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NFL's medical marketing partnerships raise conflict-of-interest issues for team physicians

"Trust the pros the Ravens trust," read the ad on Baltimore's Web site. "Click here to see a Ravens physician."

The link took fans to the page for Union Memorial Hospital's sports medicine program.

The implication was clear: If Union Memorial doctors are good enough for the Ravens, they're good enough for a weekend warrior needing an orthopedist.

The partnership between Union Memorial's parent company, MedStar Health, and the Ravens is potentially lucrative for both. The team receives sponsorship money, and the hospital can promote its affiliation with the franchise.

In 2004, after a spate of negative publicity, the NFL quietly enacted a policy that prohibits clubs from entering into marketing contracts with health care organizations that require the team to use doctors from the medical group.

"We wanted to be sure that medical decisions are unaffected by possible conflicts of interest, whether actual or perceived," NFL spokesman Greg Aiello said.

But the rules haven't stopped partnerships that continue to raise concerns. These agreements add to a climate of doubt in which players already wonder whether team physicians are more loyal to their patients or the clubs that pay their salaries, a distrust that can complicate care.

"The players want to trust you," said veteran defensive back Troy Vincent, the president of the NFL Players Association. "But we know there's a business side that sometimes sneaks its way in and causes a little bit of a conflict of interest."

In many cities, the health care provider that employs team physicians pays the franchise sponsorship money and advertises its affiliation with the club, giving both sides financial incentives to continue the relationship.

Aiello said the NFL isn't concerned that the potential for conflicts of interest remains under the current rules.

"The policy deals with that issue," he said.

Players' rights to seek a second opinion, to choose their own surgeons and to retain their medical records serve as checks and balances, Aiello said. Vincent agreed that players exercising their right to a second opinion is critical to ensuring quality care.

But Vincent would like to see the NFL put more effort into enforcing the restrictions on sponsorship agreements by investigating whether current arrangements violate the policy.

"Clubs are obligated to review any proposed medical sponsorship arrangement with our office in advance of finalizing an agreement," Aiello said.

Team physicians already operate in an environment of big money, high stakes and differing agendas. Players feel pressure from coaches and teammates and for their own financial futures - not to mention their competitive natures. The recent focus on concussions and former players' health problems emphasizes the importance of proper medical care.

"Morally and ethically, these men want to do what's right," Vincent said. "This is their livelihood. But sometimes you intermingle in the business side and what it does is distort views."

Former Atlanta team physician Dr. Andrew Bishop said the Falcons repeatedly approached him about marketing opportunities, but he declined.

"The money is so large that (owners are) paying for teams, they're looking for any potential source of revenue," Bishop said. "It used to be something that was understood as something that would cost them money. Now they look at it as a potential source of revenue."

The NFL's policy doesn't seem to have decreased sponsorship agreements between franchises and health care organizations, said Don Hinchey, vice president for communication for The Bonham Group, a Denver-based sports marketing firm. If anything, he sees a rise in such deals. The pairing is natural, he said, because injuries are often on the minds of football fans.

The health care organizations where team physicians work own major naming rights for several franchises. The Cleveland Clinic sponsors a gate at the Browns' stadium, a key source of revenue because no naming rights were sold for the facility as a whole. The Tennessee Titans' practice site is named after Nashville's Baptist Hospital, the Texans' after Houston's Methodist Hospital. The University of Pittsburgh Medical Center owns the $30 million training facility used by the Steelers.

Each promotes its role as the team's medical provider on its Web site.

Similar arrangements are also common in other pro leagues.

The Ravens and MedStar are in the midst of a five-year contract, said Lew Lyon, vice president for sports medicine for MedStar SportsHealth. The deal's medical and marketing portions are negotiated separately, Lyon said.

"We feel no heat, no pressure from the Ravens to do marketing," he said.

But he acknowledged the association is beneficial for MedStar.

"People in the Baltimore-Washington area are aware this is the team that takes care of the Ravens," Lyon said. "They think, 'I'd like to have my injury taken care of by the people who take care of the Ravens."'

Ravens head team physician Dr. Andrew Tucker, the director of Union Memorial's sports medicine program, was not hired because of the partnership - he has been with the franchise since it was in Cleveland.

"I'm completely comfortable with my own situation and how business is done," said Tucker, who is the current president of the NFL Physician's Society.

