And so the team physician is awarded not on the basis of merit or competency, but on who pays the most. And that provides that big ethical challenge. And then we've had team doctors providing banned drugs with the rationale, well, it helps the team, and they're going to get it anyway, so they might as well get it from me. And that's led to a lot of problems, which we'll talk about at the end. And then there's incentives. If you're a team doctor in a town where that's the big team, there's a lot of financial incentives. You'll get more patients. It's emotionally satisfying to take care of a team, and there's prestige, and that could lead to ethical compromise from compromising your medical values because you want to keep your job as a team physician. So I'll talk about how we address some of these things in Major League Baseball. Fortunately, concussions, mild traumatic brain injury is not as common in baseball as other sports. And for those of you not familiar with baseball, this is how it's set up. In the major leagues, there's 30 clubs. There's 1,200 players. They play 162 games in 187 days, so not very many days off. And the minor leagues are about 250 clubs with about 7,500 players, and they play a variable amount of games, either from like 50 to 144 games during their season. So that's kind of the structure that we have. And in 2010, we created an electronic medical record system for all major and minor league clubs. And over the last seven or eight years, we've had over 18,000 player records, over 100,000 injuries. So this gives us a very robust data set to be able to look at injuries in professional baseball. And one of the things in sports epidemiology we use is something called the athlete exposure. And it's a way of providing an incidence rate to see if your injuries are going up or down. So the typical denominator is 1,000 athlete exposures. So 1,000 athlete exposures are 10 athletes playing 100 games, 100 athletes playing 10 games. And this gives you a nice denominator. And you can see that we have each year about almost 400,000 athlete exposures per year. So that gives us a very rich database in order to mine some data. So the problem is that there's about 750,000 pitches per year in the major leagues. And there's only about 10 potentially catastrophic injuries per year. And this occurs about one one-thousandth of a percent of the time. But unfortunately, they don't tell us when these injuries are going to occur. So you have to be prepared 100% of the time. And Coach John Wooden from UCLA once said, failure to prepare is preparing to fail. So we really have to drill into our athletic trainers and team physicians the idea of being prepared on every single one of those pitches, because you never know when that's going to happen. And here's a short video. So this is Brandon McCarthy, who got hit on the right side of the head, right at the temple. And you can see when he got hit that he's alert, awake, he's rubbing his head. And he was taken off the field. But once they got him into the training room, they noticed that he had blood behind his tympanic membrane. And he had an epidural hematoma that was successfully evacuated. And I think he's still pitching. I think he's pitching for the Braves right now. I think he's 4-1 this season. So that was a success. And then here's another one from the World Series a few years ago. And you can see that this is Doug Pfister. He also got hit in the right temple. No, it didn't hit his glove. And Doug Pfister is still pitching as well. And in this case, he got hit almost exactly where Brandon McCarthy got hit. But he walked away without a scratch. He actually stayed in the game, did not have a concussion. I think he had a small abrasion on his scalp. He's still pitching. Tim McCarver is no longer announcing. And so if you look at it, it's really a matter of inches. You can see right where Brandon got hit, right above the ear. And then you look at Doug Pfister just maybe an inch or two higher. So one ended up with an epidural hematoma. The other ended up with basically a scratch. So we have to be prepared for all of these and evaluate them all appropriately. And then there's also, we had the case of Aroldis Chapman, who was playing for the Reds at the time. And you can see where the ball actually crushed his orbit right here. And that was successfully an open reduction and internal fixation. And he's back. He's still pitching and now four years later. So in order to try and address this problem with pitchers, we started to come up with, we wanted to come up with something that pitchers could wear that would be comfortable, would withstand a 90 mile an hour ball, and not look too different from the regular cap. So the first company we started working with, and Dr. Volodka helped us with this as well, was Isoblox. And this was the first cap that they found. And they only got one person to wear it. This was Alex Torres for the Padres who agreed to wear this cap. He took a lot of ridicule for this. He was called Super Mario and some other things. His hat actually went to the Hall of Fame. He unfortunately didn't, but his cap did. And unfortunately also we were not able to convince any other pitchers to wear this. So we