Editor's Note: Some physicians think that boxing should be banned. But that's unlikely. Despite the sport's waning popularity in recent years, the May 2 match between Floyd Mayweather and Manny Pacquiao was the most watched pay-per-view event of all time, seen by 11.6 million people.
Even the American Medical Association (AMA) believes that physicians belong at ringside. In its official policy on the "sweet science," the AMA "promotes the concept that the professional responsibility of the physician who serves in a medical capacity at a boxing contest is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even injured athletes that they not be removed from the contest should not be controlling. The physician's judgment should be governed only by medical considerations."
To better understand how the physician who serves in a medical capacity at a boxing contest meets this responsibility, Medscape recently spoke with orthopedic surgeon Rick Weinstein, MD, MBA, of Westchester Health Orthopedics & Sports Medicine in White Plains, New York. Dr Weinstein, a ringside physician for nearly 20 years, is on the board of the Association of Ringside Physicians and is medical director of the International Boxing Federation. He served as a ringside physician during the world heavyweight championship bout between Wladimir Klitschko and Bryant Jennings at Madison Square Garden in New York on April 25.
Medscape: A boxer's trainer and his cutman attend to the boxer's wounds between rounds, but it's the ref who calls the fight based on his assessment of whether a fighter has had enough. Where does the ringside physician fit in?
Dr Weinstein: Each state is different. In some states, only the ref can stop a fight. Fortunately, New York is one state where doctors are allowed to stop the fight. I can step into the ring and stop the fight. The referees usually stop a fight, and they usually make good calls, but I've had to jump into the ring and stop a couple of fights.
Medscape: At what point do you step in?
Dr Weinstein: I stopped a professional fight up at the Civic Center in Poughkeepsie, New York. The guy was just taking a beating and he fell through the ropes and climbed back in. When he got back in, his leg buckled a little bit while he was starting to fight again. And I stood up and signaled to the ref to stop the fight. It was a very tough crowd, a very blue-collar crowd up in Poughkeepsie, and they wanted to kill me for stopping a good, bloody fight.
Medscape: That gives you unique power as physician in an athletic contest.
Dr Weinstein: Boxing is probably the only sport where you as a doctor can step into the middle of the competition and stop the competition. In football, for example, if someone gets hurt, it may be a doctor's call or trainer's call to keep that individual out of the game, but you're not going to step up and say, "That's the end of this game." It takes real intestinal fortitude to step up and stop a fight, but I've learned that you have to be willing to step in and make a decision that you think is in the best interest of the boxer so that he doesn't get hurt.
Medscape: What are your criteria for stopping a fight? What do you look for?
Dr Weinstein: My criterion for stopping a fight is if a boxer cannot adequately defend himself. If, say, his hand is hurt so that he can't punch with that hand, or if he can't do a good lateral motion. If he's hurt his leg or something prevents it from moving, then I might stop the fight. If one eye is so swollen that he only has one eye he can really see out of, that'll be the end of that fight. I did the fight between Miguel Cotto and Antonio Margarito at Madison Square Garden in 2011. Margartio's eye was almost completely shut. We checked him every round, and finally in the 10th round we had to stop the fight because his eye was so swollen.
Medscape: Besides stopping a fight when you feel it's necessary, how do you interact with the boxers as a clinician?
Dr Weinstein: Boxing is one of the only sporting events where the doctor sees every participant. Before every fight, we do a full examination from head to toe: neurologic exam, psych exam, and physical exam. We check their medical history. We check them for HIV and hepatitis. We do a full screening of every boxer. During the fight, we're at ringside watching them. After the fight, we examine every single boxer again. In other sports, such as baseball, football, or basketball, you don't really examine each person. If anyone has an issue, they'll come to you. But we examine each and every participant before, during, and after a boxing match. You really get to spend time and do a full exam and see what's wrong with certain people. We'll disqualify guys before the fight for certain medical issues.
Medscape: Such as?
Dr Weinstein: I had a fight coming up where the guy was blind in one eye, but he still wanted to fight. But our criterion is that you can't fight if you're blind in one eye. I've had guys who have tested positive for HIV or hepatitis, and we had to disqualify them for that reason.
Medscape: When you examine a fighter after a fight, what are you looking for?
Dr Weinstein: The most common injury we see in boxing is lacerations, particularly cuts around the eye. For example, in one of the earlier bouts at the Klitschko event I did recently, the guy had a pretty bad cut over his eye. What's great is that we usually have three or four doctors at every fight, so as one of the only surgeons there, I'm able to sew these guys up after the fight.
Medscape: You do it right in the locker room?
Dr Weinstein: We do it in the locker room. At Madison Square Garden they have an EMS area, a trauma area, so we have a nice place to sew them up. I'm also looking for fractures and other common injuries. Boxers can hurt their hands and sustain injuries around their eyes, their orbits. And the biggest thing we're always looking for is signs of concussion.
Medscape: Do you look for concussion in the ring as well?
Dr Weinstein: In the ring, it's different from when we're examining them after the fight. In the ring, what I'll look for is how their mood is. When we look at them between rounds, if someone got hit or went down, I'll go up between rounds and take a look at the boxer. If he's responding to his corner men appropriately, that's a good sign. If I'm not sure that he's really responding right, I'll purposely ask him questions and ask him to do specific things—complex commands to see whether he's able to follow what I'm telling him to do.
Medscape: For example?
Dr Weinstein: The most common things I'll say are, "Take your right hand and touch your left ear. Put your left arm over your head. Lift your right leg" (if they're sitting on a stool). We'll ask them questions: "Where are you right now? What was the number of the last round? What city were you last in before coming here?" We ask them things we know from interviewing them the day before when we did the physical exams. "Tell us the months backward starting with December." We'll ask them to "Remember these five objects" and see how they do with memory. It's basically concussion-type testing. Between rounds it's a little more difficult with the crowd screaming and the boxers distracted. We try to assess them as best we can.
