General Considerations ( Box 15.1 )
Availability
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Being a team physician requires a tremendous time commitment.
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Must have a sincere desire to care for athletes and allow their expedient return to play
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Availability
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Ability
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Affability
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Advocacy
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Affiliation
Ability
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Possess the necessary skills to accurately diagnose and appropriately treat the athlete
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In addition to team physicians’ actual ability, their perceived ability is important. One must portray a certain level of confidence when examining, treating, and discussing treatment options with an athlete.
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A certain level of comfort and familiarity comes with time; the more experience team physicians gain by covering sporting events and communicating with athletes, the more confident and competent they will become.
Affability
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Possess the necessary social skills required to interact with not only athletes but also parents, coaches, and other staff members
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Nurturing a professional relationship with athletes will not only increase their confidence in their own ability but also increase their adherence to treatment guidelines, particularly if it conflicts with their personal desire to return to play at any cost.
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A team physician should not try to become best friends with an athlete and should maintain a professional relationship.
Advocacy
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View the individual as a patient first and then as an athlete
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Always uphold your Hippocratic oath to do no harm to the patient
Affiliation
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Surround yourself with those who have more experience, and learn from their prior experience
Differences Found at Each Level of Play
Athletic Trainers
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Pro teams will have multiple certified athletic trainers (ATCs) on staff; most also employ a Medical Director, who oversees the Athletic Training staff. The team physician must understand the organizational hierarchy and establish appropriate communication so that decision making is performed by necessary individuals.
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College teams will typically have multiple ATCs, depending on the size of the school and available resources.
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High School /Grade school teams may not have an ATC at all, depending on available resources.
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Responsibilities typically relegated to an ATC may fall upon the team physician’s shoulders.
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Must arrange appropriate follow-up for athletes who need to be supervised during the week if no ATC is available to do so
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Team Physicians
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Professional teams typically have a medical team structure that includes a Head Team Physician and several assistant Team Physicians ( Table 15.1 ).
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Most will also have a list of Consultants who provide specialty care, such as Ophthalmology and Cardiology.
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With such a large staff, communication is critical. Ideally, the Head Team Physician is kept in the loop regarding the complete medical care of athletes, even if he/she is not the primary caregiver.
TABLE 15.1
NUMBER OF PHYSICIANS PER TEAM PER COMPETITION LEVEL
Physician Type
High School
Collegiate
Professional
Orthopedic
1.1
2.3
2.2
Nonorthopedic
0.2
1.1
1.9
From Makhni E, Buza J, Byram I, MD, Ahmad C. Academic characteristics of orthopedic team physicians affiliated with high school, collegiate, and professional teams. Am J Orthop. 2015;44(11):510-514.
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College teams will also typically have multiple physicians responsible for the care of athletes; as mentioned earlier, collaboration and communication are paramount.
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At the High School /Grade school level, having only one physician is the most likely scenario.
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Impossible to cover every single practice/training room/game; try to coordinate coverage with opposing team physician, if available
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Compensation
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At the Pro or College level, there may be some financial remuneration for your services. This typically is not substantial.
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In several cases, your practice or the institution you are affiliated with pays for a marketing contract for the title of “official medical provider.”
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You may experience increased case volume based on either your presence on the sidelines as a team physician or the advertising associated with being the official medical provider.
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High School /Grade school level teams most often do not include any formal salary.
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You may see an increase in surgical/clinical volume based on athletes operated on as well as friend and family referrals through word-of-mouth referrals from those affiliated with the team.
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Do not expect this increased patient referral or surgical volume to be proportionate to the time and effort invested on your part to care for the team.
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Even if you do not receive compensation, the team physician typically is not covered by a state’s Good Samaritan laws. You must continue to uphold your ethical duty and provide the highest level of care possible irrespective of compensation.
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Public Scrutiny
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Pro: Team physicians may often face public pressure to try the latest fads in the medical field. They may also face this same pressure from the organization, coach, or the player. The physician has the autonomy to refuse to provide care that he or she does not deem medically appropriate. However, physicians should counsel the athlete regarding potential risks and benefits and encourage them to make an informed decision.
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The outcome of the athlete, whether positive or negative, may have a huge impact on public perception of the physician’s abilities. Although it is normal for physicians to be cognizant of the fact that their decisions will face public scrutiny, they should not be so overly concerned with this fact that it alters their decision-making process.
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College: May be similar to the pros depending on the prestige/ranking of the school. Division I schools in large power conferences will be more like the professional level, whereas Division II and III schools are more similar to high school.
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High School/Grade school: Typically, physicians will not experience public scrutiny that is commonplace at the college/professional level.
Medical Resources
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Pro: Very low threshold for obtaining advanced imaging (typically MRI); no need to deal with insurance before authorizations typically needed for MRI or surgery; no shortage of supplies in the training room; adequate space available for examinations/treatment
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College: Depending on resources/funding of the program, this may vary considerably. Athletes will need to go through their insurance provider to obtain imaging, or to schedule surgery; advanced imaging is ordered with more discretion than at the pro level. Some schools may have insurance plans available for athletes who do not have prior coverage or are coming from overseas.
