Outside The Lines

Thursday, September 12
Updated: November 13, 9:56 AM ET
A snapshot of sports' medical dilemma

By Tom Farrey

In May, the organization that markets itself as the official medical provider for the St. Louis Cardinals placed on its Web site a publicity article in which the team doctor offered advice to the little league community on avoiding injuries. To establish the credibility of Dr. George A. Paletta, the bulletin from Washington University in St. Louis cited his relationship with the locally popular baseball team, and included a photo of him with one of the players under his care during spring training.

St. Louis Cardinals
Cardinals players watch a video tribute to teammate Darryl Kile, who died earlier this season.
That player: Darryl Kile.

A month after that photo and bulletin went out to the public, Kile, 33, died when his heart stopped. The cause was determined to be a 90 percent blockage in two of his arteries, a condition that some medical experts say might have been picked up in spring training if doctors, upon screening Kile's family history for warning signs, had given him more tests.

While the choice of Kile's image to promote its medical care turned out to be eerily and painfully ironic -- the school removed the Kile photo from the article after this ESPN.com report first appeared on Sunday -- Washington University is just one of many organizations involved in health care that in recent years have used professional sports teams and athletes as a tool to raise their community profile and lure new patients.

"With all the high school, college and community leagues in an area, it can be an enormous boon to an institution if it can have a reputation with a pro team," said Rick Wade, spokesman for the American Hospital Association, a Washington, D.C.-based trade group. "You're talking about reaching kids as early as age 4, all the way up to 80-year-olds who exercise."

Hospitals and their academic affiliates sometimes pay those teams more than $1 million a year for the right to market themselves as the club's official medical providers, displacing team doctors who may be well-regarded by players but simply don't have the cash to compete -- or won't enter the bidding because of ethical concerns.

"From the club's point of view, it's convenient (to take the money)," said David Altchek, whose 10-year run as team doctor of the New York Mets ended last year because he says he refused to pay the team. "Problem is, if you choose the doctor based on who pays the most, it changes the paradigm. You've violated the principle of getting who's best."

At least seven NFL and 12 NBA teams have marketing arrangements with medical service providers, according to spokespersons from those leagues. Spokespersons for the NHL and Major League Baseball say they don't know how many of their teams have such deals.

More than 50 pro teams have relationships with HealthSouth, according to the publicly traded company, which specializes in physical rehabilitation.

In many cases, team officials say their selection of team doctors was made separately from any sponsorship arrangement that flowed from that relationship. But the mere perception that teams went with the highest bidder can undermine an already fragile trust athletes have with team doctors, whose allegiance has long been questioned in locker rooms because they work for management.

A Washington University St. Louis publicity article that boasts of Dr. George A. Paletta's work with the Cardinals includes a photo of Darryl Kile, who died earlier this season.
"I mean, you gotta think about it," said O.J. McDuffie, a former Miami Dolphins receiver who is suing his former team doctors after his career ended due to a toe injury he says was mishandled. "That's why you have to get a second opinion (from an outside doctor), because you don't know for sure if this guy's the best or he's the guy with the best price."

Altchek said he considers Paletta to be an "extremely good doctor." A graduate of one of the top medical schools in the country, Johns Hopkins in Baltimore, Paletta later got his break in pro baseball in 1996 when he served under Altchek as an assistant team physician with the Mets. Paletta, whom Altchek regards as a protégé, served two years there before joining Washington University as the Cardinals' head doctor.

But the circumstances that led to the selection of the Cardinals' medical team are typical of those that have created an ethical, and increasingly legal, quagmire for hospitals and teams.

Washington University is the academic affiliate of BJC Health Care, the largest hospital chain in the St. Louis area. Their doctors practice out of Barnes-Jewish Hospital, located on the Washington campus. In 1995, as competition for patients among area hospitals was heating up, BJC and Washington signed up the NFL's Rams, who had relocated from California.

Two years later, BJC and Washington added the NHL's St. Louis Blues to their stable.

In 1998, without disclosing financial details of the deal, they acquired the Cardinals contract, completing the marketing trifecta. As the BJC Web site now declares, "The Blues. The Rams. The Cardinals. St. Louis' professional sports teams are loaded with elite athletes with multi-million dollar bodies. These teams trust those bodies to another elite team: Washington University School of Medicine orthopaedic surgeons at Barnes-Jewish Hospital."

