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First, Ask No Harmful Questions


How many of you, following an injury to a star player, are asked a question like this from a teammate, parent, coach, or administrator: "Will she be able to play in Saturday's game?"

Nothing wrong with the query, right? We get it all the time. The intriguing aspect is that often it's the first question out of that person's mouth. Not "How is she?" or "How will this affect her life down the road?" In fact, the question has little to do with the athlete's health, which should be our foremost concern.

Working at a large institution, I've had scores of opportunities to observe the complex interactions that occur following a significant injury to an athlete. Recently I've received calls and e-mails from colleagues who have lost interest in being team physicians. They don't enjoy being second-guessed or unappreciated—a common feeling with those at the center of the storm (and it often is a storm, with parents, coaches, administrators, and others weighing in on medical management).

I suppose I am a little battle scarred, or at least battle tested, which has caused me to rethink my approach to many of these situations. For those of you who find the scrutiny and second-guessing disconcerting, I advise asking three alternative questions. But first, please realize that treating athletes provides unique opportunities to practice medicine. Along with the spotlight comes the opportunity to sharpen your diagnostic and treatment skills and to learn to communicate clearly. Strong, clear signals from the team physician are essential.

When dealing with an injured athlete, ask the following three questions in this order: (1) "What is the diagnosis?" Without this, there can be no discussion of management, prognosis, or return to play. Next ask, (2) "What is the best thing to do for the short- and long-term health of this athlete?" Proper medical decision making for both the immediate injury and the long-term outcome is what healthcare is all about. Answering this question is a prerequisite for the final one: (3) "When can the athlete return to sport?"

The first two questions are medical; the last one is related to athletics. Too often I find the athletic question asked first, and the physician fails to resequence the questions and tries to answer the third one before answering the other two. This is a deadly sin and one in which the attempt to be helpful often results in unanticipated negative consequences.

Share this sequence of questioning and medical decision making with everyone you interact with—athletic trainers, coaches, colleagues, staff, parents, and, most important, the athlete. Resist the influence of many others in reordering the sequence.

How, then, does one answer the third question? No one, no matter their knowledge or experience, can prognosticate accurately. The approach I use is to give a broad range of recovery times and then be very concrete about the immediate next steps.

For example: "This injury can take from 3 to 8 weeks to heal. In your case, we will do everything possible to get you back as soon as we can, beginning today. Our plans for you for the next week include the following tests, consultations, and rehabilitation . . . . We'll get together again in a week and review your progress and then establish new plans while monitoring your progress daily with the help of an athletic trainer or physical therapist. We won't make any predictions, but we'll do everything necessary to speed the healing process and return you to top form. Each time we meet to review your progress, we'll have a better idea of when you will be able to return."

Any questions?

Gordon O. Matheson, MD, PhD