DUTIES, ROLE, AND RESPONSIBILITIES OF THE TEAM PHYSICIAN

The duties of the team physician to a team may be
outlined in a letter of agreement or contract between
the organization and physician.


The duties to the individual athlete should be considered
as with any other patient–physician relationship.


Balancing this duty to team and athlete must be considered
in every situation.


A consensus statement on the duties of the team
physician has been created by several organizations
and available in its entirety from these groups:
a. American Academy of Family Physicians (AAFP)
b. American Academy of Orthopedic Surgeons
(AAOS)
c. American College of Sports Medicine (ACSM)
d. American Medical Society for Sports Medicine
(AMSSM)
e. American Orthopedic Society for Sports Medicine
(AOSSM)
f. American Osteopathic Academy of Sports
Medicine (AOASM)
• Qualifications from this consensus statement include
the following:
a. Medical or osteopathic degree with unrestricted
license to practice medicine
b. Fundamental knowledge of emergency care
regarding sporting events
c. Trained in CPR
d. Working knowledge of trauma, musculoskeletal
injuries and medical conditions affecting the athlete


Medical duties from this statement stated that the
team physician has ultimate responsibility to include
coordination of the preparticipation screening; management
of on-field injuries; medical management of
injury and illness; coordination of rehabilitation and
return to participation; coordination of medical care,
education, and documentation; and record keeping.


Administrative duties include establishing relationships,
education, development of a chain of command,
plan and train for emergencies, address
equipment and supply issues (as needed to provide
adequate medical coverage), provide for event coverage,
and assess environments concerns and playing
conditions.


Standard definitions of negligence generally apply.
The physician is held to what the reasonable, prudent
man would do. As guidelines become more
established, these may become the basis for duties
and responsibilities of the team physician.

DEFINITIONS of terms in LEGAL ISSUES

Law: A body of rules or standards of action or conduct
ordained or established by some authority. The
law of a state is found in statutory and constitutional
enactments as interpreted by its courts and contemplates
both statutory and case law.


Lawful: Legal, permitted by the law. Not forbidden
by law, not illegal.


Contract: An agreement between two or more parties
which creates legally binding obligations to do or
not to do a particular thing. A valid contract must
involve competent parties, proper subject matter, consideration,
and mutuality of agreement and of obligation.


Expressed: An express contract is openly expressed
in writing or orally stated in distinct and explicit language.


Implied: An implied contract is one inferred by the
conduct of the parties to exist.


Bilateral: A bilateral contract is one involving mutual
promises between parties.


Unilateral: A unilateral contract is a one-sided promise
where one party undertakes an obligation without
receiving in return any express engagement or promise
of performance from the other.


Civil law: Body of law that a nation or state has
established for itself. Law determining private
rights and liabilities as distinguished from criminal
or natural law. Laws concerned with civil or private
rights and remedies as contrasted with criminal
laws.


Criminal law: The branch of law which defines what
public wrongs are considered crimes and assigns punishment
for those wrongs. It declares what conduct is
criminal, and prescribes the punishment to be
imposed for such conduct.


Natural law: The moral or ethical law, formulated in
accordance with reason, natural justice, and the original
state of nature.


Case law: Law based on judicial precedent rather
than legislative enactment. The body of law founded
in adjudicated cases as distinguished from statute,
common law. It includes the aggregate of reported
cases that interpret statutes, regulations, and constitutional
provisions.


Tort: A wrongful injury, a private or civil wrong. A
tort is some action or conduct by someone (defendant)
which causes injury or damage to another (plaintiff).
Torts may be intentional (when the defendant intends
to violate a legal duty) or negligent (when the defendant
fails to exercise the proper degree of care established
by law). A legal wrong committed on the
person or property independent of contract. It may be
either (1) a direct invasion of some legal right of the
individual; (2) the infraction of some public duty by
which special damage accrues to the individual; or (3)
the violation of some private obligation by which like
damage occurs to the individual.


Negligence: The inadvertent or unintentional failure
to exercise that care which a reasonable, prudent, and
careful person would exercise; conduct which violates
certain legal standards of due care. Negligence constitutes
grounds for recovery in a tort action, if it causes
injury to the plaintiff.


Liability: Any type of obligation or debt owed to
another party. An obligation or mandate to do or
refrain from doing something. An obligation one is
bound in law or justice to perform.


