The Why Files The Why Files --

Olympics: Science of the Sporting Life

Sports jocks and sports docs: an interview
illustration of ACL injury Skating champion Michelle Kwan is striving for an Olympics berth despite a groin injury that has kept the nine-time U.S. and five-time world champion out of competition.  In sports medicine, a doctor serves a patient -- and an athlete and a team. It's a complicated relationship where the interests can conflict.On Jan. 21, U.S. skating authorities permitted her to go to Turin, if she can prove by Jan. 27 that she is in shape to compete.

Kwan's situation raises questions about the tryout process -- and about sports medicine. Sports doctors are caught in a no-man's land between medicine and athletic achievement. Athletes want to compete, but most doctors understand their role as serving the best interests of the patient. To get some answers, we corresponded with Lynley Anderson, who is completing a Ph.D. thesis on ethics and sports medicine at University of Otago, New Zealand.

While researching the thesis, she spoke to 16 sports docs who were, she wrote, "working with elite athletes and teams in New Zealand."

We've lightly edited the interview:

The Why Files:
Do sports physicians serve the athlete or the team?

Sports physicians will, at times, find themselves in a bind. This can, at least in part, be due to the tripartite relationship that commonly exists in a team setting:

Between the doctor and the employer. The employment contract will require the doctor to provide medical services for the athletes, and commonly to share the athlete's personal health information with team management or the governing body.

Between the athlete and team management. The athlete might be required to see the doctor appointed by management, and to share health information with others, including team management.

Between the doctor and the athlete-patient. [The traditional relationship; and usually the only one].

To study how weightlifting affects health, a man lifts weights and a woman doctor takes notes. Sports doctors: Who do they serve? Photo: Library of Congress

The Why Files:
What kind of problems can arise?

Athletes may ask that personal health information be withheld from the coach or management. Here the issue of who the doctor serves becomes readily apparent. Should the doctor comply with his contract and abandon what many might understand as the traditional obligation to the patient? Should the doctor uphold traditional obligations and breach the contract? It appears that many (but not all) New Zealand doctors go along with the patient's request and keep information confidential.

The Why Files:
Athletes and coaches often want the athlete to play injured. How does the doctor respond to that situation?

There are times when doctors might experience pressure to return an athlete to the field when the doctor considers them not ready. The doctors I interviewed spent time explaining the pathophysiology of injury and their reasons for recommending that an athlete not play. Sometimes a coach would take that on board, at other times they would not. Occasionally the doctors in this study held some concerns that providing advice that was perceived as unpopular could negatively impact on their reemployment with the team. Coaches also have pressures, for example, their own position is likely to be dependent on the success of the team or athlete.

Bones, tendons and ligaments of the knee are show in close-up detail. Anterior cruciate ligament (ACL) injuries may result from a quick stop combined with a change of direction. ACL injuries cause long-term damage to a career. When is it safe to return to play? Graphic: NIH

The Why Files:
How do (or should) physicians deal with athletes who insist on competing when that will compromise their health?

That is always going to be a tricky issue. The athlete might be under pressure from the coach or team management, or be striving for sponsorship. They are also usually young and may have difficulty seeing the long-term consequences of their decision to play with an injury. It appears from my research that doctors spend a lot of time educating athletes and trying to present the long-term consequences of their decision. Of course people are able to make choices for themselves and I strongly support this. However where such a choice would limit an athlete's future decision-making, such as returning to play too soon following a significant brain injury, then I think sports doctors can and should question such a decision. There are some things doctors can consider: How likely is the risk to the athlete in this situation? How severely would the athlete be harmed? How important is this event to the athlete? Doctors may benefit from clear guidelines on how to respond to severe risk-taking by athletes.

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Megan Anderson, project assistant; Terry Devitt, editor; S.V. Medaris, designer/illustrator; David Tenenbaum, feature writer; Amy Toburen, content development executive

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