The Physician and Sportsmedicine
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Why Settle for Baseline Health and Fitness?


Our medical system is principally based on disease. Fair enough. If patients have a problem that decreases function, they see a doctor, a diagnosis follows, and an attempt is made to restore their capacity to normal. When patients see a doctor, the physician's main concern is the presence or absence of disease and whether they can be treated in some fashion.

But there is another side to human function: performance enhancement, in which training load increases total reserve and capacity. We tend to define normal as values at rest in a sedentary person. We have not yet shifted our approach to think of the potential capacity within each patient we see.

Why not try to change this model of healthcare delivery so that the next generation of primary care practitioners incorporates both sides into their daily practice? Right now, I can see my doctor for routine care, and, when I have a condition that he or she doesn't feel comfortable treating, a referral is warranted. But I can't always rely on my primary care physician to diagnose and treat many of my sports- or exercise-related musculoskeletal conditions that don't require surgery (see last month's commentary by Liz Joy, MD, and Sonja Van Hala, MD, MPH, "Musculoskeletal Curricula in Medical Education: Filling In the Missing Pieces," November). Nor can I always rely on my primary care doctor to tell me how to get fit, how to stay fit, or how to train or rehabilitate.

I injured my right knee in February downhill skiing. It took a pretty strong torque from the tip of the ski after getting some pretty good air. It was swollen for a couple of months. I knew I didn't want an MRI, because it would almost certainly show pathology that could be surgically remedied, and I didn't want to have surgery. I knew it wasn't unstable. What I wanted was a doctor who would be interested in me even if I didn't want surgery—to provide a diagnosis, prescribe rehabilitation, and monitor my progress without saying, "You should have surgery," or "Maybe you should change to cross-country skiing."

Our patients are sophisticated. They want their doctors to care about their health and physical capacity and about the activities they pursue that are fulfilling to them—just as much as they care about blood pressure or allergies. One effective approach, modeled in "Pairing Personality With Activity: New Tools for Inspiring Active Lifestyles," matches patients' personalities with activity types to foster exercise.

What about a new generation of primary care physicians who can treat common conditions, provide referral and coordination for other problems such as a thyroid nodule, and possess the knowledge to treat my musculoskeletal condition, test my fitness and function, and recommend activities that increase my performance capacity? I would rather see that type of primary care physician, and that approach would be a fulfilling way to care for patients. Such a practice would have a primary preventive component based on a discrete body of knowledge and skills related to exercise medicine; offer the typical secondary treatment services, including expertise in musculoskeletal medicine; and still maintain a tertiary component of coordinating the care provided by specialists.

Right now we have that type of practice available in small pockets, but not universally. Waiting for integrative, multidisciplinary sports medicine clinics to spring up in the midst of a cost-control HMO culture is a long shot. We need to kick-start things with a concerted effort to teach the principles of exercise medicine to the current generation of primary care trainees.

Gordon O. Matheson, MD, PhD