Team Physician Consensus Statement: 2013 Update

SPECIAL COMMUNICATIONS Team Physician Consensus Statement Team Physician Consensus Statement: 2013 Update

DEFINITION and experience uniquely qualifies him or her to provide the best medical care for the athlete. Team physicians have the leadership role in the organization, This document is not intended as a standard of care and management, and provision of care of athletes in individual, should not be interpreted as such. It is only a guide and, as such, team, and mass participation sporting events. This document is of a general nature, consistent with the reasonable, objective describes the definition, qualifications, education, duties, and practice of the healthcare profession. Adequate insurance responsibilities of the team physician fulfilling this role. should be in place to help protect the physician, the athlete, and the sponsoring organization. This document was origi- nally developed as the first in the team physician consen- GOAL sus series, representing an ongoing project-based alliance of the major professional associations concerned about clinical Since the publication of this statement in 2000, the roles and sports medicine issues. The organizations are the American responsibilities of the team physician have evolved. The goal Academy of Family Physicians, the American Academy of of this update is to outline the duties of the team physician to Orthopedic Surgeons, the American College of Sports Medi- best serve athletes. To accomplish this goal, the team physi- cine, the American Medical Society for Sports Medicine, the cian should possess, be responsible for, and/or understand American Orthopedic Society for Sports Medicine, and the medical qualifications and education, American Osteopathic Academy of Sports Medicine. medical and administrative duties and responsibilities, ethical issues, and PRIMARY AUTHORS medicolegal issues. Stanley A. Herring, M.D., Chair, Seattle, WA W. Ben Kibler, M.D., Lexington, KY Margot Putukian, M.D., Princeton, NJ SUMMARY The Team Physician Consensus Statement delineates the EXPERT PANEL qualifications, duties, and responsibilities of the team physi- John A. Bergfeld, M.D., Cleveland, OH cian and provides guidelines to individuals and organizations Lori Boyajian-O_Neill, D.O., Kansas City, KS in selecting team physicians. These delineations and guidelines Cindy J. Chang, M.D., Berkeley, CA provide a foundation for best practices in the medical care of R. Robert Franks, D.O., Marlton, NJ _ athletes and teams. The team physician s education, training, Peter Indelicato, M.D., Gainesville, FL Walter Lowe, M.D., Houston, TX 0195-9131/13/4508-1618/0 Yvette Rooks, M.D., Baltimore, MD

MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ Robert Stanton, M.D., Fairfield, MD Copyright 2013 by the American College of Sports Medicine (ACSM), American Academy of Family Physicians (AAFP), American Academy of Orthopaedic Surgeons (AAOS), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine THE TEAM PHYSICIAN DEFINED (AOSSM), and the American Osteopathic Academy of Sports Medicine (AOASM). The team physician must have an unrestricted medical li- DOI: 10.1249/MSS.0b013e31829ba437 cense and be a medical doctor (M.D.) or doctor of osteopathy

1618

Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. (D.O.). He or she has the leadership role in the organization, Media training including communication skills and COMMUNICATIONS SPECIAL management, and provision of medical care for individual, knowledge of social media team, and mass participation sporting events. The most important responsibility of the team physician is the medical care of athletes at all ages and all levels of participation. MEDICAL AND ADMINISTRATIVE DUTIES The team physician should possess special proficiency in AND RESPONSIBILITIES the prevention and care of musculoskeletal injuries and medical conditions encountered in sports. The team physician in- It is important for the team physician to be available and tegrates medical expertise with medical consultants, certified accessible and to maintain sport-specific knowledge and ex- and/or licensed athletic trainers, and other allied health care perience to provide medical care for the athlete. The team professionals (athletic care network). Aided by the athletic physician should also be involved in the medical and admin- care network, the team physician also educates athletes, istrative aspects of team care (4). Certified and/or licensed coaches, parents/guardians, and administrators. The team athletic trainers and other members of the athletic care net- physician is ultimately responsible for the clearance to par- work report to the team physician on medical issues. As in all ticipate and the return-to-play (RTP) decision (5). areas of medicine, there are ethical and medicolegal issues that need to be identified and managed.

