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Evidence-based sports medicine
  1. Paul McCrory, Editor

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    We have the curse of living in exciting times. Sports medicine, for so long an art, is slowly but surely turning into a science. One of the important factors in this is the increased number of clinicians turning to this area as a vocation. In parallel, the development of academic sports medicine departments and the recognition by (some) insurers of the specialist value of sports physicians fosters this process.

    How do we progress further? Research, research, research. If sports medicine is to be seen as a viable and valid speciality then there must be an evidence base behind it. This is no different to where, for example, cardiology was 40 years ago or neurology 20 years ago. How do we foster the development of a culture that embraces EBM and recognises the need for research publication? Firstly, those individuals mentoring or supervising other clinicians have a duty to include research into individual performance goals. I am continually told in every county I visit that each person has a pile of cases “ready to write up”. The sentence usually continues “ … if I only had the time”. Time is not the issue, prioritisation is. If we see publication and research as a valuable means of increasing the evidence base of our specialty then it will happen. We are all busy. Why do some clinicians seem to write extensively and publish widely? Because they see it as an important priority. Right up there with working harder to pay for the BMW!

    For a number of years now, the thrust of BJSM has been to support an evidence based approach to reviews published within it. The next stage, currently in progress, is develop these reviews into a textbook. Two academic sports physicians, Domhnall MacAuley, the former editor of BJSM, and Tom Best from the US are putting together such a book. Although this is a small step given the number of sports medicine texts available, it is nevertheless a giant leap for our specialty. We can start to show the world just what our knowledge base is and where new research is needed.

    Other medical institutions, such as the various Royal Colleges, need to see sports medicine in an academic light. For far too long the view held of sports doctors (and especially team physicians) is that when confronted with the downed player on the field, the stock reply is something along the lines of “you will be OK” or “off you go”. In Australia, the ubiquitous “mate” is appended to such comments. This attitude in turn means that sports medicine is not held in high regard within sports and by coaching bodies. It is fair to say that this view is usually one of ignorance because once a top quality sports medicine team gets involved in a sport, then the injury outcomes are usually improved and few sports or coaches ever go back to the “good old days”. If sports medicine is not held in high regard then club administrators are certainly not going to pay for it!

    This to me is extraordinary. If I was a top soccer player being paid millions of pounds, then I would stop at nothing to have the best injury treatment available. Why should a professional athlete compromise? How can non-sports medicine trained doctors involved in teams continue this charade? I suspect that what will change things eventually is when a player sues the non-sports physician for inappropriate care and loss of earnings. Presumably the clubs themselves will be sued as well for appointing such doctors. The days of club doctors being chosen by the old boys network or by their friendship with the manager will pass. All professional clubs need to set appropriate standards and then advertise the medical position. Perhaps this should be an annual event. Certainly many professional clubs I have seen overseas conduct a formal performance appraisal of the medical services annually and determine the ongoing contract at that time. It sounds a frightening approach but when performed in a businesslike manner it works brilliantly.

    These days, this is also surprising, given that most professional clubs have chairmen/women who are in business and must surely understand the need to attract the best people in all areas—not just playing staff. Similarly for the clubs that are listed on the stock exchange. If I was a shareholder then I would certainly be raising the requirements and performance of the medical staff in a club at the annual general meeting. Why not? If a player plays badly he is widely castigated. If a club has a poor injury record and key players missing from big matches then questions should be asked. It may turn out that the coaching methods are to blame but nevertheless the process should be transparent. Each doctor at a professional club, particularly if salaried, should be subject to an annual performance review, demonstrating maintenance of professional skills and qualifications and ongoing involvement in the wider field of sports medicine. We do it for hospital doctors, why not in sport? The people with something to fear by this process are not the formally trained sports physicians but the part-time dabblers in sports medicine. It is time for a new beginning.

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