Cardinals officials did not return phone calls for this story. But one participant in the bidding, Dr. Richard Lehman of the nearby U.S. Center for Sports Medicine, said his group, backed by the resources of a competing local hospital chain, offered to pay $1.2 million a year for the contract after the Cardinals made it clear they wanted to make money off their medical services.

The thing was bid up to about $2 million. I was flabbergasted. We didn't even finish second in the bidding. BJC clearly had unlimited resources and was willing to do what it took to get the deal.
Dr. Richard Lehman of the U.S. Center for Sports Medicine, which bid for the Cardinals contract
"The thing was bid up to about $2 million," Lehman said. "I was flabbergasted. We didn't even finish second in the bidding. BJC clearly had unlimited resources and was willing to do what it took to get the deal."

Kim Kitson, spokesperson for BJC Health Care, said the financial relationship with the Blues is that it leases a luxury box at the Savvis Center, and with the Rams, BJC buys a block of seats at the Edward Jones Dome. She said BJC has a "larger sponsorship deal" with the Cardinals, but declined to provide details.

The head of Washington University's orthopedics department, Dr. Richard H. Gelberman, said he believes BJC has "much less than $1 million invested in all the teams together," and that, separate from any marketing arrangements, each team pays the doctors for their services.

"The teams could do far better (with other hospitals) if they just wanted to make money," Gelberman said. "I believe the teams come here for the quality of medical services."

Barnes-Jewish is regarded as one of the nation's best hospitals, consistently ranked among the top 10 by U.S. News and World Report. But in Paletta, who was 35 when hired, the Cardinals got a young physician who was not yet board-certified, a commonly sought, voluntary measure designed to assure the public that a doctor is well-trained in his specialty.

Paletta did not acquire that standing until passing an exam later that summer, according to the American Board of Orthopaedic Surgery. Lehman, by contrast, already was board-certified with a decade of experience working with hundreds of elite athletes, including a four-year stint as the Blues' team physician.

"Most of the (new team doctors) are young guys trying to build their practices, and that's not fair to the players," said Don Shelbourne, the doctor for Purdue University's teams and a former head physician for the Indianapolis Colts. "You don't know anything until you've been in this business five years. Doesn't matter which school you went to."

Just two months into the job, Paletta was hit with a question of national importance: Should the Cardinals condone Mark McGwire's use of androstenedione? A reporter noticed a bottle of the over-the-counter supplement in the slugger's locker, setting off a furious debate about the moral and competitive consequences of using a substance that was banned by the NFL, NCAA and Olympics due to its close relationship to anabolic steroids.

Baseball had not yet studied androstenedione, so, in that vacuum, the media looked to Paletta for answers. He announced that he would not discourage McGwire from taking androstenedione, saying that studies had not sufficiently shown it to be either harmful or effective.

Mark McGwire
Medical experts worry children will want to grow to be like Mark McGwire, who used supplements to help himself hit home runs.
Paletta said at the time that he "strongly" recommended that children not use the supplement, Washington University spokesperson Joni Westerhouse said in a statement released to ESPN.com.

But that message was lost in the excitement over McGwire's home run barrage.

McGwire would continue using andro that season and go on to set baseball's single-season home run record, with 70. Some of those blasts landed just beyond the fence in left field at Busch Stadium, where a blue and white, "BJC Health Systems" advertisement could be seen in television highlights that would play well into the future.

"You can still see the results of the decision (Paletta) made when you talk to kids around the country," said Iris Shaffer, executive director of the Healthy Competition Foundation, a non-profit organization affiliated with Blue Cross/Blue Shield that advocates against drug use in sports. "Sports supplements are a multi-billion dollar industry and sales are going up."

This year, Washington University entered into a deal with BJC that allows the school's name to now appear on stadium signage, Westerhouse said. She contends that advertising with the team does not compromise the medical decisions of the doctors.

"We strongly believe that one does not affect the other," she said.

Paletta found himself in the national spotlight again in June, when fans and media wanted to know how an athlete with Kile's family history could not have been checked more thoroughly for heart problems. In 1993, when Kile was with the Houston Astros, his father David died at age 44 from a massive brain stem infarction -- a stroke. The abrupt and premature death became part of the standard Darryl Kile story, as the pitcher mourned the loss by compiling an inspirational, 15-8 record for the Astros that season.