Medical Care MEDICAL QUALIFICATIONS AND EDUCATION It is essential that the team physician Since the primary responsibility of the team physician is to provide optimal medical care for athletes, the team physician establishes a chain of command for injury and illness must possess certain qualifications and education. Additional management; qualifications and education may be required for team physi- coordinates the assessment and management of game- cians for some collegiate, national, and professional teams. day injuries and medical problems (4); It is essential that the team physician makes the final decisions on clearance to participate, same-day RTP, and post–game-day RTP; is an M.D. or a D.O. in good standing, with an unrestricted understands the importance of the preparticipation ex- license to practice medicine; amination (PPE); possesses a fundamental knowledge of on-field medical understands medical management and prevention of in- emergency care (e.g., concussion, cardiac emergencies, jury and illness in athletes; spinal injuries, heat-related illnesses); recognizes other issues that affect athletic performance, is trained in basic cardiopulmonary resuscitation and including strength and conditioning, nutrition, ergogenic automated external defibrillator use (4); and aids, substance abuse, and psychological response to in- has a working knowledge of musculoskeletal injuries, jury; medical conditions, and psychological issues affecting recognizes unique issues in females, master athletes, ad- the athlete. olescent athletes, and other defined athletic populations; It is desirable for the team physician to have clinical training/ integrates medical expertise with the athletic care net- experience, including the following: work; and provides for documentation and medical record keeping. Medical specialty board certification Fellowship training in sports medicine It is desirable that the team physician Additional American Council of Graduate Medical Ed- is familiar with the Team Physician Consensus Statement ucation (ACGME)/American Osteopathic Association series (www.acsm.org); (AOA) certification in sports medicine performs the PPE; A significant portion of clinical practice focused on reviews PPE performed by others to address identified sports medicine conditions that may affect athlete health and safety; Continuing medical education in sports medicine provides ongoing medical care beyond game-day/event Membership and participation in a sports medicine pro- coverage; fessional association or society is involved in injury and illness prevention; Involvement in teaching, research, and publications re- addresses other issues that affect athletic performance, lated to sports medicine including strength and conditioning, nutrition, ergogenic Training in advanced cardiac and trauma life support aids, substance abuse, and psychological response to (ACLS/ATLS) injury; Knowledge of medicolegal, disability, and workers_ addresses unique issues in female, master, adolescent compensation issues athletes, and other defined athletic populations;

