Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges

Although significant advances have occurred within athletic training and sports medicine in the last few decades, the fields can be traced back to the ancient Greek civilization and the establishment of the Olympic Games.1 Today, more than 900 different sports are practiced worldwide; however, not all of them have a physical component.2 In the United States alone, more than 7.6 million students participate in organized secondary school athletics, whereas in 2012, more than 420 000 student–athletes represented their colleges in athletic play.3,4 Athletics are part of the educational process for many students and add to the growth of the adolescent and young adult. Secondary school students involved in athletics with proper coaching demonstrate better academic achievement, miss less school, and learn lifelong lessons for success.5It is estimated that more than 1.4 million injuries occur yearly to athletes playing 9 sports at the secondary school level and approximately 209 000 yearly at the collegiate level across 25 National Collegiate Athletic Association sports (Datalys Center for Sports Injury Research and Prevention, written communication, April 15, 2013).6 These statistics take into account injuries that occur in both practice and game situations. In addition, an unknown number of injuries occur in nonscholastic sports, primarily as a result of overuse, either alone or resulting from the cumulative effects of nonscholastic and scholastic sports participation. As concerns grow over the number of musculoskeletal injuries, as well as life-threatening conditions and traumatic brain injuries such as concussions, more secondary schools and colleges are being forced to reevaluate the medical services they provide their athletes. Athletes at secondary schools with proper medical teams that include an athletic trainer sustain a lower incidence of injuries (both acute and recurring) than athletes at schools without athletic trainers. Athletes at secondary schools with athletic trainers incur more diagnosed concussions, demonstrating better identification of these injuries.7 According to the American Medical Association,8 “[T]he athletic medicine unit should be composed of an allopathic or osteopathic physician director with unlimited license to practice medicine, an athletic health coordinator (preferably an athletic trainer certified by the Board of Certification, Inc [BOC]), and other necessary personnel.” This document on best practice in sports medicine management brings together resources and views from 11 associations that promote the health and well-being of the student–athlete.Modern athletic training is a young, fast-growing health care profession9; thus, many physicians and administrators are still developing proper working relationships with and appropriate expectations for athletic trainers. Wide variations exist in the administration of sports medicine programs, chains of command, and selection and evaluation of the sports medicine team. Further, different athletic training settings (eg, secondary schools, small colleges, large colleges) vary widely in staffing, resources, and budgets.This consensus paper is written to assist superintendents of schools, secondary school athletic directors, college and university athletic department administrators, athletic trainers, and team and school physicians by presenting the best practices in sports medicine management in the secondary and collegiate settings. This document outlines important considerations regarding (1) duties and responsibilities of the athletic trainer and team physician; (2) supervisory relationships and the chain of command within the sports medicine team; (3) decision-making authority regarding approval for participation of student–athletes, as well as injury management and return to sport participation status after injury or illness; (4) administrative authority for the selection, renewal, and dismissal of related medical personnel; and (5) performance-appraisal tools for the sports medicine team. To date, these recommendations have been endorsed by the American Academy of Pediatrics, American College Health Association, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, College Athletic Trainers' Society, National Association of Collegiate Directors of Athletics, National Association of Intercollegiate Athletics, National Athletic Trainers' Association (NATA), National Federation of State High School Associations, and National Interscholastic Athletic Administrators Association.The term “patient-centered care” refers to the delivery of health care services that are focused on the individual patient's needs and concerns. The same concept, “athlete-centered care,” applies in sports medicine.10 Sports medicine physicians and athletic trainers are often presented with an ethical dilemma when an individual athlete's best medical interests conflict with the performance expectations of authority figures (eg, coaches, parents). In almost every circumstance involving the provision of medical care, the legal responsibility for the decision to allow an injured athlete to return to sports participation ultimately belongs to a licensed physician.11 In many situations, a physician who is a sports medicine specialist will authorize an athletic trainer to guide the rate at which an injured athlete is exposed to progressively increasing physical demands, but the physician is still ultimately responsible for the athletic trainer's clinical practice decisions.12The Appendix provides 10 principles to guide institutions and organizations in assessing existing administrative policies, procedures, and professional service relationships. Many of these principles correspond to concepts addressed by the BOC Standards of Professional Practice,13 the Code of Ethics of the NATA,14 and state medical practice regulations.All stakeholders who have as their primary focus the immediate and long-term health and well-being of the individual athlete should be involved in creating the specific institution's job descriptions and expectations for all sports medicine