Ready, Set, Refer

As health care systems become more political and sports medicine more sophisticated, the path to the best referral is gaining some new twists and turns. Here’s how to navigate the network.

By David Hill

David Hill is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 13.9, December 2003,

When Augsburg College student-athletes need emergency medical care, they don’t have to go far, because a hospital emergency room is located across the street. That doesn’t mean, however, that Athletic Trainer Missy Strauch, MS, ATR, ATC, automatically uses the hospital’s staff for her referrals.

“We’ve told the emergency room staff that any Augsburg athletes who come in here need to be referred to our specific orthopedic surgeon,” says Strauch. “If they send them off to the hospital’s orthopedic group, we aren’t always able to get enough feedback. So we make sure our athletes stay within the network of the physicians we usually work with.”

As Strauch has learned, making referrals can be tricky, cumbersome, and time consuming. There are an infinite number of decisions to be made, and while some are simple or obvious, others require careful, measured consideration. A wrong step can leave an athlete in less-than-competent hands or facing a practitioner with the bedside manner of a medieval bloodletter. Certain athletes may need special attention, insurance may limit options, and you have to be on the lookout for doctors with poor communications skills.

“The athletic trainer is a gatekeeper, and a big part of the profession is recognizing who to get the patient to,” says Denny Miller, ATC, PT, Director of Sports Medicine at Purdue University. “It’s important that you take some pride in doing that, and you need to be willing to branch out for specific needs and situations.”

But how do you know which physician is best for your athletes? How do you navigate the touchy politics of a local medical community? What happens if the specialist your school has been using for years shows signs of losing his or her touch? And how do you assess new practitioners? How do you know if your referral list is up to date?

Whether new to a job or updating a referral list, the first place to start your referral review is by assessing the care the physician is providing. “The best way is to assess your athletes, especially operative ones—examine how the surgery appeared to turn out and how smoothly the rehabilitation went,” says Chuck Whedon, MS, ATR, ATC, Coordinator of Athletic Training at Rowan University. “Look at what kind of rehabilitation the physician orders and how aggressive it is, which, of course, is important for athletes.”

Along with assessing their surgical and rehab abilities, many athletic trainers want to see good communication skills and an efficiency on the physician’s part. Maureen Mahoney, LAT, ATC, Head Athletic Trainer at Wellesley College, cites a few warning signs of a bad referral: the professional is not answering your direct questions, provides vague diagnoses, or doesn’t get athletes into the office quickly. Also be wary if athletes do not understand their return-to-play plan.

“My nightmare of dealing with an injury is that there is an athlete whom you have been working with and you have come to the point where you need more information or further testing,” Mahoney says. “They have just seen a physician and come back to you with a vague generalized diagnosis and no recommendations for care or treatment. The MD has not told me anything that I didn’t already know and are not helping. That can happen even if I send a note with the athlete. Then I have to track that MD down for more information, and what athletic trainer has time for that?”

“I don’t see too many doctors mis-diagnose someone,” says Strauch. “But if there’s no follow-up or there’s no urgency to do what’s best for the athlete and consider that the athlete still wants to participate in athletics, that’s a warning sign.”

Whedon also assess the doctor’s bedside manner. If he is not with the athlete during the visit, he asks the athlete for feedback on this issue. “I’m very comfortable with asking my athletes, ‘Hey, what did you think of that physician?’” he says. “It’s too important to me to beat around the bush. So I simply ask them, ‘Did you like the doctor? Did he or she treat you with respect?’”

However, if the athlete does have complaints, it’s important to not take the athlete’s word as the final judgement. Jim Murdock, MEd, ATC, Assistant Athletic Trainer at the University of Vermont, often double-checks directly with the physician before deciding how a referral went.

“An athlete can come back really upset and all ticked off,” he says, “but were they really paying attention, were they really listening? If the athlete comes back and you ask, ‘What did the doctor say,’ and the athlete says, ‘Nothing. I can play tomorrow,’ but they have a torn ACL, that’s obviously a warning sign.” Murdock then knows he needs to get more information because the athlete may have misunderstood what the physician was saying.

