8 Biggest Challenges Facing Team Physicians for Professional Athletes

Orthopedic Sports Medicine

Becoming a team physician for professional athletics may seem like an outstanding opportunity, but there are many challenges that go along with the responsibility. "The most challenging part of treating professional athletes is that the expectations are so high," says Robert Watkins, Jr., MD, an orthopedic spine surgeon and co-director of Marina Spine Center at Marina Del Rey (Calif.) Hospital, and spinal consultant for the Los Angeles Dodgers and other Los Angeles teams. "Most of the procedures are the same as what we do all day long, but the stakes are higher when our patient is a professional athlete." Here, team physicians who treat professional athletes from around the country discuss how they are meeting and overcoming these challenges.

1. Conflict of interest between teams and players. Team physicians for professional athletes are often caught between players and team owners who think they have the opposite party's best interest in mind. "Per game cost of some professional athletes can range from hundreds of thousands of dollars every game, and from an investment standpoint, you want them playing as much as possible," says Karl Kaluza, DO, a family practice physician with Sports Medicine at Legacy Medical Group in Lake Oswego, Ore., and team physician for the Portland Timbers soccer team. "But the players don't want to sacrifice their health or careers to play a few extra games. The team physicians are in the middle of this because they working for the team while also respecting the individual athlete's wishes. Sometimes, these two are at conflict."

When caught in this position, the most well-respected team physicians keep their focus in mind: treating the patient. "Your job as the physician is to do what ever is best for your patient," says Dr. Watkins. "As long as you take care of your patients and do what is best for them, everything else will take care of itself." A common misconception is that teams pay their physicians when in reality it's more likely that the physician or practice pays the team for the ability treat their players, says Dr. Kaluza.

Teams market their providers and having it known that you treat professional athletes can increase your credibility in the community. The media attention cal also work the other way, if there is a poor outcome. "If a player does badly and everyone knows you are the team physician, there could potentially be a lot of negative publicity," says David Geier, MD, director of MUSC Sports Medicine and team physician for the Charleston Battery professional soccer team. Team owners that initially forego the best medical quality for the highest paying provider often find they've made a mistake. "There have been some lawsuits recently where professional athletes filed suits against their team physicians after bad outcomes," says Arthur Valadie, MD, an orthopedic surgeon with Coastal Orthopedics in Brandenton, Fla., and a consultant to the Pittsburgh Pirates and US Soccer team. If players are routinely complaining, the contract will not be renewed.

2. Communicating with all parties after an injury.
Professional athletes' contracts often state that coaches and team owners will be given information about their condition in the event of an injury. However, it's always helpful to talk with the athlete about their options and make sure a plan is in place before contacting these other parties. "I never tell the coach or owner what I'm going to do before I talk to the athletes," says Robert Dimeff, MD, director of sports medicine at UT Southwester Medical Center in Dallas. "I always tell them who else needs to know and sometimes there are other people they want involved. I never call the player's agent, parents or attorney unless I have permission." Keeping everyone on the same page can be challenging. The physicians must also keep in close contact with the other medical professionals, such as the physical therapist, athletic trainer and strengthening and conditioning coach to gauge the player's rehabilitation and return to play.

This communication can become especially critical when the athlete is injured on the road. "In the National Hockey League, they have a system where you can electronically encrypt into the players' medical records so if he gets injured in another state, you can access the MRI and physicians' notes," says Ralph Gambardella, MD, orthopedic sports medicine surgeon and President at Kerlan-Jobe Orthopaedic Clinic in Los Angeles and orthopedic consultant to the Los Angeles Dodgers.

3. High expectations for treatment outcomes.
Professional athletes have high expectations for good outcomes and returning to play after surgery. "Most of the procedures we do on professional athletes are routine procedures we do all day long, but the stakes are higher," says Dr. Watkins. Not only is the player's livelihood at stake, but team members, coaches, owners and fans are depending on the athlete and medical staff to restore the athlete to return to play, which often depends on the athlete's medical history and individual anatomy as much as it does on the physician's expertise. Injured athletes are likely to compare themselves to other athletes who have had a similar injury and expect a similar recovery, which isn't always the case, says Victor Ibrahim, MD, a staff physician at National Rehabilitation Hospital in Washington, D.C., and physician to several professional and elite athletes.

With such high expectations, it can be challenging for a surgeon to deliver bad, potentially career-ending news to an athlete. However, the surgeon must be upfront with the player and coaches on all occasions. "The worst thing a team physician can do is not be honest with the athletes or coaches," Dr. Ibrahim says. Surgeons should prepare these athletes for various outcomes depending on their previous injury history and the extent of the injury. "Depression and anxiety are always factors in chronic injuries, and surgeons may need to address the psychosocial impact on the player," he says.

4. Deciding the best method of treatment. If possible, athletes need to return to play as quick as possible, which often means avoiding surgery. "We try to keep things as simple as possible, and treat athletes non-operatively, if possible," says Dr. Watkins. Several factors go into deciding the best method of treatment for professional athletes after an injury, including where the team is in the season, where athletes are headed in their career and what their long-term goals are. Depending on whether the injury occurs during the preseason training or a week before the playoffs, team physicians may treat mild injuries differently. "We have to decide whether we want to get the athlete back on the field as soon as possible with pain management methods and put off surgery or perform surgery right away and give the athlete the largest amount of time possible to recover during the season," says Dr. Geier.

