and we're going to get rolling. This is Instructional Course 105, the Evolving Responsibilities of the Orthopedic Team Position, Managing the Sidelines and Landmines. My name is Tim Miller, and I'm a sports medicine orthopedic surgeon at the OSU Wexner Medical Center in Columbus, Ohio, and a team position for the Ohio State Buckeyes. And today I'm going to be presenting on the role of the orthopedic team position in 2022 and beyond. I'm going to start by introducing our faculty. We good there? Is that better? Yeah, this thing's a little... I'll try that. There we go. All right, I'll stay close to it. So to introduce our faculty, we have some wonderful people presenting here today with a lot of experience and people who have witnessed a lot of winning over the last 30 years. First is my senior partner, my mentor, and who I consider my general hero for the last 20 years of my career. It's Dr. Christopher Kading. He's been the team position for the Ohio State football team for nearly 30 years now. He's been a head team position for Ohio State for that entire time as well. And he's also been one of the most respected intercollegiate team positions for that entire time. He'll be presenting on the role and responsibility of the university head team position. Dr. Jim Bradley will be our third speaker today, presenting on the expectations of the professional and NFL team position. He's a former president of AOSSM. He is also a former recipient in 2014 of the Gary Hawk Ray team position, team position of the year award for the NFL Physician Society. And then our fourth presenter today will be Dr. Gloria Beam. She'll be presenting on becoming and serving as an Olympic and Paralympic team position. She's served as an Olympic or Paralympic team position for nearly 25 years now. She's also served in the past as the chief medical officer for the U.S. Olympic and Paralympic teams. So we know that sports have a major impact on our society, and injuries can really curtail a person's perspective on sports. And as Hippocrates once told us, sport is a preserver of health. So our goal, number one, as being team positions, whether we're primary care or orthopedic, is to safely maintain the participation of our athletes and optimize their performance. Sports medicine team positions have a long history and heritage, in fact, going all the way back to 2,500 years ago in ancient Greece, where many of the techniques that were applied in peacetime to the injured athlete were developed on the battlefield for injured soldiers. Herodicus, who is really considered to be the father of sports medicine, was a contemporary of Hippocrates, and he was the original person who proposed the use of therapeutic exercise for the maintenance of health and the treatment of disease. In fact, he was the first historical physical therapist documented in history. He also maintained that a balance between strict diet, physical activity, and athletic training was the key to a good standard of health, and I think even 2,500 years later we'd still agree with that. More recently, in the 20th century, the two role models we've had are the titans of being team positions, and that's Dr. Jack Houston, as you see here, and Dr. James Andrews. And their fundamental responsibility to the orthopedic team position that they presented in their philosophy states that to develop medical techniques that promote health and fitness while ensuring the safety and well-being of those who participate in athletic competition. The problem is, over the last 20 to 25 years, the attitudes toward team positions have changed a bit, and our roles have changed even more. There are traditional roles and attitudes that have been changing, really, for the last two decades, and that's really led to what we refer to as the team position quagmire that was proposed by Dr. Ed Wodich in 2018, and there are four different hats that we really have to wear to be great team positions. The first is being the musculoskeletal specialist. We are all orthopedic surgeons in the end. We have to know how to treat musculoskeletal problems. The team orthopedist is really the gateway to orthopedic care, and for your team individually, you have to be able to make sure that they get the care they need, whether it's through you or some other consultant. Arthroscopy, we have to be experts in that, but we know that just being a great arthroscopist, or as I was once referred to by one of my mentors, a scope jockey, you can't just be a good arthroscopist and expect to be a great team position. Then finally, being a sideline team position, and really to be proficient in all four of those disciplines is what makes you a great, well-rounded team position. I'm going to hear more and more about that from all of our other speakers. So how do we define a team position in 2022? Really, we have to take a step back by about 20-plus years to the team position consensus statement that came out in the American Journal of Sports Medicine in 2000, where they defined the duties of the team position, the duty being to provide for the well-being of individual athletes, enabling each of them to realize his or her full potential. Additionally, we must actively integrate the medical expertise that we have with that of other healthcare providers and allied healthcare professionals, and then assume the ultimate responsibility for making the medical decisions that affect an athlete's safer turn to sport. To borrow a page from the NATA or our athletic training compatriots would be these points that you're seeing here. I'm not going to go through all of them, but these are what the guidelines we feel are for optimally providing medical coverage for intercollegiate athletics. That would be point number one, to determine an athlete's readiness for participation, that being with PPEs or pre-participation physicals, as well as determine their readiness to go back to sport after injury, and then risk management, in other words, preventing them from getting themselves injured again or having continued problems once they return to sport. How do we do that? Well, one of the responsibilities, of course, is to develop strategies for safely returning an athlete back to sport, and it's usually a progression, not just a decision to go back after a short-term time frame off sport. We start with the evidence. So once the injury takes place, we examine the