Athletes may also have their own ideas about who to see. Miller recounts two Purdue athletes who had been treated by one of the top specialists in his field while they were in high school—one from a wealthy suburb whose parents knew of the doctor, and the other from a low-income background who was steered to the physician by a coach. But both expected to play beyond college and wanted only the best.

“It’s not infrequent that a high school athlete you recruit has already seen that level of physician prior to the recruitment, and you owe it to that athlete to continue to provide that level of care,” Miller says.

But expectations can go the other direction, too, especially at the high school level. “There are some parents who won’t drive 15 extra miles or won’t go to the next town to see someone who’s great with knees,” says Janet Kennedy, MEd, LAT, ATC, Head Athletic Trainer at Framingham (Mass.) High School. “Sometimes you have to convince parents of your knowledge and the need to follow-up on something, by asking, ‘Did the doctor rule this out?’ I tell them I see this kind of injury all the time, but their family-practice doctor may not.”

Once you’ve got a handle on your current referrals, the next step is expanding your list. The key to this process is networking.

“It’s word of mouth,” Whedon says. “Talk to other athletic trainers, to other health-care professionals, and ask, ‘If you were going to send your dad or son for shoulder surgery, who would you send him to?’ Call people who have been around for five to 10 years and have a good handle on the health care practitioners in the area. Pick their brains, write down their suggestions, and start making some contacts.” Sometimes nearby medical schools can help, as their faculty members usually are well-respected in their fields.

Whedon also suggests contacting members of the local or state athletic trainers’ professional society for recommendations, as he does for athletes who need referrals in their hometowns due to insurance requirements. “I have other athletic trainers call me on a weekly basis to ask for a good knee surgeon or a good back surgeon in our area,” he says.

When evaluating new physicians on your list, the first criteria are ability and expertise. Ask how often the physician has dealt with the injury or condition in question, and what the outcomes were.

“If we’re talking about a knee injury,” says Miller, “we want the referral person to be someone with a proven record of patients who have returned to Division I or professional competition. We want someone who has done many, many of these—as many as possible.

“I had an athlete with a tibia fracture,” Miller continues, “and our consulting orthopedist whose specialty is knees, said, ‘I can treat the athlete. However, here’s what I suggest: Take him to this other doctor who handles all the trauma cases that come out of the Indianapolis 500. He sees these injuries by the dozens, and I see only a few. He has had a track record of getting competitors back into NASCAR, CART, and the IRL. Let’s have him work with that tibia fracture for us.’ So that’s what we did.”

Kennedy likes to meet potential referral practitioners before they’re needed. “When there’s a new doctor in the area, I’ll set up an appointment and learn the new doctor’s background,” she says. “I’ll ask about some common injuries and their philosophy, such as how they’d manage the injury. I do it whenever a new person joins the clinic that most of my athletes end up at.”

Murdock takes it a step further and accompanies the athlete the first time he uses a new clinician. “It’s partly to assist the athlete,” he says, “but it’s also for me to evaluate the clinician—his or her bedside manner, knowledge, the rapport with the athlete and with me. And I look at the whole picture, including the office, the setup, and accessibility.”

It’s also good to get to know non-medical personnel. Kai Etheridge, LAT, ATC, Athletic Trainer at South Mountain Community College in Phoenix, Ariz., makes it a point to meet the key people in the medical practices he most frequently refers to. “I’ve found sending a card or introducing yourself to the staff, especially the receptionist, will get your foot in the door,” he says. “They like to do favors for people sometimes, and I’ve found a little personal contact is a good way to speed the process along. If you’ve met them, they’re going to attach a name with a face, and then you’re not Joe Patient on the phone.”

One way to increase the odds of a good referral is to screen out practitioners who aren’t familiar with sports medicine. A sports-medicine specialist will more likely understand the athletic trainer’s role and abilities. Murdock says being a sports-medicine specialist isn’t a requirement to see Vermont student-athletes, but some understanding of their special needs is.

