The main conclusions of our paper were that no significant unexpected
abnormalities were found on clinical examination of divers in the Scottish
Sub-Aqua Club, and that the questionnaire was the important part of the
screening assessment of divers. This remains the case regardless of how
the information is analysed.
In response to the questions raised by Philip Smith, only 391 divers
re...
The main conclusions of our paper were that no significant unexpected
abnormalities were found on clinical examination of divers in the Scottish
Sub-Aqua Club, and that the questionnaire was the important part of the
screening assessment of divers. This remains the case regardless of how
the information is analysed.
In response to the questions raised by Philip Smith, only 391 divers
responded "No" to all questions, and none had abnormalities on clinical
examination. All of the referrals to medical referees were prompted by
positive questionnaire responses, and the divers were assessed by doctors
with diving medicine experience. The interim step of clinical examination
by a non-diving doctor did not alter the final outcome.
Divers start training with SSAC by undergoing basic snorkel and
rescue training (as with most diving organisations) and may progress to
SCUBA training after a medical examination. They entered the SSAC system
during the snorkel training however, and in our experience GP's did not
fail divers outright before contacting SSAC headquarters or a medical
referee. It is not possible to confirm that all divers were referred in
this way, but it is reassuring that an analysis of the medical forms
following the introduction of a self certifying system has confirmed an
increase in the number of divers failing on the basis of questionnaire
responses alone.
It was necessary to include the repeat medicals in the analysis
because the introduction of a new system must be as effective in the
existing divers as it is in the new entrants. New medical conditions may
develop in the period between medicals, which can be up to five years.
Removing the repeat medicals from the analysis does not affect the final
conclusion, and confirms that the questionnaire is the most important part
of the screening process.
A new questionnaire system was introduced in March 2000 and analysis
of the short-term safety data has confirmed a slight increase in the
number of divers failing their medical assessment. A complete report will
be submitted for publication shortly. Additionally, all forms submitted by
divers are now reviewed by diving doctors, and assessment is only
performed by doctors with diving medicine experience. This helps to ensure
a consistent application of the medical standards recommended by the UK
Sport Diving Medical Committee. There has been no change in the incident
pattern although it is too early to expect major differences to become
apparent.
It is worth noting that the role of routine medical examinations has
been questioned elsewhere, and that the number of diving accidents related
to medical conditions did not significantly change when compulsory
medicals were introduced in Australia and New Zealand [1]. The main
problem in assessing fitness to dive has been the fact that divers have
been assessed by doctors without diving medicine experience, and the
introduction of the new system has allowed this to be rectified. Divers
should not be falsely reassured by the value of a screening medical
examination performed by a doctor without diving medicine experience.
(1) Scuba diving medical examinations in practice: a postal survey.
Simpson G, Roomes D. Medical Journal of Australia 1999;171:595-598
Stephen Glen
Department of Cardiology, Edinburgh Royal Infirmary, Lauriston Place, Edinburgh, EH3 9YW
James Douglas
Tweeddale Medical Centre, High Street, Fort William.
Dr Stephen Glen and his coauthors conclude from an analysis of
medical records held by the Scottish Sub-Aqua Club (SS-AC) that routine
medical examination of sport divers can safely be replaced by a system of
self-declaration, with a questionnaire designed to indicate whether
referral to a doctor with experience of diving medicine is necessary. This
conclusion should be regarded as preliminary, howe...
Dr Stephen Glen and his coauthors conclude from an analysis of
medical records held by the Scottish Sub-Aqua Club (SS-AC) that routine
medical examination of sport divers can safely be replaced by a system of
self-declaration, with a questionnaire designed to indicate whether
referral to a doctor with experience of diving medicine is necessary. This
conclusion should be regarded as preliminary, however, because the data
were not disaggregated sufficiently to allow the detective power of
questionnaires and routine medical examinations to be compared. In
addition, there are inherent statistical biases in the SS-AC data that
have not been addressed.
