Safety of care

Improving patient safety and reducing risks

Consider the unique aspects of caring for athletes

Originally published June 2015
P1503-4-E

Providing medical care to athletes can be rewarding, whether it’s as part of a regular medical practice, as a team physician, or at sporting events. While the work is similar to that in any other type of practice, it has unique aspects with potential medical-legal risks. Physicians should be aware of these risks and take steps to keep the athletes and themselves safe.

Standard of care

The courts hold physicians to the same standard of care when treating athletes as when treating any other patient. Doctors are expected to exercise the skill of a “normal, prudent practitioner of the same experience and standing.”1

Specialists are held to a higher standard of care than general practitioners and are required to exercise the skill of a “normal, prudent” specialist. Physicians who identify themselves as sport medicine physicians specializing in the care of athletes will be likely held to a higher standard than family physicians.

Doctors should accurately state their experience and expertise to athletic teams or organizers of sporting events. If a medical-legal issue arises and the medical care is questioned, physicians who inaccurately stated their training and expertise may be found to have negligently misrepresented themselves. Regulatory authorities (Colleges) would also see misrepresentation as a breach of professional standards.

Acting as a team physician

Team physicians, whether at the amateur level, at a university, or with a professional team, have a dual responsibility — to the athlete and the team.

Team doctors should clearly explain this dual role to athletes and obtain the athletes’ consent to release medical information to appropriate team members, such as coaches and managers. Most teams have athletes sign a consent form at the beginning of the season allowing for this communication. In fact, privacy legislation in some jurisdictions (e.g. Alberta) requires written consent for the disclosure of health information for purposes other than providing healthcare. An athlete’s consent should be very specific. Without expressed consent, an athlete’s personal health information generally should not be released to anyone, including the media, unless it is needed for the purpose of providing care to the athlete (e.g. a consulting specialist healthcare provider).

What is expressed consent?  Much of a health professional’s work is done on the basis of consent that is implied either by the words or the behaviour of the patient or by the circumstances under which treatment is given. When health professionals have any doubt that the patient’s actions imply permission for the examinations, investigations, and treatments proposed, it is preferable to obtain expressed consent, either orally or in writing.

Team physicians may be required to travel outside Canada as part of their duties. These physicians must be aware of the CMPA’s assistance when providing medical care outside the country. Without a licence to practise in another province or country, travelling Canadian physicians could be scrutinized by the local medical regulatory authority. If a team physician is found practising medicine without a licence from the jurisdiction, the repercussions can be extremely serious. Those considering travelling with a team outside Canada should call the CMPA to discuss the details of their situation.

When travelling abroad, team physicians should also be familiar with regulations or restrictions on bringing medications into a foreign country. When transporting controlled drugs or narcotics between provinces, team physicians should also be aware of any regulations or restrictions.

While a team physician position is often considered prestigious, it comes with potential stresses. Team physicians may feel pressured by team owners, coaches, and athletes to make difficult decisions, such as when to return to play. Doctors should avoid potential conflicts of interest and ensure their primary responsibility is the player’s wellbeing.

Return-to-play decisions

When advising on a player’s readiness to return to play, doctors may be concerned the decision exposes them to medical-legal risk. Canadian courts have “…viewed medical clearance on the part of physicians as a discretionary decision, as long as it adheres to the common and most current medical practice. In this respect, normally there is no liability for negligence when a physician makes a judgment call that is within the accepted standard of medical care.”2

A 3-step decision-based return-to-play model proposed by Matheson et al evaluates the health risk, participation risk, and “decision modifiers” such as timing (playoffs versus regular season) and external pressures.3 Physicians should consider the “modifiers” carefully and ensure their return-to-play decision is in the best interest of the athlete’s health and is thoroughly documented.

In the United States, team physicians have been found liable for not disclosing long-term risks associated with injuries. This is particularly pertinent in cases of concussion. Return-to-play discussions with athletes should include information about any potential long-term risks and should be well documented.

Anti-doping regulations

Elite athletes competing at national or international levels may be subject to anti-doping regulations. The World Anti-Doping Agency publishes the World Anti-Doping Code, a list of medications and substances prohibited in sports with which athletes must comply. Athletes may be subjected to random urine or blood testing in and out of competition. The presence of a prohibited substance can result in severe penalties to the athlete, including a ban from competition. When applicable, athletes should tell their physician they are subject to drug testing for anti-doping purposes. If a physician is aware an athlete is competing at this level and the athlete has not indicated he or she are subject to drug testing, the physician should ask. The Canadian anti-doping program and education is provided by the Canadian Centre for Ethics in Sports. Information on prohibited medications can be found on their website.

Athletes are generally advised to report any new medication to their team physicians. If an athlete requires medication that is on the prohibited list, but is necessary to treat a certain condition, the athlete can apply for a Therapeutic Use Exemption (TUE). The prescribing physician must provide information about the drug and the diagnosis for approval by the athlete’s sport federation. When medication is needed urgently or emergently, a retroactive TUE may be granted.

Concussion care

Athletes in certain sports, primarily collision and contact sports, are at high risk of concussion. All American states have concussion legislation generally requiring:

  • removal from play if concussion symptoms are reported
  • medical evaluation
  • medical clearance before returning to the sport

Currently, Canada does not have concussion laws. Legislation has been proposed in several jurisdictions however. Physicians should be knowledgeable about current concepts for concussion assessment and management as they will likely be seeing more patients reporting concussions.

Covering an event

Physicians may be asked to provide medical coverage at sporting events as a medical director, as part of the medical staff, or as a volunteer. In most cases, the standard of care, responsibilities, and potential liabilities are similar as when doctors provide care to any athlete, even when the work is voluntary. As well, doctors working at events outside their provinces should ensure their licensure is appropriate for that location.

Documenting the care

Appropriate documentation of medical care is a regulatory and legislative requirement, and essential to a physician’s medical-legal defence. It may be easy to forget to document when attending to athletes at the side of the field or at the arena, but physicians should ensure their interactions with patients are well documented. Some physicians may use portable devices such as smart phones or tablets for this purpose. Such devices should have strong password protection and encryption to prevent a breach of confidential medical information if the device is lost or accessed inappropriately.

Working collaboratively

Caring for athletes generally means working collaboratively with other healthcare professionals. Effective communication between team members and clear roles and responsibilities are critical to providing quality, safe care.

CMPA’s extent of assistance

When caring for athletes in some circumstances, physicians should be aware of the Association’s principles of assistance, i.e. on treating non-residents, treating professional athletes, providing care outside Canada. For more information on these principles, members are encouraged to contact the Association.

The bottom line

Caring for athletes can be gratifying. Giving athletes appropriate guidance on returning to their sport after injury or illness, balancing various roles and responsibilities, and being aware of anti-doping requirements make the work unique. Physicians should understand the accompanying medical-legal risks and take steps to protect their patients and themselves.

 
 

References

  1. Sylvester v. Crits et al, [1956] S.C.R. 991
  2. Wilson, Marie-France, “Young athletes at risk: Preventing and managing consequences of sports concussions in young athletes and the related legal issues,” Marquette Sports Law Review (2010) Vol.21, No.1, p.279
  3. Matheson G.O., Shultz, R., Bido, J., Mitten, M.J., Meuwisse, W.H., Shrier, I., “Return-to-play decisions: Are they the team physician’s responsibility?” Clinical Journal of Sport Medicine (2011) Vol. 21, No.1, p.25-30

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.