Professional boxing and mixed martial arts (MMA) are popular combat sports. In both sports, every punch thrown at the head is thrown with the intention of winning by knocking out the opponent. A knockout, or KO, the fight-ending winning criterion in combat sports, is a legal strike that renders the opponent unable to continue fighting. The blow usually leads to an abrupt loss of consciousness (of varying duration), which causes the combatant to fall to the canvas.
Combat Sports: The Need for Medical Expertise
In professional combat sports, combatants fight without protective head gear. As a result, knockouts are common and combat sports unfortunately have a high incidence of acute traumatic brain injuries (TBIs) such as concussion, subdural hematoma, epidural hematoma, intracranial hemorrhage, subarachnoid hemorrhage, and cerebral contusion. Traumatic subdural hematoma remains the most common cause of boxing related mortality. Over the years, many boxers have perished in the ring or in the immediate aftermath of a bout. The burden of chronic post-traumatic neurological injuries such as headache, dizziness, and cognitive and mood disorders in these sports is also unfortunately high. The true incidence of post-traumatic Parkinsonism, dementia pugilistica (punch drunk syndrome), and chronic traumatic encephalopathy in these sports is likely substantial but remains unknown, coming to medical attention after the combatant has retired. Apart from the above life-threatening neurological injuries, combat sports also have a high incidence of non-life-threatening transient injuries such as lacerations and potentially disabling orthopedic and ophthalmological injuries.
Due to the high burden of injuries, all professional boxing and MMA bouts require, by law, the presence of qualified physician(s) in attendance. These physicians are commonly referred to as ringside physicians or ringside docs. Hailing from various medical specialties, ringside physicians are entrusted to protect the health of combatants. Alarmed by the incidence of injuries, several medical associations such as the American Academy of Neurology and British Medical Association have at one point or another called for a ban on combat sports.
The work of ringside physicians is often not supported by their peers and respective professional organizations. Marginalized, many are labeled as mavericks and fans of these sports. I am one of these physicians.
Discovering Boxing
I was born in Buffalo, New York. My physician parents came from India to the U.S. to pursue residency training, my father in neurology and my mother in pediatrics. I was only 2 weeks old when their training came to an end and they moved back to India. My father, a neurologist in the Indian Army was posted to various command hospitals around India. Wherever he went, we went along. Growing up, my father had planted the "neurology bug" in me and I knew I would pursue medicine. After finishing 5 ½ years of medical school and a 3-year residency in internal medicine, I started neurology residency in Saint Vincent's Hospital and Medical Center in New York City in 2003.
In N.Y.C., I found myself lonely and homesick. One day, I went to a local gym where a boxing class was in session. I was peeping through the door when coach Tyrone saw me. He called me in and asked my name. I replied, "Sethi" (by this time I realized that many of my fellow Americans found my first name "Nitin" tough to pronounce).
"Sethi, do you want to box?" asked Tyrone.
"Yes," was my reply, and that was how boxing found me. I fell in love with the sport and have been boxing ever since.
Soon after joining NewYork-Presbyterian Hospital (NYPH) as assistant professor of neurology in 2008, I became interested in concussion and TBI. Wanting to mix my love and passion for boxing and TBI, I applied to the New York State Athletic Commission (NYSAC) in 2012 to work as a ringside physician. NYSAC is vested with the sole direction, management, control, and jurisdiction over all combat sports and sparring matches or exhibitions in New York State. Matthew Fink, MD, the chairman of the department of neurology NYPH/Weill Cornell Medical Center and my mentor, supported and encouraged me to pursue both my passions.
In 2016, I was appointed chief medical officer of NYSAC, where I am entrusted with the health and safety of all combatants who ply their trade in New York.
Working Ringside
Oftentimes when I am ringside "working" a fight, I find myself conflicted. How does a physician neurologist come to terms with his involvement in combat sports? I was trained to always protect the brain. This 1.4 kg wrinkled organ tissue with no moving parts, no joints or valves, not only serves as the motherboard for all body systems but also as the seat of our mind, thoughts, senses, and very existence. It is the seat of all emotions, joy, sadness, happiness, and thought processes. No less than a supercomputer, it is indeed our most valuable possession. Sitting ringside, I see this delicate organ taking hit after hit, and the neurologist in me tells me to stop the fight. But concussions and sub concussive injuries are common in boxing, and if I stop fights every time a boxer looks dazed or staggers after a punch to the head, boxing will cease to exist in its current form.