The risks associated with discontinuing routine examinations could
have been investigated by quantifying the number of cases in which
disqualifying conditions were found in medical examination but not
declared in the prior questionnaire. However, the authors' listing of
abnormalities recorded at examination apparently includes those due to
conditions declared in the questionnaire. Similarly, the listing of formal
referrals to approved Medical Referees does not indicate how many were
initiated by a questionnaire response and how many as a result of an
examination finding only. Crucially, the cases which were ultimately
failed were not classified by type of disqualifying condition or by stage
at which the condition was first detected. The prevalence of disqualifying
conditions that subjects were unaware of, or otherwise did not declare,
prior to the examination is therefore obscured.
Under the SS-AC system during the study period, general practitioners
could certify candidates with certain conditions ‘unfit to dive', without
referring them to a Medical Referee. Since a certificate of fitness to
dive was a prerequisite of membership of the SS-AC, these subjects would
not join the organisation and details of their medical examination would
be unlikely to enter the medical database. The discriminatory value of
medical examinations may therefore have been underestimated. It may have
been rare that subjects were failed outright without a Medical Referee
being consulted (when their details would be more likely to enter the
database), but that eventuality should be considered and, if possible,
quantified.
The data set is also biassed by the inclusion of ‘repeat' medicals
(routine periodic reexamination of divers) which comprised nearly 30% of
the records analysed. This probably involved some degree of
pseudoreplication, but even if there was only one record for each
individual, one might expect a lower prevalence of disqualifying
conditions among a group who had previously been certified ‘fit', than
among first-time applicants. The prevalence of disqualifying conditions
among new applicants therefore needs to be estimated separately.
The authors may be correct that routine sport diving medical
examinations are unnecessary, but if policy on such an important safety
issue is to be changed, the justification for doing so should be clearly
demonstrated and qualified according to the limitations of the available
data.
I was conducting research for my Masters degree in Counselling and
Guidance. My interest is in the approach adopted by Fitness
Leaders/Instructors when dealing with those wishing to get started with
exercise.
My experiences, and consequent understanding, of the typical approach used
in Fitness facilities is that the Fitness Leader adopts an 'expert' role
when dealing with beginners to exercise and underestimates the issu...
I was conducting research for my Masters degree in Counselling and
Guidance. My interest is in the approach adopted by Fitness
Leaders/Instructors when dealing with those wishing to get started with
exercise.
My experiences, and consequent understanding, of the typical approach used
in Fitness facilities is that the Fitness Leader adopts an 'expert' role
when dealing with beginners to exercise and underestimates the issue of
ambivalence that there seems to be with anyone considering a change of
behaviour, such as taking more exercise or giving up smoking, etc.
I strongly believe the development of skills for these helpers should be
toward those of a counselling nature. Listening skills develop greater
empathy and empathy helps individuals understand their ambivalence to a
greater degree. This, in turn, can lead to a resolution of the ambivalence
that seems to hold many in a state of indecision when they consider taking
up exercise.
I find little research to suggest that counselling for exercise has
involved little more than information and advice-giving. The process of
helping to facilitate change very often calls for much more than this,
including a respect for autonomy, adoption of non-judgementalism,
genuiness and empathy, all of which are key and core counselling
qualities.
Fitness Instructors might also do well to ask themselves why they got into
the industry. Many say that they love to help others get fit, but here's
the paradox: those who appreciate their expert advice are generally more
ready to exercise in the first place and need little help in doing so.
Those who are less ready seem to be in most need of help with the change
of behaviour and this requires a whole different approach that matches the
mindset of this group.
To really 'help' and really make an impact on the greater number of those
who do not exercise, Fitness Leaders need to re-address their whole
understanding of the issue of exercise 'counselling'.
We welcome Dr Boyce's letter as a useful contribution to the debate
which our article has generated. Dr Boyce is quite correct to raise the
issue of medical litigation. As the American College of Sports Medicine
pointed out as long ago as 1991, what it called "the litigation epidemic"
had at that time already "begun to engulf sports medicine" in the areas of
negligence and malpractice, informed consent, counselling, re-en...
