This article focuses on the primary care physician or the subspecialist in any field who desires to be a team physician. As important as it is for team physicians to practice in a competent and scientific manner, of equal importance is their ability to become a devoted and accepted member of the team. The team consists not only of those players who get to play the most, but also the players with lesser abilities, the coaches, the trainers, and the team physician. The lack of any element in this team can seriously weaken the team and its endeavors to succeed.
WHY BE A TEAM PHYSICIAN?
There are at least three reasons that might encourage a practitioner to become a team physician:
* Prior participation or particular enjoyment in watching the sport is perhaps the most common motive for volunteering.
* Providing a service to the community is a more important motive.
* Building a practice in a new community is helped if the physician is seen as one contributing to the community.
Pediatricians who have been in practice for years frequently regret seeing their adolescent patients stop coming to see them because they are considered "baby doctors." A reputation as the high school team physician helps in projecting an image as a doctor who truly enjoys working with adolescents.
There are at least three groups of team physicians:
* physicians for professional teams,1 most often orthopedic surgeons, and those team physicians working with NCAA Division I college sports,
* physicians who work with college sports as part of their duties as college health physicians, and
* community physicians who volunteer to the local school or community sports team.
It is to the latter two groups that this article is primarily addressed.
Physicians volunteering as a team physician need to discuss that role with the school's top administrator. There needs to be a written understanding that the physician will have the ultimate authority regarding medical indications to include or preclude a student from playing. Often, the physician is placed in difficult situations due to conflicting pressures from the players, the coach, the spectators (many of whom may be friends or neighbors of the physician), the press, and the physician's own feelings.2'6 Physicians have been sued for recommending that a player not participate; other physicians have been sued because they have allowed an athlete to play.7 Volunteering one's time in most states relieves much of the medical liability concerns, as that activity frequently is covered under Good Samaritan Acts. Legal counsel should be sought to recognize the degree of protection these statutes provide.
ATTENDANCE AT GAMES
A team physician should attend as many practices and games as possible. If the team players see that the physician is as interested in the possibility of their being injured during a practice as during a game, they will develop a greater respect for that individual who they perceive as a member of the team.
An extremely important and strong team-building program is the team physician's participation in away games. Again, the enjoyment of the sport is one thing; the tedium of the bus ride, the wasted time in motel rooms, and the sharing of the odor of the locker room are all parts of the assembly that makes the athlete know that the "doc" is their doctor. In other words, putting up with the hardships as well as the glory allows the physician to be respected as a member of the team and not considered just a "visiting fireman."
Another important part of being a team physician is observing the injury. An axiom in medicine is that the history is the most important part of any diagnosis. In sports, the players frequently have difficulty remembering exactly where their feet were planted when the injury occurred. Many physicians become team physicians because of a love for the sport, but they must dedicate themselves to observing the players in action for potential injuries and not just to observing the action to win. For instance, in hockey, a player "breaks away" with the puck, and the entire audience stands on its feet to watch that player streak down the ice - it's one-on-one against the goalie. The team physician, however, should be watching the corners of the rink, observing how the other team's members are acting in chasing the break-away piayer.
Admittedly, this is a negative aspect of being a team physician, because the thrill and the enjoyment of the game is sometimes muted. But it is like the Secret Service agents who guard the president. Bands may be playing, banners flying, and patriotic speeches being given, but the job of those individuals is to watch the crowd for any inappropriate activity. Team physicians must accept responsibility for the team and not just the star. Observing how the injury occurs may be as important as asking the player for the history of the trauma.
A convenient team physician bag is a plastic fisherman's tackle-box that has many small drawers to keep items separate. The team physician's bag can never carry everything that might be needed, but for all contact sports it should include at least the following:
* 2- to 3-oz bulb syringe,
* thyrotomy kit or 14-ga angiocatheter,
* butterfly closures (small and large),
* gauze pads (2x2 and 4X4 inches),
* blood pressure cuff,
* otoscope and ophthalmoscope,
* alcohol swabs,
* small flashlight,
* Phillip's head and slot-head screwdrivers (to remove face guards),
* elastic bandages (2-inch and 4-inch),
* oral airways - two sizes,
* manual ventilating bag and mask,
* antiseptic solution,
* tongue blades,
* sterile saline solution for eye wash,
* bandage scissors,
* pocket change in case a pay telephone is the only available form of communication,
* adhesive tape,
* rubber gloves,
* notebook to record injuries, and
* epinephrine solution 1/1000 with tuberculin syringes and needles
Many recommend an ambulance be present for college and high school varsity football, and college ice hockey games. Ambulances should be manned by certified emergency medical technicians and contain a spine board, safety litter, and pneumatic rull-leg splints in addition to the usual array of emergency equipment. For most high school and college games, however, the physician will be responsible for ensuring appropriate equipment is available to manage acute injuries.
THE SPORTS PHYSICAL
The preparticipation examination is discussed in detail elsewhere in this issue. Ideally, it is the team physician who performs this examination and does it on a one-on-one basis in a medical examining room. It is important to obtain a valid history, and as the athletes are determined to make the team, they may well mini' mize previous medical-surgical conditions in fear their previous trauma might disqualify them. The physician should be particularly vigilant in this regard when examining college students on athletic scholarships.
