A Second Opinion

Athletic Management, 16.2, February/March 2004, http://www.momentummedia.com/articles/am/am1602/teamdocs.htm

Selecting and supervising team physicians is not as straightforward as it once was. Opinions vary on everything from what the doctor's background should be to who should oversee the MD.

By David Hill
David Hill is an Assistant Editor at Athletic Management.

If there were a Norman Rockwell image of the team physician, he would be a gray-at-the-temples, kind-but-respected veteran practitioner, dressed in school colors, a well-worn stethoscope around his neck. He--and it would definitely be a he--would be at all the games, home and away, check on rehabs at the crack of dawn, know each athlete by first-name (and their parents, too) and happily make residence-hall calls, black bag in hand. He'd do it all just for the love of his alma mater, and expect no more in return than a seat at the end-of-the-year banquet.

Ah, simpler times. Both medicine and college athletics are more complex today, and so is the role of the team physician. Hiring, working out financial arrangements with, and managing a team physician are complex and demanding tasks, requiring an understanding of liability, insurance rules, and medical specialties. The options for structuring the relationship between an athletics department and its team physicians seem to multiply every year, and what may have worked for decades may no longer be in anyone's best interests.

The questions athletic administrators have been struggling with include the following:

o Should the physician be a member of the athletics staff, of the institution, or of the campus health center?

o Should you publicly designate an "official provider of health care," or maintain a less-formal arrangement?

o Do you want one head team physician, or a team physician for each sport?

o Should you seek a general practitioner or an orthopedist?

o Is extensive sports-medicine training and experience crucial?

To help answer these questions, we'll examine how several athletic departments have navigated this complex relationship and how they structured arrangements with their team physicians. We'll look at the advantages and disadvantages of each set-up, and discuss how to assess whether a particular physician will keep your team in the game--black bag and stethoscope optional.

DOC ON THE TEAM

When a Clemson University student-athlete needs to see the doctor, Danny Poole, Director of Sports Medicine/Head Athletic Trainer, doesn't have to spend much time thinking about who that athlete will see. In fact, Dr. Byron Harder may already be seeing the patient. Harder, a general practitioner, is the full-time team physician for Clemson athletics, and a staff member of the athletics department.

"He's here at 7:15 in the morning and leaves whenever we're through at night," says Poole. "And he covers basically every sport. If there's a soccer game at night, he'll work all day and then cover the soccer game at night."

The previous head team physician was officially an employee of the campus health center, but when he retired, Clemson hired Harder and his salary became the full responsibility of the athletic department. The main advantage is that Harder can devote all of his time to sports medicine, Poole says. "Even though employed by the athletic department, Harder has made it clear to coaches, administrators, and players that the student-athletes' welfare comes first. It has to be that way to work."

Harder works with Dr. Larry Bowman, an orthopedic surgeon whose office is about 15 minutes away and who conducts a clinic at the athletic complex each Tuesday. Bowman is not on retainer, but is paid by billing for each case. Poole maintains a list of other specialists who are prepared to see Clemson athletes as needed, such as neurologists, cardiovascular specialists, and general surgeons.

There's also a part-time assistant team physician, Dr. Len Reeves, who was an athletic training student of Poole's before earning an MD and completing a sports-medicine rotation. Reeves, who also has a private practice, works closely with the basketball teams and is the on-duty physician when Harder travels to away games.

Having a full-time physician on staff offers many advantages. "He sees kids on a day-to-day basis, as he or any athletic trainer deems necessary," Poole says. "In other words he may see an athlete who is sick in the morning, put him or her on some medication, and then come back that afternoon and see the athlete again. Having him in-house means you've got a go-to person right there with any type of medical problem, whether it's injury or illness. And it takes some of the burden off the athletic trainer for having to try to decide if a kid needs to go to the doctor or not. A physician is really the only one who can diagnose anything."

