The Carneiro case and pressures faced by sports medics
October 8th 2015
The Eva Carneiro case continues to make headlines in the UK this week, with claims around sexism in football taking centre stage. Carneiro, a sports medic who is named on the GMC specialist register in Sports and Exercise Medicine, worked as a team doctor at Chelsea FC for 6 years up until last month.
An incident took place on 8th August 2015, which ultimately led to her demotion and subsequently, the cessation of her time as club doctor. It involved Carneiro and team physio Jon Fearne being instructed by the referee to enter the field of play during the closing moments of a match to attend to an injured player. These actions resulted in a dispute between the medic and manager Jose Mourinho, over the seriousness of the injury and appropriateness of her actions.
Although press reports of the controversy centre on issues of sexism and integrity in football, putting these to one side for a moment, when considering the Carneiro case, a whole host of other interesting questions and interconnecting issues arise around the pressures faced by medics working in elite sporting environments today.
Elite athletes are both ‘player’ and ‘patient’ – but which comes first?
Should sports medics prioritise player welfare or return to play?
In whose interests should sports medics serve?Is the duty of the doctor first and foremost to the player or their employer, the club?
Who has a say in treatment decisions, and who should have a say?
The Faculty of Sports and Exercise Medicine (FSEM) issued a statement on 18th August 2015, in response to Carneiro’s actions, clearly stating that a doctor’s duty is to the health and welfare of the athlete, and that this should be determined on clinical grounds and not be influenced by third parties such as coaches and management.
But, can things ever be that simple?
As a part of the BIOSPORT project we have interviewed 20 medics and physio’s working in elite sports in the UK over recent months, and found that they had some interesting things to say on these matters. They talked to us about the environment within which sports medics work and the many conflicts of interest they face on a daily basis.
Consider that the football medic and team physio are also employees of the club, situated within a complex hierarchy of management and responsibility within the organisation. Not only do they have a duty of care to their patient, they also in many respects have a sense of obligation to their employer to do the job expected of them – which, for all intents and purposes centres around getting injured players back on the pitch.
[Physio’s] are put under even more pressure because they don’t want to let their coach down, or their manager down because they’re employed by that person. So, not only is the employer the club but it’s the actual manager that is demanding that this player plays. And I think the conflict of interest […] is becoming very fuzzy and hard to deal with. (Interview 11)
Despite official statements about the role and remit of the sports medic, the reality on the ground is that there are always other people involved in making decisions about treatment – the athlete themselves, their families, their agent, coach and manager – each with their own set of interests to serve. And indeed, sports medics might not always have the final say in the course of action taken. Ideally, the medic would stand their moral ground and not let clinical decision - making be influenced by third parties, but as several of those we spoke to attested, that is a very difficult thing to do.
It’s not a question of the doctor looking at the player and saying "do I think you are fit?" He has a myriad of other issues and pressures that have absolutely no bearing at all on his clinical decision, which are actually influencing him. He shouldn’t be put in that position […] There shouldn’t be any pressures, you know. If a doctor is looking at a player and making a decision there has only got to be one decision to be made and that’s in the best interests of the player, the long term position and treatment of the player and the health of the player, not are they going to lose the match. (Interview 18)
The people we talked to frequently spoke about battles over treatment decisions taking place between medic, manager, coach and player. Athletes too, exert pressures on sports medics for particular treatments they have heard about, wanting to return to play as quickly as possible or to feel better, and are often willing to try anything to make that happen. The difficulty in managing these conflicts of interest was frequently acknowledged. Those we interviewed spoke about standing their ground and refusing to sanction actions they considered would be detrimental to the patient’s health, in the face of losing their job in the process.
We had one of our young players who, the day before the training, had got a Grade II MCL injury to his knee and the manager was desperate for me to get it injected by a doctor who just started who was prepared to but I wouldn’t let him because his knee was unstable. And the manager was absolutely furious with me but afterwards accepted that I was right. And I think those are the battles you have to learn to fight because that to me would have potentially done significant damage to his knee […] But, it’s very, very difficult because by the nature of doctors becoming full time into football they’ve almost got to justify what they get paid for. (Interview 16)
But, many also told stories about times they had given in to these pressures, for example, administering therapies that they did not think would have any therapeutic benefit for the patient, as long as they would not do any harm to them either. The environment that sports medics work in means that they are often isolated from other medics so unable to get a second opinion, while being under pressure to make decisions quickly that serve the interests of these other parties - the health of the player is not the only factor under consideration. Take for instance, the excerpt from an interview with a leading UK sports medic, below:
In sports medicine, often, you’re in a dressing room. Someone is shouting at you. The player is there. You are doing stuff; you don’t have any peer review; you don’t have any outcome measures; you don’t have any idea about what’s going to happen in the next five minutes and you end up doing stuff … and you go home and you think “blimey! I’m not sure I should have done that”. You don’t have anyone to talk to, you can’t share… It’s very, very difficult […] You get pushed towards “doc will go you do this; doc will you do that” and you know that you… It sounds stupid but you end up doing things, nothing really awful but … I’m thinking [the therapy] can’t really harm you, but, you know, it’s not clinically indicated. It’s not going to do them any good; it won’t do them any harm but I’m thinking to myself “why am I doing this?” […] And yet, I did it. So, that’s my point really. I think you end up falling off the edge loads. (Interview 12)
So what can we take from this? Carneiro is not the only one to have her medical decision -making questioned, risk her job by making an unpopular decision, or be subject to external pressures over how she should perform her role. As our data show, conflicts of interest between health outcomes and getting players back on the pitch, facing external pressures and scrutiny over treatment decisions, and negotiating the fuzzy boundaries around where ones responsibilities and loyalties lie are some of the realities faced by those of working in sports medicine today.
Posted by Catherine Coveney, Reseach Fellow in Global Health, University of Sussex