It’s a longstanding back-to-school rite: The aspiring student athlete gives school authorities the medical forms that announce he or she has been seen by a doctor and is fit to play for a team.
We family physicians and pediatricians perform some 10 million of these examinations a year. And while we are doing a general checkup, our primary goal is to find serious conditions, most notably those that could result in sudden cardiac arrest and death.
The specter of a seemingly healthy young athlete suffering a fatal attack during training or competition pervades the pre-participation examination, or PPE.
Such tragedies are extremely rare but they are very alarming and usually very public. The death in March of 16-year-old Wes Leonard, a Michigan basketball player who collapsed in front of a cheering crowd minutes after hitting a game-winning shot, made national news, sending a chill down the spines of millions of parents, coaches and doctors.
Virtually all schools require PPEs. Yet, while I routinely perform the tests, I always end up asking myself: “Am I really preventing someone’s death here?”
The answer, according to many experts and scientific studies: Probably not.
Which raises the question: Are the examinations worth doing?
Most often, sudden deaths among student athletes can be attributed — post mortem — to hypertrophic cardiomyopathy, a condition in which the heart muscle is enlarged or in some other way abnormal. So of course, if we can screen for HCM, we should do so.
The problem is that we can’t, at least not with the high degree of accuracy that most parents seem to assume we possess. A 2005 review of several studies about such exams, published in the Journal of Family Practice, found no good evidence “that demonstrates they reduce morbidity or mortality.” One study of the sudden deaths of 158 trained athletes age 35 and younger reported that 115 of them had had a PPE; the heart abnormality resulting in death had been identified in only one person. Detecting heart disease in the very young — for example, students of high school age — is tricky: Warning signs that may be present in an older patient are not always obvious.
Screening for the condition, says Barry Maron, a leading authority on hypertrophic cardiomyopathy based at the Minneapolis Heart Institute Foundation, is “much more complicated than most people think.”
In 2006, however, Italian researchers said they had found an examination that might be effective: the EKG, or electrocardiogram, which records the electrical pulses of the heart.
In a study reported in the Journal of the American Medical Association, the researchers examined the rates and causes of sudden cardiac death among more than 42,000 people aged 35 and younger between 1979 and 2004. Over the 26 years of the study, they reported a startling 89 percent decrease in the annual rate of such deaths among athletes who had been screened with an exam based on an EKG. Among unscreened non-athletes, the rate did not change significantly.
The impact of this study was dramatic and widespread. The International Olympic Committee and the European Society of Cardiology put out recommendations that EKGs be incorporated into physical exams for athletes.
In the United States, the study set off a “very heated debate” of almost “religious” intensity, in the words of William O. Roberts, a family medicine professor at the University of Minnesota Medical School, who helped write the 2010 revision of national guidelines on pre-participation exams.
On one side are doctors such as Jonathan Drezner of the University of Washington in Seattle, who sees “a growing pool of scientific evidence” in support of using the EKG. Writing in the Clinical Journal of Sports Medicine, he argues that “programs using EKG offer the only model shown to reliably identify athletes at risk for SCD [sudden cardiac death] and the only evidence that such a program can reduce the rate of SCD in athletes.”
Going further, Parent Heart Watch, an advocacy organization, has launched a Web-based campaign encouraging EKGs for children in general. The site features a wide-eyed young girl with a stethoscope pressed to her heart, and a headline saying, “This is not enough. . . . Ask your child’s doctor for an electrocardiogram today.”
On the other side, Maron argues that due to differences in data collection and interpretation and other factors, conclusions from the Italian study may not be applicable to the United States.
There is also the EKG’s record of finding problems that aren’t there. These tests produce an unusually high rate of false positives — up to 20 percent, Maron says — which can trigger expensive and time-consuming follow-up testing while keeping an eager athlete off the field and needlessly frightening the teenager and his family.
Moreover, a study from Israel, published in March in the Journal of the American College of Cardiology, seemed to directly contradict the Italian findings. The Israeli researchers looked at the rate of sudden cardiac death among competitive athletes during a 24-year period before and after implementation of a national law requiring all athletes to get EKGs.
Over that time, they found that the rate essentially did not change. The study concluded that EKGs for athletes “had no apparent effect on their risk for cardiac arrest.”
There is also a resources argument against mandating EKGs, particularly because sudden cardiac deaths are so rare. “I’ve got a 20-year database of 1.7 million unduplicated athletes,” says Roberts, “and have had five cardiac deaths.”
The American Heart Association has estimated it would cost at least $2 billion a year to institute mandatory EKGs for student athletes. Maron points out the drawbacks of a screening program of such magnitude: Who would conduct the EKGs? Who would interpret them? Are there enough machines?
For these and other reasons, the heart association has not endorsed mandatory EKGs. Nor have the organizations in the consortium that wrote the current PPE guidelines. (This group included the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Orthopaedic Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine.)
Which leaves primary-care physicians still asking ourselves what makes the most sense. If the chances of finding life-threatening heart conditions during these sports physicals are so low, why do them at all? Is there really any point?
The answer is yes. First of all, doctors can check for lesser problems, such as undetected hernias, that could worsen under the stress of competition.
But the most important reason doesn’t have anything to do with sports. It’s that adolescents are notoriously difficult to reach, from a medical perspective. They’re at an age at which they tend to detach from the medical system, seeing doctors less and less routinely, even as the challenge of staying healthy becomes more and more complex. All sorts of health matters are becoming relevant at this stage in life, from sexuality to alcohol use to rapid changes in the body.
A sports physical at least gets a teenager in the door, where, Roberts says, “we must use this opportunity to connect with our adolescent patients, to talk about things that matter but often fall by the sideline.” This talk can be about how to protect themselves from head concussions, but it can also be about sexually transmitted diseases, alcohol use or immunizations.
The point is, these exams give me a chance to build a vital rapport with my younger patients. This is important, and not always easy. So, to answer my own question: Yes, doing these exams does make sense — just maybe not for what seem to be the obvious reasons.
To all young athletes: Go see your doctor. And to those who don’t play a sport: You go see your doctor, too.
Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine.