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Editor,—The article by Dr Waddington and others1 on the problems surrounding the appointment and qualifications of these personnel will come as no surprise to all who work with team sports in this country. It is a familiar story and the points raised are valid and in many aspects wholly desirable.
However, before it becomes established dogma that all club doctors must possess a postgraduate sports medicine qualification, may I raise a word in the defence of the generic GP. In doing so I confess freely to being a member of the one sport, one club breed described in the article, albeit in a different sport from Association Football.
What I believe a club and its players need from their medical advisor is immediate access to a medical opinion. The subject of the opinion is of course often sports injuries or sports related illness, but far from exclusively so. A local GP living and working in the immediate vicinity of the club is ideally placed for this task, which can at times be very demanding, at least in the urgency of the request. Club managers always need to know yesterday about the fitness of their players. Enthusiasm for the club can mitigate against the stresses of this demand which can often intrude into family life as well as work. Of course in providing that opinion, doctors must know their limitations, practising only within their competence and referring on appropriately for specialist opinion when required. But is this not part of a GP's standard job description? I suspect that all club doctors have built up a network of appropriate specialist colleagues, including sports physicians, who are rapidly able to provide that second opinion when required. It is this ability to use one channel for all its medical needs that is so valued by a club and its players.
I believe that the limited horizons of one club and its players would soon bore many doctors who have taken the time and commitment necessary to complete a postgraduate sports medicine qualification. Equally, very few clubs have the resources to adequately remunerate someone who has taken such a step. Such doctors will inevitably wish to practise their art in a wider environment for both intellectual and financial reasons.
This is not to say that the club doctor should ignore the need for further education in the field of sports medicine. All GPs should respond to their educational needs by attending courses and lectures in the appropriate area. There is plenty of excellent provision available. In my experience, clubs are sympathetic to and supportive of this need. Maybe in time there will be enough doctors with specialist qualification to supply the demand, but, at club level, it is always likely to be as an add on to an existing job, and GPs are likely to fill the role. I believe that they can do it well and safely. Is the GP who runs the practice diabetic clinic any less valuable for lack of MRCP?
The article raises other important issues about the tensions on a club doctor arising from his role as employee of the club and the needs of his patients, the players, which are certainly very real and need careful handling. But this letter is just to sound a note of caution before the “essential prerequisite” of postgraduate qualification demanded by Michael Cullen's Commentary is taken as received wisdom in the field.
We are pleased that our paper on the above subject has generated a lively discussion and in this context we welcome the letters from Rob Mackay and Claire Hay. Both letters raise issues to which we would like to respond.
Dr Mackay appears to accept most of our findings, and the central point of his letter is to “sound a note of caution” before a specialist sports medicine qualification is required as an essential prerequisite for club doctors. In this regard, Dr Mackay's “caution”, as he makes clear, is aimed more at Michael Cullen's commentary on our paper than on the paper itself. In our own paper, we argued that possession of a specialist qualification (or the willingness to study for one) “should be specified as a desirable (although not, in the short term, essential) attribute of candidates for the post of club doctor”.
However, it is fair to say that, in the longer term, we would like to move towards a situation in which such a specialist qualification is regarded as essential. Our thinking in this regard is based on a view that is, we think, fairly generally accepted: when seeking any service, whether from a doctor, lawyer, or motor mechanic, it is better—other things being equal—to have that service provided by someone who is more, rather than less, well qualified.
We should emphasise that we do not disagree with Rob Mackay's suggestion that a background in general practice is appropriate for a club doctor; what we are suggesting is that it would be advantageous if the GP acting as club doctor also had an appropriate specialist qualification in sports medicine in much the same way that the crowd doctor in football is required to hold the Diploma in Intermediate Medical Care.
Rob Mackay does raise an important issue when he suggests that the club doctor who dealt only with the limited range of injuries and illness in a single club would be likely to find this insufficiently challenging intellectually. We agree. However, there are two rather different issues involved here. The first is whether a doctor has a specialist qualification; the second issue is whether his (occasionally her) appointment is full time. A full time appointment would indeed present a limited range of clinical problems and may well result in professional dissatisfaction, but we do not argue for full time appointments; rather we argue that those who are appointed (whether full time or part time) should be appropriately qualified. This is a rather different issue.
Claire Hay's letter is much more critical of our research, suggesting that our paper is “inherently biased”. Before we respond to this general criticism, we would like to respond to the major part of her letter which points out that we make no comparisons of the methods used by chartered and non-chartered physiotherapists and their outcomes, nor do we compare the performance of club doctors who have, and those who do not have, specialist qualifications. She is of course correct, although this is hardly a criticism of our paper, because we made no claim to making such direct comparisons of quality of care. The objects of our paper were clearly set out in the title—to examine the qualifications and methods of appointment of club doctors and physiotherapists and to raise some problems and issues relating thereto. This we did. Claire Hay's claim that unchartered physios and doctors without a specialist qualification can provide good quality care is wholly irrelevant, for we made no claim to the contrary. In so far as our paper has any bearing on quality of care issues, it does so only indirectly and is based on the point made earlier, namely that other things being equal (and we are aware they often are not equal) it is better to have care provided by practitioners who are more qualified, rather than by those who are less qualified. We do not imagine that Claire Hay would disagree with this principle; after all, it is precisely the fact that medical practitioners hold a formal qualification in medicine that differentiates them from lay members of the public.
Claire Hay claims more generally that our paper is “biased” and she goes on to suggest that “published quotations from the semistructured interviews are of an emotive nature” and the “quoted questions posed by the interviewer are clearly of a leading nature”. We are at a loss to understand these criticisms. Which quotations does she have in mind? She really needs to be more specific; for our part we have read and reread our article and simply cannot identify any quotations that might properly be considered “emotive”. The quotations that we used from our interviewees were used not with a view to sensationalising our report, but because they reflected a pattern of making appointments that we found repeated again and again in the clubs in which we interviewed.
We are similarly surprised by Claire Hay's claim that our questions were “clearly of a leading nature”. Which questions does she consider leading? Most of our questions were either open ended, such as “Could you tell me how you got the job as club doctor?”, or were straightforward questions such as “Were you interviewed for the post?” or “Do you have a specialist qualification in sports medicine?” Does she regard these as “leading questions”? It should also be remembered that our paper was based not just on these interview data but also on the questionnaires that were sent to club doctors, and it is important to note that the data from these confirmed the findings from the interviews.
Finally, Claire Hay asserts that the “bias” that she claims to detect in our paper arises from the fact that our study was funded by an interested party, namely the Professional Footballers Association (PFA). She has no evidence for this claim. In fact, all aspects of the research were carried out wholly by us, with no input and certainly no interference from the PFA. The PFA did not even see the interview schedule (neither, incidentally, has Claire Hay, despite her unsubstantiated claim about “leading” questions). Nor did the PFA see the questionnaire that we sent to doctors. Nor did they have any input into the writing of our report, or exert any pressure, direct or indirect, on us while we were writing it. Although the PFA have a legitimate interest in this matter, the report was wholly and exclusively our work and we are happy to take exclusive responsibility for our findings.
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