Dr Rogier Steins / Team Physician elite athletes / General Practitioner / Utrecht, the Netherlands
How do you become a team physician?
The most common route to become a team physician is to specialise in sports and exercise medicine first. Since 2014 sports medicine is an acknowledged specialisation in the Netherlands. It takes 4 years of specialty training and there are only 7 places available each year to start. In the UK it is a bit different. After foundation programme completion, you become eligible to apply to specialty training in sports and exercise medicine. There are 11 specialty training places available in the UK and completion will take a minimum of six or seven years. Although most team physicians finish sport and exercise medicine training, luckily it is also a possibility when you are a general practitioner like myself.
For me, it all started during a visit to the first Action Sports and Exercise Medicine Congress in Italy. After an interesting talk from the World Skate team I asked if I could get involved. A few months later I was accepted as a volunteer for the World Skate medical commission. Two years after my start in the medical commission I was able to join the International Olympic Committee (IOC) World Conference on Prevention of Injury and Illness in Sports in Monaco. This meeting is organised every four years. Here I got the chance to meet different team physicians and show my interest in this field of medicine. Thereafter, I stayed in touch and meanwhile I enrolled in a basic sports medicine course. Fast-forwards and I received a phone call with a great opportunity to apply for the role of team physician for the elite swimmers at the High Performance Centre in Eindhoven, the Netherlands.
Why become a team physician?
First of all, I find it a privilege to work with these highly motivated individuals who perform at the highest levels. It is inspiring to see how they can push their physical and mental boundaries to strive for excellence every single day.
Secondly, being a team physician means immersing yourself in a dynamic and fast-paced environment. Sports teams operate on tight schedules and face unexpected health issues, requiring you to be adaptable and quick-thinking. This constant dynamism keeps the role interesting and ensures that no two days are alike. On top of that, you get the opportunity to travel with the team for competitions and events, allowing you to experience different locations and cultures.
Lastly, being part of a team where all members have the same goal is very encouraging. As a team physician, you work in the same team composition for a longer period, which creates long-term relationships with athletes, coaches, and support staff. This continuity allows you to understand the individual health needs and challenges of each athlete, contributing to more personalised and effective medical care than you might normally be able to provide.
Teamwork
While as a doctor you might be used to working in a team, it can still be a different way of working as a doctor within an elite sports team. As a general practitioner, I am quite used to being the one on the receiving end of all the information from the other players in the medical field (doctors assistants, specialists, psychologists, nurse practitioners, dieticians, etc.). In elite sports, it is the coach that fulfils the central role. It makes it even more important to get to know everyone involved so you don’t get behind in what is going on. Besides the coach, the team consists of, but is not limited to: physiotherapists, strength and condition coach, sport psychologist, nutritionists, lifestyle coach, embedded scientists and different managers. Everyone has their own role in the team, but there are overlapping roles. For example, it is important to know the diet and supplements an athlete uses before deciding which blood tests to order.
Swimmer illness
As a team doctor, you will most likely encounter ordinary diseases like every other person who is not an elite athlete would. This is one of the main reasons why a general practitioner is suitable for this job. On the other hand, there are also sport-specific diseases in swimming. Otitis externa is really common in competitive swimmers for example. The mildly acidic cerumen normally provides a waxy coating that protects the auditory canal from bacterial and fungal infections. Prolonged water exposure and physical cleaning of the ear canals may cause a swimmer to scratch the pruritic ear canals, leading to superficial lacerations that become the portal for skin infections.
Exercise-induced bronchoconstriction is also more prevalent in elite swimmers. Swimming in indoor chlorinated pools can lead to airway chlorine allergen exposure and it is suggested that this generates airway epithelial damage, inflammation, and bronchoconstriction.
Swimmers injuries
Competitive swimming is unique because it is non-weight bearing and has a large dependence on upper extremity strength for propulsion (legs only count for 10-20%). This predominance of the upper extremities combined with high volumes of swimming training explains why shoulder pain is the most common musculoskeletal complaint in competitive swimmers.
The second most common musculoskeletal injury is breaststroker’s knee. It typically causes medial and/or anterior knee pain and results from the repetitive valgus load, which causes medial distraction and lateral compression of the knee compartments. A proper breaststroke kick technique, with optimal hip abduction angle range from 37 – 42 degrees, can prevent this. Groin pain is another injury risk and is caused by repetitive hip adduction. This movement puts significant stress on the adductor longus, brevis and magnus, pectineus and gracilis that can lead to overuse injury.
