When news broke that Mets center fielder Carlos Beltran had arthroscopic surgery performed by a second-party doctor on his balky right knee in Denver on Jan. 13, it started a string of public statements from the club, the player and his agent that revealed the potentially sensitive nature of assessing and treating player injuries.
The day after the surgery, the Mets claimed foul, saying that they wanted a third opinion from another doctor before Beltran underwent the surgery.
"I have done nothing but follow the directions of my doctors," Beltran said in a statement. "Any accusations that I ignored or defied the team's wishes are simply false. No one from the team raised any issue until after I was already in surgery. I do not know what else I could have done."
The predicament highlights the stresses and strains that can develop when team doctors, general managers and even club owners try to balance doing the right thing for their clubs and players, who have numerous options in the Basic Agreement to seek outside medical help.
In Beltran's case, there seems to have been a difference of opinion between Mets doctors and private doctors about the severity of the injury to a knee that forced the player to miss about half of last season. But in the cases of Brandon Webb of the D-backs and Jason Bay, then of the Red Sox, the players used second-party medical opinions to offset what club physicians were saying about the natures of their injuries.
In the case of Webb (right shoulder) and Bay (both knees), when their clubs were in discussions about signing them to long-term contracts, they underwent physicals, and team doctors reported the injuries.
Teams are now under direct orders from Commissioner Bud Selig to have players undergo extensive physical examinations before signing large monetary contracts.
Considering the pre-existing conditions of both players, the Red Sox and D-Backs were concerned that insurance companies wouldn't write policies to cover the sizeable cost of the contracts.
Last year, the Red Sox offered Bay a four-year, $60 million deal. In 2008, the D-backs and Webb had agreed on a three-year extension worth $54 million. Though both contracts were negotiated out, the clubs pulled them off the table when team doctors rendered their opinions.
After his examination by D-backs team physician Michael Lee, Webb sought multiple second opinions and finally settled on visiting renowned orthopedic surgeon James Andrews.
"I just wanted to put my own mind at ease," Webb said. "The doctors that we had talked to said my shoulder was fine, but I just wanted to make sure so I went and saw Dr. Andrews. He told me that my shoulder looked like a typical pitcher's shoulder and that I should not be worried as long as I kept up my workouts."
Despite undergoing surgery and missing all except four innings of the 2009 season, the D-backs exercised an $8.5 million option in Webb's existing contract to bring him back for the coming season. That deal isn't covered by insurance.
In Arizona's case, at least, the club couldn't afford to extend Webb without insurance covering the contract, placing his long-term status with the D-backs after this season in doubt.
Bay, who hasn't spent a day on the disabled list during his past five big-league seasons, sought a second opinion after Red Sox team physician Thomas Gill said that one of his knees was arthritic and the other had substantial problems. He was told by outside physicians not to worry about it and recently signed a free-agent contract with the Mets that will pay him in excess of $80 million over five years. He passed the Mets' physical without incident.
Beltran was among $68 million worth of Mets players -- including ace pitcher Johan Santana, former closer Billy Wagner, first baseman Carlos Delgado, shortstop Jose Reyes and third baseman David Wright -- who sustained serious injuries and missed significant parts of the 2009 season.
Beltran is expected to miss at least 12 weeks from the date of the surgery, which means he won't be back until after the season opener. Beltran seemingly overrode the Mets' physicians and had surgery done by a second-opinion orthopedist in Colorado - Dr. John Steadman, who removed cartilage fragments and shaved bone spurs that caused continued inflammation.
Mets assistant general manager John Ricco said earlier this month that Beltran had permission to seek a second opinion from Dr. Steadman, but not to have surgery. That right to a second opinion is included in the current Basic Agreement, signed by representatives for the owners and players in December 2006.
"We told the agent for the player that we wanted to have the ability to discuss the diagnosis and possibly have a third opinion because of the nature of this injury," Ricco said. "We wanted to have the opportunity to digest the information, the diagnosis, and unfortunately we were never afforded the opportunity to do that."
There are rules in the Basic Agreement that document a player's right to receive second medical opinions by doctors on a list pre-cleared by the clubs, and even third opinions by doctors not on that list selected by the individual player and approved by the club.
