COMMUNICATION RESPONSIBILITIES OF THE TEAM PHYSICIAN

For a team to receive optimal medical care, the team
physician and trainer must communicate openly and
clearly. Even before the season, they need to discuss
medical treatment protocols, which preferably are
documented in writing (Rice, 2002). When an injury
occurs there can be no confusion over who will go on
the field for initial evaluation and who will communicate
to the coach the extent of an athlete’s injury and
playing status.


A team physician needs to develop good rapport with
the coach. Offering injury prevention suggestions and
player health education may demonstrate to the coach
a shared desire to assist the team attaining their goals.
Most importantly, a team physician must keep the
coach informed of an injured player’s ability to continue
to compete safely. Without breaching player
confidentially, the team physician should provide the
coach a timeframe for further evaluation or the
player’s return. In general, this should be communicated
in terms of a sport-specific timeline, such as: the
player is out for a play, out for a series, reassessment
will be done at half-time or game’s end, or the player
is likely lost for the remaining part of the season.


A team physician may also be required to discuss a
player’s medical condition with the school officials.
Administrators often need to know specifics regarding
physician recommendations: how long will the player
miss class or be in the hospital. They seldom need to
know medical or personal details of the athlete’s situation.
Remember that the athlete’s confidentiality is
the first concern. Members of the media rarely, if ever,
need information from the team physician.


Well-defined criteria for dealing with the media should
be established. If a team physician is encouraged to
participate in an interview, insist that written questions
be submitted before-hand so that appropriate remarks
can be constructed for the record. These planned
responses can be reviewed with team coaches, trainers,
and administrators to ensure their consistency, accuracy,
and regard for the athlete’s privacy.


A team physician may need to discuss an athlete’s medical
condition with his parents, especially if working
with minors. It may be beneficial to send a letter to
parents prior to the season, describing the role of the team
physician and the continued importance of their personal
primary care physician to the athlete’s overall health.


As mentioned above, the team physician coordinates
specialty care as medically indicated. In doing so, he
or she should provide the pertinent information necessary
to the respective medical consultant’s care and
receive written documentation of recommendations
from medical specialists.

ADMINISTRATIVE RESPONSIBILITIES OF THE TEAM PHYSICIAN

The team physician’s primary concern is the coordination
of medical supervision. This organization
includes: making sure qualified medical personnel are
attending practices and competitions as needed,
designing a plan for sideline evaluation, and having
necessary medical equipment readily available. The
team physician encourages defined roles and responsibilities
for all involved in the medical care of the
team, along with establishing a medical chain of command.
The team physician may not make all the daily
decisions but should have full authority concerning
medical policy-making.


The team physician needs to lead the planning for and
practicing of medical emergencies and urgencies. In
addition to having an emergency treatment and transport
plan, the team physician also must know the medical
capabilities of surrounding hospitals—particularly
around away competitions sites—so that injured athletes
are brought to medical facilities that are best
equipped to handle their specific medical problem
(Herring et al, 2000a).


The team physician should implement protocols that
facilitate timely and quality medical care for situations
when he or she is not immediately available.
Preestablished guidelines for return to play are very
helpful, especially when injuries to impact athletes
result in high pressure for returning to competition
before appropriate healing has occurred (Herring et al,
2000b). The ACSM consensus statement on return-toplay
issues more fully details the responsibilities of
the team physician when returning athletes to competition
(Herring et al, 2002).


The team physician oversees the playing environment.
He or she should evaluate both practice and game
facilities for safety. A safe playing environment also
involves appropriate and properly fitting protective
equipment, available hydration, and an activity level
appropriate for the climate.

MEDICAL RESPONSIBILITIES OF THE TEAM PHYSICIAN

The first responsibility of a team physician is to determining
whether an athlete is fit to participate. This
evaluation most commonly occurs during the preparticipation
physical. This examination may or may not
be preformed by the team physician, but the team
physician should review the documentation of this
examination so that he or she will know of any condition
that may limit competition or predispose the
athlete or other participants to injury. This preparticipation
physical must be done prior to athletic training
or participation—preferably 6–8 weeks beforehand so
that all potentially disqualifying conditions can be
fully evaluated without missing jeopardizing scheduled
participation (Herring et al, 2000a).


