Original Article: Right Care for Children: Top Five Do's and Don'ts
Issue Date: March 15, 2019
See additional reader comments at: https://www.aafp.org/afp/2019/0315/p376.html
To the Editor:We would like clarification on the intent of the recommendation to not routinely perform preparticipation sports evaluations. We agree with the authors that there are limitations of the preparticipation evaluation for the prevention of sudden cardiac death and identification of associated conditions. However, the potential usefulness of the preparticipation evaluation extends beyond cardiac screening. Additional purposes of t he preparticipation evaluation are to promote the health and safety of the athlete, to identify conditions that may require a treatment plan, and to remove unnecessary restriction.1
Not only is the preparticipation evaluation the standard of care, but it is required for high school sports participation in 49 out of 50 states and Washington, D.C.2 It may also represent the only regular contact that many adolescents have with a clinician. The preparticipation evaluation is a potential preventive care entry point and an opportunity to provide routine immunizations, screen for other conditions, and provide anticipatory guidance. Simply “not doing” preparticipation evaluations in adolescents is not practical or patient centered for physicians providing comprehensive primary care to these patients. As long as preparticipation evaluations are a requirement for sports participation among high school athletes, physicians should view them as an opportunity to positively affect the health and wellness of their patients.
In Reply: We appreciate the thoughtful comments by Drs. Cunningham and Naughton about our recommendation against routine preparticipation sports evaluations for children. We agree that periodic visits with a primary care physician can help establish a strong physician/patient relationship. However, we question the use of mandated preparticipation evaluations as the appropriate strategy to achieve this goal.
As the authors state, preparticipation evaluations are a standard of care. The inclusion of this recommendation as a top five “Don't” questions this standard and the resulting state-mandated requirements. These examinations are not well supported by evidence, have negligible to no benefits, and may lead to inadvertent harm. State mandates were well-intentioned attempts to respond to tragic events on sports fields across the country; however, mandated preparticipation examinations have not altered the frequency of these rare tragic events.1,2
The authors state, “Simply ‘not doing’ preparticipation evaluations in adolescent patients is not practical or patient centered for physicians providing comprehensive primary care to adolescents.” Patient centeredness is defined as: “[an] attitude that aims to deliver care that is respectful, individualized and empowering. It implies the individual participation of the patient and is built on a relationship of mutual trust, sensitivity, empathy and shared knowledge.”3 Based on this definition, we disagree that compulsory office visits, which may cause children to miss school or after-school activities (including sports), are patient centered. Similarly, restriction of sports participation because of findings detected at these visits in asymptomatic patients is not particularly patient centered, especially when such restrictions have not translated into better outcomes.