evidence, but from time to time, there is no evidence, or the evidence is very limited or at least insufficient. So we then have to rely on our colleagues for consensus statements and other groupthink to determine what's best for an athlete's safer turn to sport. Sometimes, though, the consensus isn't even there, and then we rely on ourselves, on our own intuition, and sometimes just relying on our gut to determine if the athlete really is ready to go back. We have guidelines. In fact, since that original consensus statement in 2000 that divided our duties, there have been two additional updates, one being in 2012, the team position and the return to play decision consensus statement, and the 2013 update on team position consensus. The points to really be aware of are the ones that I think are most important, is that it's essential for the team position to confirm restoration of musculoskeletal, cardiopulmonary, and psychological function, as well as the overall health of the injured or ill athlete. Additionally, the athlete should pose no undue risk to themselves or to the safety of other participants when they go back to playing sport. The fundamental principle being for all team positions, as was stated in that 2013 update, that the overriding principle for all physicians, including team positions, in managing ethical issues is to provide care focused on what is best for the patient or the athlete and only for the athlete, not necessarily what's best for the team. So how do we train our sports medicine physicians and our team positions in the 21st century? Well, we know that the majority of our training boils down to the one-year fellowship that we do, but some of it starts in residency. The problem is that only about 76% of residency programs across the United States actually offer any kind of athletic coverage. This was shown in a study from 2019 in the Journal of American Academy of Orthopedic Surgeons. And unfortunately, only 46% or less than half of those programs who actually had event coverage required it. So it's not necessarily being focused on during a residency training. Therefore, as I mentioned, that one-year sports medicine fellowship is where everything really gets boiled down to having the trainees be exposed to a variety of sports at varying levels of competition. But they're also required to hone their clinical skills, their surgical skills, and develop arthroscopic techniques, which can certainly distract them from their time of serving as a team position. Therefore, we're required to do a lot of self-learning or self-directed training as time goes by. So beyond fellowship, there are several different options that we have to learn beyond what we've learned in fellowship. That being serving with volunteer team position coverage opportunities, which is a must for most team positions to at least start out in their early careers. There are optional team position courses provided by the IOC, as well as the ACSM and AOSSM. There's subspecialty certification or the CAQ test, which can be done after you get certified by the ABOS, and then annual self-assessment exams that we can do as part of AOS or AOSSM. There's also the annual review course offered by AOSSM and AOS, which again, Dr. Kading has really been instrumental in developing that over the last several years. The fundamental principle being that to be a great team position requires lifelong learning, and Dr. Bradley's going to talk about that a little bit more, but you have to continue to learn even after your fellowship. So how do you become a team position? That's a great question because there's not a great answer. In fact, when I was a resident and I was talking to Chris before I got into sports medicine, I told him, you know, I want to be what you, I want to do what you do someday. And I asked him, how do I do that? And I didn't get the answer that I really wanted. He told me you should be excellent at what you do and develop relationships with people around you. At the time, I wasn't sure how concrete that advice really was, but over the years I've really developed an appreciation for what he meant by that. That simple statement really has driven how I've approached my career and team position coverage in general. But there are several qualities that it takes to be a great team doc. So patience is certainly one of them. It's a long road to get the opportunities that you may want to become a team doc, especially at the higher levels. Volunteerism, as I mentioned before, with volunteer team coverage is a huge part, a portion of becoming a great team doc as well. Then building those relationships and that relationship really, the key one I'm going to talk about in the next slide is with the athletic training staff. As Kevin Plancher once told me, and I know a lot of people have mentioned these three qualities, the three A's, but Kevin Plancher was the first one that I ever heard it from, was availability, affability, and the ability to do your job as a great team doc. Leadership is becoming a greater and greater component of leading the sideline coverage team, as well as passion and humility. And the qualities that have been recommended in general by this, by John Maxwell in his 21 Irrefutable Laws of Leadership are character, competence, and connection. Those were also echoed in Urban Meyer's book Above the Line. As was stated by Tane in 2020 in Current Sports Medicine Reports, emotional intelligence is really regarded as the most important factor, the most important quality that a team physician can have for leading a great sideline team. You also have to have in-depth knowledge of the team you're covering. So the example I give quite commonly is that if you're covering, for example, a surfing event, and you don't know what the term's goofy foot mean, or hanging 10, what that really means, or what it means to hit the dip or hit the lip, then you're probably not going to be ideally being able to determine what happened to an athlete when they described to you how they got hurt and what they have to do to perform their duties in sport. Additionally, sometimes a team physician has to have their own athletic skill. So for example, if you're covering hockey, but you don't know how to skate, that's going to be a problem for you getting out on the ice every now and then to see an athlete. Additionally, if you're covering, for example, a