Sideline and event coverage is the most obvious responsibility
of the team physician. A physician should cover
all collision and high-risk sports. Other athletic events
can be covered by any allied health professional who is
trained in recognition and initial treatment of athletic
injuries (Herring et al, 2000a). A team physician must
continually remind himself or herself that he or she is
more than a spectator. The physician should be a
“dispassionate observer,” meaning that the emotions of
competition must not affect medical decision making.
Attention should be directed to the safety of the participants,
not the immediate passions of the game.
• The team physician should focus attention on aspects
of play and individuals who are more prone to injury.
In other words, the seasoned team physician will carefully
follow the game, but not always follow the ball.
For instance, in American football relatively little injury
information can be gained by watching the flight of
the ball on punts, kickoffs, and passes. Rather, injuries
occur and attention should be focused on linemen, quarterbacks
after releasing the ball, and wide-receivers after
catching the ball. In every sport, special attention should
be given to situations and players at high risk for injury.


The team physician must be prepared to handle nonparticipant
emergencies for it is not uncommon for the
team physician to be called on to treat an ill-fallen
coach, referee, or spectator.


The team physician insures accurate diagnosis through
use of additional studies and specialty consults, communicates
information clearly and confidentially regarding the player’s condition to those who need to
know, coordinates the rehabilitation process, and
determines when the athlete is able to compete again.
This essential process involves active communication
with athletes, parents, athletic trainers, physical therapists,
coaches, administrators, and other medical specialists
as necessary (Rice, 2002).


Pursuing active follow-up with medical specialists is a
critical duty. Team physicians may refer athletes to
subspecialty providers to assist in treatment or with
clearance for athletic participation; however, information
from these visits does not naturally flow back to
the team physician. Assuming that the specialty
provider will call with any important information, or
that all pertinent information will flow back through
the health care system, will result in confusion for the
team physician and danger for the athletes. Shadow
files, tickler lists, and other reminder systems can help
team doctors actively and personally follow up on
referrals, thus preventing the always embarrassing and
often dangerous situations that result from incomplete
medical communication between subspecialists and
the team physician.


Documentation of medical care is often mistakenly
neglected in the team setting. The team physician
needs to keep formal and confidential medical records
that detail communication with consultants, give
treatment and follow-up instructions, and provide
details for insurance and reimbursement purposes
(Rice, 2002).


The team physician should have final say of when an
athlete is initially cleared to begin competition and
when a previously injured athlete may return to play
(Herring et al, 2000a).

CORE KNOWLEDGE OF THE TEAM PHYSICIAN

To perform his or her duties effectively, a team physician
needs an understanding of the medical conditions
common to the athlete. This knowledge should encompass
many areas of medicine, including but not limited
to—orthopedics, cardiopulmonary medicine, neurology,
dermatology, and sound principles of rehabilitation
(Herring et al, 2000b).


The team physician also needs expertise in pharmacology.
Practical pharmacology for the team physician
includes not only knowing how to treat illnesses, but
also an understanding of performance enhancing drugs
and herbal medicines. Team physicians must be familiar
with the substances that are banned by the governing
athletic association so that an athlete does not inadvertently
lose eligibility to compete (Melion et al, 1997).


A team physician must have a general knowledge of
behavioral medicine and psychology. Mood disturbances
and mental illnesses (like depression) affect
athletes and can be very common in injured athletes.



A team physician’s knowledge of exercise science and
nutrition can help prevent injuries, as well as maximize
an athlete’s performance. Disordered eating and overtraining
can prove devastating if not recognized early
and treated effectively (Herring et al, 2000b).

TIME REQUIREMENTS OF A TEAM PHYSICIAN

A team physician must have an office schedule that
can accommodate athletes with urgent and time sensitive
medical needs.


Most team physicians have designated training room
time each week, at least one to two evenings, where
they can evaluate new and follow-up existing injuries
of team members. This is an especially important setting
in which to communicate with the trainer on the
rehabilitation progress of athletes’ injuries (Herring
et al, 2001). An athlete’s behavior and responses can
vary widely depending on the familiarity of the environment;
hence, training rooms should ideally be
held in the athlete’s “native environment,” at a location
convenient to athletes and close to practice or
training facilities.