providers. This section outlines duties and responsibilities of the athletic trainer, as well as the team physician, who has ultimate responsibility for the care provided by the sports medicine team.The athletic trainer's principal responsibility is to provide for the well-being of individual athletes, allowing them to achieve their maximum potential. To accomplish this, athletic trainers work under the direction of the team physician or school medical director and generally are responsible for or actively involved withLike all health care providers, the team physician's first obligation is to the well-being of the athletes under the care of the sports medicine team. The physician's judgment should be governed only by medical considerations. The team physician should actively integrate his or her medical expertise with that of other health care providers, including medical specialists, athletic trainers, and allied health professionals.15 The team physician must have the ultimate authority for making medical decisions regarding the athlete's safe participation.The team physician has ultimate responsibility for the following duties15:A variety of models exist for sports medicine administration. Regardless of the model used, responsibilities should be clearly delineated, particularly in cases where the athletic trainer may have responsibilities other than medical care (eg, administrative and academic). This delineation should also define the supervisory relationships for each area of responsibility so that potential role conflicts are minimized and medical care is not sacrificed. Personnel charged with supervising the athletic trainer's various roles must recognize the roles and responsibilities they share with the athletic trainer. Deliberate attention must be given to avoid providing conflicting directions to the athletic trainer. All involved should realize that quality medical care must supersede other responsibilities in times of conflict. Clear delineation of responsibilities and supervisory roles should be documented in advance of employment and shared routinely as part of the hiring and selection process, with subsequent documentation becoming part of the employment contract. Typical models of supervisory relationships in sports medicine and the advantages and disadvantages of each are outlined in Table 1. Some institutions may use models that vary from or are a combination of those listed. Regardless of the model used, to avoid both perceived and actual conflicts of interest, in no case should there be a supervisory relationship in which members of the sports medicine team report to a coach. The athletic trainer should always report to the team or school physician.The potential for conflict of interest is omnipresent in sports medicine. When sports medicine team members provide care to athletes but are employees or appointees of the institution, the potential exists for medical decisions to be made that do not reflect the athlete's best interest. Regardless of the level of play, there is immense pressure toward medical clearance so that athletes can participate. However, to protect the athlete's welfare, the institution must establish a clear line of unchallengeable authority for the team physician and athletic trainer.16–18This line of authority affords sports medicine providers freedom from personal and professional bias in their ethical and medicolegal obligations to the athlete's health.19,20 The ability to act unencumbered fosters best-interest medical decisions for and by athletes.Institutional ownership of athletes' health and welfare can be demonstrated by including the athletic trainer or team physician in the senior-level athletic administration.12 This may be accomplished irrespective of the individual's appointment, whether through athletics, academics, university health services, or private practice. Freedom in their professional practice is ensured when neither the team physician nor the athletic trainer has a coach as his or her primary supervisor, and no coach has authority over the appointment or employment of sports medicine providers.12,16Shared responsibility for sports safety involves not just the sports medicine providers but the athletic administration, coaches, participants, and all associated with the athletic program.16 Medical decisions made in the athletes' best interests ultimately serve the team's best interests and thereby provide for the institution's well-being. The health care provider's primary responsibility is for the health and safety of the student–athlete; however, an additional responsibility is to protect the institution from liability. Shared responsibility means that roles and authorities must be distinct and well defined, so that each party performs duties unique to its discipline.The team physician as the final authority for medical clearance is well established in the literature and as a medicolegal principle.15,18,21 Even when return-to-play decisions are delegated to an athletic trainer by a team physician, the team physician is still ultimately responsible.13,16 The institution must affirm, in policy and protocol, that sports medicine providers are empowered to make best-interest decisions regarding the athlete at all times and in all settings, and these decisions are authoritative and not to be ignored.18 This organizational principle must be clearly communicated throughout, from the top down, both in policy and in practice.Communication is essential among the athlete, team physician, athletic trainer, coaches, strength coaches, parents or guardians, spouse, and administration regarding the approval for participation and injury and illness management. Sports medicine providers bound by HIPAA and FERPA must adhere to mandated guidelines. All communications must be legally compliant, accurate, and consistent. Communication policies should outline specific information that will be reported, by whom, to whom, and in what manner.Athletes bear responsibility to report injury and illness, whether related or unrelated to sport. The athletic trainer informs the team physician, with serial communications as warranted. The