But he recognizes such agreements create potential for conflicts of interest.

"If I'm a player or an outsider looking in," Tucker said, "it's a legitimate question that can be raised."

Tucker said he refers players to specialists at rival hospital systems if that's where they'll receive the best treatment for a particular problem. That sort of action, though, "does tend to ruffle feathers" at health care groups that have contracts to exclusively provide medical services to a club.

Tucker understands why players may distrust team doctors to start with. Consider how an athlete often first meets a physician.

As draft prospects at the scouting combine or free agents coming in for a physical, players initially interact with the doctor when he's working solely as a representative of the team - determining whether there are medical reasons to not pick or sign them.

A player joins the club, and suddenly the physician is supposedly on his side. Tucker realizes players may wonder, "With a stroke of a pen, I sign a contract, and now you want me to believe you're working for me?"

Several former team physicians recalled similar experiences.

"Players have recognized you're working for an organization, and they have suspicions that your opinions are colored by management," said Dr. Kevin Auld, the Seattle Seahawks' head team physician until this past spring.

When a player perceives that the doctor might not have his best interests at heart, it detracts from the quality of care no matter the physician's intentions.

"He may ignore what the doctor says," said Dr. Pete Indelicato, a former Miami Dolphins team physician who still serves as a consultant with the club. "He may do it with half of the enthusiasm or the effort that he would normally do it."

Former Philadelphia Eagles team physician Dr. Art Bartolozzi now sees some NFL players in his private practice and notices the difference.

"It's a much more comfortable relationship," he said. "You don't have that overwhelming relationship of the team that seems to cloud discussions."

The doctors said they welcomed second opinions, but worried about the way players went about getting them. It's often a player's agent who recommends which physician his client should use.

"He may be no more knowledgeable about who the best specialist is than the coach or owner of the Dolphins was 20 years ago," Indelicato said.

"It's a power move on the agent's part," said Dr. Pierce Scranton, a former Seahawks team physician. "It sends a message to the club of 'Don't screw with me.' To the player, it's like, 'Wow, I didn't know my agent represented me so well."'

An agent once referred a player to a doctor who had never performed the procedure needed, Bartolozzi said. Auld cited a case where an agent recommended his college fraternity brother.

Veteran agent Leigh Steinberg said it's in his profession's best interests to ensure clients receive the best treatment.

"As attorneys with responsibility to our clients, we track these doctors and are able to refer clients with a clear degree of confidence in the track record of these doctors because they've been time-tested," he said.

Several doctors expressed concern that some independent specialists court players so they can market their affiliation with elite athletes - just like the health groups who form partnerships with franchises.

As the league has changed, building trust has become more difficult.

Bartolozzi found his most rewarding relationships with players came when he had the chance to meet their entire families. But with players switching teams more often, doctors find less time to cultivate relationships.

According to several physicians, some coaches have tried to limit casual contact between doctors and players in an attempt to exert their control over the team. Physicians who used to eat in the same cafeteria or ride the same bus as players were no longer welcome.

"Many clubs have a policy of deliberately removing the doctor from that so that the player basically has this tight-focused family of team, and the doctor is not a part of it," Scranton said.

The lack of familiarity creates other challenges in care. A doctor with a long-standing relationship with a player is better able to gauge how seriously injured he is.

"When you evaluate a concussion, you need to understand their personality to see alterations in their standard behavior," said Dr. Stephen Nicholas, a former New York Jets team physician.

Complicating franchises' choices for team physicians is the high cost of malpractice insurance. Doctors in private practice may struggle to afford the premiums, making it more likely that a physician from a large hospital system will work with the NFL.

Most of the current and former team doctors interviewed said good communication and quality treatment can overcome the trust issues. But some believe the best care will never be guaranteed unless the system is changed to alter the dynamic of how clubs employ physicians.

Indelicato would like to see each team form a sort of committee that includes players to evaluate, hire and fire team physicians.

Bishop, the former Falcons doctor, takes it one step further, saying the NFL Players Association should employ team physicians.

"That would change the dynamic considerably," Bishop said.

Vincent said he didn't believe taking over the hiring of team doctors fit the union's mission.

Said Bishop: "I do think the players association needs to get a little bit more involved, get a little more accountability. These kids in the locker room, they're scared. They want their job. That's all they're thinking about."

AP Sports Writer Dave Goldberg contributed to this report.

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