We welcome Dr Boyce's letter as a useful contribution to the debate
which our article has generated. Dr Boyce is quite correct to raise the
issue of medical litigation. As the American College of Sports Medicine
pointed out as long ago as 1991, what it called "the litigation epidemic"
had at that time already "begun to engulf sports medicine" in the areas of
negligence and malpractice, informed consent, counselling, re-entry to
play decisions and other matters [1]. It is probable that we shall in
future increasingly see such cases in the UK and the club doctor without
an appropriate specialist qualification might be held to be more at risk
in such cases.
Dr Boyce is also correct to draw attention to the fact that, for the
past ten years, the "crowd doctor" at professional football matches has
been required to hold a recognised specialist qualification in Immedicate
Medical Care. The fact that club doctors are not required to hold a
comparable and appropriate specialist qualification is an anomaly which
needs to be addressed as a matter of urgency by sports medicine
authorities, by clubs and by the Football Association. It goes without
saying that he is also correct to point to the need for football clubs to
adopt more realistic policies towards safeguarding their major assets,
namely the health - and therefore also the playing ability - of their
players.
Finally, we fully accept that, as Dr Boyce suggests, the situation
which we documented in relation to professional football may not be unique
to that sport. We agree that there is a need to investigate all aspects of
the provision of medical and physiotherapy care in other sports. In this
regard, your readers might be interested to know that two of our
colleagues at Leicester, Dr Ken Sheard and Dominic Malcolm, are now
carrying out a similar study to our own, but in Rugby union.
1. Cantu, R C and Lyle, J M (eds). ACSM'S Guidelines for the Team
Physician, Lea and Febiger, Philadelphia and London,1990.
Can I begin by expressing my appreciation for the introductory free
access to the journal since its launch on the web earlier this year.
This year I have undertaken an intercalated degree in Clinical Mecine
which has been offered at Glasgow University Department of medicine and
therapeutics for the past 4 years. Over 60 of my fellow students opted to
do the same. We each however opt to do a specialist module in a...
Can I begin by expressing my appreciation for the introductory free
access to the journal since its launch on the web earlier this year.
This year I have undertaken an intercalated degree in Clinical Mecine
which has been offered at Glasgow University Department of medicine and
therapeutics for the past 4 years. Over 60 of my fellow students opted to
do the same. We each however opt to do a specialist module in addition to
a common core course. The options include cardiovascular studies,
clinical neuroscience and cancer studies amongst others. I chose to do
Sports Medicine largely a consequence of my own interest and participation
in sport. Indeed participation in sport was a common factor amongst the
ten students in this module.
Admittedly many of us felt this, compared to some of the other
modules, would not be a particularly taxing option. Our reputation a
'slackers' amongst the rest of the year group was evident. As far as they
were concerned we were lectured in fun things whilst they grappled with
the serious issues at the cutting edge of medical research.
However whilst I have thoroughly enjoyed the lectures this was by no
means the easy option and I agree wholeheartedly with Paul McCrory that it
is about time attitudes changed.
Who says there are not serious issues in this field:
Consider the dilemma of the physician who has been pleaded with to give a
pain-killing injection to a young player with the risk of more serious
damage because an international scout will be at this match and this may
be his only chance to make an impression
The responsibility, swift judgement and strength of character required
when faced with the head-injured player who knows he will be out for a
whole season if he comes off, and then of course there's his coach...
The elite athlete has emerged as an individual with specialist
medical needs and we need specialist sports medicine physicians to respond
to that.
But then the field of sports medicine goes far beyond these more
traditional roles into a wide range of other specialties:
Cardiology;Respiratory Medicine; Gynaecology; Rheumatology; Neurology to
name but a few of the areas our lecturers have explored. We need
specialists who can advise in each of these areas but to enable them to do
that we need to provide them with the necessary evidence-base.
