Peter Diana, Post-Gazette Pirates team doctor Patrick DeMeo examines shortstop Jack Wilson's shoulder during the annual pre-camp physicals last spring. Click photo for larger image. Related article: Cases in point: Sampling of malpractice lawsuits involving athletes

Robin West, team physician for Pitt men's basketball and all Carnegie Mellon teams and an assistant on the Steelers' medical staff, feels like a rarity in the profession.

And not because she's a woman.

West is one of the few high-profile orthopedic sports physicians under 35 in Pennsylvania. Most young sports medicine doctors don't want to practice in this state, she said.

"If I were in private practice, or if I wasn't covered by a big entity, I would be somewhere else because it's not worth it," said West, who joined UPMC as an assistant professor a little more than a year ago, giving her the opportunity -- and the insurance coverage -- to work with athletes.

The rising cost of medical malpractice insurance, and the proliferation of sponsorship arrangements between teams and large medical groups, have changed the landscape for team physicians in recent years, particularly at the major pro level, but also reaching down to college and high school sports.

The two developments are connected, even if inadvertently so.

As part of the sponsorship deals, health care groups provide the team physicians, who have come to realize they need the umbrella of a large health care system to provide malpractice insurance. The combination of the rising cost of malpractice insurance in states such as Pennsylvania that don't have tort reform and the potential for large judgments going to high-paid athletes has increased the risk for team doctors and made it nearly impossible for independent doctors to work in the field.

"Twenty years ago, the team physician was whoever volunteered and took an interest," said Charles Burke, who has been the Penguins' team physician since 1988 and is affiliated with UPMC.

It's a lot more complicated now. Burke recently chaired a conference in Toronto where malpractice was a main topic.

Although malpractice lawsuits filed by athletes against team physicians aren't common, there have been several multimillion-dollar judgments and settlements, and that's enough to cause a lot of concern.

"I would think if you were an independent doctor, it would be difficult to purchase enough insurance that you would be safe," said Pirates medical director Patrick DeMeo, whose salary and malpractice insurance are paid by Allegheny General Hospital.

AGH is part of the West Penn Allegheny Health System, which has a sponsorship deal with the Pirates.

The Steelers, Penguins, Pitt, Duquesne, Robert Morris, Carnegie Mellon and others have a similar relationship with UPMC, which provides malpractice insurance and the bulk of the salaries for those teams' physicians.

UPMC is further entwined with the Steelers and Pitt football because it is their landlord at the teams' South Side headquarters.

Playing roulette

With the potential for an injured pro athlete with a big contract to sue to try to recover millions in lost wages, and no monetary limits under Pennsylvania law, many team physicians are in the uneasy position of providing the best care possible while trying to ignore the liability risks.

"This is by far the hot topic in the [NFL] Physicians Society," said Dr. Jim Bradley, who has been the Steelers' team doctor for 13 years and is president of that society.

The NFL is particularly vulnerable because the bulk of players' salaries are not guaranteed.

"Physicians have to feel that they can make decisions without playing Russian roulette," said Elliott Pellman, team physician for the New York Jets, a member of the NFL health and safety committee, former president of the NFL Physicians Society and consulting physician for Major League Baseball.

"The players want to get back to play. Management needs them to get back. It's a matter of complicated decisions in a complicated environment."

One in which steady advancements in sports medicine offer better, less invasive treatments. But those procedures also are growing more specialized by sport, so the idea of replacing a doctor who is an expert in his field because of malpractice issues or sponsorship contracts becomes more daunting.

Freddie Fu, medical director of UPMC's sports medicine programs, works with athletes from high school to the pros. He sees the growing sponsorship deals as primarily a marketing device, but he understands the alarm surrounding malpractice insurance.

"Right now, it's OK for us in UPMC sports medicine, but you don't know about the future," Fu said. "Look at [obstetricians]. They are being sued to death."

Different standards

Some of the concern over malpractice issues stems from the nature of sports team medicine.

There is what DeMeo calls "functional demand." That is, a problem that might be just an annoyance to most people could be a career-ending problem without corrective surgery to someone who needs to throw a baseball 90 mph or make a sharp cut on a football field or hockey rink.