HEALTH CENTER HELP

At the College of William and Mary, administrators took a path different from Clemson's the last time a head team physician was hired, says Steven Cole, Director of Sports Medicine. To start, the student health center was responsible for hiring the team doctor and pays the doctor's salary.

"The athletic department does not pay any physician a stipend," says Cole. "This is what they're running into in pro athletics: If the student-athlete says, 'You're the physician who's going to make the decision if I should play or not, and you're employed by the people who sponsor the event, where is your allegiance? Am I really sure that you're concerned about my health, or are you concerned about whether I play Saturday because we're going to have 90,000 people in the stands?'

"So we in the athletic department don't pay anybody," Cole continues. "The institution, working through the health center, says to the physician, 'We're going to employ you to look after these students. You make decisions that are best for the student, and you protect the institution from liability risk. You don't make a decision thinking it's a big game and they've got to play.'"

With the model William and Mary maintains the school also asks the team physician to protect students from themselves, says Cole. "There was a pro basketball player who dropped dead after he'd had five different physicians tell him he had a cardiac problem that made him susceptible to sudden death," he says. "So he found somebody who said, 'Oh, I think you'll be okay, I'll go ahead and clear you.' Our theory here is that it is the team physician's job to resist that. Kids will go and see somebody else who says it's okay. It's the team physician's job to say, 'We're still not going to clear you.'"

William and Mary also felt they didn't need a team physician on-site full-time. "If you have athletic trainers there and you have planned access to a physician, I'm not sure you need a physician at all times at all events," says Cole.

The next step for William and Mary officials was to brainstorm what they would need from a team doctor. "We were looking at students who are athletes who are going to have health care needs," Cole says. "That kind of defined the expertise we were looking for. For instance, you have students who have asthma, but [when] you have student-athletes with asthma it becomes another issue. How is that asthma going to affect their athletic participation? So you want a person who has the expertise not so much just in understanding various medical conditions, but understands how that medical condition is going to affect a person in intense physical activity."

All these needs together made the college seek a primary-care fellowship-trained physician who was board-certified with a sports-medicine emphasis. (Sports medicine is not an official specialty, but rather doctors may perform a sports medicine fellowship or residency.) The idea was that there are orthopedic surgeons readily available, and that a general-medicine doctor can manage most of the non-surgical orthopedic conditions and other medical needs.

"Need to put the athlete in a cast? They can do that. Need an MRI? They can do that. The orthopedist now doesn't have to spend as much time in the office because they've got a competent and skilled physician who can kind of triage them," Cole says.

William and Mary approached the members of a large medical practice seeking to grow and suggested hiring a sports-medicine doctor to share with the college. "Now , the physicians in that practice will refer the non-surgical orthopedic care--the tennis elbow, for instance--to this physician, so they keep it within their practice," Cole says. "Not only was it good for us, but it could be good for their organization." Another advantage, Cole adds, is that as a member of the practice, the new team physician is able to expedite referrals to specialists within their partnership.

ATC OVERSIGHT

At James Madison University, the athletic department also wanted to hire one part-time head team physician. But, in its case, there were no sports medicine fellowship-trained general practitioners in the community. That made them think harder about what type of doctor to seek.

"We asked ourselves, what is it that we want our team physician to oversee primarily?" says Jeff Konin, Director of Sports Medicine. "We have very qualified and competent orthopedic physicians who are readily available to us, so we decided to go with a general practitioner who understands more general-medicine conditions, which in our environment works out well."

However, Konin says they did want a doctor with an understanding of sports medicine. "If somebody walks in here with a cold, is it a sports cold just because they're an athlete, or is a cold a cold?" Konin says. "In our opinion a cold's a cold, and our general practitioner is very qualified to treat that cold. What our general practitioner needs to understand as a sports team physician, however, is that this cold will affect this person's ability to perform or participate today or tomorrow or the next day. It's not the clinical skills, but the additional nuances that go along with the environment of sports that our team physician needs to understand."