During the preparticipation examination, it is emphasized to each individual athlete that communication between the athlete and the team physician is totally confidential, with the exceptions of any medical or surgical situation that might affect the team member's health if participation continued. The coach would be informed if a player had an enlarged spleen with infectious mononucleosis that could rupture if contact were allowed. It would be explained that if a player had a minor sprain that could lead to a serious injury precluding future athletic endeavors, the participant would be kept on an "injured rise" until healing occurred and that these decisions would be made with the athlete's best interests in mind. The team physician in this way develops a rapport that cannot be developed in a "stations" or "cafeteria" examination format. The trust that develops with this interview can ensure the team physician becomes a "member of the team."
Emotional aspects of the players' lives should not be ignored by the physician. Grief and its natural depression can have a major impact on athletic performance, even though physical activity is a good release for many emotional symptoms. The following example is from one of the authors' experience. A religious college hockey player, who was the best player on the team and a star in the local newspaper, came in tears to the team physician before an important game. He stated that he was going to quit hockey because he could no longer concentrate. He explained that his girlfriend was pregnant and was determined to have an abortion. He loved her, but could not tolerate an abortion. At that particular time, the woman was not interested in marrying him. Although his teammates and probably the coach knew of his relationship, this issue was too sensitive to discuss with either his peers or usual adult confidantes. He was not concenerating during practices, and his performance had deteriorated during the preceding few games. With counseling between the player and team physician, and with the help of an understanding priest, the issue was resolved, and the athlete went on to play both college and professional hockey. A team physician will never get that kind of rapport by only appearing at games and having performed a brief preparticipation physical examination.
A surgeon commands the operating room, and a team physician is the captain of the medical team. But for those colleges and schools with a certified athletic trainer on their staff, the most important member of the medical entourage is the athletic trainer.
The physician has many responsibilities; the athletic trainer has only one - the team members. The athletic trainer spends hours with injured athletes during preparticipation training and during rehabilitation from injuries. The physician ethically can share medical information with the trainer if it affects the athlete's treatment by the trainer.
Just as a nurse administers an injection based on a doctor's order, the athletic trainer rehabilitates the athlete. The physician does not need to tell the nurse how to draw up a certain amount of an injectable in a syringe, and the physician does not have to tell an athletic trainer the exact function of each muscle. The physician may recommend a pneumatic splint for a sprained ankle, but the trainer will maintain the cardiovascular endurance by encouraging the athlete in stationary bicycle training during the recovery time.
SPORTS MEDICINE TRAINING
One of the biggest concerns for nonorthopedic physicians is how to obtain the training required to manage minor trauma and overuse injuries as most pediatrie and internal medicine residencies include little experience in the management of minor softtissue injuries. Many short continuing medical education courses are given on sports medicine for the primary care practitioner, and the American Academy of Pediatric's twice-yearly national meetings include sessions on sports medicine.
There are several excellent texts for the beginning team physician listed in the bibliography of this article. Heartily recommended for those considering being a team physician is an outstanding article entitled "Perspectives of a Rheumatologist Team Physician."8
For primary care practitioners who want to practice sports medicine on a full'time basis, there are now accredited 1-year fellowships that can be undertaken following completion of a primary care residency and that will lead to certification as a primary care sports medicine specialist. This new medical specialty is a result of a cooperative project with the American Boards of Family Medicine, Internal Medicine, and Pediatrics.
The joy of being a team physician for the primary care physician is not the surgical reconstruction of a joint - it is the one-on-one and team relationships that develop with the athletes. Practitioners know that children and in particular adolescents seldom say "thank you." Team physicians ride the waves of the underwhelming depression and silence of the locker room following a loss, and surf the overwhelming joy of the victory. They may need no other reward.
1. Orchard J, Pricker PA, Bruckner P. Spoils medicine for professional teams. Clin J Sport UaL 1995;5:I-3.
2. MunayTH. Divided loyalties in sports medicine. The Physician and Sports MediCINE;. 1984:12:134-140.
3. Levine BD, Stray-Gundersen J. The medical care of competitive athletes: the role of che physician and individual assumption of risks. MaJ Sa Spore EWTC. 1994:26: 1190-1192.
4. Minen MJ, Marron B]. Legal considerations that affect medkal eligibility foi competiave athletes with cardiovascular abnormalities and acceptance of die Bethesda Conference recommendations. Mai Sci Sporn Exerc. 1994;26:S238-S241.
5. Graham LS. Dodging the malpractice bullet. The Physician and Spore Mediane. 198S;13:168-173.
6. Gallop EM. Sports medicine law, staying inbounds and out of court. The Phyaaan and Sports Mediane. 1991;19:145-48.
7. Hutter AM Ji. Cardiovascular abnormalities in the athlete: the role of the physician. Med Sci Sports Eierc. 1994;26:S227-S229.
8. Brown DG. Perspectives of a rheumatologist team physician. Bullirrei Clin Rheumata. 1994:8:225-230.
Bai-Or O, ed. The child and adolescent athlete. In: Encyclopedia of Sports Medicine of the International Olympic Committee's Medical Commission. Vol 6. Oxford, England: Blackwell Science Ltd; 1996.
Cantu RC. Micheli LJ, eds. ACSMi Guidelines for the Team Physician. Philadelphia, Pa: Lea&Febiger; 1991.
Dyment PG, ed. Sporti Medicine: HeoWi Core for Young AtWffes. 2nd ed. EEk Grove Village, III: American Academy of Pediatrics; 1991.
Stanitski CL, DeLee JC, Drei D. Pediatric and Adolescent Sports Medicine. Philadelphia, Pa: WB SaundersCb;1994.