Cultural Competence is the “Choices” topic this month. Authored by Marisa Colston, PhD, ATC and Shewanee Howard-Baptiste, PhDRead More
Have you ever noticed that in sports and athletic medicine, a catastrophic event is frequently required to prompt change? How paradoxical that we heavily emphasize prevention yet often fail to implement appropriate measures for minimizing risk. For example, how can we truly state that our interventions prevent injury if we aren’t even counting exposures and tracking injury rates over time? Instead, we are frequently forced to respond reactively which in turn, often creates more of a mess. The case I am trying to build extends beyond routine injury prevention initiatives and into the administrative aspects of athletic training. The national attention attributed to the University of Maryland, not just the devastating news of the heat-related death of a student-athlete, but also for the aftermath circus of firing, re-hiring and firing again should make every one of us cringe. This situation could easily happen to any athletic medicine program (regardless of setting) who fails to follow professional practice standards. As the independent review of the death of Jordan McNair illustrate, failure to comply with professional standards, resulting in a tragic outcome, may result in litigation as a response to falling short in ethical standards of making the patient the primacy of their care. Principle I of the NATA Code of Ethics is dedicated to making the individual patient the focus of the athletic trainer’s ethical obligation.
Several years ago, in the Journal of Athletic Training, colleagues and I published an editorial titled, “The Need for Accountability and Transparency in Intercollegiate Athletic Medicine.” We promoted the idea of the development of an athletic medicine review board (AMRB) to assist in the oversight of all health-related programs and services for student-athletes. After much consideration of an AMRB, and after serving on one at the University of Georgia for the past 4 years, I am even more convinced of the critical and beneficial role that such a board plays in promoting transparency of operational procedures and best practices. I have even changed my position since co-writing the editorial in that I advocate for such oversight for athletic medicine programs in all settings, not just intercollegiate.
One would be hard pressed to come up with a more effective way for a well-intended, but overwhelmingly busy athletic training staff to ensure that the existing policies, procedures and protocols are up-to-date, than to put them before an AMRB for their expert and analytical review. The Board serves as another safeguard to ensure that the AT staff adhere to professional practice as required by the NATA Code of Ethics. Such a practice can transform weak programs into strong, and help strong programs become even stronger as I have witnessed firsthand at U. Georgia. Not all programs can afford the travel expenses of bringing in the Board every year, however experts for your Board may already exist in your own back yard. Consider who works in your community. Certainly there are individuals with the necessary expertise (legal, ethical, medical, administrative, etc.) who would be willing to volunteer their time to review materials and meet as a group at least once a year. The athletic medical review board should be empowered to raise concerns and recommendations on care and services based on professional standards and mitigation of risk. These recommendations are communicated to the top executive of the school and the athletic director, as well as the sports medicine staff. The message this sends to the administration, athletes, parents, and to the community is that you are dedicated to providing the best level of care to such a high level that you are willing to open up all aspects of your athletic medicine program to an outside review process.
Finally, let’s consider the alternative, which is to maintain the status quo and take the chance of being the next national news story. Any cultural shift must obtain a critical mass for change to take place. If we sincerely embrace patient-centered care, we cannot continue to function within the same culture that has failed to adequately protect student-athlete health and welfare in far too many cases.
A special acknowledgment of appreciation to Gretchen Schlabach and Tim Neal for their review and feedback of this blog.
The latest data from GlobalWebIndex1 shows that the average internet user in the U.S. spends approximately 6 hours each day using internet-powered devices and services – that’s roughly 1/3 of our waking lives. Two of the 6 hours is allocated to social media (SM). The adoption and diffusion of SM has increased at a rate unparalleled by any prior form of media. This is the new wired world: always connected, always communicating, always multitasking. The benefits from SM far exceed the disadvantages. While the NATA Code of Ethics establishes important external guides, ethical decisions about social media use stem from informed individuals with developed ethical thinking. Notwithstanding, younger individuals typically possess strong technology skills, however, older individuals possess experience, and are perceptive at understanding important questions, such as: When do you need to avoid responding? What impact do SM decisions have on people? What are the effects of common practices?
