The Role of the Team Physician

Introduction
The role of team physician varies depending on the type of team, the location, team management, and many other factors. This article will discuss the role of the team physician from both a general perspective and the specific perspective of a national team physician traveling to international competitions. The author has had 10 years of experience traveling with various U.S. National Teams during international competition and accompanied the Women’s National Team to the World Cup in Sweden in June 1995, and the Men’s National Team to the World Cup in Italy in 1990.

Personal Qualities of a Team Physician
It is important for the team physician to want to be part of the team. The successful team physician needs to assume a subservient role. In many ways, the team physician is the least essential member of the team. Certainly the players, coaches, and trainer contribute more directly and routinely to the team’s mission. When someone is ill or seriously injured the team physician becomes essential. In this context, the customary role of the physician involving leadership and responsibility is required. The most successful team physician is one who has the respect of the players, coaches, and team administrators as a knowledgeable health professional and can comfortably adapt to a supportive team player role.
The team physician should be committed to being useful and helpful to the team. Often, international team travel delegations are small in number, and there are many chores and duties that need to be done. Although most of these chores are not in the usual domain of a physician, he/she should be willing to help whenever possible. Reports from coaches, administrators, and players indicate that the best team physicians are those who are willing to help in a variety of ways when they are not practicing medicine. Chasing balls during training, carrying equipment, and running errands are some of the ways the team physician can be of assistance. The cardinal sin for a team physician is to be unavailable to players or coaches. Shopping and sightseeing need to be limited and carefully scheduled. When traveling with teams, the players are the first priority with the needs of the coaches, administrators, and personnel from other teams addressed only after the needs of the players have been met.
Efforts to maintain optimal communication with the coaches, players, and administrators are also important. It is essential to work closely with the trainer to maintain a professional and unified approach to managing injuries and illness. It is unacceptable to compete with or undermine the role of the trainer, whose credibility with the team is essential to his/her ability to function effectively. In most situations, the trainer has worked with the players for a long time and knows them better than the team physician. Therefore, a team physician should not do anything to diminish the trainer’s rapport with all members of the team, including the physician. There is no place for medical rivalry or competition on any team.
The physician needs to maintain a professional demeanor and at the same time strike a balance between being too aloof and too cozy. Being upbeat and optimistic is always appropriate. Traveling long distances for international competition is stressful, and teams can use good humor and positive energy.
Finally, the team physician s role is not to second guess or to make soccer judgments regarding players or coaches. Although it is important to understand some aspects of team politics and interpersonal relationships to perform more effectively and professionally, it is risky to become too involved. It is better for the team physician to be perceived as neutral and above team politics.
Responsibilities
The team physician’s first responsibility is the safety and well being of each athlete.
Thoughtful and thorough preparation is the team physician’s most effective tool. The following list summarizes the most important issues that lend themselves to thorough preparation:

1. Learn the history of the team. This includes accomplishments, successes, failures and their coaching and player histories.
2. Know the names of all players and as much about their athletic and personal histories as possible.
3. Know where you will be traveling, especially the local public health issues. You can consult with the Center for Disease Control (CDC) in Atlanta for details on issues such as local health conditions and recommendations for immunizations. The U.S. State Department can also supply information about embassies and consulates. These resources can be useful for information about quality local medical personnel and facilities. Research into these issues should be done before travel.
4. Select appropriate medications and equipment for your trip. William Heinz, MD developed a standardized medical kit for U.S. Soccer based on extensive travel and sports medicine experience. Reviewing the contents of this kit, or other similar sources, can be helpful in anticipating your medicine and equipment needs. If you are traveling to a location where traveler’s diarrhea is likely, you need to bring enough medications to treat an outbreak and provide prophylaxis for the entire team or delegation. It will be necessary to know the prescribing information and side effects of all the medications in the kit. In this regard, the Physicians Desk Reference (PDR), the Washington Manual of Medical Therapeutics, and other medical texts are available in an electronic book format.
5. Talk with people who have been with the team previously or have traveled to the same locale. It is essential to talk to the trainer (and coaches, if appropriate) and any other physicians who have been with the team recently.
6. Find out about any special medical problems, current injuries, and previous significant injuries for any members of the team and delegation. Effectiveness will be greatly enhanced by knowing this information ahead of time. Most teams have records for each player that list all pertinent medical information, past medical histories, medications, allergies, hospitalizations, surgeries, and other information. Be sure that either these records or personally created summaries of them accompany the team for possible reference. Ideally, previous contact with the players, including periodic or pre-participation screening, will familiarize the physician with the players.
7. Finally, find out about drug testing that might be done. Many over-the-counter cold preparations and herbal remedies contain banned substances, so players must be educated and advised to avoid inadvertent positive drug tests. In all drug testing situations, be on constant alert so that medications containing banned substances are not accidentally prescribed. Be thoroughly familiar with all the categories of banned substances and with all of the medications in the kit that contain them. Labeling all such medications with highly visible warning labels (to remind the physician, trainer, and players) and keeping them separate from the rest of the drugs in the medical kit can be helpful. Up-to-date information on drug testing and banned substances can be obtained from the U.S. Olympic Committee in Colorado Springs, CO, and through the following Hotline (800) 233-0393 (M-F 8AM-5PM Mountain Time)].

