James Genuario, MD

Physicians who treat patients with sports injuries face great pressures because of conflicting team and personal goals. The nature of the patient-physician encounter is changing. Paternalism, in which the physician assumes an autonomous role in selecting treatment, has been the predominant model. Informed decision making gives the patient ultimate responsibility. In shared decision making, an amalgam of these models, there is mutual responsibility for treatment decisions; now physicians can address injuries and match best clinical outcomes with patients’ values to decrease treatment errors and morbidities. Open communication between patient and physician is essential, but there is a discrepancy between physicians’ perception of their communication effectiveness and the reality. Several decision-making aids are available to help physicians promote good communication. (

First, do no harm. It is branded on the intellect of all physicians, a maxim to protect patients, the crux of medicine. However, no field of medicine challenges this ancient Hippocratic precept more than sports medicine, which has earned its own subspecialty with distinct forces placing great pressure on the patient-physician decision-making process.

Take, for example, the following 2 patients. One, a 35-year-old all-star pitcher with dislocating peroneal tendons, elects to have them injected with a numbing medication and temporarily sutured to the skin to allow him to play in the World Series. The other, a 35-year-old research assistant with the same injury, opts to have his peroneal tendons stabilized surgically, requiring him to be immobilized while they heal.

The patients have identical injuries, but they receive strikingly different care. The former treatment is dictated by the American sports ideal that winning is everything, and the latter is dictated by an evaluation of various options, matched with patient values, aimed at achieving the best possible outcome.

Green Bay Packers quarterback Brett Favre and Baltimore Orioles shortstop Cal Ripkin, Jr, are professional sports icons partly because they decided to “play through” their injuries to “win one for the team.” However, they may have placed too much emphasis on their sport and let their good health slip by the wayside. They are not alone. Many athletes, amateur as well as professional, follow in the footsteps of these idols in upholding the time-honored conviction that there is no “I” in “team.”

The juxtaposition of team desires alongside individual desires creates a unique obstacle for injured athletes to overcome when these desires are at odds. The obligation that injured athletes feel to place the sport above self may serve better on the field than on the body. Pressures that injured athletes face include the need to return to their premorbid skill level, to return hastily, and to compartmentalize the effects of their injury emotionally.

This juxtaposition of team and individual goals essentially characterizes the unique needs of sports medicine patients. In addition, it places tremendous emphasis on the role of physicians in maintaining the Hippocratic aphorism by ensuring that the treatment rendered-which may harm the team-will do no harm to the individual.

In this article, we illustrate how sports medicine and other physicians may find help in upholding the antediluvian medical creed from the sharing of treatment decisions with patients. In the shared decision-making process, physicians may ensure that the decisions injured athletes make are based on thoughtful consideration of their unique needs, desires, and values and their relationship with the disease/injury state. Through this framework, physicians can enable injured athletes to self advocate and succeed both on and off the playing field.

As technology and treatment options in sports medicine blossom, the nature of the patient-physician encounter also must change. In an article on decision making in orthopedics, Bryant and associates

 divided the patient-physician encounter into 3 categories of interactions: paternalism, informed decision making, and shared decision making.

Historically, paternalism dominated the landscape in a model sometimes known as “disease-centered care.” 

 In this model, the physician is an expert in injury and disease, has knowledge of the treatment options, controls the care, and dispenses information to the patient in discrete visits as he or she sees fit. As such, the physician assumes an autonomous role in selecting treatment.

In the practice of sports medicine, the team physician typically adopts the paternalistic role. Decisions (eg, return to play) often are left to the medical staff, without an intimate assessment of patient values. If individual values are not factored into decision making, there is potential for harming the patient. For example, returning an athlete to play before an injury is completely rehabilitated because of pressure from the coaching staff could result in significant harm or reinjury.

Later, the medical community began to recognize the importance of including the patient in the decision-making process and reversed the roles of patient and physician. In this informed decision-making model, in which the patient assumes ultimate responsibility for care, the physician presents information about the risks and benefits of various treatment methods. From this point on, the patient is left with complete autonomy on treatment options without more physician input.