Prevention and Performance
In addition to illness and injury management, the team physician plays an important role in prevention and in optimizing the performance of elite swimmers. The main goal is to have as many healthy training hours as possible. It is crucial to recognise if performance is declining to reduce the risk of injury. Different tools are used to get a global idea of the performance of these athletes. Every week different strength measurements are done and compared to their personal mean. Another tool is an athlete self-reported daily questionnaire about subjects like their sleep, stress and mood to signal early signs of non-functional overreaching. The coach can also have a look at the acute to chronic workload ratio (ACWR). ACWRs are calculated by dividing the acute workload (total load over the last week) by the chronic workload (average of the last 6 weeks). The higher the outcome the higher the risk for an injury.
Mental Health
The pressure to perform at peak levels in combination with rigorous training regimens can have an impact on the mental health of elite athletes. The expectations placed on these athletes, both internally and externally, can lead to a range of mental health challenges. Anxiety, depression, eating disorders, injury related stress, social isolation and burnout are some examples. The pressure to continually perform better, coupled with the fear of failure, can have a big impact on the mental well-being of athletes.
As a team physician it is important to be extra aware during certain periods, because the athletes are more prone to mental health challenges. These include, yet are not limited to:
- When they are away from home for extended periods due to training abroad homesickness and loneliness can be a challenge.
- During major events like the Olympic Games or World Championships. These events can add extra pressure to perform and create a fear of failure.
- After a major competition or achievement, some athletes may experience a sense of emptiness also known as post-competition blues.
- Dealing with injuries and rehabilitation can lead to fear of not fully recovering and anxiety about returning to competition at the same level.
It is crucial to have a good relationship with the athletes and know their personal background. This will facilitate the identification of any out of the ordinary behaviour and also lower the threshold for them opening up to a conversation about mental health challenges. As a physician in elite sports, it is fundamental to be aware of signs of mental health challenges, open up the conversation and, if necessary, refer to a sports psychologist.
Antidoping
As a doctor, you are also responsible to promote a clean and fair environment in elite sports. Each year the World Anti-Doping Agency (WADA) publishes an updated version of the List of Prohibited Substances and Methods. This list contains all the substances that are prohibited at all times, in competition and specific sports. A substance can be added to the list if it satisfies two of the following three criteria:
1. It has the potential to enhance or enhances sport performance
2. It represents an actual or potential health risk to the athlete
3. It violates the spirit of sport
Anabolic agents, oral corticosteroids, stimulants and diuretics are obvious examples. Beta-blockers are probably not the first to come to mind when thinking of prohibited substances. Though, when you think about it, it makes sense that this substance is prohibited in particular sports like archery, darts and shooting. Certain athletes may have an illness or a medical condition that requires particular medication. If this medication contains a substance that is on the List of Prohibited Substances and Methods, you can apply for a Therapeutic Use Exemption (TUE). A TUE allows the athlete to use the medication as it will not afford a competitive advantage but rather ensures the athlete to compete in a proper state of health.
Elite athletes often use several supplements and as the team physician, you should be aware of this. Supplements can be contaminated and cause a positive test. This is why there are several systems developed to check for a guaranteed clean supplement, such as: ‘Informed Sport’, ‘Banned Substances Control Group (BSCG)’, ‘National Sanitation Foundation (NSF) International’ and ‘Informed choice’.
Top tips to work as a team physician
- Get to know the sport. I listened to podcasts about swimming and read different biographies of famous swimmers to better understand the sport. Furthermore, I took lessons to learn freestyle swimming myself. Swimming is a technical sport. If you understand the technique you can also explain why certain injuries happen to certain athletes and make adjustments to prevent this.
- Get to know the supporting team. As mentioned before, there is a big group of supporting personnel and it is really important that you know the role of each person in this group. If an illness or injury is present you want to make sure you can tackle this as fast as possible so it helps to know who to consult in every situation. In elite sports, every missed training day is one too many.
Get started
In my opinion, the best way of learning is to learn on the job. Luckily for me there are many experienced professionals in the team who I can ask for advice. However, if you want to follow a course, the IOC Advanced Team Physician Course may be a good start.
