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Team Physician or Athlete's Doctor?

Aaron Rubin, MD


My high school lost its final scheduled game of the season. When I say "my" high school, I mean the local high school where I've spent the past eight seasons on the sidelines and in the training room as the volunteer team physician.

It was our last scheduled game because a win was needed to make the playoffs. And we lost.

We lost, in part, because our leading defensive back and kick returner was sent to the hospital early in the first quarter with what turned out to be a neck spasm.

And I sent him there, soon after he was involved in a tackle and didn't get up. He said his neck hurt, and I stopped the game long enough to get him trundled off to the local hospital in our standby ambulance. At halftime, I called the hospital and found that he was pain free with no neurologic problems and awaiting x-ray results.

Also at halftime, I was called to check a running back from our opponents' team. He had apparently recovered fully from a mild concussion he had suffered early in the first quarter. I allowed his return to play. He scored the go-ahead touchdown past our backup defensive back.

Our injured defensive back returned in time to see the last seconds ticking off the clock of our last game.

Defending the Call

I wondered if the outcome could have been different if I had not been so "conservative" on our sideline and "liberal" on theirs. But I also wonder if, 2 years ago in the finals, we should have gone for the touchdown and the win from the 3-yard line. It was fourth and goal and the coach elected to go for a field goal to tie the game, hoping for a win in overtime. Of course, if he had known the field goal would be missed, he would have come up with another plan.

Looking back, I know I made the right decision, just as that coach had—but that doesn't stop me from second-guessing. One reason for this seemingly futile mental exercise is the hope of making the right choices in future medical care. Also, I feel I influenced the outcome of the game and want to be sure I didn't do so capriciously. Lastly, I feel as if I let my team down.

So whom did I serve? Whom should I serve? As the athlete's doctor, I made the right choice in his care. I was the team's physician as well, doing my part along with the coaches and school personnel to keep the game as safe as possible. So, am I a part of the team?

Defining the Goal

If a team is defined as any group organized to work together, then there's no doubt the team physician is on the team. We're part of the group, working toward a mutual goal. But what is that goal? Most of the time, it seems the uppermost thing in the minds of players and coaches is winning, and that's understandable. But team physicians can't afford to buy the idea that winning is "the only thing." If we do, we are putting winning ahead of the athletes' health. We need to remember that team sports are also about having fun, learning teamwork, and building fitness.

But having our priorities straight doesn't automatically protect us from a tangle of conflicting feelings and pressures. We often want to be bored as hell on the sidelines. We want to be noncontributory to the outcome of the game. In that sense, we are not an active team member. We are like the scrub third-string kicker who doesn't want to be put in at a critical juncture of the game and given the chance to mess up the outcome.

But we do want to be on the sidelines "in uniform." Whether that be the team jacket and shirt (I've got closets full), the NFL look (navy blue sport coat, white shirt, khaki slacks, athletic shoes), or the "cool" look (leather jacket, jeans, T-shirt, cowboy boots), we need to be prepared to get involved. And when we do, we sometimes can't avoid affecting the outcome of the game.

We are not, however, at every practice, lifting session, run, meeting, and team meal. To a certain extent, we're outsiders who need to maintain some distance. To be effective in helping the athletes, we need to stay focused on their health and safety rather than on the outcome of the game.

Team Relationships

As team members, physicians have special relationships with other members of the team. Our closest teammate, by far, is the athletic trainer. The trainer is our eyes, ears, and voice to the team. Together, the team physician and trainer are the health-protection and injury-prevention-and-treatment coaches.

We also work closely with the (athletic) coaches. I've rarely had a problem with a head coach, but I have had the occasional run-in with a position coach desperate to get an injured athlete back in the game. I've also seen those assistant coaches arguing vehemently with their head coach about the next play. Such disagreements are to be expected, and they don't diminish the teamwork as long as the assistant coaches return to their responsibilities afterward.

Most important are the athletes. They are our ultimate responsibility, whether they like it or not. Of course, the athletes are indestructible and impervious to all injuries and problems—just ask them. That is, until they are injured. Then they feel they're letting down their team if they can't play. We must often be their surrogate parents, confidants, cheerleaders, social workers, psychologists, and, most important, their doctors.

Sports can be dangerous and put athletes at risk, but I support them in their determination to be in the game, because not playing is far more detrimental. Our job is to keep the risks, real and perceived, to a minimum. On a practical level, we pick up the pieces after an injury and get players back into action. We need to have the athletes see us as trying to keep them playing and not as the barrier to playing.

Put the Athletes First

Sometimes we need to take the heat off the athletes. Anyone who has been a team doctor for any length of time has seen the athlete with a minor injury who just doesn't want to play. The reasons are many, and I feel responsible to protect such a player from the coaches', other players', and parents' pressure to return. That's the responsibility to the player. The responsibility to the team is to delve into the motives delaying the player's return and make recommendations.

Also, in our approach to treating young athletes, we must take their endeavors and aspirations seriously. I have watched numerous high-school athletes win scholarships or go to college so they could continue to participate in sports and further their education. Presumably, these opportunities have made a positive difference in their lives. To get these chances, many, if not most, of them had to perform well in a single game with a scout in the stands. For this reason, among others, I don't believe we should accept the belittling attitude that "it's only a high school game."

Given the nature of a team physician's responsibilities, it concerns me that some physicians now are willing to "buy" positions with professional teams in order to boost their own reputation. I foresee a day when similar activity could take place with college teams and at other levels.

Those few I know who are involved in this are excellent physicians and, as far as I know, give very good care, but it concerns me that the blurry line between team physician and athlete's protector becomes even more indistinct as the business of sports medicine becomes the driving force. Will physicians motivated by increased visibility really put the athletes' best interests first? We in sports medicine must determine ethical standards for this and other situations before others legislate the standards.

Cynicism about the motives of pro-sports team physicians is already evident in some quarters. I once heard a player's agent state in an interview, "The player should just as soon let the team physician care for them as they would allow the team attorney to negotiate their contract." Perhaps in the not-too-distant future we will have "game doctors" providing first aid, and injured athletes going to other physicians for their care outside the game. I would not favor this approach, especially for athletes at the high school and college level. It could invite "doctor shopping" for a more liberal or conservative approach for a given problem and deprive the athletes of the consistency and continuity of care that the team physician can provide.

Having It All

Sports medicine is practiced by many practitioners on many levels. I, for one, will be out on the sidelines at my high school next season. I will continue to try to "do the right thing," making sports as safe as possible for the athletes, cheering, hoping for a winning season—and hoping for no tough decisions that make my life miserable. I want to take care of athletes, and be part of a team that helps them to develop skills beyond sports. I want to have it all. Despite the dilemmas the job presents, I want to continue to practice as the athlete's doctor—and be on the team as its physician—for the simple enjoyment it brings me.

Dr Rubin is director of the Kaiser Permanente Sports Medicine Fellowship in Fontana, California, and a member of the editorial board of The Physician and Sportsmedicine. He is a fellow of the American Academy of Family Physicians and the American College of Sports Medicine. Address correspondence to Aaron Rubin, MD, Kaiser Fontana Family Medicine Residency, 9961 Sierra Ave, Fontana, CA 92335; e-mail to [email protected].




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