Consensus Statement Medicine & Science in Sports & Exercised 1619

Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. understands the effect of exercise and sports participation and/or parent/guardian to make an informed decision. on medical conditions as well as the effect of medical Examples include the following: conditions on exercise and sports participation; develops and participate in the selection of the athletic ) Discussion of all reasonable treatment options, in- care network; and cluding short- and long-term risks and benefits educates athletes, parents/guardians, coaches, and admin- ) Athlete autonomy/desires versus optimal medical istrators. treatment ) Occasions and locations for which informed consent must be given in time-sensitive situations (e.g., train- Administrative Duties ing rooms, sideline) It is essential that the team physician Conflict of interest: any factor that may compete or inter- fere with the physician/patient relationship. The disclo- is aware of or involved in the development and rehearsal sure and management of potential conflicts is essential. of an emergency action plan (1,4); Examples include the following: is aware of or involved in other aspects of sideline and event preparedness (e.g., environmental concerns, sup- ) Financial relationships with industry plies, equipment, medication, policies, postseason review ) Financial relationships with a team/organization [1,4]); and ) Personal/professional gain versus welfare of the develops an agreement of medical care and administra- athlete tive responsibilities between the team physician and the organizing body, including a reporting structure from the Influence of third parties: implicit or explicit influence athletic care network (4). on medical decision making. Examples include the following: It is desirable that the team physician oversees the development and implementation of the ) Pressure from teammates, coaches, and administrators emergency action plan as well as other aspects of sideline ) Pressure from parents/guardians, community, media, or event preparedness; and social media obtains a written agreement outlining medical care and Drug use. Examples of ethical challenges include the administrative responsibilities (4); and following: educates athletes, parents/guardians, administrators, coaches, and other interested parties. ) Pressure to supply/administer, hide use of or provide counsel regarding illegal, illicit, or performance- enhancing drugs ETHICAL ISSUES ) The use of local or systemic pain medications to allow Ethical challenges are present for all physicians, including participation team physicians. These challenges may have unique presen- Advertising/marketing/publicity. Examples of ethical tations in sports medicine. Examples of ethical challenges in- challenges include the following: clude the following: ) Confidentiality: respecting the rights of patients and Individual or corporate payment to the team to be a safeguarding confidences within the constraints of the team physician ) law. The confidentiality relationship with athletes may Individual, corporate, or institutional payment to the need to be clarified in advance. Examples include the team for sponsorship or naming rights following: New products and technology. An example of an ethical challenge is as follows: ) Information disclosure compliant with the Health In- surance Portability and Accountability Act (HIPPA) ) Endorsement, utilization, or prescription of treatments, and the Family Educational Rights and Privacy Act medications, devices, and equipment without evidence (FERPA) of efficacy or safety. ) Athlete_s medical and psychological conditions that affect participation and well-being (2) The overriding principle for all physicians, including team ) _ Athlete s medical condition(s) that affects other physicians, in managing ethical issues is to provide care fo- participants cused on what is best for the patient and only for the patient. ) Drug testing results An effective way to address ethical challenges is to obtain Informed consent: the content of information and the the greatest possible clarity regarding the team physician_s process of supplying information in order for the athlete relationship with all interested parties (athlete, parent/guardian,

1620 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. and club/team/organization) when the relationship is estab- Compliance with school and governing body guidelines, COMMUNICATIONS SPECIAL lished. Disclosure and management of potential conflicts is standards, policies, regulations, and rules (3,4) essential. Compliance with local, state, and/or federal rules, regulations, and laws (3,4) Compliance with privacy laws (HIPPA and FERPA) MEDICOLEGAL ISSUES Decisions made as a result of the PPE, clearance to play, Medicolegal issues are present for all physicians, including waivers, and RTP team physicians. Some ethical issues may also be viewed in a Evaluation and management of significant on-field inju- medicolegal context (6). Medicolegal issues may have unique ries and illnesses (e.g., concussion, cervical spine, cardiac, presentation in sports medicine. Some key areas of potential and heat-related illness) medicolegal liability include the following: Medical record documentation

REFERENCES 1. Herring SA, Bergfeld JA, Boyajian-O’Neill LA, et al. Mass partic- 4. Herring SA, Kibler W, Putukian M. Sideline preparedness for the ipation event management for the team physician: a consensus team physician: a consensus statement—2012 update. Med Sci statement. Med Sci Sports Exerc. 2004;36(11):2004–8. Sports Exerc. 2012;44(12):2442–5. 2. Herring SA, Boyajian-O’Neill LA, Coppel DB, et al. Psychological 5. Herring SA, Kibler WB, Putukian M. The team physician and the issues related to injury in athletes and the team physician: a con- return-to-play decision: a consensus statement—2012 update. Med sensus statement. Med Sci Sports Exerc. 2006;38(11):2030–4. Sci Sports Exerc. 2012;44(12):2446–8. 3. Herring SA, Cantu RC, Guskiewicz KM, et al. American College of 6. Kane SM, White RA. Medical malpractice and the sports medicine Sports Medicine. Concussion (mild traumatic brain injury) and the clinician. Clin Orthop Relat Res. 2009;467:412–9. team physician: a consensus statement—2011 update. Med Sci Sports Exerc. 2011;43(12):2412–22.