In Country
After arrival, it is necessary to think about possible escape routes and emergency medical facilities and personnel. If a player sustains a serious head, neck, eye, cardiac, chest, abdominal, or musculo-skeletal injury at training or during a game, it is necessary to know ahead of time where and how to take them for emergency care. Often, in foreign countries, language and communication are issues. Fortunately, most international competitions have local organizing committees that assign liaisons to deal with the team. Be sure to make arrangements with them to be available in the case that local medical care is needed or the player and team physician need to be accompanied to the hospital.
Besides an acute injury to a player, other medical situations could arise that require help. Sometimes an illness in a player or member of the team delegation can become serious. Appendicitis, cholecystitis, cardiac conditions, prolonged gastroenteritis can all occur during travel to different countries, and hospitalization or consultation with an appropriate specialist may be necessary. Do not forget that there is always the option of calling familiar expert consultants back home for advice.
For serious injuries or illnesses, the team physician must insure proper care, even when other medical personnel are directly involved. Sometimes the best option is to fly the patient home, by international air ambulance if necessary. Often, the best choice is to allow local medical specialists to treat the patient. In this case, the team physician should be prepared to monitor and assist in whatever way is best for the patient. Physicians traveling with U.S. teams have been called upon to oversee abdominal surgery in the Soviet Union, hospitalization for a serious head injury in China, emergency eye surgery in Hong Kong, and transient quadriplegia accompanying a cervical spine injury in Mexico. All of these situations were handled well because the team physician acted appropriately and responsibly to secure and monitor local specialized medical care.

Food and water
Good food and safe drinking water are essential issues for every traveling team. Although rarely necessary, the team may need to bring their own food
and water. In every location the team physician and staff need to work together to secure adequate sources and supplies. As a general rule, it is best to rely on bottled water in virtually every location. Gastroenteritis can develop after drinking tap water, even in first class hotels in developed countries.
The problem with unsafe water is often the worst in tropical or sub-tropical climates where adequate hydration is most essential for players. Adequate
water supplies (sometimes 2 liters or more per player) need to be available at training and games. Players must be educated about the risks of even washing out their mouths or brushing their teeth with potentially contaminated sources. Ice is also a problem, since it is often made from questionable sources. If necessary, players have to be educated to drink fluids that are warm.
In addition to being responsible for securing safe water and educating the players about avoiding all sources of contamination, the team physician must also be thoroughly familiar with the physiology of exercise and hydration as it applies to athletic performance so he/she (along with the trainer) can advise players and coaches about what they should be drinking and when. Although not within the scope of this chapter, it is also important for the team physician to be well informed about the proper use of carbohydrate sports drinks, the role and proper timing of carbohydrate ingestion to enhance athletic performance, and nutrition in general. Personal experience shows that all athletes are eager for advice regarding nutrition, especially as it applies to enhancing athletic performance. There are many opportunities for education and discussions on these issues during travel situations.
Food can also be a source of contamination and disability from gastroenteritis. In most locations, especially in hot climates and developing countries, raw vegetables should be avoided. Although salads can be tempting, keep in mind that players have been disabled with gastroenteritis from eating raw vegetables in salads in a setting that seemed perfectly safe.
Food can be a problem simply because it is unfamiliar and, therefore, players do not consume it in sufficient quantities to sustain intense athletic performance. Try to work with the hotel to provide American style dishes that the players will readily consume in sufficient quantities and in the proper ratios of carbohydrate, protein, and fat. The U.S. Women’s National Team practices good nutrition and recognizes the relationship between proper diet and performance, especially in intense competition. For example, at the World Cup in Sweden in June 1995, they had to play 6 strenuous matches in 11 days Team personnel worked closely with each hotel staff in Sweden to have familiar, popular, and appropriate dishes served at each meal.
In summary, food and water are important issues for the traveling team and the team physician. Too much attention cannot be given to insuring proper hydration and nutrition during international team travel and competition. The successful team physician should be thoroughly familiar with all the medical and nutritional issues. Long airplane flights and changes in climate can quickly induce dehydration. The physician should be prepared to help players stay free of unnecessary illness (or treat it when it occurs) and provide nutritional counseling, especially as it relates to performance enhancement. The team physician needs to be prepared to make the decision to treat players with prophylactic antibiotics to prevent traveler’s diarrhea by weighing the cost and side effects of the prophylaxis against the risk of illness.
Dress and Demeanor
The following thoughts are based on personal experiences and those of colleagues. These issues can be very important to the success of the team physician.
Personal appearance is an important issue for physicians in the hospital, office, and while working as a team physician. When traveling with a team, it is better to avoid looking like a player or a fan. The team physician should dress with some consideration for professional image, especially when not familiar with the team (in which case the players will be more likely to make judgments based on appearance). Informality, in dress and manner, is generally good around athletes. When carried out appropriately, and especially after the physician is known and accepted by the team, informality enhances communication. When informality and familiarity are interpreted by players as the team physician trying too hard to be one of the players or trying to impress, then it works to the physician’s disadvantage. It is best to be open and approachable and to recognize the distinction between the players and the physician. The physician’s position on the team is unique as neither player, coach, or administrator. The team physician must be friendly and open to enhance effectiveness, but also remember that the ability to be effective requires respect from the players.
At games and at training the physician may often get involved and should dress appropriately. Many national team physicians dress in business suits or a jacket and tie. Although this is appropriate and supports their professional image, dressing in the same game warm-up apparel that the coaching staff wears is not inappropriate.
The team physician will not get along with all players, coaches, administrators, and staff. Yet, it is essential to try. The distraction of interpersonal problems between the physician and players is detrimental to the team and is not tolerated by coaches. It is useful if the team physician adopts the attitude that he/she is there to serve the medical needs of the team and the coaches. It is not appropriate or effective to try to impress players, coaches, or anyone else associated with the team. This is especially true in medical situations. The most effective team physician is honest. If confronted with an unfamiliar situation admit lack of knowledge and do thorough research to arrive at an answer.
Most elite athletes have had a lot of experience with doctors. Perhaps some of it has been bad, but more often than not, the experiences are good. As team physician, it is necessary to measure up to the level of the players favorite doctors back home. Since the players have not chosen their team physician, but have been assigned, the situation requires humility and honesty on the part of the physician. Being helpful and willing to go the extra mile also improves the physician’s chances of acceptance.

