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Thinking through return-to-play decisions in sports medicine

2913800550_7fc291c915_zIn an opinion piece appearing in the AMA Journal of Ethics today, two Stanford physicians - Michael Fredericson, MD, and Adam Tenforde, MD - explore the ethics of how doctors should advise patients recovering from an injury.

Consider this scenario, the case which opens the piece:

Jordan is a 17-year-old senior in high school who has been his football team’s star quarterback, led his team to two state championships, and has a real possibility of receiving a full scholarship to a top college sports program next year. In his last session of summer training camp, Jordan took a fierce hit... [an MRI] showed that Jordan had a torn labrum in his right shoulder that would require surgery and months-long recovery, meaning that he would miss the rest of his final season.

[His physiatrist] had known instances in which this particular type of injury ended a quarterback’s athletic career. She had also read about a few cases in which athletes recovered fully from the injury. Since so much of recovery depends on the injured person’s following the rehabilitation and physical therapy plans, [she] wanted Jordan to approach his injury with the optimism that adherence to the plan would enable him to return to athletics. At the same time, she did not want to hold out false hope that might keep Jordan focused exclusively on football when, in the long term, that might not be the best use of his senior year.

The most important part of what we're trying to convey when treating athletes is that as team physicians our goal is the health and well being of the athlete

When college scholarships and admissions decisions are on the line, a doctor's recommendations affect more than her patient's physical health. How to weigh the different interests at stake? Fredericson and Tenforde make clear that medical decisions must prioritize the long-term health of the athlete. When I interviewed him, Fredericson, a professor of orthopedic surgery, director of PM&R Sports Medicine, and team physician for Stanford Athletics, told me:

The most important part of what we're trying to convey when treating athletes is that as team physicians our goal is the health and well being of the athlete. Ultimately, we are the ones who are trying to protect their health. Sports physicians have gotten a bad rap; people think we're trying to help coaches, or help athletes at the expense of their overall or long term well being. We might push the process to help try to get them better more quickly, but ultimately we have their long-term best interests in mind.

Fredericson and Tenforde, a PM&R Sports Medicine Fellow at Stanford and a former Stanford long-distance runner, stress that communication is key to a successful physician-patient relationship, including communicating a commitment to shared goals, and check-ins with the whole team (athletic trainer, physical therapist, parents, coaches) at regular intervals during the recovery. They suggest a "return-to-play progression plan," providing goals for each stage of recovery and a clear description of when full clearance will be achieved:

In addition to guiding rehabilitation following an injury, the plan provides better buy-in; the athlete can focus on each goal in the progression, evaluate whether or not he or she has achieved that goal, and assess how this translates to successful participation in sport. In this way, the physician is not the “bad guy” who says that the athlete may or may not return to play. It is the athlete’s meeting (or not meeting) the goals in the progression plan that determines return to play.

In turn, a good physician-patient relationship makes it more likely that the patient will comply with medical recommendations. The authors explain how the evaluation and management of an injury "must take into account the tension between the ethical principles of beneficence and respect for autonomy." By cultivating a relationship through communication, physicians respect the patient's autonomy while maximizing the likelihood of the athlete's long-term well being.

Previously: Director of Stanford Runner's Injury Clinic discussing treating and preventing common injuries, Sports medicine specialists, educators endorse checklist to reduce injuries among youth athletes, Stanford physician discusses prevalence of overuse injuries among college athletes and To stretch or not to stretch: Experts discuss the benefits of stretching before exercise
Photo by Better than Bacon

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