What has been most evident throughout is the requirement for more
well-conducted research and clinical guidelines based on this in this
field. We are a generation of medical students for whom the term Evidence Based Medicine is
used as commonly as coronary heart disease. My fellow students this year are involved in
researching areas as diverse as the thrombolytic response and
contrastingly platelet activity during exercise ( surprisingly there are
still no definitive answers here); the role of strength training in
rheumatoid arthritis; the relationship between knee injuries in female
footballers and the menstrual cycle; the barriers to exercise in cardiac
rehabilitation patients to name but a few.
I may only be at the conception of my medical career but I feel I
have had a valuable insight into the challenge and diversity presented by
this field and the great future potential it yields and I welcome a future
of changed attitudes and a more formal recognition of this specialty.
I read with interest the paper by Waddington et al,[1] highlighting
the inadequacies of the football club doctor system in Britain. This paper
confirms the situation that many people already knew to exist.
Advertisements for club doctors are rarely published in medical journals
and are normally appointed on a “who you know” basis. It is also
particularly disappointing, that in a time when the specialty of...
I read with interest the paper by Waddington et al,[1] highlighting
the inadequacies of the football club doctor system in Britain. This paper
confirms the situation that many people already knew to exist.
Advertisements for club doctors are rarely published in medical journals
and are normally appointed on a “who you know” basis. It is also
particularly disappointing, that in a time when the specialty of Sports
and Exercise Medicine is being established in this country, the majority
of doctors working in contact with professional footballers have no
qualifications or little experience in the specialty. However, this
situation is not confined only to football clubs. I suspect that this may
also be the case for rugby clubs and many sporting associations.
One aspect not mentioned in the paper is the subject of medical
litigation. Although doctors involved in club football will hopefully have
arranged medical defence cover, if a situation arises where a player's
sporting career was threatened by medical mismanagement, the doctor
involved, with no professionally recognised sports medicine qualification,
could possibly be found guilty of medical negligence. With the amount of
money involved in professional football this could lead to dire future
consequences for the medical career of the practitioner involved.
After Hillsborough[2] following a report commissioned by the Football
League, the concept of the “crowd doctor” was introduced whereby any
doctor involved in the medical care of the crowd at a football stadium
would require to possess at least the Diploma in Immediate Medical
Care.[3] Prior to this the situation was similar to that of the present
club doctor system where few doctors held any recognisable qualifications
or training in medical emergencies and resuscitation.
A similar recommendation by sports medicine authorities is required
to enhance the quality of service provided to football clubs and increase
the stature of the specialty. However, it is not a one sided situation.
Football clubs must realise the importance of a medical team in looking
after their prime assets, the players. Advertising jobs in medical
journals, insisting upon experience and qualifications, adequate
remuneration and the provision of job descriptions and contracts all
require to be implemented. By working together to improve the current
situation a service can be provided that both professional football
players and the medical profession will have confidence in.
References
(1) Waddington I, Roderick M, Naik R. Methods of appointing and
qualifications of club doctors and physiotherapists in English
professional football: some problems and issues. Br J Sports Med 2001;35:48-53.
With regards to the excellence of the Australians in the last
Olympics, a small reposte is required. We need to examine Darwinism to
fully understand this concept. As you pointed out the Aussies did
exceptionally well in the water but have yet to fully evolve and are still
swimming. The Brits on the otherhand are further along the evolutionary
scale and have realised that to get from one island to...
With regards to the excellence of the Australians in the last
Olympics, a small reposte is required. We need to examine Darwinism to
fully understand this concept. As you pointed out the Aussies did
exceptionally well in the water but have yet to fully evolve and are still
swimming. The Brits on the otherhand are further along the evolutionary
scale and have realised that to get from one island to another you don't
need to swim, you can sail. And as for rugby (Union the proper code) I do
believe the English beat them recently. The other code attempted a
"world" cup recently but each side was made up of Australians and was
starting to resemble the US's version of a world series.
I read with great interest the article by Waddington, Roderick and
Naik regarding the appointment and qualifications of club doctors and
physiotherapists in English professional football.
Further to the messages put over in the text I feel that from a
physiotherapy side, just being chartered is not enough. In my experience
many professional clubs are employing chartered physiotherapists, s...