Although this model is rare in recreational sports, it may be more common in professional sports. The case of the finger-tip amputation of San Francisco 49ers defensive back Ronnie Lott’s pinkie during the 1985 NFL season to allow him to continue to play is a graphic example of the patient probably having autonomy in the ultimate choice of treatment. In this paradigm, the mantra of team first often heavily influences decision making capacity, possibly to the detriment of the patient.

With all dramatic shifts in medicine, the pendulum tends to swing back to a middle stance. In this case, the middle is shared decision making, an amalgam of paternalism and informed decision making.

In shared decision making, the patient provides intimate information about his values and goals to the physician who, in turn, provides clinical expertise on the disease or injury state (including discussion about the current scientific literature on the topic, such as experiments, analysis, and forecasting). The final treatment course represents the best option in the context of the patient’s situation being melded with the physician’s knowledge of outcomes.

 As indicated by its name, shared decision making involves mutual responsibility; here there is the least possibility of harming the patient.

The nature of shared decision making is illustrated in a work by Eddy

: “the people whose preferences count are the patients, because they are the ones who will have to live (or die) with the outcomes. . . . Ideally you and I are not even in the picture. What matters is what Mrs Smith thinks. . . . It is also quite possible that Mrs Smith’s preferences will differ from Mrs Brown’s preferences. If so, both are correct, because ‘correct’ is defined separately for each woman. Assuming that both women are accurately informed regarding the outcomes, neither should be persuaded to change her mind.” There is 1 common injury, but sharing decisions with 2 patients who have 2 sets of values can result in different treatments. As long as the patients are adequately informed, both are correct and neither suffers from the decision.

In 1999, the Institute of Medicine (IOM) published a landmark work, 

To Err Is Human: Building a Safer Health System

 which related nearly 100,000 annual deaths to health care mistakes.

 Although fatalities related to sports medicine decision making are rare, they may occur in instances of continued participation or premature return to play.

 In the rare case of postconcussive “second impact syndrome,” the attitude of team first may lead to an athlete’s demise-a second head injury after premature return to sports activity may result in death.

Although mortality grabs the headlines, nearly as important is the morbidity associated with poor decision making. For example, a high school football lineman in whom low back pain develops as a result of spondylolysis may play through the injury rather than seek medical care. As a result of the continued repetitive hyper extension trauma, a nonunion of the pars interarticularis is more likely to develop. The decision to forgo medical treatment to play another game could result in long-term disability and pain.

The athlete often views the injury with blinders, asking “What can I do now to get back into the game or return to play sooner?” rather than “What would be best for my health in the long term?” Shared decision making provides a framework for addressing these injuries and matching best clinical outcomes with patients’ values to decrease errors in treatment, ultimately decreasing sports-related mortalities and potentially long-term morbidities resulting from uneducated decisions.

An IOM follow-up study suggested that a large part of the problem with US health care was a tremendous variation in the treatments given to patients and a large gap between the care patients need and the care they receive.

 In this report, the IOM noted that the quality of health care can be improved if it is safe, effective, patient-centered, timely, efficient, and equitable. Central to this improvement paradigm is the need for patient centered care, the crux of which is shared decision making.

Patient-centered care involves transferring medical knowledge to patients and their families to enable them to construct an educated treatment choice within the setting of their individual values and desires. Ultimately, the patient selects the treatment course based on values, risk tolerance, and priorities.

 Because in sports medicine the difficulty is sorting the athlete’s priorities from the team’s, and team goals may flavor the patient’s values, the patient-physician encounter must be navigated carefully to prevent an ultimate treatment decision based on team-centered rather than patient-centered care.

Open communication between patient and physician is the essential map in charting the appropriate course of treatment. In “Physician-Patient Communication: A Lost Art?” Frymoyer and Frymoyer

 emphasized the importance of effective interaction. In the clinical setting, communication has been described as the process of influencing patient behavior, producing the changes in knowledge, attitudes, and skills required to maintain and improve health.