had to go back to the drawing board and we tried another cap which would go around the external part of the cap. And again, we really, this did not sell well. We couldn't get any pitchers to wear this. So we went to the next one which was a carbon fiber cap that really looks almost like a regular cap. It's about the same weight. It has some cutouts where you don't really need protection. And we made about 60 of these at a very high cost. I think these were printed on a, these were made on a 3D printer, some of the original ones. But unfortunately we couldn't get any pitchers to wear these despite the fact that we gave out about 60 in spring training the year before in 2017. So now it's still a work in progress. And I think one of the telling things, I had a pitcher try one of these on and I asked him, why won't you wear it? And he had actually been beaned and had a very serious injury. And he said, because if I wear it, I'm admitting that I'm worried about it. And I tried to convince him that if you wear it, you don't have to be worried about it, but he's a left handed and he didn't really buy it. So some people said, well, maybe we need helmets on these people. So does anybody know what sport this, the helmet's from? All right, well, this is a cricket helmet. And this has a rigid, it's a rigid hat with a face mask. And you think, well, that would be great. Well, helmets aren't always the answer. This is Phillip Hughes who was an Australian cricketer who died four years ago when the ball ricocheted off the ground, reflected back, caught him behind the back of the neck and dissected his vertebral artery. And he died very quickly in that case. I think he died on the field. So again, helmets, even with the best of helmets, they may not be the complete answer. So a few years ago, we undertook a study to look at how to reduce the incidence of concussions in major league, in minor baseball. And Dr. Volodko was a co-author on this. And what we did is we looked at two seasons of major league baseball using our injury surveillance system. And we had a total of 300 concussions. Most of them were in the minors. As we said, there's more players in the minors than the majors. And the players in the minor leagues were a little bit younger, which reflects that that's the typical age for the minor league players. And what we found is very high exposures. So 500,000 in the minors, 100,000 exposures in the majors. And again, we found a rate using these 1,000 athlete exposures. It was about 0.26 per 1,000 athlete exposures, which is about once every 200 games. Just to give you an idea, there are some sports and some football leagues, the rate is 18 per 1,000. So you can see that this is very, very low. Even in the minors, which were slightly higher, it really wasn't very high. And 98% of these occurred in games, which as I mentioned, they play 162 games in 187 days. There's not much time for practice. And what we did is we looked at the number of concussions based on the level of play. So from major leagues to the low minor leagues, and the number of days missed. And there really wasn't a big difference. So the severity was pretty much the same across all levels of play. And then we also looked to see where these injuries occurred. And for anybody that's followed baseball, not surprisingly, about 50% of them happen at home plate, whereas that's where the action is. And then we looked to see whether the concussions happened on offense or defense. So when they were in the field or when they were at bat. And the majority, about 55%, occurred on defense. So we drilled down a little bit deeper on this to look at these defensive or fielding concussions. And it turned out that catchers were about 40% to 50% of the concussions, which is overrepresented. Because if you know baseball, catchers are one-ninth of the positions. So they should be about, if it was equally distributed, they should be about 11% or 12% of the concussions. But they're actually about 50%. So we realized, using the Willie Sutton rule, go where the money is, we looked at the catchers a little bit more closely. So it turned out that about 40% of the concussions in catchers were from collisions at home plate. And so based on that, what we decided to do was look at the rules that govern this. So we looked at home plate collisions. So here's a video. Watch the catcher here. So I think there's a man on first and second. And this was before the rule change. All right, so it's a hit to the outfield. So watch the catcher. So one run will score. There comes the throw to the plate. So this player received a concussion and you can see that the batter or the runner didn't even try to touch home plate. He had to go actually back and touch home plate after he knocked over the catcher. So based on this, we passed rule 7.13 in 2014 that basically said the runner attempting to score cannot initiate contact with the catcher and if he does, then he's called out. And at the same time, the catcher can't block the plate and not give the runner access. Otherwise the runner would be declared safe. And for those of you who may have watched this was applied in the playoffs in 2017, I'm sorry for Patty and any Cubs fans, but in this case the