An excellent team physician provides comprehensive and holistic care to athletes by both instituting injury and illness prevention programs as well as appropriately treating injuries and illnesses as they occur. However, to successfully navigate the pathways of optimizing athletic and sports team care, the most successful team physicians credit a cornerstone of their success to leadership skills. Physician leadership as the head of the medical team requires navigating the complex environment of coaches, family members, school or professional administrators, agents, insurances, and supporters or fans who surround the athlete while always maintaining a duty to the athlete and respecting their individual health and autonomy (1,2).
The sports medicine team is an interdisciplinary team consisting of physicians, athletes, parents, coaches, athletic trainers, and more. While the members or extent of the medical team may vary depending on whether in a high school, collegiate, or professional environment, the team must work together to care for the athletes, under the leadership of the head physician. A high school or community-based team physician will have to effectively communicate with the school's athletic trainers, nurses, and individual primary care physicians. When working in a professional or elite collegiate environment, the team physician may place an emphasis on choosing the right team members of their own team, supporting and optimizing the characteristics of an effective group and promoting positive group dynamics (3). Regardless of the level of the athlete, interdisciplinary teams will work most effectively when there is a culture focused on shared goals that all work to optimize the highest quality of care for the athlete (4,5).
Physician leadership of the interdisciplinary sports medicine team depends on fundamental skills that are often overlooked in medical school but are required of leaders in any field (1,3–12). A physician leader must have communication skills, the ability to perceive and be open to the needs of the athlete and those that surround them, as well as self-awareness of their own preconceived thoughts or biases (7,12). There is a gap in physician training regarding leadership education. Medical schools, residencies, and fellowships need to engage in coaching students on these skills so that they can become leaders in their fields. Many of these management skills, which go beyond the technical skills and knowledge of sports medicine, may make the difference between success and failure in the role of head team physician (2,9).
In 2018, a leadership group from the American College of Sports Medicine, the American Sports Medicine Society, and the American Orthopedic Society for Sports Medicine developed a leadership session within the Advanced Team Physician Course which sought to describe the important elements in educating team physicians on becoming better leaders within their multidisciplinary health care teams and within the greater community of sports medicine physicians (13). This session sought to acknowledge the gap in medical training regarding leadership education and began to address it in a forum specifically for team physicians. This article presents a summary of the leadership education of the course in the hope that an even broader audience of team physicians can benefit from the important pearls shared at that event.
Leadership Model and Emotional Intelligence
Positive health care leadership is founded on a cornerstone of ethical motivations that can positively influence other health care providers and leads to the benefit of individual patients/athletes and larger patient/athletic populations (9,14). The central principle of this ideal is that each provider recognize that the focus should always be on the patient/athlete. To accomplish the ultimate mission, exceptional care that is in the best interest of the athlete, the central focus is supported by five core competencies: emotional intelligence, teamwork, selfless service, integrity, and critical thinking (Duke Healthcare Leadership Model: Fig. 1) (9,15). Each of the core competencies is interdependent on the others. Indeed, each member of the team must buy into and contribute to each competency for the mission to achieve optimal success.
Emotional intelligence is one important piece of patient/athlete-centered care (8,15,16). Emotional intelligence is an ability to recognize one's own emotions as well as the emotions of others, and to use this information to guide thinking and behavior (Fig. 2) (8,13,16). In the sports medicine team, emotional intelligence allows for greater recognition and understanding of the emotions within themselves, family members, other members of the team, coaches, and athletes. This validation and recognition of other ideas and thinking allows the team leader to better manage behavior and relationships and keep the team focused on a positive outcome.
The foundations of integrity and selfless service also are key to a well-functioning team. The need for integrity within sports medicine is increasingly obvious with the catastrophes of sexual abuse that have occurred in several sports and organizations. Similarly, selfless service is at the core of the athlete-centered approach, remembering that the goals of the sports medicine team are to support the health and success of the athlete, not the team, coach, or provider. As such, most team physicians put in extended hours of service and availability.