A failure in communication results in a failure to understand a patient’s needs. This breakdown results in inadequate counseling, thereby destroying a cornerstone of shared decision making and, ultimately, worsening outcome. In addition, benefits of good communication on emotional health, symptom resolution, and pain control have been shown.

 The transmission of appropriate information to patients also is strongly associated with adherence to treatment plans and active participation in care.

Although communication is a concept learned early in life, the ability to communicate effectively during a patient-physician encounter often is lost. In one study, 70% to 80% of orthopedic surgeons reported that they were effective in listening and relaying information.

 The same group stated that only 18% to 29% of their peers were equally successful, however, and the public reported that only 36% of orthopedic surgeons spent enough time and were empathetic.

Clearly, there is a discrepancy between the perception and the reality of communicating with patients, and these misunderstandings have translated into adverse outcomes.

 In an analysis of more than 3500 patient-physician discussions, Braddock and colleagues

 found that fewer than 10% resulted in informed patient decisions. Malpractice was associated with poor delivery of information in 26% of cases,

 and primary care physicians in Oregon who had received explicit training in patient-physician communication had reduced rates of malpractice.

Shared decision making is a key to always valuing patient needs first, and providing patient education through good communication lies at its core. Several decision-making aids are available to help physicians promote good communication in sports medicine. Decision aids are unbiased tools designed to facilitate shared decision making by helping patients and their physicians choose among clinical options. They are adjuncts to counseling that “explain options, clarify personal values for the benefit versus harms, and guide patients in deliberation.”

The common denominators of a well-designed decision-making aid include an unbiased look at various treatment strategies (including those that are outside the realm of care provided by the treating physician), their outcomes, and their relationship to the patient’s values.

 Note that decision-making aids are intended and designed to only supplement the patient-physician interaction. In the case of sports medicine, their use can help avoid the common paternalistic approach to treatment decision making. Information also may be delivered in paper format via organizational charts and in a variety of other media, such as audio, video, and computer-driven programs.

Overall, decision aids positively influence patient care. In fact, in a Cochrane systematic review of decision aids, O’Connor and associates

 found improved patient knowledge, positively affected decisional conflict, and improved patient satisfaction.

Although decision-making aids have obvious benefits, implementation into practice has met with both psychological and logistical barriers.

 Most physicians already believe that they are doing an adequate job and do not need to supplement their patient-physician relationship. In addition, implementation requires an increased duration of patient visits, dedicated office space, coordination of aid materials, and increased expense; also, despite the aids’ proven efficacy, there is no increased reimbursement for their use. Still, the importance of implementing these aids into practice is greater in sports medicine than in perhaps any other specialty. Their use increases the probability of fully informing the athlete, allows for patient-centered care, and decreases the probability of choosing a treatment option that is in congruent with the patient’s values.

Sports medicine has lagged behind other areas of medicine in adopting decision aids as well as the notion of shared decision making. For current information on decision-making tools, visit Web sites (eg, 

 [the Ottawa Health Research Institute]) that provide input on the usefulness of specific aids and serve as resources for programs that guide patient choices. They currently contain formal decision aids on anterior cruciate ligament reconstruction and rotator cuff tears and a generic form aimed at guiding any patient decision-the Ottawa Personal Decision Guide is a worksheet that patients can fill out to help them assess their decision-making needs, plan the next steps, and track their progress in decision making.

The practice of sports medicine provides an exclusive venue for the opposing dictums of putting the patient first and emphasizing team needs to collide. Shifting the paradigm of patient-physician interaction to a shared decision-making model is essential for upholding patient values in any treatment choice. Implementing such a model for the care of injured athletes in everyday practice can improve patient outcomes.

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Articles

Open communication between patient and physician is essential, but there is a discrepancy between physicians’ perception of their communication effectiveness and the reality.

Author | James Genuario, MD

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The Role of Shared Decision Making in Sports Medicine