SUGGESTED READING Black JL, Nader PR, Broyles SL, Nelson JA. A national survey on pediatric training and activities in school health. J Sch Health.1991; Almquist J, Valovich McLeod TC, Cavanna A, et al. Summary 61:245–8. statement: appropriate medical care for the secondary school-aged athlete. Dikic N, McNamee M, Gunter H, Markovic SS, Vajgic B. Sports JAthlTrain. 2008;43:416–27. physicians, ethics and antidoping governance: between assistance and Barrow MW, Clark KA. Heat-related illnesses. Am Fam Physician. negligence. Br J Sports Med. 2013. doi:10.1136/bjsports-2012-091838. 1998;58:749–56, 759. Dunn WR, George MS, Churchill L, Spindler KP. Ethics in sports med- Binkley HM, Beckett J, Casa DJ, Kleiner DM, Plummer PE. National icine. Am J Sports Med. 2007;35:840–44. Athletic Trainers’ Association Position Statement: exertional heat ill- Female athlete issues for the team physician: a consensus statement. nesses. JAthlTrain. 2002;37:329–43. Med Sci Sports Exerc. 2003;35(10):1785–93.

Consensus Statement Medicine & Science in Sports & Exercised 1621

Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Hart KA, Kevorkian G, Rintala DH. Continuing medical education: Olson DE. Team physician challenges in 2013: dealing with media interests of former and current residents of a physical medicine and reha- and travelling across state borders. Br J Sports Med. 2013;47:5–6. bilitation residency program. Am J Phys Med Rehabil. 1999;78:561–70. Provvidenza CF, Johnston KM. Knowledge transfer principles as Holm S, McNamee MJ, Pigozzi F. Ethical practice and sports phy- applied to sport concussion education. Br J Sports Med. 2009;43(Supp sician protection: a proposal. Br J Sports Med. 2011;45:1170–73. 1):i68–75. International Federation of Sports Medicine Web site [Internet]. Ribbans B, Ribbans H, Nightingale C, McNamee M. Sports medi- Code of Ethics [cited 3/29/13]. Available from: http://www.fims.org/ cine, confidentiality and the press. Br J Sports Med. 2013;47:40–3. en/general/code-of-ethics/. Selected issues for the adolescent athlete and the team physician: a Kutcher JS, Eckner JT. At-risk populations in sports-related con- consensus statement. Med Sci Sports Exerc. 2008;40(11):1997–2012. cussion. Curr Sports Med Rep. 2010;9:16–20. Selected issues for the master athlete and the team physician: a Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion knowledge consensus statement. Med Sci Sports Exerc. 2010; 42(4):820–33. base, clinical practises and needs for continuing medical education: a survey Selected issues in injury and illness prevention and the team phy- of family physicians and cross-border comparison. Br J Sports Med. sician: a consensus statement. Med Sci Sports Exerc. 2007;39(11): 2013;47:54–9. 2058–68. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on Stockard AR. Team physician preferences at National Collegiate concussion in sport: the 4th International Conference on Concussion in Athletic Association Division I universities. J Am Osteopath Assoc. Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250–8. 1997;97:89–95. McCrory P. Clinical governance in sports medicine. Br J Sports Stovitz SD, Satin DJ. Professionalism and the ethics of the sideline Med 2003;37:472. physician. Curr Sports Med Rep. 2006; 5:120–4. Mitten MJ. Emerging legal issues in sports medicine: a synthesis, sum- Team Physician Consensus Statement. Med Sci Sports Exerc. mary, and analysis. St Johns Law Review. 2002;76. 2000;32:877. Muhlemann R, Cassidy M, Bodmer HG, Philippe P. Swiss con- The team physician and conditioning of athletes for sports: a continuing education meetings for school physicians. An evaluation of sensus statement. Med Sci Sports Exerc. 2001; 33(10):1789–93. preferences for selected subjects. Soz Praventivmed. 1984;29:227–8. Viola T, Carlson C, Trojian TH, Anderson J. A survey of state Murthy AM, Dwyer J, Bosco JA. Ethics in sports medicine. Bull medical licensing boards: can the travelling team physician practice in NYU Hosp Jt Dis. 2012;70:56–9. your state? Br J Sports Med. 2013; 47:60–2.

1622 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org