Other core competencies involve effective communication, supporting diversity, and developing mindfulness. Diversity within the team, with a variety of personal backgrounds and professional expertise, increases the flow and exchange of new ideas and approaches. Mindfulness, similar to emotional intelligence, creates an awareness toward the individuals on the sports medicine team and of the individual athletes, an understanding of the different backgrounds, perspectives, and circumstances that may dictate treatment. High-quality personnel allow the physician leader to open the framework which in turn expands critical thinking contributions from each member and encourages a sense of teamwork, all for the benefit of the patient/athlete. These competencies are consistent with previous literature on physician leadership which has emphasized the necessity of building these skills to effectively manage and lead a medical or sports medicine team (4,9,11,16).
Developing Trust and Optimizing Communication
A leader is often most successful by being able to demonstrate a clear vision of the common team goal, and by inspiring others on the team to believe in that goal and in the process of achieving it (9,15). For the team physician, the health of the athlete should be the primary goal, and always placed before the interests of the parents, coaches, administrators, agents, or team owners (9,14). For a team physician to act effectively, the athlete must trust that the team physician has their best interest in mind and cares about them as an individual, not just a member of the sports team. For a high school or community-based team physician this is facilitated through availability and effective communication with the athlete, their family, and their primary care provider. For a collegiate or professional sports team, rapport can be built with athletes by spending time with them at or after practice, at meals, and while traveling. They should trust the team physician to maintain both their autonomy and privacy.
It is important for the athlete to maintain autonomy over their body and their decisions (14). Athletes may sign a release to communicate information about their physical condition with specific people; however, they reserve the right to withhold information if they so choose. At times, the athlete's (or third party's) immediate goals of participation may not align with long-term health. It is at these times that the team physician needs to help the athlete navigate the pros and cons of their health care decisions by fully explaining the potential long-term risks or effects when describing treatment options and participating in shared decision making (17). This makes the athlete a well-informed consumer. The more the athlete is educated about their injuries and options, the more the athlete will trust the team physician. While there are several health issues which have historically been recognized as requiring disqualification from play, a great many disqualification and return-to-play challenges will fall into a less clear pathway or decision tree. This is especially true as the treatment or management of many diseases now allows for athlete participation in making informed decisions regarding risk for themselves (17). At these times, it is important that the team physician educates, informs, and collaborates with the athlete to create a shared plan for athlete participation (17). Establishing a trusting relationship with the athlete will ease the process and allow the athlete to be more confident in their decision.
Communication is important whether it be with the athlete, the coach, the athletic trainer, parents, or administration (9). The parents or guardians of youth, high school, and college-aged athletes are essential contributors to the athlete's health care decisions and should play an integral part in all health care and return-to-play decisions. A strong working relationship and open communication with the athletic trainer is critical, as they are the day-to-day first responder and communicator. The athletic trainer is embedded within the team, interacts with the athletes on an almost daily basis, and has an observational advantage regarding the athlete's state of mind and ability to take on the physical challenges of the sport. The best team physicians recognize the essential position of the athletic trainer and work diligently to optimize the open communication between athlete, athletic trainer, and physician (1,9,18–20).
Ideally, the environment within the athletic department or organization has already established an open, athlete-first mentality which in turn optimizes the sense of trust and communication within the sports medicine team. It is important that the team physician help foster and facilitate this important foundational focus within the administration and organization. The shared mission and vision will assure positive communication with coaches and administration regarding health issues for athletes when the tough decisions arise and, hopefully, avoid the risk of other priorities or influences that might be counter to the health of the athlete. All members of the team should be encouraged to contribute impressions and recommendations. Shared decision making and collaboration particularly between the physician and athlete will have the biggest impact on athlete health (17).
Currently, the major National Collegiate Athletic Association (NCAA) conferences in conjunction with the NCAA have made strong efforts to assure independence of health care decisions for athletes. In an effort to separate the potential negative influence by coaches or administration regarding medical decision making, each institution has been strongly encouraged to designate an Athletic Health Care Administrator, and create an administrative structure that will ensure that the Athletic Health Care Administrator, not the coach or athletic administration, will serve as the primary supervisor over all medical personnel and medical decisions related to athlete health. This structure is designed to help prevent conflicts of interest between the team, coach, and organizational motivations with what is truly in the best interest of the athlete (6). Similar guidelines have been published in regard to the chain of command for all college and high school sports. These guidelines discuss the importance of a designated team or school physician to whom all medical staff report in regard to medical decisions and return to play (1,18,19). As former Duke University Team Physician Frank Bassett, MD used to say, “the coach decides who plays, but the doctor decides who does not!” Clearly the decision tree regarding return to play is complex and must take into account the various influences and pressures, including the needs and wishes of the school, team, coach, parents, medical team, and the athlete. Communication between all contributors is essential. Ultimately, all decisions need to be athlete focused with the best short- and long-term impact on athlete health taken as a priority.