Plaintiff: Person who brings a lawsuit; the complainant;
the prosecution in a criminal case. The party
who complains or sues in a civil action and is so
named on the record.


Defendant: The person accused in a criminal case or
sued in a civil action. The person defending or denying
wrongdoing.


Captain of the ship doctrine: This doctrine imposes
liability on the surgeon in charge of an operation for
negligence of his or her assistants when those assistants
are under the surgeon’s control, even though the assistants are also employees of the hospital (Nolan
and Nolan-Haley, 1990).

RELATIONSHIP WITH COLLEAGUES

Among the problems that can arise for a team physician
are those involving other physicians participating
in the care of the athlete–patient. There must be sensitivity
demonstrated to the relationship of all medical
professionals involved.


The sports physician must never criticize the actions
of another physician to the athlete–patient. Private
discussions with the primary care physician regarding
recommended therapy should be undertaken.


The sports physician is in a position to positively
influence his or her colleague’s care of athletes in the
future by such positive input.


If playing restrictions have been imposed on an athlete
by a primary care physician, while not countermanding
them, the sports physician must always insist
on an individual assessment of the athlete’s return to
play status.


Consultation between the sports physician and the
athlete’s primary care physician usually solves the
problem and provides an opportunity for education.


Sports medicine is a team effort involving physicians
and many paramedical disciplines. The sport’s physician
recognizes that these can be helpful while coordinating
the athlete’s care. The sports physician must
insist that such assistants adhere to the same high ethical
standards he or she practices.


The sports medicine physician has an obligation to
expose quackery and unproved practices employed in
the guise of improving performance, thus protecting
athletes and their careers.

DRUG USE

It is common knowledge that there is illicit drug use
by athletes at all levels: recreational drugs, anabolic
steroids, pain controlling agents, ergogenics, and
alcohol.


Therapeutic medications are an integral part of sports
medicine. Used appropriately, they control pain and
inflammation, speed recovery, and hasten return to
function.


It is the obligation of the sports physician to know
each drug thoroughly, especially its potential effect(s)
on the safety or effectiveness of the athlete’s performance.
Appropriately prescribed drugs must not expose
the athlete to potential disqualification, e.g., as in the
prevention of exercise-induced asthma, when an
effective legal medication can be found.


Nowadays, available testing makes it impossible to
catch all participants who use banned substances.
That is rapidly changing.


There are those who would remove all bans on
enhancing agents, hormones for instance, allowing for
a “free-for-all” with unrestricted use.


There are two major arguments against such an attitude:
one should not condone cheating; and the essence
of sport itself.

POTENTIAL FOR DIVIDED LOYALTIES

While rare in high school and uncommon in college
sports, there is major distrust between professional
athletes and team physicians (George, 2002).


Athletes may feel that there are too many instances
when the quality of their treatment is often secondary
to the doctor’s obligation to team owners and coaches.


A salaried position can interfere with the traditional
doctor–patient relationship.


To many the role of the salaried physician leads to a
conflict of interest. Such a conflict exists when the
employed sports physician’s objective professional
duties are compromised by personal interests, e.g., the
financial reward of his or her association with a professional
team as well as the publicity and high visibility
one gets from such a position.


It is an ethical breach for anything but the athlete’s
health interest to be considered, again, recognizing
judgment errors in too conservative or too liberal therapy
can occur.


The ultimate welfare of the athlete may seem in conflict
with the wishes of parents or spouse, coaches or
team management. The fact that an organization or
someone other than the athlete pays the physician is
immaterial. The loyalty of the sports physician is to
the continued healthy physician–patient relationship.


Decisions must be made solely based on sound medical
judgment. A reasonable third party, e.g. a university
or professional team, will understand this. If it
does not, the physician should remove his or her services
from that party.
• Occasionally, wishes of the athlete-patient conflict
with what the physician believes are in the athlete’s
best interest. If after negotiation and additional consultation
the sports physician feels uncomfortable
with another’s recommendation, continued care of
the athlete-patient could be difficult or impossible.
The athlete should be reassigned to another physician.


For the professional athlete, the unfavorable mix of
high salaries and short careers can make for risky
decision making by both the athlete and the physician.
Coaches often encourage physicians to rush players
back on to the field to win games. Players themselves
often desire to rush back too quickly.