athletic trainer communicates the athlete's participation status, including indicated activity limits, to all coaches. Coaches should notify the athletic trainer when they suspect an athlete has suffered an injury, illness, or other adverse condition or is having a performance or conditioning problem.Return-to-play decisions should be made in an objective and unbiased fashion and not influenced by the emotion of competition.20 Participation decisions should be based on the best available evidence balanced with the sports medicine provider's experience and judgment and with specialty medical expertise as warranted.Using objective criteria, the sports medicine provider determines whether the athlete is allowed to participate based on medical history, clinical evaluation, and symptoms. Progressive return to play with conditioning followed by sport-specific activity, limited practice, and full practice before resuming competition provides an individualized approach that allows each athlete to advance at the appropriate rate given his or her condition and injury severity.22The athlete must be an active participant in medical decisions. Parents or guardians and spouse may be involved whether the athlete is a minor or emancipated.20 All sports medicine providers must clearly communicate the short-term and long-term risks associated with continued athletic participation.23 should include (1) and with as (2) that may return to play but the athlete's best medical and (3) that may return to play but are not in the athlete's best medical The information must be in and so the athlete can potential adverse including and make a responsible Sports medicine providers should the athlete's of the provided information and to make the necessary decision and that the athlete has the freedom to among the medical without or must be in medical clearance for participation. physicians and athletic trainers must recognize the of athletics to the may be in all the athlete, his or her and may and with the short-term and long-term than the sports medicine to the of the athlete's best medical trainers in the secondary school work in with team The team physician should be actively involved in the athletic health care across all teams the Athletic trainers to a working relationship with their team physicians so that decision making through a the relationship must be of and This relationship and shared of expectations of both allows the athletic trainer to be an of the team physician, under and following written policies and procedures, to provide the best care for the athletes. The team physician should be to communicate with the athletic trainer at and make athlete evaluation and care a to participate in sports must a physical The of is to for conditions that an athlete in sports to injury, or significant of a injury or illness without appropriate management or Athletic trainers or other school should from participation athlete who has not provided the school with documentation of the athletic trainers should have in written policies and regarding injury management and return-to-play decision-making These may be by the athletic trainer and team physician; the final written document should be by the team physician and by the school administration. all schools should have written that are practiced and followed in the of injury or The policies and should include specific return-to-play for and other injury and illness situations. should also that the team physician by the athletic trainer have the final and authority regarding return-to-play decisions. Although parents and guardians, coaches, and physicians can an athlete from of these can the decision of the team physician working with the athletic trainer to the The athletic trainer's administrative may be the athletic but medical should with the team the athletic trainer the interests of the school, or should be in medical decisions by the athletic director and other school administrators, provided the athletic trainer established policies and should be to report their injuries than the athletic trainer that an injury or illness of the athlete from part or all of the practice or the athletic trainer should have the authority to do Communication with the the athlete's parents or guardians, in the athletic is However, the injury with those should not be as their approval to the athlete of competition or practice. Parents or guardians and are not allowed to the athletic trainer's decision to or an athlete from participation to injury or athletes medical attention the sports medicine providers, is for the provider to the athletic trainer. of should be to and the expectations of the medical so a the provider and the school sports medicine providers and regarding the process and return-to-play decisions. When the provider the athlete to return to is the responsibility of the athletic trainer to to return to full participation. Athletic trainers should work with the physicians and communicate the athlete's trainers should recognize that physicians are the medical The athletic trainer has an ethical obligation to the well-being of the athlete and the of the when the athletic trainer is to document evidence of to the athlete's the athletic trainer should these concerns to both the and team or not the physician authority for the final decision on the athlete's return to play should with the team The team physician should be to the physician or with the athletic trainer that is necessary to the athlete's participation sports medicine should have unchallengeable authority for the health and welfare of the athletes. The athletic trainer should be as a athletic to provide for the and welfare of all athletes and have into administrative such as the quality and athlete This organizational a clear that the athletic director the of and has for athlete As a administrative appointment, the athletic director should not authority over sports medicine or sports medicine providers to a coach. The institution and all employees should be of and adhere to all state regarding the of all sports medicine athletic trainer should be and with to administrative by the athletic with to