In November 2019, my love and passion for combat sports collided head on with my love and passion for neurology and protecting athletes' health. Working a big fight, I stopped it on medical grounds. I was forced to make a tough decision but I did so objectively, unbiased by the stature of the fight and the money riding on it. I based my decision solely on medical facts in front of me. As the ringside physician at the fight, I must always keep my prime responsibility in mind: to protect the health and safety of both fighters. If I do not do my job, I am wasting a seat at the table. I have always been guided by the principle that I must make decisions as an objective doctor, not as a potentially biased fan.
Facing the Aftermath
Soon thereafter, I was forced to reflect on my call. Not the call itself, for I knew I had made the right one, but by the reaction that followed. If I had made the same call for a lesser-known athlete fighting at a smaller venue, would the reaction have been different? Would I have heard a fan yell "good call, doc" rather than the profanities that rang out? I had the courage to do what I knew was medically correct. If I had not made that call, I would have let myself down. "Do no harm" is the oath I took as a physician in 1999. In November 2019, I lived up to that oath under tremendous pressure.
Yet, I endured the repercussions of living up to my medical oath. On social media platforms I was called "a f***ing scum" and "genetically inferior." My reputation as a neurologist was destroyed with fake reviews; a reputation that took 18 years to build, and was probably my most valuable possession. Fans were calling my office yelling at staff members.
I understood the passion of combat sport fans, for I am one too. When I am not working a fight, I too am roaring loudly when my guy lands a knockout punch. To the fans who criticized me, I held no ill will. My only request was to look at my actions through the eyes of a ringside physician entrusted to protect athletes. Would they have not done the same thing? What if it was their brother in that ring; would their response be different? As fans, let us not forget that behind every athlete is a human being; someone who feels pain, someone who, when the bright lights turn off, returns to their family physically hurt or is transported to the ER. The athletes give their all to entertain us, but it is also our duty (fans and doctors alike) to respect and enjoy that entertainment responsibly.
What hurt the most in the aftermath was the racist slurs. I never knew this to be a part of combat sports. It was boxing that had accepted me unconditionally when I first landed in New York City. There, I was only NK, Sethi, or simply doc. We would settle our scores in the ring and then step out for a drink. There was no white, Black, Asian, Indian, Latino, Christian, Jew, Hindu, or Muslim. It was only brother or bro. That is why I had fallen in love with boxing.
We have lost too many in our family to boxing. Too many young lives burnt out too early. And that is just the surface. Hidden are the chronic injuries these young men and women may deal with for the rest of their lives: chronic headaches, problems with memory and concentration, chronic dizziness, mood and behavioral changes, Parkinson-like diseases, chronic eye problems (holes in the retina, detached retinas, cataracts), chronic fractures of the nose, face, hands, jaws, and other bones, all which reduce their quality of life and life expectancy. We owe these athletes, yet, we are not doing enough. No one cares for them when their careers are over, but we should. Ringside physicians should feel conflicted when working a fight. But when they do, they should also remember that they make a difference. Their work helps to make a very dangerous sport safer. I never say completely safe; I say safer. As a neurologist, I understand a sport in which one punch can kill can never be completely safe.
I admit that the storm of 2019 broke me down. James Leary, Assistant Executive Deputy Secretary of State, my friend and one of the wisest men I know, reached out to me and said, "Nitin, remember diamonds are made in the rough." Fast forward to 2022 and I can say that the events of 2019 only made my resolve stronger to make the sport I love safer. I have written and published numerous articles on how boxing and MMA can be made safer.
As chief medical officer, there shall be no loss of a promising young life on my watch if I can prevent it. There is no finer group of men and women than those who serve NYSAC. These remarkable people (commission officials, inspectors, ringside physicians) help safeguard athlete lives.
It is understandable why even my own peers in neurology and medicine oftentimes do not support the work of ringside physicians, and call for a ban on combat sports. Combat sports and medicine cannot co-exist without conflict. The gap is too large to bridge. Do I have all the answers? No. But I do know that the day I hang up my stethoscope and retire from working fights, I will retire with the satisfaction of knowing I did everything I could to make combat sports safer and to protect the health of the athletes.
Nitin K. Sethi, MD, MBBS, is associate professor of neurology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
Disclosures
Sethi serves as the Chief Medical Officer (CMO) of the New York State Athletic Commission (NYSAC). The views expressed by the author are his own and do not necessarily reflect the views of the institutions and organizations which the author serves.