Paletta, at a news conference six days after Darryl Kile's death, said Kile provided a complete and accurate family history to the Cardinals' doctors. But, Paletta insisted, it was almost impossible to detect the kind of heart problem that killed the pitcher. "That's not to say we can ignore it and we don't have to be diligent in our screening," he said. "But you're talking about an extremely uncommon and unfortunate set of circumstances that in most cases would be very difficult to pick up."

Paletta said that because Kile's father died from a stroke, not a heart attack, team doctors had no reason to screen for the heart blockage that would kill him. But a leading expert in pre-participation physical examinations, as identified by the American College of Sports Medicine, told ESPN.com that he disagrees with that assessment.

"If the Cardinals had information on any premature death in the family, even if it's from a stroke, they should have done a stress test," said Dr. Doug McKeag, chairman of the department of family medicine at Indiana University and a former team doctor for Michigan State's teams for 18 years.

The type of stroke that David Kile died of is not considered by most medical experts to be a significant risk factor for premature coronary artery disease. Cardiology consultant that we have discussed this case with have reiterated this fact. In fact, Darryl's past screening history would support this.
Joni Westerhouse, spokesperson for Washington University St. Louis, in a statement
In a stress test, Kile would have been asked to run on a treadmill while a computer monitored the actions of his heart. The Seattle Mariners give stress tests to all players during spring training as a precautionary measure, but most baseball teams only do so if they suspect a problem.

"For doctors, linking a stroke to a heart attack is becoming more common," said Bill Roberts, a Minnesota doctor who is also identified by the ACSM as an expert on athlete physicals. "The vessels in the heart and brain are similar, so (Kile) probably should have been tested."

Paletta did not respond to repeated interview requests for this story, but did fax a brief statement and a copy of the death certificate for David Kile. He reiterated that "coronary artery disease and myocardial infarction (heart attack) are not listed as causes of death" to the late pitcher's father.

"The type of stroke that David Kile died of is not considered by most medical experts to be a significant risk factor for premature coronary artery disease," Westerhouse said. "Cardiology consultants that we have discussed this case with have reiterated this fact. In fact, Darryl's past screening history would support this."

Neither of Kile's previous teams, the Astros nor Colorado Rockies, did any "more rigorous testing" of Kile due to his father's death, she said. The independent insurance company that insured Kile's contract didn't do any additional testing, either.

Doctors for the Rockies and Astros did not return calls for comment. Dan O'Brien, who was the Astros' director of scouting at the time, said Houston did do some "additional tests with Darryl" after his father died, but couldn't recall what exactly they consisted of.

"Anytime something this tragic takes place, it causes the industry to step back and look at the diagnostics," said O'Brien, now an assistant general manager with the Texas Rangers. "It causes all of us to say, 'Have we been as thorough as we should be?' "

Darryl Kile
When Darryl Kile's curveball was working, he was one of the best pitchers in baseball.
The Cardinals players see no sense in questioning the actions of their team doctors, at least publicly. Mourning the loss of Kile, a beloved teammate, was tough enough. None of the half-dozen or so players that ESPN.com spoke with expressed concern about the team doctors' failure to detect Kile's heart condition, although some said future spring training physicals should be more comprehensive.

Manager Tony La Russa said the lesson that should be taken from the Kile tragedy is players should do as he's been doing for years: Get a separate physical examination from their own, independent doctor during the off-season.

Some pro athletes do not even have a personal doctor. In the free-agency era, when players rarely spend their career in one city, many find it easier to use the team doctor for all their health-care needs. They trust the doctors -- at least in the case of the Cardinals, many of whom said they are unaware of how the team picked the physicians.

"I don't have any idea," outfielder J.D. Drew said. "I'm sure they got the best they could find."

But more than a few athletes know about these marketing arrangements. Despite failing to get the Cardinals contract, Lehman said his own practice is booming, in part because the distrust fostered by sponsorship deals. Agents regularly send players from around the country his way, for surgeries and second opinions on injuries.

"(Those) players aren't stupid," he said. "They know what's going on."

Tom Farrey is a senior writer with ESPN.com. He can be reached at tom.farrey@espn3.com.

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