JMU found a perfect solution to its needs in Dr. David Knitter, the medical director for the school's athletic training curriculum program, where he also teaches pharmacology and general medicine. Knitter's education includes a residency in internal medicine and a fellowship in pulmonary diseases. "He has an office in our sports-medicine department, and for a couple hours each day, on a walk-in or a scheduled appointment basis, he will see our student-athletes. And of course he's responsible for some event coverage as well," says Konin.

The other issue JMU considered was who should oversee the team physician. Or should the team doctor oversee others? The school ultimately decided that as sports-medicine director, Konin should be responsible for supervising the team physician, even though by professional standing, Knitter supervises Konin and his athletic training staff in medical matters.

Konin says it's a matter of administrative duties. "It's a nonissue what that individual's credentials are," Konin says. "My role is to direct a department, which involves a number of individuals with different skill sets, and to make the department work effectively. It just so happens that one of the individuals is a medical doctor. I don't see that as being different than directing any other department."

JMU did consider hiring team physicians for each sport, but preferred the one-doctor model. "Hiring several team physicians has its advantages," Konin acknowledges. "You reduce the workload of the team physicians, which is critical because they're spending a lot of time helping. But you change the continuity and consistency of care. What about when an athlete comes in and their team physician isn't available? They see who is available. But now they're seeing a person who's foreign to them and not familiar with their medical history."

A staff doctor also promotes communication, Konin adds. "You might disagree at times for the sake of making sure you're making the most accurate and appropriate decisions, but ultimately in the long run the decisions are always made jointly," he says. "And you certainly can't have the same communication level when your physician is not with you on a daily basis. Most legal issues come about not only due to negligence, but due to a lack of communication. Having one physician certainly enhances communication, thus decreasing our risk of potential liability."

A FULL TEAM

Other athletics programs, however, prefer to have an array of team physicians, typically one for each sport. Among them is the University of Denver. There's some overlap--for instance, the doctor for volleyball also covers men's lacrosse and works at the university health center. But more importantly, the MDs have various specialties among them, and doctors will often see student-athletes who are not on their assigned teams.

The situation allows sports-medicine staff members to direct each case to the physician who seems best-suited for the injury or condition they assess. "We have a head surgical team physician, a head orthopedic team physician, and a head non-surgical team physician," says Erik Rasmussen, Head Athletic Trainer at Denver. "So, obviously if we've got injuries affecting knees, shoulders, hips, or ankles, athletes are going to be steered toward the orthopedist--not that our non-surgicals couldn't assess or evaluate them, because most certainly they do. On the flip side, if we've got an illness or we're dealing with something like asthma or a concussion, then we steer our kids toward our non-surgical, primary-care physicians."

The approach also avoids overloading any one person. "The key is to find a balance for your team physicians," Rasmussen says. "If you're making them cover everything, there's not a doctor who's going to want to be your team physician. If they're here all the time, it's going to affect their outside life and they're not going to be around for long."

The physicians at Denver are compensated through case-by-case billing--as well as for administering physicals, flu shots, and the like, Rasmussen says. They also get perks like complimentary tickets and Denver-athletics merchandise. And the doctors benefit from the public association with a Division I program.

"Our head orthopedist's group also covers the University of Colorado Buffaloes," Rasmussen says. "Here or up in Boulder, it's the same thing: You walk in their office and they've got a University of Denver hockey jersey and a University of Colorado football jersey up on the wall. This is a very health-conscious community, with people who look at themselves as athletes--they want to go to a doctor who known athletes go to."

FORMING A PARTNERSHIP

Western Carolina University has also chosen to use a team of team physicians for its sports medicine coverage. However, their team is from a single business entity, and the relationship with the university is more proscribed than at Denver.

The idea began when Jeff Compher became Athletic Director and noticed that there was no firm arrangement for quickly obtaining the X-rays that are often essential for assessing athletes' injuries. So he arranged a meeting with Sylva Orthopedics, the practice named for the nearby town. Sylva and Compher began to discuss several ideas, and much more came of it than expedited radiology.

