Being a Team Physician: a Special Privilege, an Awesome Challenge
Special Role
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Team physicians have a unique responsibility of leadership while taking care of athletes.
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Athletes, their parents, and their team administrators expect team physicians to make decisions in terms of clearance to participate in the sport as well as to assess and manage healthcare issues in order to ensure safe participation of athletes.
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In addition, such decisions may be required in a setting of intense time pressure, such as when required on the sidelines.
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Team physicians may play a leadership role within an organization and may provide care for individuals and teams at mass participation sporting events. In addition, team physicians have responsibilities and duties that are both medical and administrative, and these frequently include ethical and medicolegal issues.
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This chapter discusses the requirements of a team physician in terms of medical qualifications, education, and roles and responsibilities.
The Sports Medicine Team
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Care of an athlete is a team effort, wherein members of a sports medicine team support each other for the benefit of the athlete and the athletic team.
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An athletic trainer occupies a unique position at the center of the athletic healthcare triangle.
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A team physician cares for the team and also serves as a key player on the sports medicine team comprising the athlete, the team physician, the coach, the athletic trainer, and other supporting health professionals. Similar to the athletic team, sports medicine services are best provided following a team approach ( Fig. 1.1 ).
Figure 1.1
The sports medicine team.
(Modified from Mellion MB. Office sports medicine. Philadelphia: Hanley & Belfus; 1996.)
Availability
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Availability is a cornerstone for success of a team physician.
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On the sidelines, at events, and during travel
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In the training room
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In the office: Team physicians may have to include special accommodations in their office schedules for athletes who require urgent medical attention.
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After office hours and weekends: Most athletic activity happens outside a normal work day; thus, team physicians must accommodate this in their coverage considerations.
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Definition of the Team Physician
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Six major professional associations focusing on clinical sports medicine issues collaborated to develop guidance documents for team physicians.
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These “Team Physician Consensus Statements (TPCS)” cover various topics for team physicians, including the definition of team physicians: TPCS (see Appendix A, online) and Sideline Preparedness for the Team Physician: Consensus Statement (see Appendix B, online).
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All other TPCS are referenced in “Recommended Readings,” which are useful resources that cover specific topics and populations.
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The TPCS that defines the qualifications, roles, and responsibilities of team physicians along with guidelines for individuals and organizations seeking to select a team physician were updated in 2013.
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The team physician must be a medical doctor (MD) or doctor of osteopathy (DO) with an unrestricted license in good standing and knowledge of on-field emergency care and basic cardiopulmonary resuscitation techniques as well as musculoskeletal injuries and medical and psychological issues that affect athletes.
Responsibilities of the Team Physician
Medical Care
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The most important role of the team physician is to address the physical and psychological needs of an athlete.
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In addition to the essential requirements described in the TPCS, it is also desirable that the team physician has additional training and education in sports medicine, with medical specialty and fellowship training and additional American Council of Graduate Medical Education (ACGME)/American Osteopathic Association (AOA) certification in sports medicine, and additional experience, including:
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Ongoing continued medical education in sports medicine
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Experience in sports medicine
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Membership and participation in a sports medicine professional association or society
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Training in advanced cardiac and trauma life support
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Ongoing involvement in education and research in sports medicine
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Understanding the complexities of medicolegal, disability, and compensation issues that can occur in sports medicine is helpful.
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To perform effectively, the team physician must maintain a broad and up-to-date knowledge base that addresses athletics as well as medicine.
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All team physicians should feel comfortable in providing emergency care at sporting events.
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Training in cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use is essential, and additional knowledge of advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) is useful.
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In addition, the team physician should have knowledge in the following areas:
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Medicine: full-spectrum primary care, including musculoskeletal system, growth and development, cardiovascular and pulmonary medicine, infectious disease, gastroenterology, nephrology, neurology, and other medical areas pertaining to exercise and sports
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Psychology and behavior: mental health issues such as depression, anxiety, eating disorders, alcohol and other drug use/abuse, and psychological response to injury
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Pharmacology: therapeutics, supplements, performance enhancers, recreational drugs, interactions among these agents, and effects on performance
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Nutrition and exercise science: nutrition, exercise physiology, biomechanics, sport-specific issues (e.g., altitude and other environmental issues)
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Sport- and population-specific issues: sport- and population-specific issues, including gender, age, disability, or other unique population factors
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Additional Medical Responsibilities
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Coordinating assessment and management of injuries and illness on game day, including making decisions about clearance and same-day return to play
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Understanding the importance of pre-participation physical evaluation (PPE), emergency planning, and issues of sudden death and heat illness as well as recovery and rest
Administrative Responsibilities
The team physician has a range of important administrative responsibilities:
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Establish a chain of command for injury and illness management, including:
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Involvement in planning and implementation of emergency action plans
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Involvement in and awareness of protocols and equipment required for sideline preparedness
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Coordinating assessment and management of game-day injuries and illnesses, including return-to-play decision-making
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Clearance for non-game day participation and return-to-play decision-making
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Understand the importance of injury and illness prevention
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Understand the importance of collaboration with other healthcare providers, including athletic trainers, physical therapists, nutritionists, strength and conditioning specialists, psychologists, and other specialists, in the care of an athlete
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Understand the role of nutrition, supplements, and performance-enhancing agents
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Important decisions regarding PPE and what it may include (e.g., screening for mental health issues, concussion baseline testing, and cardiac screening)
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Such decisions are often complex and may involve several other stakeholders.