Art Bartolozzi, former team physician for the Eagles and Flyers in Philadelphia, pointed out that team sports medicine doesn't always follow a rigid standard of care. Athletes might not need the prescribed amount of time to recover sufficiently enough to play, for instance.

"They might be willing to play in pain or play at less than 100 percent," Bartolozzi said. "Ninety-nine percent of the time, nothing bad happens, but when it does, who's at fault?"

He found out the hard way when he was targeted in a lawsuit by former Flyers defenseman Dave Babych, who claimed he wasn't warned during the 1998 playoffs that he could do permanent damage by playing on a broken foot that he originally thought was bruised.

Bartolozzi contended Babych got second and third opinions and knew the risks. The case was settled for $1.37 million. Bartolozzi's malpractice insurance rates soared, and he quit working for the Eagles and Flyers, who have since contracted with Tenet Pennsylvania to provide physicians.

Some team doctors are wary of the sponsorship deals with big health groups because the team might not be able to retain or choose its doctors.

"It's great to have all the corporate sponsorships as long as the team chooses the persons who are going to take care of the players," Bradley said.

When the Pirates and WPAHS formed their agreement in 2001, DeMeo of AGH became medical director, and longtime team physician Jack Failla became a consultant for what general manager David Littlefield said was a transitional period. After a year, Failla was let go.

"At that point, we felt and I felt comfortable enough with Patrick DeMeo as the medical director that we no longer needed a consultant," Littlefield said.

In New York, Mets team physician David Altchek lost his job in 2001 when the team entered into a sponsorship arrangement with New York University-Hospital for Joint Diseases that earns the Mets more than $1 million a year. The hospital group provides doctors free and gets ads in Shea Stadium, tickets and visits from players at hospital events.

Mutual agreement

Officials with UPMC and WPAHS say they enjoy comfortable arrangements with local sports teams and benefit from promotions and advertising, although they declined to provide details of the contracts.

"The Steelers are a foundation of the local environment, and I like to think that UPMC is as well," Jim Terwilliger, administrative director of UPMC sports medicine programs, said. "We brought these two organizations together in a mutually beneficial way. The relationship is very important to us. But it is difficult."

And it would become more so if the climate in Western Pennsylvania moves toward that in Philadelphia, which has been called the black hole of medical malpractice because there have been a plethora of malpractice lawsuits with large monetary awards or settlements, leading to escalated premiums for malpractice insurance.

"If all of a sudden a couple of big awards are granted [locally], then the problem becomes bigger and UPMC may even think about whether they want to [keep sponsoring team physicians]," the Steelers' Bradley said.

It hasn't reached that point. Yet.

"We've managed to provide what we've needed to provide so that our physicians are connected to those teams, but the coverage is challenging," said Karen Hartley, UPMC chief risk officer. "You might not think the medical malpractice issue affects sports teams, but it does."

Hartley said UPMC stresses to its sports team physicians to convey information to athletes about their injuries.

"Informed consent is the law in Pennsylvania," she said. "We want to make sure we're communicating as much as possible about things like informed consents and risks. It's even more critically important related to these athletes because there's often a push by the teams to get these athletes back out there."

That last part makes some doctors cringe.

"I've never received pressure from management to get a player back -- usually, it's the player that does it," the Pirates' DeMeo said.

That's not always the case, apparently.

"I can and always will exert as much pressure as I can on the player and doctors to get a player back on the field, but the integrity of the medical staff is never compromised," Tom Coughlin, then the Jacksonville Jaguars coach, said in a deposition, according to the Florida Times-Union, after former player Jeff Novak filed a malpractice suit.

Burke said his arrangement with the Penguins always has been to give his recommendation, then defer to the team. West said she is insistent that teams follow her timetable for a player's return.

Care for preps

Malpractice issues aren't as dire in college sports, although Terwilliger points out that if an accomplished high-profile athlete -- he hypothetically mentioned former Pitt receiver Larry Fitzgerald -- got hurt and decided to sue, it could be problematic because of his potential lost wages.

Even the high schools in Western Pennsylvania have begun to align themselves with hospitals and medical groups for health care, although athletes still rely heavily on family doctors and insurance.

UPMC and West Penn Allegheny Health System have contracts to provide trainers and physicians for many school sports teams and games. Unlike the relationships with pro teams, with high schools it's usually strictly a pay-for-care deal, with no sponsorship considerations.