Today, more than three years later, Sylva Orthopedics, doing business as Carolina West Sports Medicine, provides a team of team physicians who are readily available, hold regular office and clinic hours, and cover contests. They also rent space in the WCU athletic training room, in which they hold a twice-weekly public sports medicine clinic at hours student-athletes are unlikely to be in, such as weekdays between 10 and 2, and Saturday mornings. It helps the practice carry out its marketing promise of being able to see sports-related injuries quickly and provides an extra facility, one that may be better equipped than its own clinic.

"We have a signed agreement by the university, the orthopedic practice, and the hospital," Compher says. The practice covers athletic events and bills WCU's student-athletes' and the university's secondary insurance coverage for examining and treating athletes. "It definitely makes the roles much more clear. We now know that there will be a physician at football games and at men's and women's basketball games, there'll be office hours, and there'll be a physician for athletes to easily see. Before, the doctor would come and see athletes, but what if the doctor couldn't come some time? Now, it's formally provided for. We have five doctors compared to one before."

Thomas Mallette, Head Athletic Trainer, says the set-up helped attract him to WCU because it guarantees a level of care not found at all small colleges and universities. "In coming to a small community such as this," Mallette says, "you want to be confident that you can get follow-up care for your athletes--that the physicians are going to be able to follow through on their end of the bargain. With this arrangement, they do. They're very willing to help out, they're there when we need them."

Unlike at JMU and William and Mary, the Western Carolina doctors specialize in orthopedics, which Mallette favors--though general-practice physicians at the campus health center and in the Cullowhee area are referred to for many non-orthopedic conditions and injuries. "Our daily duties are a lot more orthopedic-based than general practice," Mallette says.

In addition, the rent has helped improve WCU's athletic-training facilities. "We've got a flouroscan in the physician's office so we can do X-rays," Mallette says. "Everything's business these days, and I think administrators have to treat it that way, and find a group that really wants to be there, not just to make money, but to give the best quality of care and give something back monetarily. That's going to add to your athletic training program, so that you have the best equipment for your athletes and you're not scrounging to buy tape at the end of the year."

Mallette says the set-up does have some limitations that the school is working through. For instance, a doctor who treated National Football League and Major League Baseball athletes during a Cleveland Clinic residency recently moved to the region, and student-athletes respond well to him. He's in the Carolina West system but not a full-fledged member, and referrals can be delicate.

"The administration's been very supportive of doing what's best for the athlete," Mallette says. "If we can't send somebody to Carolina West and get the best care, then we're free to send them to someone else. We know we may jeopardize that relationship with our primary orthopedic group, but the administration has said we can bend the rules a little bit to get the best care for our athletes."

Compher says the flexibility was part of the original agreement, and he advises anyone entering such an arrangement to be honest about it. "I give credit to the doctors," he says. "They'll refer a patient to someone else if it's beyond their expertise. They understand that the bottom line is getting our student-athletes well. Our first line should be our physicians who serve us. But if things aren't progressing satisfactorily, we have an obligation to get the athlete the best care we reasonably can. Our aim is to get the athletes healthy. Our doctors don't have a lot of ego where that's concerned."



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Outside The Bases

In structuring the role of the team physician, there is one model not to use: allowing coaches to choose and oversee their own team doctors. The University of Washington found this out the hard way last fall when state health officials suspended the medical license of Huskies softball team physician Dr. William Scheyer after investigators determined he had improperly prescribed and dispensed large quantities of narcotics, tranquilizers, and other prescription drugs to UW softball players.

According to numerous news reports, most Washington student-athletes are treated by doctors from the University of Washington Medical Center. But Head Softball Coach Teresa Wilson requested Scheyer be kept as an outside team physician for softball, and administrators allowed it. Wilson told administrators that team doctors based at the UW Medical Center weren't always as reachable and didn't act as promptly or seem as concerned about student-athletes' welfare as Scheyer was.

