Guest post by Tane Eunson
– A student of the game (5th year M.B.B.S.)
As a typical kiwi bloke, I’m a dyed-in-the-wool rugby fanatic (pardon the sheep reference). So when opportunities with two Super Rugby franchises arose for me in the past year, I picked the ball up and sprinted for the posts.
As an ‘intern’ with the franchises, I was part of the ‘athletic performance’ teams. The hierarchical structures differed subtly within each team, but they both comprised the team doctor, two physiotherapists, two strength and conditioning coaches and a number of other interns in the varying disciplines. With regards to professionalism and teamwork, there was much for a student to learn in these environments.
The athletic performance team would typically meet before 7am to discuss the players’ training statuses; the sports equivalent of ward rounds.
“Andy has a Lisfranc fracture, remove cast and begin rehabilitation today”.
“Johnny has an infraorbital fracture from last night, maxillofacial review tomorrow”.
“Tom has a posterior malleolus fracture of his Tibia, arrange CT ?os trigonum fracture” etc.
Of course, not all medical complaints were hard tissue, there were an array of soft tissue injuries too; posterior cruciate rupture, intercostal haematoma, pectoralis major rupture, pre-patellar bursitis and everyone has ‘bumps and bruises’. These injuries are hardly surprising when you have 30 muscle-bound men launching themselves at each other for over an hour every week. What I did find surprising though was the majority of presentations to the team doc were for ailments more familiar to you and I; viral pharyngitis, shingles, folliculitis, sleep problems. Professional sportsmen are apparently human too and being a doc for a professional rugby team has more in common with general practice than one may expect.
The players would stroll in at 8am and log their ‘wellness’ scores. We want to know how they’ve been sleeping, how well they’re eating, how well they’re hydrating, how fatigued they feel; these are the professional sportsman’s vital signs. They’re screened with ‘adductor squeeze’ and ‘sit and reach’ tests and all the data is compiled to yield their ‘training-stress balance (TSB)’.
The players’ physical workloads are closely monitored and their training can be adjusted accordingly e.g. “Last week Joe had a season high for contacts and GPS metres run. His back has flared up and he has slept poorly. His sit and reach is down significantly and his TSB is high. We’ll rest him from full-contact today and treat his back with physiotherapy at 11am.” This structure gives the athletic performance team tangible markers to assess whether the player is “well or unwell” and gives the players the best opportunity to put a strong performance on the park, week in and week out.
And perform week in and week out they must.
In few other areas of medicine are our ‘patients’ so performance driven. Physical performance is what puts bread on the athlete’s table and without elite physical performance, their days as a professional athlete are numbered. Therefore, treatment and rehabilitation is ‘accelerated’ wherever possible. If the general public rehabilitates from PCL rupture with conservative management in 12 weeks, we’ll look for evidence to support 8 weeks. If the general public suffers an incomplete rib fracture that requires rest, we’ll consider the player getting an injection of local anaesthetic to mask the pain before a game.
This approach may sit uncomfortably with some medical professionals, but this is the reality of professional sport. We are dealing with grown men who have chosen to play a combative game for a living and it is the responsibility of the sports doctor to do everything, ethically and legally, in their professional capabilities to have these men prepared to perform. I concede it can be a delicate line to tread at times, but we must remember these are not your standard ‘patients’ in a hospital ward. These are fit men in a unique position where the currency of their livelihoods is athletic performance and we must do all we can to support them.
The position they find themselves in is truly unique, particularly in my homeland of New Zealand. These men are more than just rugby players, they are ambassadors for our country and they put our shaky isles on the world map. Most Kiwi boys grow up dreaming to be them and it is without hyperbole that their 80 minutes of work can affect the mood and economy of an entire nation.
With influence comes responsibility and some will cope better than others. At the end of the day, they are just young men and men are fallible. For instance in New Zealand, drinking culture is almost as firmly embedded as rugby culture and the two are intimately intertwined. You can even purchase t-shirts proclaiming, “My drinking club has a rugby problem”. Hence, it is with little surprise that we have rugby players making poor choices around alcohol. In a country like New Zealand, this means headline news and every season there is a very public incident involving a high-profile rugby player. Therefore, the team doctor must provide support for not only the physical demands of the athlete, but the psychosocial stressors too. Alcohol misuse is just one example, but depression and anxiety are possibly even more prevalent. The Lancet reported in November 2013 that a poll by the New Zealand Rugby Player’s Association found approximately a quarter of retired New Zealand rugby players have had alcohol or substance abuse problems. Moreover, approximately a third have had depression, feelings of despair, and/or experienced high levels of anxiety or stress. The team doctor must have the capabilities and resources to deal with mental health issues, as they will almost certainly be encountered in a rugby team environment.
Fortunately for the doctor though, he or she is not an island, and they are part of a team of health professionals. There are physiotherapists and strength & conditioning coaches that are integral parts of the team. However, the team doctor also needs to readily facilitate expert opinions and treatment from a number of other medical experts. In particular, strong relationships with orthopaedic surgeons and musculoskeletal radiologists are vital for timely and effective treatment of their players. This includes whether the team is at home, away domestically or playing internationally in any of the 3 competing unions; New Zealand, Australia and South Africa. On game day, there must be a neutral ‘game day doctor’, a ‘concussion doctor’, a ‘stitch doctor’ and can even be a ‘resuscitation doctor’ to manage the workload of the team doctor who acutely treats the players on the field. Therefore, to be an effective team doctor, one must not only be exceptional in their own field, but it is imperative they also have meaningful professional relationships with their peers in complementary disciplines. The maxim that ‘no person can make it on their own’ rings particularly true for the team sports doctor.
Therefore, to make it as a team doctor for a professional Super Rugby team , one must have the breadth of knowledge a GP possesses, yet the depth of knowledge for pathology common to the professional athlete. They must be able to accurately assess the wellbeing of their players to optimise consistent performance and be willing to ‘accelerate’ their management whenever appropriate. They must have the interpersonal skills to treat mental health issues and function well within a team, while having access to a strong network of health professionals. If one person can achieve all of these to a high standard, then they truly are ‘Super Docs’.