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High School/Grade school: Again, may considerably vary depending on school funding/resources or public versus private; not atypical for several inner city schools to have a shortage of supplies. Athletes often purchase their own tape and other medical supplies for use.
Patient Autonomy/Decision Makers
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Pro: At the professional level, the team physician is responsible for providing team management with accurate medical information about the athlete. With regard to the athlete, it is imperative that the team physician clearly outline the risks, benefits, and alternatives to treatment so that the athlete can make an informed decision. Often, an athlete will ask for specific recommendations, wanting the physician to simply “do what you think is best.” It is the responsibility of the team physician to always do what is in the best interest of the player and not the team.
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College level: Physicians have the authority to clear for participation/bench a player. Athletes themselves have the legal right and authority to make their own treatment decisions. They should be given all the information necessary to make an informed decision and should be counseled regarding potential conflicts between short- and long-term gains (i.e., if diagnosed with a potentially repairable meniscal tear, they should be told about short- and long-term outcomes, risks, and length of convalescence with both meniscectomy and repair).
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High School /Grade school team physicians have the ability to clear/bench a player. If under the age of 18 years, an athlete’s parents have the final say regarding medical decisions/treatment options.
Immediate Return to Play
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Pro:
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At the professional level, judicious use of local anesthetic to allow immediate and safe return to play is indicated for selected conditions, such as low-grade acromioclavicular sprain. It is important that the team physician understand the league rules regarding use of other injectable agents such as Toradol.
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College:
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May consider local anesthetic injections (not in knee, ankle, hip or shoulder [i.e., glenohumeral]), or possibly even ketorolac, to allow short-term participation with relatively minor injuries (e.g., AC separation or back spasms)
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If the athlete has a suspected concussion and passes sideline testing, they may potentially be able to return to play once concussion is ruled out.
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High School/Grade school:
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Rarely appropriate to administer injections of local anesthetic agents
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Even the suspicion of a concussion warrants immediate removal, with no potential for return to play
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Drugs in Sports Appropriate at All Levels
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Physicians must discourage the use of illegal substances at all levels of play. Moreover, they should be familiar with the list of banned substances at each level of play: Pro, College, or High School/Grade school
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The physician should obtain a thorough history of all substances being used by an athlete, including natural supplements, and should encourage athletes to be honest and forthcoming regarding their use of all substances.
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The physician must encourage compliance with governing bodies at each respective level, in terms of participation and requirements for drug testing, and enforcement of all policies.
Confidentiality
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Team physicians should be familiar with Health Insurance Portability and Accountability Act (HIPAA), and Federal Educational Rights and Privacy Act (FERPA); the latter pertains to the privacy of educational records/medical information that is part of a student athlete’s health record.
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Pro: Professional sports teams have HIPAA forms that clearly outline who the athletes’ job-related medical information will be shared with. All athletes are required to sign this document.
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There is a distinction made between personal and team-related medical information at the professional level. The physician has a duty to communicate any relevant team-related medical information with the organization that may have an impact on an athlete’s participation.
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College: If the physician is employed by the school, medical information is not considered Protected Health Information (PHI); however, if the school directly receives any federal funding, the medical information is governed by FERPA. Technically, medical information that is not electronically stored is not governed by HIPAA; this would then allow physicians to communicate with coaches and trainers on the sideline regarding a player’s assessment. Several schools now require athletes to sign a waiver before season play, which permits sharing of their medical information with coaches or ATCs .
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High School/Grade school: Parental consent must be obtained before sharing medical information of athletes aged <18 years. However, a physician also has an obligation to prevent harm to other players on the team, which may arise with certain infectious diseases.
Second Opinions
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Pro: Rules related to second opinions vary from league to league. Level of play may also be a factor. For instance, Minor League professional baseball players are considered employed at will and as such have less autonomy than their Major League counterparts regarding medical care outside of the organization.
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One should not take offense if an athlete chooses to pursue surgery or seek other forms of treatment from a different provider. Particularly at the professional level, several athletes may have pre-existing relationships with orthopedic surgeons, and they may choose to continue their care with them. If the athlete so desires, the team physician should facilitate second opinions and also share medical information with other healthcare professionals.
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College or High School/Grade school: Typically, an athlete will only seek external care in the form of surgery or imaging if their insurance provider does not allow care at their own institution.
Team Travel/Cross Coverage
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Pro: Depending on the sport, physicians may or may not travel with the team. Note that for sports in which physicians do not travel, you may also be responsible for providing coverage to the opposing team. In such situations, do not directly approach players (except in cases of medical emergency). Always interact with the ATC of the opposing team, who will make the decision regarding whether or not they would like you to evaluate a player.
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College: May or may not travel; may share responsibilities with other physicians; important to develop a schedule before the season starts so that any lapses in coverage can be promptly remedied; be cognizant of laws when crossing state lines. A study conducted in 2012 revealed that 18 of the 54 medical boards (that responded) allowed physicians travelling with their team to practice medicine with their home-state license. The remaining 36 states (67%) do not provide a legal pathway for the practice of medicine without their state license. This may come into consideration if an unfortunate circumstance of malpractice claim arises ( Fig. 15.1 ).