I read with great interest the article by Waddington, Roderick and
Naik regarding the appointment and qualifications of club doctors and
physiotherapists in English professional football.
Further to the messages put over in the text I feel that from a
physiotherapy side, just being chartered is not enough. In my experience
many professional clubs are employing chartered physiotherapists, straight
out of University to look after their academies and so comply with the
first regulations of employing Chartered physiotherapists.
These physiotherapists, have little (if no) experience of managing
the injuries of professional sport, and are been given the responsibility
of looking after the medical needs of junior footballers. There is a move
afoot within the Association of Chartered Physiotherapists in Sports
Medicine to ally with the National Athletic Trainers Association in
America with the possibility of producing Sports Rehabilitation and
athletic trainers within this country as recognised therapists to work
within sports.
I would urge all involved in the employment of physiotherapists
within sport to look for suitable candidates who have a good understanding
of the management of sports-related injury.
This will mean that the pay scales within professional football, on
the medical side, will need adjusting accordingly.
At the time when clubs are worrying about the abolition of transfer
fees - stating that fees are linked to the "skill level" of the player. I
feel the same system of financial compensation be applied within the
medical set-up, thus raising the standard of medical back up within
soccer.
Ian Horsley MCSP SRP
Lecturer In Sports Rehabilitation
University of Salford, Manchester, UK
Authors' Reply:
The main conclusions of our paper were that no significant unexpected abnormalities were found on clinical examination of divers in the Scottish Sub-Aqua Club, and that the questionnaire was the important part of the screening assessment of divers. This remains the case regardless of how the information is analysed.
In response to the questions raised by Philip Smith, only 391 divers re...
Dear Editor,
Dr Stephen Glen and his coauthors conclude from an analysis of medical records held by the Scottish Sub-Aqua Club (SS-AC) that routine medical examination of sport divers can safely be replaced by a system of self-declaration, with a questionnaire designed to indicate whether referral to a doctor with experience of diving medicine is necessary. This conclusion should be regarded as preliminary, howe...
I was conducting research for my Masters degree in Counselling and Guidance. My interest is in the approach adopted by Fitness Leaders/Instructors when dealing with those wishing to get started with exercise. My experiences, and consequent understanding, of the typical approach used in Fitness facilities is that the Fitness Leader adopts an 'expert' role when dealing with beginners to exercise and underestimates the issu...
We welcome Dr Boyce's letter as a useful contribution to the debate which our article has generated. Dr Boyce is quite correct to raise the issue of medical litigation. As the American College of Sports Medicine pointed out as long ago as 1991, what it called "the litigation epidemic" had at that time already "begun to engulf sports medicine" in the areas of negligence and malpractice, informed consent, counselling, re-en...
Can I begin by expressing my appreciation for the introductory free access to the journal since its launch on the web earlier this year.
This year I have undertaken an intercalated degree in Clinical Mecine which has been offered at Glasgow University Department of medicine and therapeutics for the past 4 years. Over 60 of my fellow students opted to do the same. We each however opt to do a specialist module in a...
I read with interest the paper by Waddington et al,[1] highlighting the inadequacies of the football club doctor system in Britain. This paper confirms the situation that many people already knew to exist. Advertisements for club doctors are rarely published in medical journals and are normally appointed on a “who you know” basis. It is also particularly disappointing, that in a time when the specialty of...
Dear Editor
With regards to the excellence of the Australians in the last Olympics, a small reposte is required. We need to examine Darwinism to fully understand this concept. As you pointed out the Aussies did exceptionally well in the water but have yet to fully evolve and are still swimming. The Brits on the otherhand are further along the evolutionary scale and have realised that to get from one island to...
Dear Editor
I read with great interest the article by Waddington, Roderick and Naik regarding the appointment and qualifications of club doctors and physiotherapists in English professional football.
Further to the messages put over in the text I feel that from a physiotherapy side, just being chartered is not enough. In my experience many professional clubs are employing chartered physiotherapists, s...
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