Fielding Questions

Major League Baseball Medical Director Gary Green Joins Saint John’s Palisades Team

Dr. Gary Green, formerly of the Pacific Palisades Medical Group, has joined a new team, and he could not be more excited. Now with Saint John’s Physician Partners, located on the first floor at 881 Alma Real Drive in the Village, he is glad to still be practicing in Pacific Palisades, as are his patients. Saint John’s Physician Partners is a network of primary care and specialty physicians that serve communities on the Westside and beyond. A member of UCLA’s Division of Sports Medicine since 1988,  Dr. Green has researched performance-enhancing drug use in athletics through UCLA’s Olympic Analytical Laboratory and for five years he chaired the NCAA Committee on drug testing and drug education. Board-certified in both Internal Medicine and Sports Medicine, Dr. Green is a fellow in the American College of Physicians and the American College of Sports Medicine. He has been a consultant to Major League Baseball on anabolic steroids and performance-enhancing substances since 2003 and he has served as Medical Director for MLB since April 2010. Among his roles are evaluating baseball’s drug prevention and treatment programs at the major and minor league levels, making recommendations on updates to the programs and being a primary liaison to club physicians and certified athletic trainers. Dr. Green also assists in the development of educational programs and materials and advises on all issues related to the health and safety of MLB personnel. His research was vital to the league’s concussion protocols in 2011 and he has long been involved in researching pitching injuries that result in Tommy John surgery. He was also a member of the advisory committee that helped develop MLB’s Pitch Smart program. When he isn’t consulting with Major League Baseball, Green is in the Palisades seeing patients and last week he took a timeout to chat with Palisadian-Post Sports Editor Steve Galluzzo about his love of sports, his new position with Saint John’s and his role in getting Major League Baseball’s shortened 2020 season underway:

PP: When did you start at Saint John’s and why did you decide to join them?

GG: I started August 1, so it’s been about a week seeing patients and it’s been great so far. My partner Dr. Krystyna McNicoll and I were actually talking to Saint John’s for about a year. There were many things to consider in terms of where we were going to practice. Then the coronavirus hit and it changed a lot of things because of the hospital having to focus on other issues. So that delayed our starting but Saint John’s came back and restarted the process and we were able to start the first of the month so we’re thrilled to be part of the Saint John’s group.

PP: Has this been a relatively smooth transition for you?

GG: Yes, but when you’re at one place for 16 or 17 years it’s always hard to make a move and I have to say that the Saint John’s people have really eased my anxieties. They’ve been so welcoming to both Dr. McNicoll and myself. It’s eased my concerns a lot and I’m really pleased with the move.

PP: What area of medicine is your specialty?

GG: I’m board certified in both internal medicine and sports medicine. So that’s been most of my practice the last 32 years and for the last 17 years I was part of the Pacific Palisades Medical Group here in the Palisades and in that practice I was with three other partners, including Dr. McNicoll, who has come over with me to Saint John’s. My other partners decided they wanted to make the practice a concierge only practice, where you have to pay an additional fee to be able to be seen. I wanted a more inclusive practice where I could see all my patients and Saint John’s was willing to provide that. It was a win-win situation. I have a lot of patients who are in the Palisades that I’ve cared for the last 17 years. It’s nice that we’re one block away from our previous office so it’s really convenient for me and the patients and we get to stay in the Palisades.

PP: What did you do prior to practicing in the Palisades?

GG: Before I was in Pacific Palisades I was at UCLA for 15 years. I was a team physician there and for the last 20 years I’ve been a team physician for Pepperdine. I’m now the head team physician for Pepperdine athletics and I continue to do that. I live in Malibu so it’s great to be able to live there and practice in Pacific Palisades. I couldn’t ask for a more perfect fit than that.

PP: Approximately how many patients do you see in a day or in a week?

GG: At Saint John’s they’ve purposely started us off slowly as I adapt to a new electronic records system so there’s a learning curve with that. Typically in a full day I’ll see about 15 patients depending on the severity. In addition to doing sports medicine I like doing regular medicine. I have patients who range in age from 15 years old to in their 90s. There can be relatively brief visits for uncomplicated problems or extended visits for annual physicals that require a more thorough exam and additional testing.

PP: As a sports medicine doctor do you notice patterns that lead to athlete-related injuries?