“Does the physician understand the pressures and lifestyle of a college student-athlete, which, as we affectionately say, aren’t normal?” Murdock says. “There are some general practitioners who’ll say, ‘Oh, you don’t feel good. Take the day off.’ For some athletes, that’s not a viable choice, internally or externally. Or if we send an athlete to a clinician and they say, ‘So, what sport do you play? Oh, field hockey. But there’s no ice this time of the year!’ that kid’s turned right off. They won’t hear anything else, even though, medically, this person could be tremendous.”

Physicians with a sports-medicine bent are more likely to understand the need to act quickly and aggressively. “Sometimes in athletics, you play through things,” says Russ Hoff, MS, ATC, Assistant Professor and Director of Sports Medicine at Valdosta State University. “A broken hand takes four to six weeks, so the protocol says, but is that person really out four to six weeks? Maybe not, if you cast it and protect it so it doesn’t move and it can heal. And in college athletics, there are other considerations. They want to play, and the coach’s livelihood depends on some of those guys playing. You don’t go to the extreme as in professional athletics, but it’s an art, not a cookbook.”

The physician’s availability is also key. “We’ve had people say, ‘We can’t get you in to see the doctor for two weeks,’ and that’s an unacceptable answer for an athlete eager to get back on the field,” Strauch says. “We have a sports medicine center that different orthopods and general practitioners belong to, but to belong, they have to see athletes on an urgency basis—a day or two, max. Waiting two weeks to see a specialist is unacceptable in the world of athletics.”

Another point that referral doctors should be able to grasp is that athletes are public figures, even if they’re not on TV every week.

“You don’t want a clinician going around saying, ‘I’m the team physician for men’s ice hockey,’” Murdock says, “because people will say, “Hey, what’s going on with the team?’

Physicians, for the most part, aren’t going to be giving out specifics about injuries, but generalities sometimes in casual conversations can create issues. We try to address that in a casual way and remind them there is a confidentiality component. HIPAA has been tremendously helpful for us because it’s really reminded the medical community of the role of confidentiality.”

Perhaps the most delicate part of referrals is navigating the sometimes-murky world of connections from practitioner to practitioner. In an era of consolidated medical practices, where professionals in many specialties may be part of the same health-care system or corporation, and where long-established team-physician arrangements are in place, it’s especially important for athletic trainers to try to understand these relationships. Toes stepped on today may lead to closed doors later on.

“It’s about money, no doubt,” says Whedon. “In our area, we have six or seven very good sports medicine groups. There are probably two that are the cream of the crop, and they battle it out. That’s just the nature of our society.”

Politics can be especially tricky for high school athletic trainers in a small community. “If there are two orthopedic surgeons in town and you keep referring only to one, that can be a problem,” Hoff says. “That other doctor may have kids who go to the high school.”

When he moved to Phoenix from a small town in upstate New York, Etheridge learned to find people he could get to know and trust to offer honest opinions regardless of the politics. “Be aware of all that, and analyze the recommendations with that in mind,” he says.

Diplomacy and tact will often go a long way, especially when faced with a most difficult situation: Having suspicions about a doctor’s performance. If Kennedy gets a bad feeling about how a doctor has handled a case, she’ll ask questions and discuss it with the athlete and parents, but she is reluctant to come out and criticize the physician.

“I’ll say, ‘I’m not sure the doctor noticed something,’” Kennedy says. “I’ll tell them an orthopedist specializes in bones and joints and sees many more of these injuries. Then it’s up to the parent to move to the next level of care.”

Murdock also suggests avoiding direct questioning of a physician’s judgement. “I might ask a doctor, ‘Can you explain to me why you’re doing it this way?’” he says. “‘I’m not understanding what you’re trying to get at.’ If he or she is doing something that in my estimation is simply not right, I would talk with another doctor, such as our team physician, and say, ‘Hey, what’s going on here.’ I do not question a physician’s medical practices, but explain I just want to make sure what’s being done is for the best. Our role as athletic trainers is not only to provide care, but also to be an advocate for, and protect, student-athletes.”

