Domhnall MacAuley: shadows in sports medicine

Domhnall MacauleySport is seductive. Its exciting, thrilling, and emotional. Watching a sport you enjoy, it is hard not to become drawn into the drama. As a doctor involved with the players, it is difficult to remain dispassionate. When Wendy Chapman sat before the GMC, with events drawn out by counsel, the scene was very different to the highly charged dressing room where she felt pressured into making her unfortunate decision. She is caught in the spotlight. But, in the shadows of sports medicine there are many uncertainties.

Doctors should stand apart, make objective decisions while weighing up risks and benefits, evidence, and probabilities. But, swapping a white coat for a tracksuit changes the dynamic.

It is often more than a job. Sports doctors may have played at the highest level and feel they can still contribute. Or, perhaps they were average and this is their only opportunity to experience high level competition. Often it is because of their love of the sport or previous involvement with the team or organisation. Management and coaches trust them because they share the same philosophy, players too. They are, inevitably, part of the team and with that comes an expectation.

Sport can be glamorous and even the doctor is sprinkled by a little stardust. Watching a doctor rushing onto the pitch to the aid of a player or as a key actor in the drama on the sideline brings out the child in all of us. Few are untouched by success, even at a lower level.

Add to this the very different contractual arrangements. This is not the health service. Sports doctors are contracted (paid or unpaid) to an organisation where the goals are performance and the outcomes are measured in the short term. Everyone is dispensable; to be dropped, transferred, let go, eased out on the strength of a few bad results Where livelihoods depend on short term goals  there will be an inevitable discordance with the long term outcomes we value in medicine. It takes a strong character to stand apart, make difficult and objective decisions, say no to the players and management. And, be prepared for dismissal if judged not to be a team player. The doctor is easily replaced.

There are many grey areas.  Doctors may feel pushed into making decisions that are marginal; ignoring a minor concussion, injecting where the risk benefit ratio may not be that clear; allowing a player risk re-injury for the benefit of the club; turning a blind eye while suspecting an athlete may be using performance enhancing substances; sharing knowledge of an athlete’s injury.  Few understand and appreciate the unique and difficult role and the extraordinary tensions at play. Sports medicine is high profile, high pressure and high risk. In the storm of emotion and expectation, you will sometimes have to walk alone.

Although I am involved in sports I am unaware of meeting Wendy Chapman nor am I involved with rugby. I do know her barrister, Mary O Rourke, but we have never discussed this case.

Domhnall MacAuley is primary care editor, BMJ