runner was initially tagged out but it was determined that the catcher blocked the plate and he was allowed to score. So this is the effect of the rule change and it's really had a dramatic effect. This is the annual number of injuries due to home plate collisions and this is before the rule and this is after. So it went from about 100 injuries at home plate down to 55. And then the number of days missed due to home plate injuries went from over 2,000 to about 900. And this was significant at less than the .0001 level. And then we looked at actual concussions at home plate and so the average number of concussions due to home plate collisions was 11 per year. It's down to 2 and if you see, there have been no home plate collisions, no home plate concussions at home plate in catchers since the rule was passed in 2014. And the average annual days missed due to concussions was almost 300. Now it's down to about 36 per year. So you can see that the rule change has had a really big effect on reducing these injuries without really altering the essence of the game according to most people except maybe for Pete Rose. And he said, I just don't understand. I mean, does everybody know what we're playing for now? I mean, you get a tweak, you got to leave the game, you get a knee in the head, you got a helmet on, you got to leave the game to go take a test that you passed. I mean, because you're a little lightheaded. I got lightheaded how many times in my career? I would say probably a lot based on this statement and in pretty much if Pete Rose is on one side and science is the other, I'm pretty happy where we landed on this. And again, it hasn't altered the essence of the sport and it's allowed us to really reduce the number of injuries in this. The other thing we did is we changed the disabled list. Prior to 2011, the only choice for going on the disabled list was either going to a 15 day, which is now 10 in 2017, or a 60-day disabled list. Well, we looked at the data and we realized that most concussions resolve in under a week. So what teams would do is if a player got concussed, they wouldn't put them on the 15-day disabled list, they would leave them on the active roster. And he'd usually be there for a few days and after a few days he's feeling better. And then let's say it's an extra inning game, the team's shorthanded, they'd go up to him and say, hey, Johnny, do you feel okay? Yeah, I'm feeling better. And they'd put him back in the game. So we went to a 7-day disabled list just for concussions so that the team could replace that player on the roster and still let that player have time to heal. And 7 days is the minimum, it's not the maximum. And we discussed that with all the stakeholders, including the team physicians, the athletic trainers, and our union. And it was instituted in 2011. Prior to 2011, we only put about four or five players on the disabled list per year for concussions. Since that time, we now are putting about 10 to 14 at least on there. And they're all on the 7, it's because of the 7-day disabled list. So that's really where the numbers are coming from. So again, it's allowed players to have their rest and recovery from concussion. So I just want to finish with talking a little bit about performance-enhancing drugs in sport, which has been my main area of expertise for the last 25 years. So this is a very topical thing. It seems like there's always something in the news. You probably have followed the Russia investigation. And this was a cartoon. It says, our entire team has been banned for doping, even us girls. So I'm not going to talk about the whole Russia scandal. If you're interested in this, there's an excellent movie called Icarus, which I think won the Academy Award for Best Documentary this year, which really details the degree to which the Russian doping scandal unfolded and the degree that it had. I won't go into detail about this except to show you one slide. Dr. McLaren from Canada did the definitive report by the IOC on the Russia state-sponsored doping. And he and I have done a few talks together. And I think this is particularly, and you can look up the McLaren report online, but I think this is the slide that I think really says a lot, not only about Russia doping, but about performance-enhancing drugs in all sports. So this is the number of what they call disappearing positive test results. So what the Russians would do is, if an athlete tested positive, they would make that test disappear and go away. And they kept pretty good records. So Dr. McLaren went through and he looked at all the number of disappearing positive tests by the sport that they were involved in. So obviously athletics and weightlifting were up here. But I don't know how well you can see this, but I think the interesting thing is table tennis is included, canoeing, beach volleyball, all the sports that you wouldn't think of as typical performance-enhancing drugs, they used all of these athletes used that. So it wasn't just limited to weightlifting or track and field, but it really ran the gamut of almost all the Olympic sports that they oversaw. And while we focus on the athlete who tests positive, and that's what makes the papers, that's what we see, you know, that