Attributes of a Good Team Physician
The role of the team physician was discussed with several elite U.S. National Team players. They were asked what they thought were the key attributes of a good team physician. Their responses coalesced on the following three general categories.
Affability, or general social skills, was recognized as an important quality in a team physician. This includes the ease with which the players can talk to the physician and the ability to communicate well with members of the team and staff.
Availability was also cited as an important factor. The physician should be there when needed by players either medically or just to talk. The physician is not effective or helpful when out every night or shopping during the day. The best way to be available is to spend time in the training room (on the road, a hotel room is designated as the training room). In that setting, the physician can watch players interact with each other and with the trainer, and become part of the interaction. It is useful to arrange specific times when the training room will be open for players who want to see the physician or the trainer. Before training, when the trainer is taping, is an appropriate time. Meals are also an ideal time. While eating, the physician can announce availability or arrange meetings with specific players. It is best for the team physician to attend all team meals, since this is such a reliable time to communicate. Contact with the trainer during meals is also important to insure regular communication.
Ability refers not only to actual skills and ability, but to the confidence that is conveyed nonverbally when examining players. One player explained that she had been examined so many times by so many different doctors that she could get a sense of a physician’s competence and confidence simply by the way he examined her and explained things. Just as players are being watched and evaluated when they play, the team physician is being watched and evaluated when providing care.
Qualifications of a Team Physician
Since many injuries in soccer are musculoskeletal, a team physician needs to have a good understanding of orthopedic diagnosis and treatment. At the same time, the team physician will encounter many general medical problems including upper respiratory infections, gastroenteritis, asthma, migraine headaches, and acute allergic reactions. The best team physician, therefore, is one with both orthopedic and general medical skills. It is beneficial to have experience dealing with athletes and teams under travel situations. It is also essential to have an athletic trainer to work with who has similar skills and experience.

Coaches
It is essential for the coaches and the team physician to have an appropriate relationship, governed by mutual respect. Without the respect of the coach, the team physician cannot function effectively. A good coach will communicate directly and openly with the team physician (and vice versa) and will defer to the physician in matters of medical judgment and player safety. In an ideal relationship there is no need for the physician to be assertive. Yet, the physician must be prepared to be assertive to protect players from injury, inappropriate risk, or abuse. If the coach and physician understand and appreciate each others’ roles, responsibilities, professionalism, and value to the team they can work together to solve problems effectively.

Helpful Hints
I. Have small paper envelopes for dispensing medications. Names, doses, and times can be written on the envelope to help busy and forgetful players remember to take their medications.
2. Dispense medications only one or two days at a time and keep careful records of who is getting what. This insures frequent communication with the athletes being treated.
3. Keep a log of who is being treated, for what, and with what medications. It is easy to get distracted and forget to finish a course of medication or to skip medication that would be useful. Players can be forgetful under stressful circumstances. Through good organization the physician can prevent oversights. 4. Meals are a good time to dispense medications, especially nonsteroidal antiinflammatory drugs (NSAID’s) since they are best taken with meals. Many players take them and it is easy for them to leave their medications in their rooms.
5. Because so many players are accustomed to taking NSAID’s on their own, and since multiple varieties are now available over-the -counter, it may be necessary to counsel players about taking multiple agents at the same time and overdosing.

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