As difficult as it may be to question a doctor, Murdock stresses not shying away from raising issues if they’re serious. “A lot of times people don’t address situations with physicians because we’ve put them on a pedestal,” he says. “But we sometimes need to remind them that they’re human, and they’re providing a service.

“You don’t want to come off as a pompous person trying to question a physician whose medical knowledge is light-years ahead of yours, but it comes back to more than just medical knowledge,” Murdock says. “Good care is all about people skills, professionalism, and follow-up.”

Sidebar: Athlete Prep
Seeking the right professionals is only part of getting good results with referrals. The other part is making sure referral appointments go as well as possible. And part of that is preparing athletes for the visit.

First, recognize the trauma facing a young student-athlete who is probably upset about the injury and might be worried about not being able to return to the sport at all. Some may even be entering the medical system for the first time. While talking with a physician may be routine for you, it’s not for them. Take some extra time to explain what’s going to happen, try to build their sense of control, and let them know they not only can but should ask lots of questions.

“They’re going through a grief response,” says Chuck Whedon, MS, ATR, ATC, Coordinator of Athletic Training at Rowan University. “You have to explain, ‘Look, you can’t do anything about it now. It happened. You’re not going to change that, but now what we can do is get you to the best person we know.

“Tell them,” continues Whedon, ‘You have to pay attention to what the physician says, and write down your questions, because no one remembers all their questions when they go in there. And write down the doctor’s responses. Make sure you understand what is being done to you.’”

“Explain to them why this referral is necessary, and what you hope to get from this visit,” says Maureen Mahoney, LAT, ATC, Head Athletic Trainer at Wellesley College. “Also, athletes need to understand their medical insurance and how it works, such as what co-pays are, as well as the need for office visits and possibly physical therapy or treatment visits.”

One thing many athletes may need help with is understanding the inconvenient, often intimidating, atmosphere of a medical specialist’s office. Jim Murdock, MEd, ATC, Assistant Athletic Trainer at the University of Vermont, says if an athletic trainer can’t go with the athlete, he and his colleagues like to send an upper-level student in UVM’s athletic-training academic program. “It’s a great educational component for our athletic training students, and it helps improve communication,” Murdock says.

Kai Etheridge, LAT, ATC, Athletic Trainer at South Mountain Community College in Phoenix, Ariz., tries to warn athletes that a specialist spending only a few minutes in the examining room doesn’t mean they’re getting short-changed. “Athletics is such an important part of their lives, and if the doctor spends only two minutes with them and doesn’t stay to discuss their case, it can be a shocking thing,” Etheridge says. “I try to explain to the athletes that the physician’s not trying to be short with them and isn’t just seeing dollar signs. He or she probably has a waiting room full of people who have been sitting there for 45 minutes because he or she was late getting out of surgery.”

Any tips you can offer athletes for opening dialogue with the physician can be helpful. An orthopedist in Phoenix earned a World Series ring for working with the Arizona Diamondbacks, and Etheridge advises athletes to break the ice by asking about it.

Many athletic trainers send forms along with athletes to help facilitate communication with the doctor, physical therapist, or other practitioner. In part because he works with a huge array of doctors, relatively few of which are sports-medicine specialists, Etheridge uses a form that’s only a page long but highly detailed. It’s a modified version of what he used at the State University of New York College at Cortland and includes his impression of the injury, a section for the physician’s findings, an X-ray report if needed, scheduling follow-up, and check boxes for unrestricted play, limited participation, or complete rest.

“This makes it easy for the doctor to communicate,” Etheridge says. “Sometimes it’s hard for the doctor to make a phone call or take my call.”

He’s also found athletes are quite conscientious about returning the form because they can’t play without it. “I just say, ‘Hey, I need this back. This is clearance to play,’” says Etheridge. “The athletes get it back because they realize it minimizes the time they’re out.”