Central Catholic athletic director Chuck Crummie said his school was one of the first to enter into a business agreement with UPMC.

"We were not in a position to have full-time people here, so this has worked out well," Crummie said, adding that this school year for the first time UPMC is providing a full-time trainer, Andy Machurak.

Even small, outlying schools have followed the pattern.

Class A Springdale is tied to Allegheny Valley Hospital and Dr. Shahid Sharif. Athletic director Raymond Davis boasts about the care his athletes get, but he also points out the precautions that have become standard.

"Any injury, minor to major, is documented with paper, and phone calls are made home," Davis said.

Sharif said he probably wouldn't be able to continue as the Springdale physician if Allegheny Valley didn't help with his malpractice insurance.

He worries about the future of health care for high school athletes in Pennsylvania. "The state has to step in," he said.

Fighting reform

Tort reform would be difficult in Pennsylvania, one of 12 states in which the constitution would have to be amended to allow caps on payouts before the Legislature could hash out new guidelines.

And not everyone wants reform.

"Obviously, we have a belief that the so-called medical malpractice crisis has been blown way out of proportion or created by a lobbying group of physicians and insurance companies," said David Lozier, associate for Harry S. Cohen & Associates, whose phone number translates in part to "MedMal."

"I believe it's highly immoral and a violation of people's rights. There are many precautions built into the system to prevent the so-called frivolous lawsuits."

Lozier said his firm won't touch a potential lawsuit unless there is clearly "a preventable error that a jury will understand ... a doctor reading a test wrong, not ordering a test he should have."

He also said there are built-in limits on payouts according to physicians' policy limits.

Pennsylvania physicians are required to have malpractice insurance coverage of $1 million per incident and $3 million per year. They must also pay into the state Medical Care Availability and Reduction of Error, or MCare, Fund, which helps pay when damage awards exceed a doctor's coverage.

The Penguins' Burke said UPMC provides him with the minimum coverages.

"Additional coverage would be very expensive," he said. "What happens if somebody gets a judgment bigger than your limit?"

Perhaps the MCare Fund would cover it. Or perhaps the plaintiff would go after the doctor's partners or his employer, such as UPMC.

Terwilliger, who came to UPMC from Los Angeles, would like to see tort reform similar to that in California.

Recent laws there have capped the amount for punitive damages, including pain and suffering, at $250,000. There is no limit on recovering medical costs. Lawyers' fees also are capped -- 40 percent of the first $50,000, 33 1/3 percent of the next $50,000, 25 percent of the next $500,000 and 15 percent of anything above $600,000.

Bartolozzi, a former team physician in Philadelphia, is among those who want to see teams step up, perhaps designating physicians as team employees, which in some states might offer them protection under workman's compensation laws.

Or, he said, team doctors in the pros might need to step back and work in a triage capacity, with athletes then being treated by their personal doctors.

The NHL averted a crisis in Canada in recent years. The government dropped team doctors from the socialized coverage of Canadian Medical Protective, but the league was able to step in and help get additional coverage.

The NFL's Pellman said it won't be that simple in other leagues in the United States. The NFL, he said, looked into buying malpractice coverage for all of its team doctors. No insurance companies would bite.

While there is a fundamental right to protection against gross negligence, Burke is concerned about cases that fall short of that standard.

He reviews malpractice cases for defense teams, though not involving high-profile athletes, and said he sees too many that make it to court that involve known but unavoidable medical complications, poor communication or someone acting on a bad second or third opinion.

Something needs to change, the Pirates' DeMeo said.

"The system has no brakes," he said. "You have a lot of trial attorneys who have no disincentive to sue. There is no room for common sense."

Especially with the smell of a potentially fat award or settlement and no risk for an athlete when a lawyer takes his case on a contingency basis.

"People think it's like a lottery they just won," the Steelers' Bradley said.

For now, there is the protection of the large entities such as UPMC and WPAHS.

"I think that's been helpful," UPMC's Hartley said. "We've been fortunate that we've been able to bring it all together.

"But it does cause anxiety for the physicians, and justifiably so. There has to be more sanity to this process."

Fu couldn't agree more.

"Doctors are not God, but we are good doctors, and we cannot live in fear," he said.