Getting our athletes the care they deserve
Licensing team physicians for sports events
– Written by the Fédération Internationale des Sociétés d'Aviron (FISA) Sports Medicine Commission
The conditions of practice for team doctors accompanying athletes to international competitions and thus working in different medical jurisdictions, poses a problem for all sports teams, International Federations (IFs), National Federations and National Olympic and Paralympic Committees (NOCs and NPCs), whose teams travel regularly for training and competition. Each country (or each state/province) has its own legislation and governing body overseeing the licensing and practice of medicine in their specific territory.
Medical practice legislations are extremely variable from one country to another1 and even across the different states of the same country2-5. An example in point is the documents detailing information and regulations for doctors to practice and move within the European Union, which are not only extremely detailed, but also restrictive and difficult to fully interpret6-9. An international ‘manual’ for the use of team doctors and NOCs, containing all the relevant legislation across the world, would be a cumbersome document, difficult to achieve and to keep updated.
International multi-sport events such as the Olympic Games are not usually exempted from these restrictions, although the processing of temporary applications for the Games period is usually expedited and fees are occasionally waived. For the 2010 Winter Games in Vancouver, an innovative system was implemented, whereby the NOC/NPC and their Chief Medical Officer were made responsible for ensuring that the medical qualifications and liability insurance for all the medical and paramedical support staff that would accompany the athletes, was valid and appropriate for their teams. Upon signing this confirmation, the medical staff listed on the NOC/NPC declaration then received a restricted accreditation and a numbered personalised stamp, to order tests and treat their delegations only within the Olympic/ Paralympic arena and facilities.
Unfortunately, this was not continued in London for the 2012 Olympic Games, where the number of documents required for the submission to obtain the right to practice on athletes within the Olympic arena discouraged many colleagues from even applying to accompany their teams. A similar situation again faces all teams that will be competing in Rio in 2016. This lack of foresight and uniformity has become a significant logistical burden not only to travelling teams and physicians, but also to event Organising Committees and continues to become more burdensome every year.
These logistical and medico-legal limitations are having an unintended negative impact on athlete health. Currently, some team physicians may refuse to accompany their athletes to these large events, because their insurance companies or medical licensing bodies decline to cover them when they are not working under their national legislation. Competitions and Organisising Committees are finding it harder to recruit medical volunteers for coverage because of the licensing requirements if they are from another medical jurisdiction – and the potential consequences of medical malpractice.
At the same time, particularly for smaller competitions or single-sport events, some team doctors who agree to travel extensively may unintentionally be putting themselves at medico-legal risk when they do not comply with the national medical licensing laws. To complete the legally required paper work requires the team doctor to be multilingual, as documents are usually in the language of the country where the competition is being held. So team doctors are working illegally and irresponsibly putting themselves – and potentially their athletes – in legal jeopardy. Some physicians are now limiting their practice while travelling to ‘advanced first aid’ only, to avoid both the medical licensing and liability issues. It is clear that this is not in the best interest of either the physician or the athletes.
When a team physician is travelling, they need to be aware of the rules regarding the professional medico-legal liability cover required to practice in every country or jurisdiction where the team trains or competes. This may require the team to take out additional specific medical liability insurance for the team physicians while travelling. The transport of medicines (prescription and non-prescription) for professional use might also become challenging, since customs documentation requirements also vary significantly around the world. Medications can be grouped in products not on the World Anti-Doping Agency Prohibited List and in products noted on the WADA Prohibited List.
For an athlete needing medication on the WADA Prohibited List, the athlete must have a valid Therapeutic Use Exemption (TUE) and must be able to document the need for their treatment when going through customs with the relevant papers – TUE, prescription etc. For the emergency medications (e.g. injectable corticosteroids, epinephrine, analgesics, diuretics etc.) that all doctors should have in their emergency kits, having to make a detailed declaration each time they go through customs is a further concern. The prescribing and ordering of tests and treatment away from the competition venue also needs to be considered.
Presently, a significant number of physicians, national and international federations, NOCs and organising committees are turning a blind eye to these issues. At a time when the number of medico-legal cases is surging, we have to recognise that these practices are no longer acceptable and work towards providing a solution.
SMART SOLUTIONS ARE SIMPLE
Being confronted with the problem both in their own competitions and at major Games, the Sports Medicine Commission of the International Rowing Federation (Fédération Internationale des Sociétés d'Aviron, FISA), started to work on potential solutions some time ago. Today, we are in a position to suggest two possibilities to address the problem.
NATIONAL AND REGIONAL SOLUTIONS
The first option is to address the problem at a regional or international diplomatic level, although a first step would be at a national level, which would already solve a number of problems. Many countries have granted an automatic authorisation for physicians to practice for the duration of international competitions organised in their county. This was the case for the 2010 Winter Games in Vancouver and is the case in France, where Parliament recently adopted a law enabling health professionals accompanying a national team on French territory, to carry out their profession throughout the country10. This authorisation is only valid for treating members of their national delegations. This procedure in France could be taken up for implementation by certain continental associations such as the European Union.
At the very least, given the mutual recognition of degrees and the free movement of citizens within the European Union, team physicians with a degree awarded within the European Union (and recognised by their ‘supervisory authority’ e.g. ministerial department, order, professional association, college etc.) should be granted the right to practice temporarily at events anywhere in the European Union territory, under the condition that they only treat their athletes during the official period of the training camp or competition in question.
This could be a first step and, while one might argue that it would only concern the European Union (and their national teams), this first step would allow for reciprocal agreements to be signed with other non- European countries. Such an approach, with a short, clear and simple agreement text would not be a financial burden, would avoid unnecessary paperwork and would allow everyone to escape the current legal limbo and address the issue for European and some further countries.