GG: That’s another reason why I like practicing here. I’ve been a sports medicine team physician for 35 years at the collegiate level. I’ve also worked with elite athletes such as the USA men’s national soccer team and professional baseball, so I like taking care of people who are active. It makes life much easier because a lot of the things we see in medicine can be fixed with just exercise. It’s a great prescription for preventing diabetes, hypertension and cardiovascular disease, so I consider all of my patients as athletes to some degree. The nice thing about taking care of athletes is that they want to get better quicker. A lot of people ask me what’s the difference between medicine and sports medicine. Well, a sprained ankle is a sprained ankle. The only real difference is that when a regular person can resume their activities of daily living they feel like they’re cured. In sports medicine we’re not really satisfied until you’re back to the level of play they were at before the injury. Athletes are a different breed. They are highly motivated and the problem can be patience while they heal. The days when you could tell someone ‘Well if it hurts don’t do it’ are long gone. You can’t tell people that. The main thing I see in recreational athletes is really more overuse injuries. A lot of things can be tied to training errors. If somebody all of a sudden decides they want to run the LA Marathon and this is in January or February and they’ve never run before I’m going to tell them that’s not realistic and we work on more realistic goals. When people ask what sort of exercise they should do the first thing I tell them is it should be something you enjoy because if you’re just doing it because I’m telling you it’s good for you, you’re not going to do it very long. You’re better off doing a kind of exercise that may not be quite as aerobic but if you enjoy it you’re going to do it more. I don’t want people saying ‘That darn Dr. Green is making me do this.’ I want them to have fun. The other two questions I ask are ‘What are their goals?’ and ‘How much time do they want to put into it?’ If someone says I want to run a marathon and I’m willing to train an hour a week, well that’s not really going to work. You have to match their goals and reality. The biggest thing we see in overuse injuries is training errors in terms of people doing too much too quickly, having the wrong equipment or not having enough of a base to do what they’re trying to do.

PP: Would you encourage kids to try multiple sports growing up?

GG: A number of years back I was asked that question because we’d seen an increase in overuse injuries in kids under the age of 13. As an example, stress fractures in kids used to be relatively rare and now we are seeing that more often.  Much of that can be attributed to early sports specialization and playing year-round sports. Youth sports should be fun. The reality is that most kids aren’t going to make a living as professional athletes. So yes, children should be encouraged to play multiple sports. A kid who may be the best at something when they’re 12 may not be after hitting puberty, which can be discouraging if they only play one sport. Focusing on a single sport can lead to burnout, emotional problems and physical issues. You never want to turn your kids off to sports so let them specialize when they get older, around high school age.

PP: How has MLB handled the 2020 season in terms of safety regarding the coronavirus?

GG: That’s a tough question because as the medical director for Major League Baseball I’ve been working on that since February. This is really a challenge. It’s really unprecedented because no one has ever played sports in a pandemic before. For MLB we worked for months putting together a protocol to allow us to play and it was really hard because we didn’t even know if we were going to play, we didn’t know where we were going to play and we didn’t know how many games there were going to be. It was a big challenge on a lot of fronts. So I’m really happy that we were able to start playing. It’s an experiment and we’ll see how we do. Unfortunately for baseball we couldn’t play in a bubble. A lot of reporters are asking me ‘Why don’t you just play in a bubble like the NBA?’ And I ask them, ‘Can you name a place where there are five major league fields within like 20 minutes of each other. Tell me where that would be. We looked very closely into playing three months of a season in a bubble but even if we had used three sites with 10 teams each we couldn’t find any places that would accommodate the number of games and people required. Overall, we’ve done pretty well so far with 28 of the 30 teams. We’ve had two outbreaks on two different teams that hopefully were contained but it’s going to be a real challenge. It’s a big challenge at the professional level given the resources that we have. I’m not sure how high schools and colleges are going to be able to handle this and play. It’s going to be an extremely difficult task for them.

PP: How do the challenges with COVID-19 compare to those MLB faced in the steroid era?

GG: I was initially hired by baseball in 2003 to help them develop a program designed to deter performance-enhancing drugs and at the time baseball had a real issue with this. Because of my expertise in drug testing and the fact that for five years I chaired NCAA committees and worked in the Olympic testing lab at UCLA, Commissioner Bud Selig asked me to help them develop that and I’m pleased to say that Major League Baseball has gone from having significant problems to now being recognized as one of the best in the world. We get requests from people all over the world about how we were able to accomplish this. One of the things I’m really proud of in my career is that we took a program that really didn’t have a good reputation and now it’s a world class testing program. The reason I think drug testing is important is because it creates a level playing field. It also goes to the nature of sports, of playing by the rules. At the professional level, it’s part of a collectively bargained issue. Each sport tests for specific drugs and most sports have a caveat that you can’t use a related substance. We were very lucky in a lot of things that helped us along the way but the other significant thing is that there’s been a really big shift in the players’ mindset. Our surveys have shown that athletes are supportive as long as the testing is applied fairly. The players have gone from opposing a drug testing program to now embracing one and now it’s part of their sport. Now when you see a player test positive they often accept their penalty and they understand what they’ve done. In the last collective bargaining agreement the players actually proposed stricter penalties than what we had and we implemented that. Initially I believe it was a 10-game suspension for the first positive test, now it’s 80 games with loss of pay and you can’t play in the postseason and you can’t be an All-Star. It really affects someone’s career dramatically. The second offense is 162 games, which is a full season, and we also have the minor league program. It used to be when I went in and talked to the players about drug testing I’d get cold stares and ‘Why are you here, why are you bothering us?’ Now I go in and talk to them and they’re like ‘Yeah we know, it’s part of the game.’ The purpose of it is not to catch the dirty players, the purpose of it is to protect the clean players so they don’t feel like they have to use PEDs in order to not be at a disadvantage. That’s what we’ve accomplished in that regard. Now, that’s not to say there still won’t be people who test positive. We have pretty strict laws against murder and people still kill each other, so people are still going to disregard the rules but we want to limit use and make sure there are adequate penalties to discourage people and hopefully we’ve been able to do that.

