Treating Athletes: Medicine Under Pressure
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 12 - DECEMBER 98
Last year I told an athlete he might have a stress fracture of the tarsal navicular, but that we'd have to do a CT scan to be sure. Fifteen minutes later, his anxious coach phoned the athletic trainer for clarification because the athlete had told him, "The doctor doesn't know exactly what's wrong with me and doesn't know how long I'll be out."
What, in the athletic world, raises the expectation that medical answers will be both immediate and definite? Among athletes, the core values—winning and personal achievement—are supported by key "virtues": Certainty, speed, and commitment are among them. Delays and uncertainty are antithetical. For an athlete, injury-induced delay may mean losing a starting spot or risking a "malingerer" label. Further ratcheting up the sense of urgency is the number of people who have a vested interest in the athlete's performance, including coaches, athletic trainers, parents, and school administrators.
Not surprisingly, athletes tend to project their value system on others, including the physicians who care for them. To treat these patients, physicians must understand the athletic culture and work within it. But we can't forfeit the principles of good medicine: Our art requires patience and care. What we need is the knack of convincing our active patients that unraveling a differential diagnosis doesn't amount to dawdling, hedging, or confusion.
Our pace, of course, needs to be adjusted to the circumstances. When genuine urgency arises, we must use emergency systems to ensure a good outcome. Seldom, though, is there a need to suggest a diagnosis prematurely or make promises about when a sidelined athlete will be back in action. An approach I've found useful is to say something like, "There are two possible scenarios here. We're going to obtain tests to determine the extent of the problem and our treatment. Meanwhile, you'll be busy with rehabilitation and treatment." Prognostic information is delivered with the utmost care, plenty of cautions, and a wide range around the mean.
Stated with confidence, this approach lets the athlete know that a differential diagnosis means "we are hot on the trail." It satisfies the athlete's need to act now. And, because it is honest and straightforward, it gains the athlete's trust and maintains the essential avenues of communication that let us practice our art at its best.
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