Additionally, the player must consider their long-term goals heading into treatment. A rookie might approach handling an injury differently from a seasoned veteran or an athlete on the brink of retirement. The athlete may also have their own ideas about what type of treatment they want to pursue. "If the athlete wants to do something different than my recommendation, we negotiate that," says Dr. Dimeff. Either way, it's also important to look beyond the athletes' professional careers and help them understand the long-term implications of their treatment. Sometimes, foregoing the fastest treatment option for better long-term outcomes can be the best for the athlete.

5. Knowing when to return athletes to play. Orthopedic surgeons working with professional athletes must have a keen sense of when the athlete will be able to return to play after an injury, whether treatment includes surgery, some physical therapy or another pain management technique. "We often have no idea exactly how long it will take, but we need to make an estimate based on our experience," says Dr. Watkins. "For spinal injuries, we base our estimation on the patient's history, but there's no way to tell on an individual disc for an individual person." Coaches want to know the player's play status so they can set their rosters in advance. The general manager and team owners also need to know what to expect from their athletes and what they can tell the press. Fans and fantasy leagues are often anxious to learn when the player will return. All these entities depend on the physician to make an accurate estimate.

As time goes on, the physician must keep key players updated on the athlete's condition, says Dr. Ibrahim. "Often we keep in very close touch, sometimes on a daily basis, to monitor the players' progress and modify expectations," he says. Sometimes, the player is able to return early and other times its best if they are kept out a little longer than expected. Keep in mind that these players aren't only waiting for their injury to heal, but also making sure they can return to a high-level of play, which often means additional rehabilitation to hone their specific skills and extra cardiovascular training.

6. Returning the player safely and quickly. When treating professional athletes, orthopedic and sports medicine physicians must make sure the athlete is healthy enough to return to play, while also understanding they want to get back as soon as possible. "There are often financial and personal incentives to get back as soon as possible," says Dr. Kaluza. Team physicians are often more inclined to order tests for mild injuries, such as ankle sprains, to make sure they don't miss anything. High-level athletes might also be more inclined to undergo different treatment methods to promote faster healing, such as shockwave therapy or platelet-rich plasma injections.

This is especially true for pain management among professional athletes. "Most athletes are so anxious to find a treatment that they are excited about trying something new," says Dr. Ibrahim. "But we always help them understand that it is experimental." The cost of treatment is often a non-issue for professional athletes, which makes them prime candidates to undergo a new treatment or utilize new technology. "We get to push the envelope quite a bit and be aggressive in our treatment," says Jon Divine, MD, an associate professor in the department of orthopedic surgery at the University of Cincinnati  College of Medicine and head team physician for the UC Bearcats. Divine is also an orthopedic sports medicine physician with University Orthopaedics & Sports Medicine  and the team physician for the Cincinnati Commandos, a professional indoor arena football team. "However, we still keep the athlete's best interests in mind. We have to balance when is too soon with when they need to go back." This is especially true when athletes incur injuries such as an ACL tear or a concussion. The athlete might be able to still perform, but their ability is hindered and they are at risk of sustaining more serious and longer-lasting injuries.

7. Answering media inquiry. Professional athletes are constantly in the public eye and when one is injured, everyone wants to know his or her status. However, team physicians are held to the same level of confidentiality when treating professional athletes as with any other patients, which means they can't release personal medical information. "HIPAA protects the confidentiality of all patients, so it actually makes this part of our job pretty easy," says Dr. Watkins. "The key for the physician is not to say anything. It's the player or the team's job to release the information as they see fit." The surgeon is under no obligation to speak with members of the media who try to contact them about a specific player.

However, teams and their physicians should have a process in place to disseminate this information. "The challenge many times is trying to make sure the framework is set for getting the information out correctly so there's not distortion that leads to confusion," says Dr. Gambardella. As the physician, know whether you are giving information to the general manager, public relations team or another source within the organization. "There's been a trend to try to disseminate that information through a third party, usually someone within the team's organization, such as the media manager or the public relations team." These people can relay the information to the media through a single source.

"With high-level athletes in today's world, everybody wants information instantaneously," says Dr. Gambardella. "Trying to get a handle on that and control it so the information that's out there is accurate is often a challenge."

8. Ensuring availability for the team. Being a team physician for professional athletes takes a great deal of time and energy. Team physician responsibilities include preseason and new acquisition evaluations, standing on the sidelines at games and making time in their schedules to see injured athletes right away. "When somebody gets hurt, they can't take a week or two to see you in the office," says Dr. Watkins. "You have to examine them and get the tests done quickly so you can make estimate when they will be able to return to play." The immediacy of the diagnosis and treatment for these athletes can easily cut into your regular practice or personal time. "These athletes compete at a high level and have a high level of commitment to their sport, so they expect you to have the same level of commitment when taking care of them," says Dr. Divine. "We're used to being on call frequently and often."

But this doesn't mean you can forget about your regular clinic. "If you look at the economics of the situation across the board, the number of athletes that get injured and need surgery represent less than five percent of the patient population," says Dr. Gambardella. "It's definitely a balance." Most team physicians also have practice partners who can cover for them when necessary, and be consulted if an injury is out of the head team physician's subspecialty.

Experience makes juggling these two responsibilities easier because you learn when to expect the demands of the team to increase. "You know the team's demands will be higher around the time of the draft and training camp," says Dr. Kaluza. "Then you hit a drier period, and then things tend to become more burdensome around the time of the playoffs. I know on those day's I'll be working through lunch or staying longer as opposed to other times of the year."

Read other coverage on team physicians:

- 79 Orthopedic and Sports Medicine Physicians for Professional Football Teams

- 68 Physicians for MLB Teams

- 58 Orthopedic and Sports Medicine Physicians for Professional Basketball Teams

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