Michael Ciccotti, MD, of Philadelphia-based Rothman Orthopaedic Institute, wears many hats. He oversees sports medicine at Rothman, and he's the head team physician and medical director of the Philadelphia Phillies.
Dr. Ciccotti spoke with Becker's about the work he's been up to at Rothman and managing care for professional athletes.
Note: This conversation was edited for clarity and length.
Question: What are some of the big achievements that have happened so far this year, and what are your goals for the rest of the year?
Dr. Michael Ciccotti: Things are going extremely well here at Rothman Orthopaedics. In our Sports Division, we have 23 fellowship-trained sports medicine surgeons and 25 fellowship-trained primary care sports physicians. We're one of the largest sports medicine programs in the country, spanning four states: Pennsylvania, New York, New Jersey and Florida. And we provide sports medicine care for all levels of athletes from the broad spectrum of sports. We've seen significant development and impact of our research program, which is one of the largest sports research programs in the country. We see more than 80,000 sports injuries a year and perform over 12,000 sports surgeries a year. That's arguably one of the largest volumes in the U.S. with respect to sports medicine. And so, our sports medicine program is something that we're truly proud of at Rothman.
Q: Can you talk a little bit more about the research? What's something really interesting that you're working on now or something that you just published that you're really excited about?
MC: We currently have more than 80 sports medicine research projects in varying degrees of completion running the full gamut of sports from basic science to clinical research, diagnostic evaluation to nonoperative treatment to operative treatment to rehabilitation and preventive measures. We recently completed a level one prospective, randomized trial of ulnar collateral ligament reconstruction in throwing athletes. The ulnar collateral ligament is the main stabilizer of the elbow in a throwing athlete, and there is an increasing incidence of tearing of that ligament in throwers that can dramatically impact their career.
A variety of surgical treatments have been proposed for this type of injury, but two main surgical techniques are currently most commonly used: the original developed by Frank Jobe, MD, and modified by Lew Yocum, MD, called the Modified Jobe Figure-of-8 Technique, and the more recent alternative procedure developed by Dave Altchek, MD, called the Docking Technique. Those are the two most commonly used procedures in the world. There had never been any direct comparison of them, and we carried out the first prospective randomized clinical trial of those two techniques, following these patients for two to five years. We found no statistically significant difference in their outcomes, indicating that both techniques are optimal procedures for this injury. That study received one of the highest clinical sports medicine awards in the world, the O'Donoghue Award from the American Orthopaedic Society for Sports Medicine. The study also won the prestigious Herodicus Award from the International Sports Medicine Research Society.
Q: Can you talk about your work as medical director for the Phillies and balancing patient care and also the team's interests like business moves?
MC: The role of team physician has been an incredibly rewarding experience for me. I'm in my 30th year of providing care for the Philadelphia Phillies as a team physician, head physician and medical director. I've seen sports medicine, specifically the care of throwing athletes, develop dramatically over those 30 years.
There is an art that you develop to balance your clinical practice, your early office hours, seeing patients and then operative time operating on patients with this added responsibility of taking care of a professional sports team. That permeates everything you do as issues happen throughout each day while you're performing your regular job of seeing patients in the office and operating. When issues do arise, you communicate with the head athletic trainer of the team. The large majority of Major League Baseball games are in the evenings, so once I finish my "day job," then I would go to the ballpark and evaluate and make medical decisions on any players who had issues. In baseball, medical decisions are made most often before the first pitch. And so, you develop an art to balancing all that, but it takes a true team, a team of medical providers. And we have such an outstanding group of athletic trainers, strength and conditioning coaches, and sports medicine physicians with the Phillies and Rothman that allow us to provide optimal care of these athletes and the team.
Q: Have you had any times where your medical judgment was different than what maybe the team wanted?
MC: I have been just blessed working with the Philadelphia Phillies. The Phillies are an amazing organization and have always been so incredibly respectful of the medical perspectives that I might provide. My goal has always been to keep a player on the field by preventing injury and identifying players that might be at risk and helping them to avoid injury. If an injury does occur, then the goal is to determine what is best and safest for the player, to get that individual player back when it is safest for the player. The Phillies have been so consistent in their respect for that. As an ownership, they want their team to be as successful as possible and they want their highest-level players on the field. But they also have a long-term perspective, and know that if I or any member of the medical team makes a medical decision that might put a player on the injured list, the Phillies' ownership and management realize that's in the best interest of that player and ultimately for the team.
Q: The AOSSM put out a statement about physician liability, and in light of some recent lawsuits and wins involving former athletes; how are you viewing this? Have you heard any concerns from your peers?
MC: At a professional level, the hope is that the physicians who have the expertise to care for those athletes would be able to provide that care without feeling the risk of their decisions being scrutinized when they do things that are absolutely evidence-based and appropriate for an athlete. We know that even with all the tremendous advances in sports medicine and the extensive research on diagnosis, nonoperative treatment, operative treatment, rehabilitation and injury prevention, there are still undetermined issues, still shades of gray. Nothing is absolutely black and white. There's a massive amount of research that guides us on our treatments, and even when we do things exactly the way they should be done, sometimes an athlete doesn't end up performing at their pre-injury level even when diagnosis, treatment and rehabilitation are done perfectly.
The idea would be that you allow the most appropriately trained and experienced physicians to provide care for these athletes without feeling the risk of legal scrutiny when an athlete, who for other non-medical or non-orthopedic reasons, might not be able to return to pre-injury level of performance. The hope is to maintain and create an environment that allows the most skilled, experienced physicians with that added sports medicine expertise to be able to feel confident and comfortable enough to care for those elite-level athletes. The American Orthopaedic Society for Sports Medicine Statement speaks to that hope fully endorsed by the American Academy of Orthopaedic Surgeons and its broad list of sub-specialty societies.
Q: What advice would you give to other sports teams and other team physicians on improving communications to prevent cases like what we've seen recently?
MC: I think that so much of it comes down to developing a relationship with a patient, a patient who happens to be an athlete. At a professional level, that athlete often does something that very few people in the world can do. So, you must develop a relationship with that person, that patient, and that's most appropriately and hopefully built on trust. With that trust, you can provide them with all the information on a specific injury and then navigate together to the optimal treatment. If he or she chooses that treatment under your direct guidance or chooses to have another physician be involved as well, I think it all comes down to generating trust and communicating thoroughly that you have that athlete's best interest at heart. If you really, in your heart, always make decisions that are based on what is best for that particular athlete who happens to be your patient, then you're really doing what's right for them and you establish a trust or a bond that hopefully will prevent any kind of miscommunication or dissatisfaction with care. And after 30 years as a sports team physician, I can say that type of trust, of bond, is real, it's attainable and it's essential.