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Additional considerations include preventive measures:
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Immunizations
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Educational efforts (e.g., concussion, heat-related illnesses, nutrition, and cardiac illnesses)
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Injury and illness prevention (e.g., anterior cruciate ligament [ACL] injury prevention or prophylaxis for communicable skin diseases)
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An important administrative responsibility of the team physician is to work with the organizing body (e.g., school, university, or club) to develop an agreement that clearly defines the roles and responsibilities of the team physician as well as the reporting structure for other healthcare providers (e.g., the team physician makes clearance decisions and the athletic trainer reports to the team physician and not the coach)
Ethical and Medicolegal Responsibilities
The team physician has a range of responsibilities that reflect the many relationships involved in the care of an athlete:
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Responsibilities toward the athlete, the team, and the institution and its representatives must be considered.
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All physicians have ethical responsibilities, but those of team physicians may be somewhat unique given the complex and often public nature of sports participation.
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As stated in the TPCS, “the overriding principle for all physicians, including team physicians, in managing ethical issues, is to provide care focused on what is best for the patient and only for the patient.” Several examples of ethical challenges are provided below.
Informed Consent
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Information provided by team physicians to an athlete and/or his or her parent/guardian must be complete and inclusive of all options so that the athlete can make an informed decision.
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Information should include a discussion of short- and long-term risks and benefits and balance the athlete’s autonomy, desires, and optimal medical treatment.
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For example, an athlete with a meniscus tear amenable to repair should be provided with all information so that he/she can make an informed decision (e.g., short-term benefits of meniscectomy and return-to-play versus potential long-term benefits of repair).
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Team physicians should provide information with a goal of protecting athletes from injury, re-injury, permanent disability, and themselves.
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Athletes must be counseled and thoroughly informed when there is a valid medical contraindication to participation or resumption of participation.
Confidentiality
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Team physicians must respect the rights of patients and safeguard their confidentiality within the constraints of the law, respecting both the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as the Family Educational Rights and Privacy Act (FERPA).
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Relationship with athletes may have to be clarified in advance. Challenging examples may include:
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Medical conditions that limit or affect participation
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Psychological issues that may limit or affect participation
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Medical issues that may affect other participants
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Drug testing results
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Conflict of Interest
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There are some situations where team physicians may experience a conflict of interest or a perceived conflict of interest.
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These include situations where a team physician is hired by a professional organization to care for team members, wherein there is a financial relationship with particular organizations, which may lead to a conflict with the care provided to the athlete.
Influence of Others
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Influence of others, such as teammates, parents, coaches, and administrators, may conflict with the medical care provided to the athlete.
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Team physicians should remain aware of potential implicit and explicit influences, including those provided by the community and media.
Marketing, Publicity, and Advertising
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A potential ethical issue for team physicians may occur when a company or individual offers compensation for services and medical care provided by them.
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Team physicians may be sponsored by a company or industry with the biased expectation that they will use one product over another.
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Ethical issues can arise when team physicians are expected to endorse or use a new technology (e.g., equipment, treatment modality, or medications) without substantial evidence of efficacy or safety.
Drug Use
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Team physicians may be asked to prescribe or administer pain medications in order to allow an athlete to participate.
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Athletes using illegal, illicit, or performance-enhancing drugs may pressure team physicians to supply, administer, or help cover-up the use of such drugs.
Medicolegal Issues
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Certain medicolegal issues may be unique for team physicians. Specific concerns may include:
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Team physicians should clearly define professional autonomy over medical decisions.
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Issues regarding HIPAA and FERPA compliance
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Guidelines, standards, policies, and regulations set by school and governing bodies
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Rules, regulations, and/or laws of local, state, or federal government
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Issues regarding the management of on-field (e.g., cardiac, concussion, cervical spine, or heat) injuries or illnesses
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Issues regarding clearance to play and/or restriction from play, waivers, and return-to-play decision-making
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Issues regarding medical documentation
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