mountainous event, like you're seeing here on the bottom right, you don't know how to ski, but you're covering a skiing event and or a snowboard event, you're going to be not only a liability to yourself, but also to the team and the athletes themselves. So I mentioned the key relationship for being a great team doc. It really boils down to the relationships we have with athletic training staff, and that starts with mutual respect for what they do. We can't do our job without them doing a great job themselves and vice versa. That means you have to trust them, you have to develop collegiality with them, which then leads to that team concept on the sideline, fostering great communication where everyone feels valued for what they do and appreciated, and the athlete gets the best possible care. As was shown in 2016 in the Journal of Orthopedics by Lombardi et al., when we agree on the sideline, the athlete gets the best care. And the majority of the time, we do agree. In fact, 92% of the time, we agree with the diagnosis on the sideline between the trainer and the physician staff. But where the lowest reliability between the physician and the team athletic trainer comes in is with meniscal injuries, labral injuries, and fractures, and we see a lot of those on the sidelines. Though, as the agreement between the athletic trainer and physician improves, there's greater likelihood of arriving at the correct assessment and the proper treatment plan for these athletes. So what are some of the modern challenges we face as team physicians? Certainly there are a lot of them. Number one being increased media scrutiny. We all know that everything we do these days is being evaluated and sometimes criticized, particularly with social media. Everything we do on the sidelines is being videoed. Even if it's not necessarily being broadcast, someone is recording what you're doing on the sideline, and that can be sometimes a challenge for people to accept. The increasing pressure to subspecialize. We know that in orthopedics and sports medicine, many of us are being required to overall focus our practice on either one joint, one area of the body, or sometimes even just one kind of procedure on that particular joint. That makes it very difficult to provide general orthopedic or sports medicine care on the sideline if you lose those skills over time. We also have to maintain our physician's perspective, and what that really means is balancing wellness versus winning. So understanding that in the end, the loyalty should be to the athlete and or the patient, not necessarily to the team, although sometimes there's some conflicts of interest if you're contracted with the team. Scholarships and million-dollar contracts. Certainly over the last year or so, this has become a major, major factor, particularly in college sports and money talks. If you're not familiar with the initials NIL by this point, you're going to be very soon. NIL, meaning name, image, and likeness, has really basically dominated the news lines for intercollegiate sports over the last six months or so, and the floodgates have opened in college sports, particularly in Columbus, Ohio. That's led to even bigger egos of the athletes, bigger egos of the coaches and parents, and all the other stakeholders that the athlete has for their success. Medical legal liability isn't going away either, and even interstate and international travel can be a huge factor since we sometimes can't do what we need to do from a practice standpoint in an area where you're not licensed. At the point I have at the bottom, I'm going to talk about in the next slide, as well, is shared decision-making, again, a huge part of what athletes and the stakeholders of the athletes really want these days. What do I mean by that? Well, shared decision-making has been shown in 2019 by Beck et al. and JAOS as being what's regarded as the most important characteristic of a surgeon by youth athletes and their parents. So patients and their guardians reported in 2019 that shared decision-making as the most important surgeon characteristic followed second by an understanding of the patient's sports and goals. So how do we communicate with our athletes and with the stakeholders? Well, we certainly have to communicate with the consultants, and that's what we do at Ohio State with what we call the hub of the wheel strategy. What you're seeing here on the bottom right is how we do this. The hub of the wheel is where the center of the wheel is the certified athletic trainer or the team physician, and the spokes of the wheel are pointing out or radiating out to the consultants that we use to optimize their care. But the ultimate responsibility goes to the base of the wheel, which is the head team physician or the orthopedic team physician, sometimes one and the same. So again, my role today is to speak about the role of the orthopedic team physician in 2022 and beyond. And I think in general, our job is becoming more and more of a political position. And the fundamental principle guiding that should be athlete advocacy. We're over time redefining our responsibilities to the athletes as a whole during their athletic careers and beyond. And then post-career and disability determination, not only for professional athletes, but also for our collegiate athletes is becoming a bigger and bigger part of our practices. We have to interact with all the stakeholders, including the coaches, the trainers, the administrators, and then balance those loyalties that we have between the team, the school or the club and the player themselves. Additionally, we have to avoid the perception of being a company doc or a company man or woman so that the athlete continues to trust us as time goes by. Then we have to educate those stakeholders. That includes the athlete, the trainer, the administrators, as well as the other primary stakeholders, including their parents and their agents. Because again, I started with a quote from Hippocrates. I'll finish with one. As he said, the greatest medicine of all is teaching people how not to need it. And I think we'd agree with that even in 2022. So with that, I'll step aside and let Chris come up and speak on the role of the university head team position.

Orthopedic Team Physician

Sports Medicine

Role of Team Physician

Responsibilities of Team Physicians

Changing Attitudes of Team Physicians