PP: What are you the most proud of achieving as medical director of MLB?

GG: I became medical director in 2010 and besides the drug testing program the thing I’m very proud of is that we’ve instituted several rules changes that have made the game safer through our research. I’m also the MLB research director and one of the things I’m really happy about is that we changed the home plate collision rule in 2014. I co-authored a research paper where we looked at concussions in baseball and baseball has much less concussions than other sports. For example, in the major leagues we have about 25 a year which is obviously much less than say football. One of the things we found is that 40 percent of the defensive concussions were on catchers. If you think about it, catchers are only one-ninth of the fielders so they should only have about 11 percent of the concussions, but they had about 40 percent and of the catchers who have concussions about 40 percent were from home plate collisions. So based on that research we were able to convince MLB to change the home plate collision rule and since we changed it we’ve only had I believe one catcher home plate concussion from a collision and that was last year when Jonathan Lucroy of the Angels got run over by Houston’s Jake Marisnick. It showed the rule worked because the runner was called out and later suspended for violating the rule. Not only have we cut down the number of home plate concussions but the number of injuries and the number of days lost due to home plate collisiions has dropped dramatically since we passed the rule. We published a paper last year documenting these changes and I’m really happy that we were able to make baseball safer without materially altering the game. Even though Pete Rose and some current and former players were critical of the rule when it was passed, just like drug testing, there’s been acceptance because they realize it’s making the game safer. You can’t run over people at other bases so why should you be able to do it at home plate? I’m glad I was able to, in a small way, make baseball a little bit safer. It just shows that if you do good research and you show the effects something can have, you can change a rule and help the game.

PP: Did you play any sports as a child? If so, what was your favorite?

GG: Yes, I’ve always played sports. I played football for a little bit in high school. I’ve been a pick-up basketball player my whole life. I love basketball most. I played basketball twice a week at UCLA at lunchtime for the last 32 years, so it’s been frustrating not to be able to do that during COVID. Sometimes I think the reason I’m still playing is because I never was forced to play by a coach. I always played because I enjoyed it. At UCLA I’ve been playing with the same guys for like 30 years and it’s been a great social thing and we have really good games as well. I also do a lot of hiking and bicycling and I still run and jog. If you’re going to be a sports medicine physician you also have to practice what you preach. Patients ask me ‘what do you do for exercise?’ and I’m reply, ‘It’s really not important what I do, what I want to find is what’s good for you, what you’re going to enjoy because the more you enjoy it the more you’re going to do it.’ We know exercise can cure a lot of the woes of these chronic illnesses that people have. It could be as simple as walking or swimming or biking. I tell people you don’t have to go to a gym (well you can’t now anyway) or you don’t have to run, it’s really about getting moving. All of our bodies function much better with movement than with being sedentary.

PP: Is it true that you were on the rowing team in college?

GG: I rowed crew back east at the University of Pennsylvania. The nice thing about crew is that you can come to a college never having done the sport and compete very quickly. Most of the people on my team had never rowed before they got to college. It’s a sport that you can pick up fast, but it’s mentally challenging. The actual motion of rowing is not that hard to learn. It becomes is a test of wills because it’s a very physically demanding sport. The technique is relatively easy to learn but the mental challenge is the thing. In crew, you have six races a year and each one lasts for like seven or eight minutes and you train an entire year for those 45 minutes or whatever. There’s a fantastic book called “The Boys in the Boat.” It’s a true story about the 1936 University of Washington gold-medal winning crew and it probably captures the essence of rowing better than any book I’ve ever read.  They’re making it into a movie at some point too but to learn more I highly recommend it.

PP: How much does being a sports enthusiast help you in your  profession?