Teammates should not be allowed to pressure injured
athletes by suggesting they are malingering while collecting
a substantial income. Under these circumstances
many physicians play by the rules of the
coaching staff.


An untimely death or worsening injury sets the stage
for lack of trust in the team physician.


By actions alone, the team physician demonstrates
that his or her utmost responsibility is to protect the
players. If a player should not be on the playing field,
that players will not be there.

THE SPORTS PHYSICIAN’S RESPONSIBILITIES

An athlete’s autonomy, his or her interests and desires,
and the third principle of medical ethics must always
be taken into consideration in any decision made by a
sports physician. Such decisions should always be
made in the athlete’s best interest.


Whether the decision involves a diagnostic test or the
athlete’s eligibility, its end result is the maintenance of
good health with the least risk to the athlete.


Conflict between physician and athlete should always
be minimal or absent.


While autonomy is respected, most athletes can and
should rely on their sports physician to lead them in
the decision making process.


It is quickly recognized by the sports physician that
one solution rarely fits all with the same problem. The
same set of circumstances can lead to a different suggested
solution by the same sports physician.


Exactness and infallibility, while desirable, are not traits
of even the finest sports physicians (Maron, 1994).


The sports physician’s primary duty is to make the
best effort to maintain or restore health and functional
ability (Howe, 1988).


The athlete’s welfare must guide all efforts.


To be a good sports physician, he or she must have a
genuine appreciation for the importance of athletics in
his or her client’s life. The precepts of Dr. O’Donoghue
for sports physicians are timeless: accept athletics, avoid
expediency, adopt the best methods, act promptly, and
try to achieve perfection (O’ Donoghue, 1984).


The injured athlete must know the diagnosis, understand
its implications, and participate in all therapeutic
decisions.


Despite the athlete’s wishes, the sports physician
cannot do less than seek the best possible outcome.


All sports medicine physicians gain knowledge and
better judgment with experience, soon recognizing
many recommendations or forms of therapy have
risks as well as benefits.


Harm can come to the athlete-patient from unnecessary
or excessive restriction as well as from failure to
restrict activity when appropriate.


The sports physician does not operate in a vacuum. To
make sports oriented medical decisions, one must be
well versed in current recommendations for eligibility
and continued participation and not depend on his or
her own limited personal experience or unscientific
reasoning (Mitten, 1999).


Recognizing the wide range of opinions and individual
fallibility, athlete-patients can assert their right to
another opinion.


Continuing education of the sports physician aids in the
development of a suitable level of skill and knowledge
and their maintenance (26th Bethesda Conference,
1994).


While sports physicians will be able to treat most
referrals, they must be aware of their own level of
competence. They must know when and where to
refer for specialized consultation or therapy. It is
essential to know their colleague’s ability, personality,
and empathy for athletes in order to make competent
referrals (Rizve and Thompson, 2002).


The referred patient should not be abandoned. The
consultant may gain insight from the referring physician.
This affords the athlete continuing support from
his or her primary sports physician.


There is no obligation to accept without question the
recommendations of consultants, especially if incongruent
with the referring physician’s knowledge of the
patient.


All the above lead to trust established between athlete
and physician, allowing for more comfortable resolution
of the decision making process.

OTHER CONSIDERATIONS FOR THE TEAM PHYSICIAN

Sports medicine abounds with opportunities for
research. Simply keeping accurate epidemiologic and
injury data has the potential to impact training regimens,
competition rules, or mandates for protective
equipment (Rice, 2000).


Every would-be team physician must research the
medical liability risk and insurance coverage associated
with the position. A written contract or memorandum
of understanding with the institution or team that
defines responsibilities and level of coverage expected
is essential—even if no compensation is to be
received (Rice, 2002). Good Samaritan laws exist in
many states but the exact law varies widely between
different jurisdictions. Most Good Samaritan laws
apply only if the physician is receiving no compensation
for his or her services. Compensation may be
defined by a specific dollar amount, or as little as
receiving a team shirt to wear at games!


Compensation as a team physician is variable. Almost
all work with teams competing at less than collegiate
level is voluntary. Deferring offers for nominal remuneration
in favor of paying a trainer’s salary can be a
beneficial and time saving option (Rice, 2002). Most
team physicians work with athletic teams solely for
professional and personal satisfaction owing to their
interest in sports and athletes.