An adult electrophysiologist’s sports physical…

Will he get to play, or not?

Dear Coach, (or administrator, or secretary, or school legal department.)

I have seen and examined, Mr. “Joe Teen.” (name changed for HIPPA)

He came to me for a school physical because he is deathly embarrassed over the check for inguinal hernias.

He is a healthy teen. This I know from direct observation of his power output on a bike. Medically, we could term this outstanding “functional capacity,” which correlates with a favorable prognosis.

The cardiac exam, carefully done in a quiet room (my kitchen) was normal. Even with provocative maneuvers, done primarily to show off, no murmurs were heard.  This strongly argues against the possibility of hypertrophic cardiomyopathy—the most common cause of sudden death in a young athlete.

In the US, unlike in many European countries, an ECG is not recommended for routine screening. Therefore, I cannot exclude congenital long QT syndrome. He has no family history of sudden death, nor syncope, so I believe his QT syndrome risk is very low.

Sure, doing screening ECGs on students would increase the sensitivity of finding asymptomatic, potentially life-threatening cardiac conditions, but the problem in American health care, is that many “normal variants” would be mis-diagnosed as abnormal. And it is likely that for every QT syndrome or cardiomyopathy found, there would be many more who suffer complications from the diagnostic work-up of non-specific and even normal ECGs.  The fury of “cover-your-buttocks” American medicine is not without risk.  In fact, this is a metaphor for many seemingly sensible “screening tests,” the PSA for example.

I freely admit to omitting the inguinal hernia exam. If this omission or excessive pedanticism nullifies my exam, so be it, he will have to go to Walgreens for a real sport’s physical.  A promise is a promise though, and as in the patient-centered care model, he requested an exam with his pants on.

As far as I know, and aided by the power of modern-day electronic search, inguinal hernia has never been reported as a cause of sudden collapse in an athletic endeavor. Medicine, like any profession, has its share of farcical smokescreens, but few approach the silliness of the turn and cough maneuver as a criteria for clearance to exercise.

Finally, Mr Joseph Teen may indeed drop dead (like you, or I, or anyone for that matter), but there is no evidence from his history and physical exam to suggest that he is at enhanced risk.

Sincerely,

DrJohnM 

JMM