Unfortunately most of the time the story goes on to express the athlete’s frustration at the failure of the “sports medicine” community to fully address this problem. Your comrade goes on to tell a tale of having seen Orthopedists, Chiropractors, Physical Therapists, Rolfers, Massage Therapists, etc only to have the same scenario play itself out. The clinician addresses the problem, returns the athlete back to their pre-injury status and sends them on their way to resume their activities. All may go well for a time until the athlete starts pushing themselves to again take their performance to the next level and then… the same thing happens. Many climbers, runners, cyclists and others have told me this story again and again. For most of these athletes their injuries were never completely resolved the first time. So they continue on, trying to improve their performances and at the same time managing nagging little aches, hoping that those injuries waiting to happen don’t crop up and take them out for another four to six weeks. This begs the question, whose responsibility is it to ensure that the athlete continues improving while avoiding injury plateaus? Is this a case of clinicians wanting to work with athletes and not being well enough equipped to do so and/or clinicians who want a piece of the sports medicine pie and so throw out buzz words like, “sports injury rehab”, “functional training”, and the like? Or is this a case of the athlete having a distorted perspective of what medicine can accomplish combined with a portion of being the classic “non compliant” patient? The true problem here is that both sides are trying to assume as little responsibility as possible. Rather than look at this problem as one of where to place the blame, it would be more beneficial to look at this situation as one of misunderstanding. My hope, as both an athlete and a clinician, is to clarify what I believe each party’s responsibilities should be.
Before making a list I would like to say that when choosing a clinician it is important to do your homework. Personally I’m not going to call a plumber to ask questions about my computer problem. Certainly this is an oversimplification but my point is that even though the human body is pretty standardized from one individual to the next, the particular variables associated with each sport create an equation unique to that sport. For my own part I know that as a clinician it would take me much more effort and I would have less insight into trying to solve a shoulder problem that arose through swimming versus one that happened due to bouldering. It comes down to the simple truth that theory and practice are not always the same. Having two docs who are of equal talent I would have to go with the one that has read no books but is a an active participant in the sport and works with other athletes in the sport versus the doc who has read every book but has no personal experience with the subject. So what should an athlete expect from a sports medicine clinician?
It is the clinician’s responsibility to come up with a plan of action to help resolve the athlete’s problem(s). This is what the clinician is getting paid for, to take all of their experience and expertise and bring it to bear on the problem at hand. This is the responsibility that every health care provider must assume regardless of the particular area of medicine in which they practice. The business of diagnoses and treatment is one of probability and best guesses. Medicine is not an exact science but that is how it works and each clinician should own up to their decisions. It would seem that the better clinicians are more willing to use their own judgment and experience in order to come up with a unique solution for each problem. Rather than playing it safe and always following “established guidelines”, these clinicians strive for better than average results exactly because they are willing to take responsibility for their choices. In any field this is certainly the more challenging route to take, requiring much more thought and effort. Invariably it is those who do choose to put in the time and work who excel and become the innovators that increase the overall standards within their respective fields.
One of the primary responsibilities of the sports medicine professional is to adapt to the athlete’s progress. Anyone claiming to work in the field of sports medicine should ensure to the best of their ability that their athletes are able not only to return to the sport at the athlete’s previous level but also to have a plan of action that will allow the athlete to continue achieving gains in performance while risking as few injuries as possible. Much like a coach that ensures the athlete’s training continues to improve their performance; the clinician working on athletes should adapt their treatment plan in order to keep the athlete healthy and prevent as many potential injuries as possible. This is where it seems that most sports medicine provider’s performances are wholly inadequate. If this means that the clinician or therapist themselves is unable to provide the necessary education, then that clinician should be able to provide the athlete with a recommendation on how to proceed and who to seek out. The current situation within sports medicine is one where nobody really wants to be held responsible for this task. Unfortunately for the majority of us that play and train like athletes but are not full time professionals, as well as some who are, we do not have the resources to resolve this problem. The typical athlete doesn’t have a dietitian, coach, and therapist all keeping tabs on how they’re performing, continually tweaking their training in order to prevent all manner of problems and allowing them to keep training as hard as they can. In actuality the case is one in which athletes are left trying perform all of these roles themselves. It is not too much of the athlete to ask of their sports medicine clinician to address this issue. In fact it should be a fundamental responsibility of a sports med clinician to educate their athletes how to better perform each of these roles themselves.