In December, after further investigation into the scandal, Wilson was let go as Head Coach of the softball program, which she had built into a national power. Scheyer later denied he acted improperly and sought to have his license reinstated.

What can other athletic departments learn from UW's crisis?

Administrators and athletic trainers at other schools are reluctant to discuss Washington's situation. But Marcia Saneholtz, Senior Associate Athletic Director at Washington State University, says her school made some key changes in how it administers sports medicine after a problem arose in the late 1990s over a staff athletic trainer's handling of medications. One of those changes entailed switching from using private physicians in the Pullman area to those at the campus health center--though a private orthopedist is also regularly consulted, under the direction of the head team physician.

"A priority here for many years has been to integrate the athletic department into the university as much as possible, so this made sense," Saneholtz says. "It also takes hiring the physicians out of the direct hands of the athletic department, and I think it takes away most of the potential for conflict of interest and allows greater protection for student-athletes."

Coaches are not allowed to refer student-athletes to other physicians. "If a coach has an idea about something," Saneholtz says, "he or she can sit down and talk to the team doctors about it, and sometimes the team doctors will investigate and agree to consult a specialist in a certain field. But frankly, a lot of times those kinds of inquiries are turned down."

A major component of keeping tabs on physicians--and all aspects of the sports medicine department--is good communication, says Saneholtz, and that's facilitated at WSU through weekly staff meetings. "Our athletic training staff and our docs meet every Monday morning and talk about each student athlete on the injury list," she says. "They talk about the treatment protocols and options and get everybody on the same page. When you have that kind of communication, you're much more protected.

"When you have anybody working in isolation, that would be a red flag," she continues, "and you would hope to have a system that would prevent that from happening."

Another important consideration is attitude, Saneholtz says. "In the heat of battle, it's easy for a coach to feel a lot of pressure and maybe try to wield some influence and put pressures on doctors and the athletic training staff," she explains. "So those sports medicine folks have to be levelheaded, not get overly emotional, and not get overly enthralled with intercollegiate athletics. We're a very addicting and alluring enterprise. And some people get stars in their eyes and get enthralled with the whole thing, and sometimes that leads to bad decisions."



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Liability Talk

With malpractice suits occurring more frequently, what type of liability does a university face if its team physician is sued by a student-athlete?

If the team physician is made part of the staff, an athletic department may have some liability under the general rule that employers can be liable for employee negligence. But using an outside physician to treat the university's athletes would likely be characterized as an independent-contractor relationship, says Matt Mitten, a Marquette University law professor and expert on sports medicine legal issues.

"If the local university contracts with an area orthopedic surgeon who's got his or her independent sports medicine practice to provide treatment to members of its athletic teams and the doctor provides negligent care, in most instances, it's only the doctor who's on the hook for malpractice liability," says Mitten. This, he adds, is in addition to the ethical and legal duty of all those providing sports medicine care to do so consistent with an athlete's best health interests.

However, liability for negligent hiring or selection of an outside physician can arise if an athletic department doesn't perform due diligence to ensure that a reputable and well-qualified doctor is chosen as its team physician. In addition, there may be potential liability if athletic department employees such as coaches interfere with medical matters relating to the treatment of athletes. For example, the team physician should not be pressured to put the team's need for a player before his or health.



Web Resources

Before hiring a new team physician, it's a good idea to check his or her practice background. Here are some resources:

Basic educational and professional information on nearly all licensed physicians is available without charge at the American Medical Association's Physician Select service: http://dbapps.ama-assn.org/aps/amahg.htm.

More details, including state disciplinary actions, are available from most state medical boards, which are listed at the web site of The Federation of State Medical Boards, www.fsmb.org,

The Federation also offers a fee-based ($9.95 for each doctor you want to check) online and mail-in service that allows the public to check whether physicians have been disciplined by state medical boards: www.docinfo.org/.