Medscape: You mentioned that there could be several physicians at ringside.
Dr Weinstein: Typically in New York we have three doctors at every fight. We have one in each corner—one in the red corner and one in the blue corner to keep an eye on each fighter, and we have one doctor in back to check them out before and after the fight. Typically one of us will go in the back if we need to sew. If I'm the only surgeon there that night, I'll do the sewing to take care of them.
Medscape: Are all of the physicians sports medicine doctors?
Dr Weinstein: We typically have different specialists. We usually have a maxillofacial surgeon, so that if someone has a trauma to the jaw, I know whom to defer to. We have an ophthalmologist if there's an eye injury. We have an internist for medical issues with breathing or cardiac questions. As an orthopedist, I'm really glad to have different specialties represented. When I'm taking care of these boxers, and if there's something that doesn't look right but it's out of my specialty, I can defer to someone else. At every boxing match we always have at least one ambulance and EMS personnel so that they can readily transport an injured fighter to a level-one trauma center if necessary.
Medscape: The fighters don't go to the hospital for a checkup as a matter of course?
Dr Weinstein: No. That's part of what we do. We check them at the ringside to make sure they're okay.
Medscape: You've also served as a team physician for football and ice hockey teams. How is boxing different from other contact sports, from a physician's perspective?
Dr Weinstein: In boxing, like wrestling, it's one-on-one. In a lot of instances, an individual's health will determine whether they win or lose. If you have a football team and one or two guys aren't in good shape, you can depend on the rest of the team to step up. That's not the case with boxing. I've had some instances in which guys may have had a slight cold and they still boxed but couldn't get it together to win that night.
Medscape: What about health problems caused by a boxer trying to lose enough weight to qualify for his weight class?
Dr Weinstein: This is another major issue with wrestling and boxing: Guys trying to make weight will dehydrate themselves to the point where they're not going to be healthy enough to fight well. They'll try to lose 10 pounds in 2 weeks, and then they have to put the weight back on to re-hydrate themselves. A big-name boxer like Ricky Hatton is infamous for losing something like 30 pounds before a fight, and then he'll put on 30 pounds afterward. That's just not healthy. In most sports, weight control isn't an issue.
Medscape: As a ringside physician, is this something you would step in on—a boxer endangering himself because he shed too many pounds too quickly to make weight?
Dr Weinstein: We're trying to work on rules so that boxers won't put themselves at risk. Right now it's not really regulated. They just have to meet weight on fight night. We're trying to change it to where boxers have their weight measured 2 months, 3 weeks, and the night before the fight to make sure they're not cutting too much weight. As things stand now, each state determines how they want to measure boxers' weight gain and weight loss.
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Medscape: You mentioned earlier that you may check a boxer for concussion between rounds as well as after a fight. Concussion is a huge issue now among sports medicine physicians, athletes at every level of play, their families, and society at large. From your perspective as a ringside physician who has doctored football and ice hockey players as well as boxers, is a concussion always a concussion? Is a football concussion the same as a boxing concussion?
Dr Weinstein: This is a very heated discussion that we have at the Association of Ringside Physicians board. One of the discussions that we have all the time is that if you were a doctor for a football team and a guy banged his head, got tackled, fell down, was a little out of it for a couple of seconds, and then got up, he'd be out of the game. He'd be done. But in boxing, if a guy gets knocked down, we give him 10 seconds to recover, and if he's able to fight again, he continues to fight. So we view concussions differently. We don't know exactly what the answer is, but most boxers who get knocked down get back up, are able to continue fighting, and are absolutely fine, without a problem.
Medscape: In football the object is to score points. Getting hit is collateral damage. But in boxing there is no collateral damage. That's what you're there for: to inflict and receive blows. From a clinical standpoint, does this make the injuries incurred in boxing qualitatively or quantitatively different from those in other contact sports?
Dr Weinstein: The point of boxing—of fighting someone else—is to win the fight. Sometimes it's by a knockout, but usually it's by outscoring your opponent by winning each round. One objective is to knock the other person out so that you win the fight. In that way, it's different from other sports. However, percentagewise, there are actually more concussions and more injuries in football and—believe it or not—cheerleading than in boxing. They're dangerous sports, and boxing is definitely a dangerous sport as well.
Medscape: Have you ever had a boxer die on your watch?
Dr Weinstein: I was working at an event on the USS Intrepid [a former aircraft carrier, now the Intrepid Sea, Air & Space Museum Complex, moored in the Hudson River on Manhattan's West Side] in 2001, and one of the boxers died. He was a light heavyweight named Beethavean Scottland, and he was boxing a 10-round fight. He took a lot of shots but never went down. He actually won the 8th and 9th rounds. In the 10th round, he got punched pretty hard once or twice. He went down and never recovered. EMS transported him to Bellevue Hospital, and he ended up having an intracranial bleed. He died a week later. It was the most tragic event I've seen.
Medscape: Does a tragedy like this ever give you, as a physician, pause for being involved in such a violent sport?
Dr Weinstein: Before boxing was allowed in certain states, backroom brawls were common. We still have people getting hurt all the time doing stupid things in their backyards—amateur wrestling or whatever. A lot of that stuff goes on without any doctors present. I feel very honored to be there to help these boxers out. Boxing has been around since Ancient Greece. The AMA official policy 20 years ago was that boxing should be outlawed. But it's going to continue whether a doctor is there or not. I would rather be there to keep an eye on things and do what I can to help out.