HPSM: Definition and models of care

HPSM can be described as the provision of an integrated model of medical care of the high-performance athlete, focusing on the maintenance and optimisation of health, well-being and competitive sporting performance under circumstances of high physiological and psychological stress.

It should be emphasised that the core principles, the duties of care and the codes of conduct of practitioners in HPSM are no different from any other field in medicine. However, it is unique in many aspects, including clinical challenges, working models and measures of outcome. One such challenge is protection of the health of high-performance athletes while they undertake substantial training loads that aim to optimise their performance, yet can in themselves induce ill health.

While many models of care exist, HPSM is often highly dependent upon an interdisciplinary model, involving a large and multifaceted Integrated Medicine and Sciences Support Team (IMAST). This team practices with fewer walls between professionals, aiming to provide a seamless system of support for the individual athlete. The composition of the IMAST varies according to the needs of the sport and the individual athlete. It represents an ideal way of working when high-performance is the agenda but can present challenges. Ensuring there is a cohesive and unified approach to the care and support of the athlete is a key necessity. Strict confidentiality issues mean that some ‘walls’ must still exist. The support team must have keen insight into the nature of their specific sport, and be trained and experienced in dealing with the specific physical, physiological and psychological requirements that the sport imposes upon the athlete. Successful engagement with third parties such as the coach and manager of a team often assists with the athletes' medical management. This interface is crucial but can be demanding. Ensuring that all parties act in the athlete's best medical interest is a key role of the physician. Therefore, the practitioner's skill set must include keen altruistic, interpersonal skills. Support staff share ideas, and respect technical and personal expertise boundaries while providing positive and constructive challenges to the methods and processes employed in the sport.

Roles of the sports physician in HPSM

The many roles of the physician start with ‘doing the simple things well.’ The physician acts as a ‘Medical Guardian,’ ensuring that optimal medical care is provided to the athlete, reducing the risk of injury and illness by preventive strategies, helping to prevent their exposure to inappropriate or harmful training practices, contributing to the safe optimisation of their training and recovery to enhance performance, and working hard to ensure that the athlete understands and adheres to antidoping codes (table 1).

The physician contributes to performance optimisation by leading and facilitating the cohesive working of the IMAST and working to establish illness and injury prevention strategies. They ensure there is rigorous attention to periodic evaluation,4 5 rapid diagnosis, early intervention and enhanced athlete compliance strategies and protocols. The role also includes identification of a network of specialists worldwide who may contribute to optimising an athlete's care and performance, implementation of athlete and coach education programmes, and development of audit systems. Having a clear insight into principles of exercise physiology, nutrition and psychology is vital in order to work with sports scientists to aid the development of optimised training and recovery strategies. Playing a role in research and innovation are both important and will be discussed in later in this series.

Developing a good patient-physician relationship is critical to having a positive impact on the athlete's healthcare. Accessibility, reliability, communication, concordance, trust and maintenance of confidentiality within a pressured team environment are all important in developing that relationship. Many athletes believe themselves invincible or feel they need to be perceived to be by others; many do not consider ‘health’ as a priority, and some perceive illness/injury/psychological issues as representing weakness. ‘Helping the hero’ can be a challenge; arguing the case for good health measures to optimise performance is often an effective strategy to promote adherence and compliance. In the current professional era, the athlete's consistent fitness to train and compete will often determine their funding or continuing salary.

Communication pathways in HPSM are crucial: between the athlete and individual members of the IMAST, with coaching and support staff and with the sport's governing bodies and management. This will help to promote concordance and unified strategies. Where conflict does occur, the practitioner must always adhere to their standard medical codes of ethics and conduct, and their duty of care to their individual patients.4 6 7 The Faculty of Sport and Exercise Medicine (UK) will shortly publish a ‘Professional code’ for SEM practitioners. International consensus on such documents would be invaluable.

Other challenges

There are many other challenges for the physician in HPSM. For example, decision-making and medical strategies in HPSM may be very different from in the recreational athlete. The timing of intervention may be different; for example, earlier when performance is affected even to a tiny degree, and/or timed according to the season's competitive schedule. The choice of intervention may be different; for example, surgical intervention may be preferred over non-surgical management if there is an earlier return to play with the former, even if no difference to the long-term outcome. All decisions are made by the athlete, after thorough counselling by the physician, as with any area of medicine. The physician may frequently have to make very difficult decisions in the context of protecting the athlete's health where competition is looming in the face of significant injury/illness. The scenario of ‘is the athlete fit, doc?’ is a common one—but it is important to differentiate between ‘medical fitness,’ defined as the athlete being safe to compete in an event, and ‘performance fitness,’ defined as the readiness and ability of an athlete to participate and to compete at a high level. The latter is not purely a medical decision and hence is beyond the remit of the HPSM physician alone.

Working environments in HPSM can vary from the conventional clinic setting within a hospital, surgery or training facility, to the side of a pitch, pool or other similar venue, a hotel room, or indeed by distance through telemedicine approaches. Travelling with the athlete and team necessitates training, experience and much preparation. The physician typically also contributes to non-medical duties that facilitate the smooth running of the team. At other times, athletes may be anywhere in the world, and the HPSM physician needs to facilitate care through distance communication and international medical networks.

Providing medical services to a sport includes attention not only to the needs of the individual athlete and the team as a whole but also to allied staff such as coaches. To this effect, the physician performs in an occupational health role. The physical stresses of travel and the mental stresses of ‘surviving by results’ are frequent issues that arise in the management team. Declaring a coach unfit for work has implications not only for the coach, but also for the sport and the athletes. Nevertheless the duty of care remains focused upon the patient's needs.

Developing the field: research and innovation

High-performance athletes are often extraordinary human beings, physically, physiologically, psychologically and behaviourally. Responses to the intense stresses of training and competition can show high interindividual variation, often stretching our conventional understanding of physiology, psychology and medicine. There is a paucity of scientific literature on responses to training programmes that accurately replicates the demands of the high-performance athlete and on the specific medical issues and management of these groups. Much of our knowledge about treatment strategies comes from the literature based upon research in the general population. For example, do athletes who are training intensively metabolise and respond to medications in the same way as the general population? Given that aspects of bone and muscle metabolism are seemingly different from the general population, what is our expectation of response to treatment with conventional therapies when considering treatment and prevention of injuries? Is the pathophysiology of tendinopathies similar to those seen in the general population? Should they be treated differently?

Much research is needed to expand our scientific understanding of the high-performance athlete. Given the unusual working models involved, the broad remit involved for the physician and the current lack of evidence-based medical practice, there is also the need to innovate. These areas form the focus of the next two articles in this series.