Team physicians often neglect team practices. While
it is not necessary that all practices be attended, occasional,
brief appearances during practice will allow
the physician to gain insight into the environment and
conditions in which the athletes train, the team’s training
regimen, and interactions between coaches and
players. A better appreciation of all these factors can
prove invaluable in the physician’s medical decision
making. Additionally, brief appearances at practice
help the physician build collegial relationships with
coaches and players, establishing his or her role as a
part of the team and distinguishing the physician from
other officials, support staff, and media representatives
who only participate in game-day activities.


Amount of time spent at the actual competition
depends on the team physician’s role and availability,
as well as state laws and regulations of the governing
athletic association. Some laws mandate that a physician
be in attendance for every game. Other laws
allow nonphysician medical personnel, such as an athletic
trainer, to cover an event with on-call physician
backup (Herring et al, 2000a).


A doctor who is the team physician for an entire institution
must decide whether to attend all the games for
a few teams, or to attend a few games for every team.
We recommend that team physicians attend at least
part of one practice and at least one game for each
team they supervise. Providing good team medicine is
very difficult without observing the interactions and
conditions of play and practice.

WHAT IS A TEAM PHYSICIAN?

Very little has been published about the duties and responsibilities of a team physician and no formal
studies exist as to the qualifications and skills necessary to be effective in these duties.


The following consensus statement from the
American College of Sports Medicine (ACSM)
defines the unique role of a team physician:
The Team Physician must have unrestricted medical
license and be an MD or DO who is responsible for
treating and coordinating the medical care of the athletic
team members. The principal responsibility of the
team physician is to provide for the well-being of individual
athletes—enabling each to realize his or her full
potential. The team physician should possess special
proficiency in the care of musculoskeletal injuries and
medical conditions encountered in sports. The team
physician also must actively integrate medical expertise
with other healthcare providers, including medical
specialists, athletic trainers, and allied health professionals.
The team physician must ultimately assume
responsibility within the team structure for making
medical decisions that affect the athlete’s safe participation.
(Herring et al, 2000b)


Doctors from many specialties serve in the role of team
physician with primary care physicians comprising the
majority. The most common fields of medicine with the
percentage of the total in parentheses is family practice
(25.5%), orthopedic surgery (16.2%), osteopathic medicine
(10.9%), internal medicine (10.1%), general practice
(6.3%), pediatrics (5.4%), emergency medicine
(4.9%), general urgery (4.5%), obstetrics/gynecology
(2.8%), cardiology (2.0%), and all others (11.5%)
(Melion, Walsh, Shelton, 1997).


The team physician is part of a team of professionals
that cares for the athletes and contributes to their success
by maximizing training and competition preparation.
He or she also assists by accurately diagnosing
ailments and promptly, yet completely, rehabilitating
injuries to get athletes back to competition as quickly
and safely as possible. In addition to expertise in the
common medical conditions encountered in athletes,
other necessary qualities include: flexibility and availability,
good communication skills, a desire to educate,
and an understanding of injury prevention
principles (Herring et al, 2000b).

Artériopatie oblitérante des membres inférieurs

No studies showed reduction in the risk of occurrence of arteritis
lower limbs in physically active individuals (prevention
primary) but many articles have reported a net profit of activity
in the physical treatment of arteritis of the lower limbs.
The Transatlantic Inter-Society Consensus in its consensus conference
on peripheral vascular disease (12) between stresses the importance of other-
of regular physical exercise, if possible as medically supervised
study shows Regensteiner & Co (see Table 4). In this randomized, 10 peripheral arterial disease were subjected to a training program at home
explained by a nurse and maintained by telephone interviews
weekly. The other group was subjected to a training program on
medically supervised treadmill at 3 sessions per week. after three
months a 137% improvement in the walking distance (PM) is found in
supervised the group, without significant improvement in the other group. other
studies show an improvement in the 2 groups but increasingly
important in the supervised group.
Also according to this consensus conference, the comparison of
benefits between physical activity and shows a balloon angioplasty
superiority of angioplasty as six months on the quality of life of the
walking distance. However, there is significant difference after
2 years of follow up, while there are advantages of complications -
during interventional angioplasty.
If we now compare the physical activity cal to surgery by
bypass, we find that the best results are obtained by combining
2 techniques (PM increased by 263% against 173% for surgery alone and
151% for the year only) (Lundgren & Co 1989).

    Table 4: Changes in scope of work groups "physical activity" in relation to groups "cookies".