We can conclude this much about the ethics of SM: When we stray from truth that is based upon verifiable evidence, it is impossible to defend actions through moral reasoning. In that respect, SM are not different from other media contexts. Simply tell the truth, which is the first and foremost sound practice that should be employed. Aurelius Augustinus of Hippo (aka, Saint Augustine) stated: “The truth is like a lion. You don’t have to defend it. Let it loose and it will defend itself.”
Other sound practices2,3 for protecting your online reputation are shown in the figure below. Being transparent about your identity and relationship to your employer makes your honesty - or dishonesty – readily apparent. Be judicious about protecting patient privacy, confidentiality and legal guidelines. As tempting as it can be, avoid venting about workplace frustrations or conflicts, whether they involve managers, colleagues or patients. Even harmless posts like: “TGIF: this was a horrible week at work!” can open the door for negative chatter around your workplace. Write what know on your areas of expertise and do so in first person. Do not forget to provide a disclaimer that your postings are your own and do not represent your company. The lines between public and private are frequently blurred which may lead to false perceptions. Make every effort to keep the two separate.
Do your postings add value? If your post is not helpful, thought-provoking, or builds a sense of community, then don’t post it. Remember it is your responsibility to follow terms and conditions of SM platforms, as well as HIPAA Privacy and Security Rules. Be an online leader, avoiding inflammatory and sensitive topics, and if you make a mistake, admit it and be quick about it. Finally, trust your gut. Sit on it for a day or so before you post and never post when highly emotional. There is an inverse relationship between intellect and emotions. If in doubt, try to remember the last intelligent thing you said when we you very angry. To wrap up this blog, like any good relationship, a positive online reputation is determined more by how you listen than what you say.
1. https://wearesocial.com/blog/2018/01/global-digital-report-2018; accessed 5/1/18
2. Farfan JM, et al. Online medical professionalism: patient and public relationships: policy statement from the american college of physicians and the federation of state medical boards. Ann Intern Med. 2013; 158: 620-627.
3. Symplur LLC. Healthcare social media policy for physicians and staff. Symplur LLC. 2018; https://www.symplur.com/public/healthcare_ social_media_policy_for_physicians_and_staff.pdf.
A couple of questions to consider:
When does your license expire?
Do you have the checks and balances in place to make sure you start the renewal process in plenty of time to stay current and legal?
Think it will never happen to you?
If you think it can't possibly happen to you, just check the Medical Board Examiners monthly disciplinary report and see how often it happens to some of our peers who probably thought the same way. The process is easy, but takes about a month to complete and it's OUR responsibility to make sure all the t's are crossed and all i's dotted in plenty of time to avoid any lapses.
The "our administrative lady forgot" or "the application was lost in the summer mail" excuse won't cut it; the State board doesn't play. All therapy charges are dropped, we can't work and then there's that little thing called a fine. By the way, did you know the fine is up to $1,000.00???
The Medical Board, like us, is fully committed to the safety of all under our care and working on an expired license is illegal practice. At the end of the day it's not complicated; its just professionals being professional.
Injured Indiana Athletes Describe Isolation, Poor Treatment by Staff. P. Lavigne, ESPN.com: OTL, April 23, 2017
The above referenced article is in response to allegations made by several student-athletes from Indiana University. This was brought to light by the firing of Indiana University’s head football coach, Kevin Wilson, following a series of issues regarding the treatment of injured athletes.
One such maltreatment allegation included Katlin Beck, a rower on the 2013-2014 Indiana University Crew team. She went to the medical director of Hoosier Athletics for low back pain. She was prescribed physical therapy, conditioning modifications, and hydrocodone. She was compliant with all medical direction except the hydrocodone, which she refused to take due to the possibility of addiction and symptom masking. Her pain persisted for several weeks with no improvement, so she saw another IU physician, and then a third.
