DO team physicians on highs, lows of their craft

Daniel A. Clearfield, DO, has assisted on the sidelines of nearly every sport, including boxing, mixed martial arts, judo and football.

But Dr. Clearfield, who is currently a team physician for USA Wrestling and USA Judo, says one of the craziest tournaments he’s ever worked was the USA Volleyball girls’ junior national tournament in Dallas last year. During the eight-day tournament, 40 of the roughly 14,000 athletes competing got concussions. One girl fractured her tibia and fibula, leaking bone marrow onto the court. Dr. Clearfield put pressure on the wound, cleaned her up and assisted with her transfer to the operating room. The next day, a stray ball struck another player’s head and caused temporary blindness. Later, yet another athlete broke a few of her ribs and collapsed a lung after diving for a ball.

“I saw her carrying herself a certain way, and I knew something was wrong,” says Dr. Clearfield, a primary care sports medicine physician. “I put my stethoscope on. She wasn’t moving air into one of the lobes of her lung. We helped her get emergently transferred.

“When I give talks about being a team physician, I say that I was a Boy Scout, and the Boy Scout model is to always be prepared. In sports medicine, if you’re prepared for everything, then you’re surprised by nothing.”

For Dr. Clearfield, the path to team physician began when he was a teenager on his high school’s wrestling team. In medical school, he volunteered at wrestling events. Later, a mentor helped him land the opportunity to cover a few key events, such as the men’s Greco-Roman and the women’s freestyle national championships at the 2011 Olympic Trials in Dallas. Covering those events eventually led to Dr. Clearfield’s placement on USA Wrestling’s international travel list.

Life for Dr. Clearfield and other DOs working with prominent athletes typically involves long hours watching and traveling to games. They share their team’s wins and losses and accompany teams to tournaments in foreign countries, the Olympics and the World Cup. They serve as the voice of reason when young, game-focused athletes are injured but insist on soldiering on.

Many team physicians aren’t paid directly for their services, though they often benefit financially via increased traffic to their practices. Still, the team physicians The DO spoke with say they love the work, and they note that the field of sports medicine is changing in surprising ways.

U-S-A! U-S-A!

As a team physician for USA Wrestling, Dr. Clearfield fields requests to cover local, national and international tournaments and events. He attends these events when he’s not working his full-time day job of primary care sports medicine physician at the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth. He took a week of vacation in February to travel with the men’s and women’s teams to the Paris Grand Prix Tournament.

The experience of following her teams to the Olympics was worth dedicating three years’ worth of vacation days to water polo, says Marcia E. Whalen, DO. Dr. Whalen was the head team physician for USA Water Polo from 2008 to 2012—the year the women’s team won gold at the London Olympics.

Dr. Whalen traded beach vacations with her family for hours spent poolside in far-flung countries watching athletes whip balls into goals, swim at lightning speed and block passes while treading water.

“Just watching these dedicated athletes was the coolest thing,” says Dr. Whalen, who is now the medical director of a family medicine practice in Newport Beach, California. “Words can’t explain it. I saw them transform and really come together as a team.”

During games, Dr. Whalen treated athletes for lacerations, concussions and overuse injuries. While the team trained at home, she focused on instituting preventive medicine regimens, such as working with the team’s head athletic trainer to videotape players’ functional movement screens. A functional movement screen is a way of documenting a person’s movement patterns to identify asymmetries and limitations that can then be corrected with targeted exercises.

Dr. Whalen’s focus on prevention helped ensure healthy teams ready for the Olympics. Being on the sidelines when the women’s team won gold was a surreal feeling, she says.

“I’m looking at a poster in my office of the athletes standing poolside with the American flag and the gold medals in their hand,” she says. “And I have the same picture on my phone because I was right there watching them at the time.”

Team physicians often, but not always, are graduates of sports medicine fellowships. DOs who enter sports medicine fellowships typically have backgrounds in family medicine, emergency medicine, internal medicine, pediatrics, physical medicine and rehabilitation, orthopedics or osteopathic manipulative medicine. Team physicians usually serve a specific team, usually in their off hours outside of a day job, in a full- or part-time capacity by attending games and being on call for players. Professional teams often retain both primary care and orthopedic team physicians, though coaches are increasingly requesting emergency physicians on the sidelines as well, according to George T. Chiampas, DO, the chief medical officer for U.S. Soccer. Sports psychiatry is an emerging field involved in the care of athletes.

As a primary care team physician, Dr. Clearfield will handle athletes’ general medical needs during events, in addition to providing osteopathic manipulative treatment as needed. He typically treats bloody and fractured noses, lacerations, rashes, and concussions—injuries common for wrestlers. One of the challenges of treating high-level athletes, Dr. Clearfield notes, is learning and adhering to stringent rules and regulations.