Team Building and Team Optimization
As noted previously, sports medicine teams are interdisciplinary teams consisting of physicians, allied health care professionals, athletes, parents, coaches, athletic trainers, and more. It is exciting and a privilege to have relationships with athletes at all levels, and an honor to be serving on the sidelines at events. For many health care providers, it is a desirable and highly sought-after goal to become a member of the sports medicine team. One of the essential foundations when selecting a sports medicine team is a sense of shared mission and purpose. An additional key to team building is determining which positions need to be core to the team and which should serve a more ancillary role. Too many professionals in the training room can be overwhelming to athletes. The core team needs may vary from sport to sport, or even from athlete to athlete.
The head team physician should serve as the leader of the sports medicine team and recruit additional team members as the need requires. Each team member is chosen for a specific role, brings a unique set of skills, and should be willing to share in the mission of athlete-centered care (15). A consultant may have the best reputation in the world, but if they are unwilling to understand and navigate the unique facets of athlete care and sports teams, another consultant may be best for the team. When building and optimizing the sports medicine team, it is important to look for characteristics in each provider which will be essential to the future success of the team: commitment, collaboration, communication, and continuity. The loss of any one of these four pillars can lead the team to collapse.
Collaboration involves maximizing the contributions of each individual. Learning and capitalizing on the individuals' different skill sets, backgrounds, and passions will lead to a stronger team. The team leader can maximize each member by giving credit and appreciation for all contributions including in front of the athlete, coaches, and administrative leadership. The optimal sports medicine team functions with shared decision making and collaboration among team members. There must be trust among team members to disagree and discuss approaches, and the head team physician needs to be open to alternative ideas and approaches. Ultimately, the roles and responsibilities of each team member must be clearly defined, and each team member should be accountable for their role. One challenge that can occur is the dichotomy between a consensus-based decision and a unilateral decision. Though unilateral decisions should be rare, and the optimal sports medicine team functions with shared decision making and collaboration among team members, each team member needs to be able to respect and support the decision-making structure. There has to be a head team physician who can break ties and make final decisions in a timely fashion when a critical health care decision arises.
Open communication through the sharing of praise, credit, thoughts, ideas, concerns, and solutions is the center of effective collaboration. The leader should consistently reiterate and model the team mission and priorities so that they are clear to all members of the team. The team leader should strive to be open-minded and available to discuss new ideas or issues. By continuously asking for ideas and feedback, as well as promoting critical thinking and creativity, the team will grow accustomed to open communication, which will promote the collaborative atmosphere. Conflicts or disagreements will arise within all teams. However, well established patterns of open and effective communication with inherent respect among all team members will help in resolving conflicts quickly, confidently, and constructively. Reiterating the mission and focus of the athlete will diffuse most disagreement and open the door to a win-win solution.
One measure of the success of the sports medicine team is the continuity of membership. If communication, collaboration, and commitment are maintained, then most of the sports medicine team will want to stay involved. Continuity of care is important for maintaining positive relationships within the athletic team, the sports medicine team, coaches, and administration. Consistent critical review of team members provides positive and constructive feedback to help every individual and the team improve. Creating an environment of appreciation and positivity will retain quality staff who are committed to the team mission. Practicing emergency response scenarios or participating in alternative team building activities can be fun and effective techniques to keep things fresh while building comradery and preparing the team for true emergent side-line situations. Team-building lessons can be learned and applied from the military, as well as successful sports teams, sports organizations, businesses, and service organizations.
Managing Return to Play and Psychologic Stresses of Injury
Sports medicine is unique and involves complex relationships with athletes, coaches, and parents, which may become most apparent with the decision of return to play following injury. Various members of the team may have their own motivation regarding return to play. The outcome of a game should never affect the team physician's decision to allow an athlete to return to play. The team physician must have a sound understanding of the return to play principles and maintain the highest ethical standards. Principles, guidelines, and standards should be clearly communicated to the entire medical team, athlete, parents, and coaches. Shared decision making with open input from all members of the team should be encouraged making the return to play decision as collaborative as possible. The final decision should ultimately be made by the head team physician with all perspectives and input taken into account.