GG: In some ways it’s good if you’re a fan to do sports medicine because you understand the demands of the sport and enjoy covering games. Sometimes it can get in the way because you can’t really root for your team. Whether the team loses or wins, people get hurt. While the players are happier when they win, injuries are a constant. No matter what’s happening on the field you have to keep checking on things. For example, in major league baseball there are 750,000 pitches thrown every year and there are potentially maybe 10 catastrophic injuries, but they don’t tell you which 10 those are going to be. So the medical staffs have to be on alert every single pitch because every single pitch has the potential to cause a catastrophic injury. So, for instance, one of the things I instituted in the league was making sure that all of the teams have emergency action plans and that they drill on those. You might go your whole career without having a serious injury, but when it happens you’d better be ready. It’s a huge challenge for the medical staffs as opposed to football where you’re on your toes every single play because injuries are so much more common in that sport. Each sport has its own set of unique challenges. You don’t have to play every sport in order to take care of athletes but you do have to understand the biomechanics and you have to understand what the potential risks are and what demands a person puts on them.

PP: What is the scope of the coverage you provide? Are most of your patients athletes?

GG: Internal medicine is really just adult medicine, so the most common thing we see in people is hypertension, high cholesterol, diabetes and general medical issues as well as injuries and illnesses people get. I certainly enjoy sports and like treating athletes but I also enjoy taking care of the whole patient. One thing people ask me is ‘What percentage of your patients are sports patients?’ The  answer is it’s really hard to tell because let’s say somebody comes in with high blood pressure but they also had a hamstring injury or they have asthma and want to know how to maximize their treatment for asthma in order to run? So it’s really hard to tell where one thing stops and the other thing starts. That’s why I like taking care of the whole patient and I think my patients appreciate, especially the ones who are active, that they can see me for their injuries but also for their routine medical care. A lot of times people think of sports medicine as only orthopedics and for a long time it was but for about the last 25 years or more there has been what’s called primary care sports medicine in which we work closely with our orthopedic colleagues but most of the things you see in sports medicine are not operative type things. Obviously there are some things that need surgery but most of the things are not surgical. So primary care sports medicine doctors who are board certified can take care of those things.

PP: How difficult is it to determine the source of a problem in order to treat it?

GG: Most things are treatable. Usually, a diagnosis itself is very easy. Where you have to be a detective is in finding out why it happened. For example, if somebody comes in with shin splints. Okay, what’s the reason? Did they increase their mileage? Are they running hills now? Did they get new running shoes? Are the running shoes old? What happened to cause it now? Most things are easy to diagnose and to treat but the challenge for me is to find out why it happened and once we do that we find out how to prevent it. Everybody always wants treatment and what you have to sometimes do is take a step back and figure out why this happened and how we can prevent it because prevention is a lot better—that’s really your goal. The other thing that’s different with sports medicine is that if someone gets hurt the  first  thing they want  to  know is ‘When can I go back?’ So you have to be real honest with them, but you also have to realize that sometimes the answer is not apparent for a few visits, until you can see which way they’re going. That’s where it’s important to find the underlying factors, because if you make somebody better but you don’t fix the underlying factor it’s just going to come right back and you haven’t done them much of a favor. It’s really important to be effective in figuring out what caused a particular injury and how we can prevent it going forward.

PP: Having worked in the Palisades for so long and being active, have you hiked any of the local trails?

GG: We live in Malibu so I’ve hiked most of the trails in Malibu and the Santa Monica Mountains. I’ve pretty much hiked all of those and I probably bike anywhere from 60 to 100 miles a week along Pacific Coast Highway up where we live. I tried a couple of times to bike to work into the Palisades, but it’s just not enjoyable because you feel like you’re going to get killed every time a car passes. So that’s not really a lot of fun. That section from Pepperdine into the Palisades is pretty dangerous so I wouldn’t bike on that part.

PP: Have you ever worked the Nautica Malibu Triathlon?     GG: Actually no, I haven’t been a part of that although I think Saint John’s has been a sponsor in the past. I’d certainly be willing to help out in the future if the schedule permits.

PP: How confident are you that Major League Baseball will be able to complete the season? Will the league consider neutral sites for playoff games?

GG: We have guidelines in place, but they’re just guidelines. We have to look at the whole situation and evaluate as we go along. If we see more cases the question becomes where are the cases coming from? Is there some sort of a pattern? It’s going to be on a case-by-case basis going forward. Like I said earlier, most of the teams are doing a really good job with this situation and I’m hoping that continues. As far as playoff venues we’d have to look at the logistics with baseball operations, but if you were able to get down to a point where you had a limited number of teams for a limited number of games, I think that’s certainly more doable than playing a whole season in a bubble. As it stands, after the first round you’ll be down to eight [playoff] teams. The problem is that it’s impossible to predict how and where the virus will spread by October. I don’t think I’m going to take a deep breath until the World Series is over. It’s going to be a real challenge to complete our season.