The third physician informed her that the probable cause of her low back pain was tight hamstrings. By this time, her coach doubted the severity of her injury and “isolated” her from the team along with the other injured athletes. She was denied team gear for not meeting practice goals.
According to the ESPN Outside The Lines article, Hoosier athletes are instructed to see athletic department and school approved physicians and not personal physicians. Ms. Beck, frustrated with 15 months of pain and having seen three IU physicians, sought help from an outside spine specialist. This physician diagnosed her with a significant lumbosacral injury so severe that she was instructed to stop rowing immediately. She was told that scar tissue was the only thing connecting her lumbar spine to her sacrum.
The prevalence of maltreatment of IU athletes was well known throughout the athletic department and with the firing of head football coach Kevin Wilson, an investigation of other incidences began. The result of an investigation of the football program determined the athletes had not received improper care and the coaches had not exerted pressure on the medical staff. It did note, however, “behaviors by the coaching staff that may create an unhealthy environment for players”. With these occurrences brought to the publics attention, many changes have been implemented. One such change is employing physicians through Indiana University and naming a Chief Medical Officer.
The take away from these incidences is that we, as healthcare professionals are the first line of defense and support of the athletes in our care. The presence of overbearing coaches and others, as well as insufficient follow-on care, can make the lives of the athletes difficult and in some cases unhealthy. Our role as advocates should provoke us to action to ensure the recovery, health, and performance of those we care for.
Robert Back Case: Athletic Trainer Testifies She Didn’t Know About Concussion Diagnosis.
S. Larson, Great Falls Tribune, March 19, 2018: https://www.greatfallstribune.com/story/news/crime/2018/03/19/robert-back-case-athletic-trainer-testifies-she-didnt-know-concussion-diagnosis/440251002/
The article referenced above relates the testimony of Jessica Klette, ATC, Athletic Trainer for Benefis Health System and Belt High School in Belt, MT. In September 2014, Robert Back, a 16 year old high school football player, suffered head trauma in a football game. It is claimed he should not have been playing in this football game due to a previous concussion diagnosis. Reports and testimony state that he suffered a concussion prior to that game and through communication breakdowns between the coach, athletic trainer, parents, and physicians, was allowed to participate in the game.
Several issues are brought up in this article.
One: Lack of communication between the Athletic Trainer and treating physician. (The AT states she was not told of the diagnosis and treated the athlete as if he had the flu.)
Two: Lack of communication between the Athletic Trainer and the athlete's parents.
Three: Coach was allowed to oversee a post injury ImPact test.
Four: Lack of apparent responsibility per the athletic trainer's contract to communicate with anyone except the school and coach regarding athlete medical issues.
Many lessons can be learned from this incident. Maintaining open lines of communication with everyone directly involved in the athletes’ wellbeing (coach, parents, and physicians) could prevent or at least reduce mistakes such as these. Contractual obligations should not preclude an AT from communicating. Non-medical professionals should not have access or be allowed to administer diagnostic testing on any athlete. Lastly, we should all remember to be an advocate for the athlete.
It's a mean world out there, and as much as we want to always believe that our athletes and patients are so happy WE are caring for them, if their return to play or life doesn't go as they expected it to, we can easily become a victim of legal problems.
Kornblau and Starling, in "Ethics in Rehabilitation", remind us to “protect yourself” and list some steps we all should review:
- Put your licensure law on your desk and read it frequently: It’s easy to think we're always doing the right thing.
- Report ethical and legal violations to the licensure board: It's not "tattling" - It's protecting the integrity of our profession.
- Open your eyes: If it doesn't seem right it usually isn't.
- Follow the 4 "C's": Cover yourself with Contemporaneous, Complete and Comprehensive documentation. If it's not on paper it didn't happen.
- Keep your athletes interest above all else: Do the right thing.
- Understand the laws and rules that govern our world: JAHCO, Medicare and HIPPA give us important boundaries. Know them.
And finally, my personal advice: retain professional liability insurance. Your employer will protect you, but only if you do what you are legally allowed by your licensure and state laws. Nobody protects you like you.