“With any prescription you want to use, you have to make sure it’s not prohibited on the World Anti-Doping Agency list,” he says. “That’s where being a DO who does OMT is so helpful, because I don’t have to write so many prescriptions. I’m able to fix a lot of problems with my hands. My allopathic colleagues don’t always have the same options to offer patients treatmentwise.”

OMT on the sidelines

A few examples of OMT-friendly problems include tennis elbow, joint pain, knee and ankle sprains, and cramps, Dr. Clearfield says, noting that DOs skilled in OMT sometimes have an edge over other team physicians.

“I had an allopathic colleague who went out to the Olympic Training Center a few months after me,” Dr. Clearfield says. “He was telling me, ‘I was bored out there.’ If athletes needed manual medicine, he had to send them to a therapist or athletic trainer. He couldn’t do as much as I could. And I developed a much better rapport with my athletes because of that. We got to know one another better because I had that extra treatment in my armamentarium.”

OMT can be invaluable for common athletic injuries such as ankle injuries, notes Michele Gilsenan, DO, who has worked with World Wresting Entertainment and trained with the NFL’s New York Giants’ team physician.

“We do special manipulative techniques to the injury immediately to relieve some of the edema and increase the vascular flow, and that hastens the healing process,” she says.

“Placing a hand on the athlete also helps to relieve anxiety. And it provides some immediate relief of the swelling, which is encouraging.”

Job joys: Relationships, teamwork

Several team physicians say the chance to build relationships with athletes is one of the best perks of the job.

“I love having the chance to work with a group of people over a long period of time,” says R. Robert Franks, DO, a team physician for USA Wrestling. “Whether it’s week to week or month to month, I really become invested in not only the athletes’ health care, but also in helping them achieve their goals, dreams and aspirations.”

Dr. Chiampas says watching athletes grow in their careers is his greatest on-the-job joy.

“You see players grow from 18-year-old young men into athletes who have built unbelievable professional careers,” he says. “You see them mature and become athletes who are watched all over the world.”

Dr. Whalen says she most enjoys witnessing teamwork in action.

“For me, the most exciting part about taking care of a team is watching the players come together and transform themselves and achieve a collective goal,” says Dr. Whalen. “I don’t know that I would have had the same experiences if I was taking care of athletes individually.”

Money, power and respect

On the flip side, Dr. Whalen says dealing with money was one of the most frustrating aspects of serving as a team physician. USA Water Polo runs on sponsors and private donations, and money was often tight, she says.

“USA Water Polo’s national governing body just didn’t have a lot of money, so investing in injury prevention wasn’t a top priority,” she says.

Thomas C. Fiel, DO, the team physician for the NBA’s Phoenix Suns, says one of the biggest challenges of his job is counseling patients who want to play when they’re injured during a high-stakes game.

“You have to realize, this is a huge financial business,” he says. “There’s a lot of investment involved on the part of the owners, the agents and the players. And there’s the ego of the player who wants to play. You have to really weigh all those sides.”

But the team physician and the athletic trainer ultimately have the final say over whether an athlete plays or not, Dr. Fiel says. And most of the time, athletes respect the ruling even when they desperately want to play.

Other team physicians lamented that while they loved helping athletes, the long hours and lack of remuneration sometimes posed a challenge. The vast majority of team physicians are volunteers and not paid directly for the time they spend attending games and conducting physicals beyond meals and travel reimbursement. However, team physicians often gain prestige from the role and attract patients, including their team’s athletes, when they seek treatment in the physician’s practice. Some clinics and physicians even pay the teams for the privilege, a practice that has been questioned.

Amy Weiss, a spokeswoman for the NFL Physicians Society, acknowledges these partnerships, but attests that the arrangements are simply marketing agreements.

“While individual team owners are free to engage in marketing partnerships with local businesses, including medical centers, team doctors who treat NFL players are not involved in orchestrating these partnerships, nor are the doctors obligated to affiliate with any institution,” Weiss wrote in an email.

Pro-level teams often don’t pay physicians in order to avoid the suspicion of bias, Dr. Fiel says. People may assume that a physician paid by the team will make decisions to help the team win the game, rather than prioritizing each player’s health.

When asked about NFL team physician compensation, Weiss notes that physicians are compensated, but that team physicians are not paid for some of their essential responsibilities.

“Physicians are only paid on a fee-for-service basis for operative procedures and not for other duties required by the job such as training room visitation, game coverage, and attendance at the NFL Combine and training camp,” she wrote in an email.

