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Am Fam Physician. 2001;64(8):1326-1328

to the editor: I found it disconcerting to read the recommendations for screening of student athletes in “Cardiovascular Screening of Student Athletes.”1

According to the information presented in the article, I would have to examine 200,000 student athletes to prevent one sudden death. Assuming I performed 200 examinations per year and practiced for 40 years, I would expect to save no lives and would have to stay in practice another 960 years for the chance to do so. If a high school had 1,000 athletes among its students, it could expect to experience a sudden death every 200 years, and if I could examine all of the 200,000 athletes and could charge them between $50 to $100 for my services, it would have cost $10 to $20 million to prevent this death.

Surely the most logical conclusion is that there is no current economical way of medically preventing this type of sudden death, and that the criteria of a medical examination for screening athletes to prevent this death have not been met. With the annual, preparticipation, return-to-school physical examination scramble now going on, I note in my community that one supermarket is offering them, one local clinic conducts them en masse at the high school and most are conducted with varying degrees of cardiovascular focus in private offices.

I think it is unfortunate that the medical profession has taken away from the schools the responsibility for any medical mishaps in athletics. Should a death occur, it becomes our problem for not recognizing and preventing it—the school being protected by the presence of a “physical examination form” in the student's record. We are doing athletes and parents a disservice by giving the impression that we can adequately screen for the problem, and the article promotes a standard that does not withstand analysis and is difficult to uphold.

in reply: The article, “Cardiovascular Screening of Student Athletes”1 clearly confirms Dr. Searle's statement that there is no cost-effective method to screen millions of student athletes for relatively rare cardiac-related diseases and conditions that may predispose athletes to sudden death. However, our article does not propose a new responsibility for physicians caring for these athletes. The “Preparticipation Physical Evaluation (PPE)” (Figure 1 in the article) was developed by the American Academy of Family Physicians (AAFP) and several other medical groups.2 Our article recommends the addition of three items to this form, as proposed by the American Heart Association (Table 2 in the article). The article recognizes the variation among states in the use and content of sports PPEs and in the qualifications of those who perform these examinations. It encourages a more uniform screening process and recommends practices already endorsed by the AAFP and others. As stated in the editorial3 that accompanied the article, the American Medical Association (AMA) does not call for the creation of any new cardiovascular screening process.

Dr. Searle states we are promoting a standard that does not withstand analysis. Our article1 concludes that there is no standardized method for screening student athletes for occult and possibly lethal heart disease. Lacking standardization, it is not possible to assess the value of a focused history and physical examination in detecting cardiac abnormalities and preventing sudden cardiac death in these athletes. In our conclusion, we acknowledged the limitations of current and varied screening practices and implicitly suggested that the hypothesis that cardiovascular screening has value cannot be tested unless a more standardized approach is used (e.g., focused history and physical examination). The AMA Council on Scientific Affairs supports testing that hypothesis in an organized manner. Despite the limitations of current PPE screening practices, we believe that physicians involved in the care of student athletes play an important role in the prevention of sudden cardiac death and should be familiar with its various causes and with current medical recommendations for screening athletes before participation in sports.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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