the athlete's in disgrace or, you know, whether they've tested positive. And we forget that that's really just the tip of the iceberg, that the athlete doesn't do this on their own. They're supported by a whole cadre of scientists, researchers, their social network, their peer group, coaches, athletic trainers. All of these contribute to the decisions that athletes make, whether to compete cleanly or to cheat. So while we focus on the athlete, it's really important to know that they're not the ones, they're not the, they're just the tip of the iceberg. And if you look at some of the major scandals in doping in sport over the last 30 or 40 years, whether it's the Soviet Union and East Germans in the 70s and 80s, Ben Johnson at the 88 Olympics, the Balco in San Francisco in the 2000s, human growth hormone use, Lance Armstrong in the Tour de France cycling scandal, or the Russian, the recent Russian track sports scandal, one thing they all have in common is that all involve physicians, scientists, and sports personnel. And unfortunately, you know, we like to think that physicians are operating at a very high ethical level, but all of these involve physician, physicians that participate in, and not only do they participate, but these programs probably wouldn't have been possible without their cooperation. And Reike Reinisch is one of the East German swimmers who was in, as part of the doping program in East Germany. And she said, the coaches and doctors were our guardians, the people we trusted at sports school. I'll never know how good I could have been without drugs. And most of these East German women have offered to give back their medals because they realized they were tainted. They did a survey, and a lot of them would have all turned in their medals if they could have their health back, because a lot of them have had serious health effects. In fact, several of the women are now living as men because they had so much androgens pumped into them that they just found it easier to live as men. The other thing is, not only is it affecting these women, but it's affecting their offspring, and sometimes two generations down from everything that they were given. Fortunately, there's a little bit of a solution to this. Major League Baseball, in cooperation with the NFL, U.S. Olympic Committee, and the U.S. Anti-Doping Agency, formed the Partnership for Clean Competition, and we fund anti-doping research. In the last 10 years, we've funded almost $20 million in research for anti-doping and made some major breakthroughs for this. If anybody's interested in applying for one of those grants, let me know. Major League Baseball also has our own research program to help the health and safety of professional baseball. We provide information to clubs and players, and we try to use the wealth of data that I described in order to fund studies. We review grants twice a year. We're open to projects utilizing our data or outside information, and we have funding available. So these are our research groups at our administrators at MLB, or you can email me. I'll put my email at the end. We actually have a very brief application. It's not anything like an NIH proposal. It's about three or four pages, and we try to make it not very onerous so that we can encourage research. We also have started a PitchSmart.org, which is a website that's to help parents and young athletes protect their arms. We realize that when pitchers especially get to the professional leagues, they've already had significant damage to their elbows and shoulders, so we've been trying to provide information to allow to protect those young arms and give parents and coaches guidelines as to best practices in order to protect these young arms. And the last thing I'll end with is kind of going with what Alex's theme of privilege and service is while we think of doping and we think of athletes cheating as going back hundreds if not thousands of years that athletes have cheated, we also have to remember that most athletes compete cleanly, and most athletes would like to compete cleanly. And not only that, but the idea of competing fairly goes back thousands of years. And this is the Greek dramatist Sophocles who said, rather fail with honor than succeed by fraud. And I think we get caught up in the negative stories about athletes cheating, using performance-enhancing drugs, and we forget that most athletes really do have the ideal of playing cleanly. And so it's really one of the reasons that I've devoted lots of my career to anti-doping efforts is not because I think it's a good thing, it's because we're really fueled by the clean athletes who want us to make their sport clean so they can compete on a fair level, and that's really what I think drives our research. And so if you have any questions with this, I covered a lot in a short period of time, feel free to email me. Everybody else in baseball does about anything that bothers them, so feel free as well. And I want to thank Dr. Vilodka and the American Association for the opportunity to give this very prestigious lecture. So thank you very much. APPLAUSE

sports medicine

physicians

injuries

concussions

performance-enhancing drugs

clean sports

fair competition