In addition to maintaining their own ethical practices, athletic trainers may find themselves in the predicament of witnessing another athletic trainer, coach or other professional engaging in unethical behavior. When this happens, what is your role? Should you report the behavior, or simply brush it off as none of your business? The best answer might be somewhere in between.
When I was a high school athletic trainer I was faced with such a dilemma. I had been at the school for several years and had built up a lot of trust with my athletes. Most of them were comfortable enough with me that they would talk to me about almost anything. One day an athlete came to me and said she needed to talk but wanted me to promise not to tell her parents. I was very wary of the situation, I wanted her to feel like she could come to me with problems but I wasn’t sure I was comfortable with the idea of having to keep something from her parent. In the end, curiosity won me over and I decided to hear her out.
The athlete proceeded to tell me that she had been feeling awful all day. She had the worst headache she remembered ever having and even the thought or sight of food make her feel sick. Upon further investigation, it turned out that the athlete had her first experience with alcohol the night before and she had a hangover. I informed her that this was her body’s reaction to drinking too much and promised that I would not tell her parents. However, as the athlete elaborated on her story of the previous night’s events, it was revealed that the alcohol had been provided to her by one of her assistant coaches. This coach had graduated from the same high school a few years earlier and had returned to help coach her team. At this point in the conversation I knew this had escalated way past not telling a parent that their daughter had been drinking. I knew that I could no longer keep this to myself and informed the athlete of this. At first she was upset that I was no longer going to keep her secret, but after I explained my dilemma, and why it was inappropriate for the coach to provide her with alcohol she understood. At this point, I met with the head coach and let her know what had happened and let her handle the situation from there.
In this particular situation I felt it was my duty to let the head coach know that one of her assistant’s wasn’t behaving in a way that he should be with his athletes.
By: Ryan Clark, AT Student & Marisa Colston, PhD, ATC
A ‘Jekyll and Hyde’ is one who has a dual personality that alternates between phases of good and bad behavior (www.merriam-webster.com). Every component of athletic training is people-oriented. Risk management and injury prevention, clinical examination, acute and chronic injury care, therapeutic exercise, nutrition, psychosocial intervention, and many other aspects in the AT job description all require effective communication skills. The wheels of the athletic medicine bus can fall off when a Jekyll and Hyde personality exists among the healthcare team. You know that person, the one who you never know who you are going to get from day-to-day, so you tip-toe around gingerly, hoping to avoid the wrath. This is the individual who thinks that the ‘golden rule’ is something to be mocked at, when things do not go his or her way. Unpredictable behavior of this nature often interferes with trust (by colleagues, AT students, and athletes) and can substantially interfere with the effective delivery of health care.
Certainly, the profession of athletic training is not for the faint of heart. The world of sport competition is filled with extreme pressures to perform which can have a negative impact on all individuals working within the system. Developing a thick skin is a must, but tolerating belligerent outbursts from people of power is an abuse and should not be accepted or condoned (either actively or passively). Simply because someone can get away with abusing his or her power demonstrated through a lack of self-control, does not make it right. An AT must learn to be flexible to work with all different kinds of personalities, and approach each individual and situation with professionalism, respect, confidence, and a positive attitude. Compromising one’s ethical standards; however, should not be part of the employment agreement.
Although many disagree with this philosophy, a career, athletic training, should be what you do, not who you are. Who you are and the moral compass that guides you should govern your career. Are you the same person, both in an out of the work-setting? If not, why? Is it difficult to treat people in the work setting with the same kindness that you would a friend or family member? If so, again, why? Consistency is paramount in establishing trust and a good rapport. We all have bad days and say or do things that should not have been said or done, so we need to embrace forgiveness. Be unyielding in your ethical standards, be consistent, be approachable. At the end of the day, it’s not about perspective or opinion, but the uncompromised welfare of the athlete. We all cringe when having to work with a Jekyll and Hyde personality. Don’t be one of them!