Guest blog by Dr Lynley Anderson
In the recent BJSM blog post, Team Doctor…how far is too far?, Dr James Thing raised the issue of clinical professional boundaries in the provision of sports health care; he is ideally placed to comment as both a team doctor and GP.
Determining the limits of what a team doctor can, and should, take on and what should be referred to a GP is problematic. Providing guidelines will not be easy given the diversity of environments, the needs of athletes, and the difficulty in determining what is and what is not a sport-related medical problem. Nevertheless there are risks to patient safety if clinical boundaries are not established.
The work environment and team requirements
For athletes who have a local GP, it might be relatively easy for a sports doctor to limit their treatment to sports injuries only. However, for a sports doctor who travels with the team and is on tour for some time, then broader medical needs will have to be met. It may not be practical or medical services too unfamiliar, for the team to access services while on tour. In these circumstances the team doctor may take on more of a GP role and will need to be prepared for this. Having met these needs once, it may be difficult to revert back to limiting treatment to sports related issues only. Athletes may expect this convenient service to continue, and team doctors may find it too difficult to say ‘no’, once the team returns. Team management may also put pressure on the sports doctor to provide this more expansive service.
The underlying ethical value in determining the clinical reach of the team doctor has got to be due regard for patient/athlete safety. Dr Thing’s example where two practitioners are both prescribing sleeping tablets demonstrates how easy it is for patient safety to be potentially compromised. Unlike Dr Thing, some team doctors may not have undergone GP training and may not be so well equipped to take on this wider role.
Establishing clinical boundaries
Dr Thing wrote that he attempted to establish clinical boundaries at the outset, including expecting athletes to have their own GP, and not providing antibiotics without seeing the athlete first. Dr Thing then goes on to comment that these have been ‘ground down’ over time. This raises questions about Dr Thing’s attempts at establishing boundaries. Were his original boundaries perhaps in the wrong place; somehow naively placed, meaning that they could never be upheld given the realities of clinical life? Or, perhaps the clinical boundaries were well placed but are ‘ground down’ due to the demands of others. Part of the problem here are the subtle (and not so subtle) pressures from management and athletes on a doctor to deviate from their expected clinical standards. While it may be possible to resist those pressures, it may become the path of least resistance to take on roles that were perhaps not originally intended. As already stated, once the line of a clinical boundary has been crossed, it may prove difficult to re-establish. Resisting these pressures may be more significant than just deciding what clinical problem should be referred to the GP and which can be handled by the team doctor. It is not difficult to imagine that small steps of deviation under pressure can accumulate and result in clinical practice that is far from ideal.
At some point the sports medicine profession may have to bite the bullet and establish guidelines that protect patient welfare, maintain collegial relationships with GPs, and establish standards for communication between sports doctors and GPs.
Dr Lynley Anderson is a Senior Lecturer at the Bioethics Centre, and the Faculty of Medicine, University of Otago and the primary author of the Australasian College of Sports Physician’s Code of Ethics.