Unfortunately, this first step would affect a relatively small geographical area and not address the issue in the rest of the world. It is however of note, that a similar process has started in the USA, where a bill was introduced in the Senate in August 2014 and discussed in the report of the Federation of State Medical Boards, in order to provide protection for certain sports medicine professionals providing certain medical services in a Federal State other than where they are licensed11,12.
ACCREDITATION BY INTERNATIONAL SPORTS FEDERATIONS
The second option proposed by the FISA Sports Medicine Commission, is that IFs enable team doctors to carry out their profession in a safe environment by establishing and maintaining a list of doctors who have been officially accredited by the IF. This accreditation would be valid for the entire career of the team doctor, subject to the doctor providing a document with the following information, which has to be verified annually by the National Federation13:
Personal data (name, date of birth).
Contact details (email address, mobile phone, name of the National Federation).
Information on degree obtained (medical school, year of graduation).
Name of the professional association/ governing body or order and license number.
Certification that the physician’s licensing is in good standing within the jurisdiction of their home country.
Confirmation of liability coverage as required in their home country’s jurisdiction.
Team physicians further need to certify that he (or she) is familiar with:
The World Anti-Doping Code.
The IOC Medical Code.
The medical rules of the IF, mainly for those able to intervene on the field e.g. concussion protocol.
It is important to note that within this scenario, failure to comply with the rules would lead to loss of the accreditation.
The next step is for the respective IF to obtain official confirmation from the different organising committees for international competitions for team physicians accredited by the IF to have the freedom to practice, provided that their practice concerns only:
their athletes and
the official period of the training camp or competition in the country.
It is important to note that such certification does not enable prescribing or ordering tests outside of the venue (or village and facilities of major games), but allows physicians to take care of their teams on an ongoing basis until the point where external testing or intervention is required.
Ideally, the requirement for an Organising Committee to comply with these IF regulations should be made part of the event bidding process.
The above mentioned accreditation process for team doctors was adopted by FISA 3 years ago. The bidding committees for the FISA World Championships must now answer the following question:
“Please confirm that all the ‘FISA-accredited team doctors’ will be allowed to practice temporarily in your country during the official period of the training camp or competition, on the condition that they only treat their team members”. For the 2017 World Championships in Sarasota, Florida, the bidding committee went one step further and submitted the relevant statutory provision from the State of Florida that exempts professionals who will be treating the staff and team members of a travelling sports team.
We should note here that the International Olympic Committee and the International Paralympic Committee could intervene in a similar way, via their NOCs/ NPCs, to determine the status of national team doctors – and require registration and accreditation of travelling Olympic and Paralympic sports practitioners. This accreditation could be dependent on:
compulsory participation in certain meetings or workshops.
obligation to keep up-to-date with education and skills.
sports medicine-specific training and certification.
As a minimum and in the interim, we would strongly suggest that organising committees of international competitions implement the temporary restricted licensing that was successfully used for the 2010 Vancouver Olympic and Paralympic Games14.
Travelling team physician – international regulations regarding temporary medical practice, medication import and prescription practice. Available from: www.fims.org/files/6614/1934/5838/ Travelling-Team-Physician-2013.pdf Accessed January 2016.
Simon L, Achar S. Team physician and travel: sports medicine physicians and the DEA. Available from: www.amssm.org/ NewslestterPDFS/November2011-40pdf Accessed January 2016.
Davis M. Medical legal considerations of the traveling team physician. Clin J Sports Med 2000; 10:311.
Wang J, McPheetters R, Vigil D. Survey of state licensure boards regarding interstate practice of sports medicine. West J Emerg Med 2008; 9:71.
Viola T, Carlson C, Trojian TH, Anderson J. A survey of state medical licensing boards: can the travelling team physician practice in your state? Br J Sports Med 2013; 47:60-62.
Rowe A, García-Barbero M. Regulations and licensing of physicians in the WHO, European region. Available from: www. som.uq.edu.au/media/341189/medical_ licensing_in_europe.pdf Accessed January 2016.
Allen I. Doctors crossing borders: Europe's new reality. CMAJ 2009; 180:156-161.
Medicine: mutual recognition of qualifications. 1993. (EEC) Available from: www.europa.eu/legislation_summaries/ other/l23021_en.htm Accessed January 2016.
System for the recognition of professional qualifications. 2007. (EU). Available from: europa.eu/legislation_summaries/ education_training_youth/vocational_ training/c11065_en.htm.
[National Assembly. Fourth Legislature. Ordinary Session 2014-2015. Text No. 524 - 2015]. (France). Available from: www. assemblee-nationale.fr/14/ta/ta0524.asp.
Thune J. A bill to provide protections for certain sports medicine professionals who provide certain medical services in a secondary State. (USA) S.2220 — 113th Congress (2013-2014).
Report of the FSMB Workgroup on Innovations in State Based Licensure Federation of State Medical Boards. 2014. Available from: www.fsmb.org/Media/ Default/PDF/FSMB/Advocacy/report_of_ state_innovations_adopted.pdf. Accessed January 2016.
FISA Team Doctor Registration. Available from: www.worldrowing.com/athletes/ medical-and-antidoping/team-doctorregistration. Accessed January 2016.
Medical Services Manual. 2010 Winter Olympic and Paralympic Games. VANOC.
FISA Sports Medicine Commission:
Chair, Alain Lacoste M.D., Dip.Sports Med.
Michael Wilkinson, M.B.B.Ch., M.B.A., Dip. Sports Med.
Jo Hannafin, M.D., Ph.D
Henning Bay Nielsen, M.D., D.M.Sci.
Jürgen Steinacker M.D., Ph.D.
Mikio Hiura M.D., Ph.D.
Tomislav Smoljanovic M.D., Ph.D.
Piero Poli M.D.
Image by Kosala Bandara