Physicians who treat patients with sports injuries face great pressures because of conflicting team and personal goals. The nature of the patient-physician encounter is changing. Paternalism, in which the physician assumes an autonomous role in selecting treatment, has been the predominant model. Informed decision making gives the patient ultimate responsibility. In shared decision making, an amalgam of these models, there is mutual responsibility for treatment decisions; now physicians can address injuries and match best clinical outcomes with patients’ values to decrease treatment errors and morbidities. Open communication between patient and physician is essential, but there is a discrepancy between physicians’ perception of their communication effectiveness and the reality. Several decision-making aids are available to help physicians promote good communication. (J Musculoskel Med. 2008;25:63-69)
| This is the second in a special series of articles, invited to celebrate our 25th anniversary of publication, in which leading physicians discuss the key points of clinical decision making for common musculoskeletal problems, particularly in the primary care setting. |
“Primum non nocere.”
First, do no harm. It is branded on the intellect of all physicians, a maxim to protect patients, the crux of medicine. However, no field of medicine challenges this ancient Hippocratic precept more than sports medicine, which has earned its own subspecialty with distinct forces placing great pressure on the patient-physician decision-making process.
Take, for example, the following 2 patients. One, a 35-year-old all-star pitcher with dislocating peroneal tendons, elects to have them injected with a numbing medication and temporarily sutured to the skin to allow him to play in the World Series. The other, a 35-year-old research assistant with the same injury, opts to have his peroneal tendons stabilized surgically, requiring him to be immobilized while they heal.
The patients have identical injuries, but they receive strikingly different care. The former treatment is dictated by the American sports ideal that winning is everything, and the latter is dictated by an evaluation of various options, matched with patient values, aimed at achieving the best possible outcome.
Green Bay Packers quarterback Brett Favre and Baltimore Orioles shortstop Cal Ripkin, Jr, are professional sports icons partly because they decided to “play through” their injuries to “win one for the team.” However, they may have placed too much emphasis on their sport and let their good health slip by the wayside. They are not alone. Many athletes, amateur as well as professional, follow in the footsteps of these idols in upholding the time-honored conviction that there is no “I” in “team.”
The juxtaposition of team desires alongside individual desires creates a unique obstacle for injured athletes to overcome when these desires are at odds. The obligation that injured athletes feel to place the sport above self may serve better on the field than on the body. Pressures that injured athletes face include the need to return to their premorbid skill level, to return hastily, and to compartmentalize the effects of their injury emotionally.
This juxtaposition of team and individual goals essentially characterizes the unique needs of sports medicine patients. In addition, it places tremendous emphasis on the role of physicians in maintaining the Hippocratic aphorism by ensuring that the treatment rendered—which may harm the team—will do no harm to the individual.
In this article, we illustrate how sports medicine and other physicians may find help in upholding the antediluvian medical creed from the sharing of treatment decisions with patients. In the shared decision-making process, physicians may ensure that the decisions injured athletes make are based on thoughtful consideration of their unique needs, desires, and values and their relationship with the disease/injury state. Through this framework, physicians can enable injured athletes to self advocate and succeed both on and off the playing field.