Dr. Fiel is quick to note that he’s with the Phoenix Suns because he loves working with pro athletes. As the Suns’ physician, he covers all of the team’s home games—that’s roughly 41 every year. Usually, this entails working days at his private family and sports medicine practice in Tempe, Arizona, then covering games at night. He also travels with the team to any playoff games and conducts physicals for players and college recruits.

Additionally, Dr. Fiel serves as the primary care physician for a number of players, their families and the Suns’ staff. Available to the team 24/7/365, Dr. Fiel cares for several players during the off-season. For these services, Dr. Fiel is compensated, as the players often visit his practice and are billed as patients.

Alex B. Diamond, DO, MPH, who works with the NHL’s Nashville Predators, recalls the time he attempted to recruit a colleague when the NHL decided they wanted an emergency physician on deck at games.

“Everyone said, ‘Oh yeah, I’d love to come and help,’ ” says Dr. Diamond, who is also a team physician for Vanderbilt University. “Then they asked, ‘How much do you get paid?’ ‘Nothing.’ All of a sudden, the pool of applicants went from 10 to one. It takes a unique mentality to be a team physician. But we all feel that this is the fun part of our job.”

A changing field

Back in 1992, Dr. Gilsenan, who formerly worked with the WWE, helped establish one of the first osteopathic sports medicine fellowships in the country at Union Hospital in Union, New Jersey. Two years later, she became the fellowship program’s medical director. Back then, few women went into sports medicine, she says.

“In the beginning, it took a while for the coaches and the staff to adjust to a female physician,” she says. “But now, they are usually fully accepting. I used to go out on the field with a coach, and he would tell the officials, ‘I know she’s a female, but she’s my physician.’ We’re over that now. The field has a lot more women than it used to.”

Dr. Whalen says she’s seen more female team physicians and athletic trainers in the U.S., but coaching in the U.S. is still male-dominated, and all three fields are heavily male in most of the 10 countries she visited while traveling with the team.

“As a water polo physician, we travel to all these countries for championships and tournaments,” she says. “Even for the women’s teams, I didn’t see any women head coaches for any of the national or international water polo teams, which is very disturbing to me. And I only saw one other female water polo physician in the international community, in Australia.

“Also, I’ve covered world championships for FINA, which is like a mini-Olympics just for water sports, and I didn’t see any female physicians covering any teams.”

In 2004, just 15% of the members of the American Osteopathic Academy of Sports Medicine were women, according to AOASM data. This year, women make up more than a quarter of the group’s membership. Women currently hold 40% of AOA-approved sports medicine fellowship positions, according to AOA data. Although the number of women in these positions has fluctuated since 2007, the earliest year for which data is available, more women have been entering osteopathic sports medicine fellowships for the past five years. In 2010, women held just 13% of the positions.

Sports medicine has become a more prominent subspecialty in general in recent years—20 years ago, the AOA had just approved its first few sports medicine fellowships, and today the profession has 23 fellowship programs employing 25 fellows. Total AOASM membership has grown from 349 to 652 in the last 10 years.

On the allopathic side, sports medicine fellowship programs for family physicians and pediatricians increased 14% and 36%, respectively, over the past five years, while sports medicine fellowships for emergency and orthopedic physicians remained constant, according to data from the Accreditation Council for Graduate Medical Education.

Another change in sports medicine is that the field is transitioning toward more preventive care for athletes, several DOs say.

“Shifting our frame of mind from a treatment-centered approach to a prevention-centered approach is going to be part of the future of our field,” says Dr. Diamond, who notes that two areas in which he’s seen a lot of development are hamstring and anterior cruciate ligament injury prevention.

Becoming a team physician

Medical students: If the idea of working with an Olympic team appeals to you, you’ll want to get started now, Dr. Franks says.

“Do game and event coverage early,” he says. “Do rotations that are relevant to sports medicine, such as orthopedics and physical medicine and rehabilitation. Rotate with people in the field who are team physicians and fellowship directors.”

Dr. Franks also recommends conducting sports medicine research.

“The goal is to get as experienced as you can while you’re a student, an intern and a resident,” he says. “So that when you’re a fellow, what you’re doing is just refining your skills, not learning them from the beginning.”

Once you become a team’s physician, you’ll want to spend as much time as possible with the athletes, Dr. Whalen notes.

“I love giving lectures to medical students and residents about my experience, and I always tell them to be present all the time,” she says. “Be at every practice. Even if the coach tells you, ‘You don’t have to come to the weight room today, we’re just going to lift some weights,’ just go. You can learn so much. Medically, you can get a lot of clues and tips and figure out which athletes are taking their workouts seriously and which ones aren’t. The knowledge will help you treat injuries better.”