Return-to-play decisions are usually based on the return of full functional range of motion, strength, and ability, as well as the psychological readiness and desire of the athlete to return to sport. Functional testing can be done with parents or coaches present so that they can witness any disability or functional impairment in performing sport-specific tasks. Return to play also depends on the type of sport, timing in the season, level of play, position, limb dominance, and efficacy of bracing, taping, and padding. Underage athletes should always have their parents as escorts for return-to-play discussions and decisions. However, psychological assessments of readiness are best performed privately to allow the athlete to sincerely and honestly voice any cautions or concerns regarding return to play in an arena not influenced by the presence of parents or coaches.
Studies have shown that psychological stresses and mental health play significant roles in outcomes following musculoskeletal injuries (20). While athletes may be hesitant to express emotions following injury for fear of being perceived as weak by parents, coaches, or teammates, verbalizing emotions related to injury is associated with better outcomes (20). Both parents and coaches can have a large impact on the psychosocial aspect of an athlete, and the team physician must recognize and help mediate this impact. The importance of psychological readiness regarding return to play has been increasingly emphasized in various return-to-play programs. Motivations and pressures on the athlete to return to sport will vary depending on whether the athlete competes in the community, high school, college, national, or professional level. Regardless, inadequate psychological readiness for return to play has been associated with poor performance and increased risk of injury recurrence. Based on this awareness, the sports medicine team needs to look beyond musculoskeletal function and be more focused on the athlete as a whole when considering return to play decisions.
Adolescents and adults respond differently to surgery and injury. Parents play a critical role in adolescent athletes’ psychological well-being, which is associated with athletic success (5,20). The team physician may encourage parents to provide positive and realistic feedback, and to focus on effort rather than outcomes. Those athletes who are forced into participation may have negative experiences with the sport, including anxiety and greater risk of injury. This is important to remember for younger athletes, especially those who may feel pressure to earn college scholarships, or elite athletes training toward participation on a national team. Once athletes reach legal age, despite many parents remaining involved, the team physician must remember the patient is legally in charge of their own decision making and respect that autonomy.
Coaches also can have a dramatic effect on an athlete’s psychology through their actions, words, and nonverbal communication. The manner in which a coach delivers verbal feedback can be as important as actual words. The team physician should be aware of psychological readiness to return to play and help facilitate understanding and communication between coaches and athletes. Optimizing coach-player communication, as well as coach-physician communication, can decrease the number of sports injuries, increase performance, and improve the psychological health of the athletes (20).
Successful outcomes are predicated upon clear communication and goal-oriented rehabilitation. Guidelines and expectations should be established at the beginning of the season for all players, coaching staff, and the medical team. While there may be external pressures to return to play from students, fans, boosters, politicians, agents, sponsors, team owners, and others, the athlete should not be cleared to return to play until physically and mentally ready for training and competition (20). The keys for successful return to play include setting realistic expectations early, encouraging a culture that facilitates open athlete discussion with constructive feedback, assuring that the athlete is not only physically but psychologically ready to return to play, and always placing the athlete’s well-being first, regardless of external economic or societal pressures.
Leadership skills are an essential component of being a successful and effective team physician at any level of sport. Core skills include team building; shared decision making and collaboration; open communication and trust; integrity and self-less service; as well as mindfulness and a shared mission with an athlete-first focus. The head team physician must use technical skills and knowledge, as well as self-awareness, communication, and collaboration to successfully navigate the complex environment surrounding the athlete. As the leader of the sports medicine team, maintaining strong relationships with all members of the medical team, the coaching staff, the athletes, and their families is essential and will aid when making difficult decisions such as return to play. Most of all, the team physician should have a strong and professional relationship with the athlete and be a role model to the entire sports medicine team regarding the athlete-first focus of care. When leadership skills are optimized, the sports medicine team will be in the best position to provide optimal care for each individual athlete and team.
The authors declare no conflict of interest and do not have any financial disclosures. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Army, the Uniformed Services University, Department of Defense, nor the U.S. government.
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