This then leads to the question: what are the responsibilities of the athlete? Most athletes would have a much better experience working with sports medicine providers if they would simply believe their clinicians. Actually they wouldn’t even have to believe their clinician but simply trust them enough to commit themselves to that clinician’s treatment plan. As an athlete/patient your number one responsibility is patient compliance. This means that you do what your clinician tells you, it is not a suggestion. The treatment plan is what that clinician feels is the best approach to resolving your problem. You have sought out a professional to diagnose and treat something that is beyond your capacity to take care of. You are paying them for their expertise, follow their instructions. It is interesting that this dilemma seems one peculiar to the health care profession. It is amazing how athletes will either form their own opinions for the best course of action, even while pretending to listen to what their clinician is telling them, or flat out argue why their idea is a better solution. This doesn’t mean that athletes should blindly follow what their clinician tells them. The athlete’s sports med provider should be able to justify all the points of their treatment plan and give satisfactory answers to their questions… and the athlete should have questions.
The second main responsibility of the athlete is to be a good student. If you’re serious about improving in your sport you should make a point of educating yourself in how to do so. This means that you’ll have to learn something from each of the roles previously mentioned. You’ll need to learn about those aspects of sports medicine that affect you. You will need to understand the basics of nutrition as they pertain to you. What types of protein do you tolerate best? Do you need to pay attention to caloric intake and aerobic training more than the 15 year old waifs that flash V11 in their tennies because it’s more difficult for you to stay lean? The objective of the athlete as student is to learn the specifics of their own body. As an athlete you should know how your body responds to the training you are performing, how much is too much or too intense, what foods are the best fuel sources for you, how much sleep you need, etc. You are the primary subject in an ongoing experiment in how to improve as an athlete. How will you know if you’re improving? How else will you know which variables are causing the improvement if you don’t record your data and then look it over to draw conclusions about your progress? As the athlete you are in the best position to do this work, you know the most about the intricacies of the experiment. Outside help is just that, it’s an “expert” in the field checking out your findings and collaborating on creating more efficient techniques for improving. They should also be able to look at your work and suggest new directions within the experiment that might give better results.
One final point that athletes and clinicians alike should be aware of is the influence of the media. For those of you that aren’t clinicians but know one personally ask them the biggest down side of the job. The likely answer you’ll get, the patients themselves. At worst patients can seem exceedingly ignorant, have no common sense and then want to argue with you about the best course of action for their treatment. The easy way out would be to simply blame patients as a consumer group. This misses the bigger picture. The blame should be directed toward the media. It is the media that perpetuates most of the attitudes and misperceptions that the medical community constantly struggles to overcome. Foremost the media must sell a product in order to sustain its own existence and this often times is in direct conflict with conscientious reporting. At best this means that inventions, discoveries and new trends in science are painted to be more promising than they are. Science is a tedious and frustrating labor of love where the rewards are often few and far between. Since this one paragraph is unlikely to create the changes I would like to see, this means that athletes and clinicians serious about performing their best in the realm of sports medicine must do their utmost to learn, think and make sound decisions based on that information.
“In connection with the Columbia accident, most engineers I spoke to speculated that the tiles on the underside of the craft, designed to absorb the heat of reentry, probably caused the problem. Dan Canin of Lockheed wrote in an e-mail, ‘Every precaution and material science known to man has been applied to the problem of making the thermal protection system work. It’s a know risk. The tiles are soft, and every astronaut knows that if the wrong ones are damaged, the shuttle burns up. But the odds against it are pretty good, especially when compared to the rewards of being an astronaut, so they’re willing to take the chance. In fact, they FIGHT for it… as would a lot of us. But getting the public to buy this is a lot tougher, especially a public that expects every risk in their lives to be mitigatable to zero. It will be interesting to see if NASA tries to take on this challenge, explaining to the public that doing bold thins isn’t about engineering risk to zero. Shit happens, and if we just want to restrict ourselves to things where shit can’t happen… we’re not going to do anything very interesting.’” (“Deep Survival” by Lawrence Gonzales)
In order to earn the trust and respect of athletes, clinicians must realize that simply fixing problems as they arise and returning the athlete to training without preparing them for the future simply will not get it done. Athletes need to understand that sports medicine doctors are practicing scientists that don’t have all the answers but are improving and refining their skills one problem at a time. Both clinician and athlete need to understand what it is they are trying to accomplish, have clearly defined goals and be realistic about what it will take to achieve those goals.
Brent Apgar D.C.