The reason this procedure exists is to head off club physicians, who may have the best interest of the club, rather than the long-term welfare of the player, in mind. In many cases, a club physician's job simply may be perceived as trying to patch up a player so that he can quickly get back on the field.
Webb, the National League's Cy Young Award winner in 2006, said this week that his right to seek a second opinion was never questioned by the D-backs.
"Dr. Lee told me to go out and get as many opinions as I wanted," he said. "After I saw the different doctors and had to decide what I was going to do, he was very supportive, very helpful. He actually made [those calls for me]. He was all for getting opinions."
Tony Gwynn, a Hall of Famer who spent his entire 20-year career with the Padres and had numerous surgeries on his knee, feet and neck, never sought an outside opinion.
"I was very happy with the medical team," said Gwynn, whose career ended in 2001. "I had doctors there I could trust, who I built relationships with and knew how I operated. I wanted to play. I'd do everything I could so I could play. I loved our doctors with the Padres. I always thought they had my best interest in mind as well as the interest of the club."
Gwynn had trust in the Padres' physicians, which evidently is the case with many clubs.
There is a procedure to follow in the Basic Agreement regarding dueling opinions by doctors, which is explained in an attached letter penned by Don Fehr, the former executive director of the union. Fehr said that players have the right to seek outside medical opinions and the club has the right to designate any doctor not on the payroll of the club to perform a medical procedure on its players.
But once the club physician and the outside physician are at odds, there is a remedy specified in the Basic Agreement.
"Without attempting to resolve this disagreement, the parties will continue to avoid disputes," Fehr wrote, "urging their constituents to agree on a qualified third-party expert ... who would resolve the dispute."
Mets physicians were well aware of Beltran's right-knee problems, but club officials may not have been given the right to approve the procedure by an outside physician. The right of that selection and permission is the crux of the issue and is stipulated in the Basic Agreement under Article XIII-D, Second Medical Opinions.
Ricco's statement about seeking third-party medical intervention seems to support the proposition that Dr. David Altchek, a respected orthopedic surgeon and the Mets' medical director, didn't agree with Steadman that Beltran needed surgery. Thus, a third-party opinion should have been sought. Scott Boras, Beltran's agent, said that the club had given its permission for the surgery.
A Safety and Health Advisory Committee was created by Major League Baseball and the union to make non-binding recommendations to head off such problems. But the resolution of any post-surgery dispute would be a grievance filed by the Mets under the normal process spelled out by the Basic Agreement. They have not filed a grievance.
What would be at stake perhaps is Beltran's salary for the three months after what might be considered surgery unauthorized by the Mets. Also on the table would be "reasonable medical expenses," including travel costs incurred by Beltran to have the surgery, plus any follow-up appointments that are stipulated to be paid by the team. His seven-year, $119 million contract, which ends after the 2011 season, apparently isn't insured, either.
Globally, a possible grievance and the Beltran incident would seem to have little ripple effect on the way clubs or players handle injuries and surgeries as long as they follow the process detailed in the Basic Agreement, which will expire in December 2011. Negotiations between the union and MLB are expected to begin next year and it wouldn't be surprising if further safeguards are placed in an already intricate medical system that exists between MLB and the union.
Because of the possibility of a grievance, Michael Weiner, the new executive director of the union, declined when asked last week to speak about any general medical issues, including expanding the scope of the already existing Safety and Health Advisory Committee.
Rob Manfred, MLB's executive vice president of labor relation and human resources, was unavailable for comment.
With preparations for collective bargaining already in full swing, current general managers for the 30 clubs have been asked not to publicly discuss any of the pending issues, including medical. For the first time, the GMs have now been included in the pre-collective bargaining process, having attended the last owners' meeting in the Phoenix area. Commissioner Bud Selig said they will be invited to the May meeting in New York as well.
But at least one former GM said he likes the system the way it is.
"We never had any of those medical issues when I was with the Padres," said Kevin Towers, who was dismissed as their GM last year after 14 seasons. "We had a great relationship with the doctors at Scripps Clinic in La Jolla. The players trusted them and you can't replace the history that the players have with those doctors from the time they're in the Minor League system on up to the Majors.
"To me, that's really important. These doctors, who are associated with the ballclub, know these players better than anyone. As long as the players remain comfortable with them and feel that they're working in their best interest, that's the best result for everyone."
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