medical by the team physician, and with to academic by the academic department or coach should be the of an athletic trainer to concerns. All employment and for selection, evaluation, renewal, and dismissal should be outline of the specific job expectations should be provided and before the employment is When an athletic trainer has responsibilities to more than a clear delineation of of and performance-appraisal should be a athletic trainer is on individual should have significant responsibility in the hiring process within the policies and This developing the and appropriate and of the as well as the top to the In the of a athletic trainer, the athletic director and principal should be responsible for the hiring process, as well as the resources of the athletic trainer should be addressed in the These include but are not limited to evaluation, policies, and and of and should be the that final authority for medical decisions should with the team physician or his or her who be the athletic of the athletic trainer's employment should be based on a and evaluation process involving all of the job performance and The evaluation process should be by the team physician, athletic and each in their of responsibility as outlined in Table team physician should athletic training services, and of all duties associated with as an athletic trainer should be by the team physician, the athletic or principal or a combination of In of the the athletic director and team physician may for a The should not be the only in the process but can serve as a for and This conflicts and of of the athletic trainer's responsibilities will not the as the coach not the athletic trainer to his or her ability to coach or or the athletic trainer not the coach to or and an athlete's in which the athletic director is also a coach may a potential conflict of interest. In these the performance of the athletic trainer should be the responsibility of the team physician and a or (eg, athletic director or performance-appraisal process employees for performance in the following addition, the performance-appraisal process should include the may the or dismissal decision to the appropriate school or medical administration within a his or her performance or individual is as for athletic trainers in the athletic are an important for an for the sports medicine team. The of section is to provide a and resources that an to and the performance of sports medicine in a that the selection, evaluation, and to a sports medicine that the athletes' well-being. These tools should be in to the institution's or resources policies and performance-appraisal tools should be based on established and job for each athletic trainer and serve as a document providing an active process the The should be not just on performance but also on and professional should include individual performance and athletic training services and schools should have clearly written organizational that outline health care services and All members of the sports medicine team should have written job descriptions that serve as a for developing yearly and and job These should be and at the of the so that can for and their should provide and the the This written and process allows for and and and provide an objective for job and toward job can demonstrate and to athletic administrators and resources performance is best tools available for both and These tools should be for the specific (eg, health so that athletic as well as health care administrators the evaluation and the performance process should include not only tools but also a of the process and the roles of all of the team team physician, athletic coaches, athletes, and athletic and schools should the roles of the athletic director and the team physician in the evaluation should be for allowing athletes the to provide such as through an athlete a a or an The is to allow and athletes to provide in a that can to in care and members should be to provide of their performance toward their and job This with the model as and expectations may employees and should be to have with each to and for As the process should be and should take the than only at the important to sports medicine is the and clinical of young in programs, in the secondary school or should account for and clinical responsibilities as well as medical care Many sports medicine members have a or clinical role that should be for in the and in individual job at the of the and be to the These academic or clinical should be as part of the performance and addressed within the and and performance can be in on and should include a with an individual for each sports medicine team to professional and is important to the sports medicine in to individual from specific for the medical care of athletes provided in the sports medicine can for administrators to whether the and can that may the The are often to and other policy decisions to service delivery and can be as as the number of injury or each of a more is the and for Medical for Intercollegiate service model that can demonstrate the and performance of a sports medicine is the and Secondary School tools can be to whether are following best practices and policies and the of the health care for and can be to and serve as a Athletic trainers into a job or job can from of to for in the that should be The or an for all athletic are of evaluation tools that and for The School Athletes of also of a safe and athletic or in service should a for the or to the These in the should a and process for the of these of sports medicine the has a of so that athletic trainers a will not have to from This is to grow and provide additional resources, which will promote in athletic trainers across schools and and the schools, athletic training and institutions to and the The information in the document is neither nor to all or such as state or or as well as may the and of these The and the their members and to and each of the recommendations the of same to circumstance or The should not be as an for care but as a available to members or no is regarding the quality of care that to or from of other The and the the to or their at