Question 1
Anabolic steroids are classified as Class C drug controlled under the Misuse Drugs Act 1971 in the UK. It is accepted to be used and imported for personal need (Iverson, 2010). Doping has been observed all through history, but should not be considered as an issue limited to the athlete, it is mostly a result of the social doctrine of winning and the importance of appearance widely shared by the public (Yesalis and Bahrke, 2000).
In this particular case, depending the situation I am disclosed the delicate information, I would move the conversation to an area where it can be carried out in confidentiality. Often, the doctor-patient encounter in the sport setting doesn’t necessarily happen in an ideal private clinical setting, but pitch-side or in crowded training rooms (Johnson, 2004). I would take exceptional care in my documentation of the dialogues, my findings on physical examination. These have to be stored and kept securely, to prevent open access for other clinicians, coaches or managers. First I would take and in-depth, detailed history, including the length and dosage of steroid use, establishing the specific drug if possible. I would want to explore the reason for using the anabolic steroids, there might be a medical reason although highly unlikely in this setting. I think it is important to understand why, an athlete is using this substance and jeopardizes his career and livelihood. Competition at a professional level caries a great social and psychological pressure. A 1995 study done in the United Sates has shown that winning at competition is more important for an athlete than the consequences of doping, half of participants rated it more important than their own life (Ehrnborg and Rosen, 2009), showing the magnitude of mental pressure. The athlete has to be kept well not only physically, but looked after psychologically as well. Onward referral for counseling might be a good idea if the patient shows signs of depression or has difficulties coping with the high expectations and pressures of professional sports. During careful physical examination I would be looking for symptoms caused by side effects of anabolic steroids. These side effects can be widespread, including structural changes to the heart, derangement in liver function test, elevated blood pressure, changes in sexuality and mood, increased body hair growth, acne vulgaris. Some of those have direct correlation with the length of drug exposure (Hartgens and Kuipers, 2004). These might need treatment or further investigations if clinically appropriate, just as common medical conditions. Controversially taking the blood test could be interpreted as a facilitation to drug use that is condemned by the sports medicine community (FIMS, 2016). The doctor’s primary duty is to provide the best available care and advice to his patient regardless of what causes possible health risk. The athlete’s health has to be monitored and followed up at further appointments. These encounters provide good opportunities to educate on drug abuse and discourage further use of the banned substance (Johnson, 2004). Confidentiality and privacy are the most common issue raised by a group of New Zealander sports doctors, describing the constant struggle between keeping health information confidential and satisfying requests by coaches and team officials (Anderson and Gerrard, 2005). Although the physician is part of the team, disclosing information to third party would harm the doctor-patient relationship, that could have a pivoting role in turning the athlete. Any disclosure can only take place with written consent of the patient (GMC, 2009). Some teams have contractual rights to access full medical records. If it is the case the patient has to be made aware in advance before any further disclosure happens. Ultimately I share the view, that the athlete’s medical circumstances are to be regarded as confidential and are never to be disclosed without their knowledge and consent (BMA, 2016). In high profile competition, the media has a dominant role, especially social media of nowadays. It can be a great tool to educate the wider public and promote healthy lifestyle, or share information with a group of athletes and should be used by the clinicians. As most online information can be accessed by the wider public, it is imperative that the sports doctor is extra careful when posting events online (Ahmed et al., 2015), as the negative appreciation of doping will have a devastating effect on the team as well as the individual involved. Patient confidentiality is paramount, but a slightly controversial tone the sports doctor must denounce usage of illegal performance enhancing drugs (Dunn et al., 2007) and has a duty to report doping in a confidential, anonymized way (FSEM, 2016). The above also adds to the pressures most team doctors face in the world of professional sports. The professional risk regarding the treatment and management of this athlete has got two aspects in my opinion. The doctor has to look out for his patient and treat the medical conditions arising from the drug abuse, but by doing so we arguably enable the safe usage of a potentially dangerous and illegal substance. This requires careful risk stratification not only in this particular case, but at all consultation. For example when certifying someone fit to return to compete after an injury (Chen and Esposito, 2004). If I find serious or potentially life threatening side effects and hospital admission or referral is required, information may be shared with the immediate medical team (GMC, 2013). Further to above, information may need to be shared with the athlete’s General Practitioner after gaining consent. He can be great help in encouraging the athlete in returning to a healthy, clean lifestyle and training. Involving the General Practitioner in this delicate case provides good mean to maintaining continuity of care (FSEM, 2016). All physicians practicing in the United Kingdom face a statutory requirement to provide adequate liability insurance to provide safe care (GMC, 2013), sports doctors are no different. Adding to that a sports doctor’s employer might share liability with the physician under the “vicarious liability” doctrine (Chen and Esposito, 2004). I would consult my insurance company for advice on how to further manage this athlete after our first contact and keep a well-documented record of that discussion and the advice given.
The constant need for pushing the boundaries of athletes is also driving a tense battle between the use of performance enhancing drugs and anti-doping officials. Somewhat mirroring the theory behind competition on the field of sports. Clean competition has to be advocated by any sports doctor. It is any athlete’s duty to ensure no illegal substance enters their body (WADA, 2015).
Question 2
Correct and prompt treatment of the shooter’s temporal arteritis is very important as it can lead to loss of vision or stroke, that will have devastating consequences to the athlete’s career (Hayreh et al., 1998). As the sports physicians we have to be aware of regulations and correctly follow the procedures set by the World Anti-Doping Agency (WADA) and United Kingdom Anti-Doping (UKAD). When prescribing medication to an athlete it is important to check if the substance can be used in or out of competition. Globaldro.com is such a website. You can search for use of specific substances in specific sports (GlobalDRO, 2016). It is very useful and should be consulted routinely as rules and regulations change.
The use of glucocorticoids is prohibited (WADA, 2016) and is to be avoided in-competition (GlobalDRO, 2016) in shooting. In order to compete at an international level, the athlete has to apply for a Therapeutic Use Exemption (TUE) at hers sport’s international federation (WADA, 2015) in this case the International Shooting Sport Federation. Alternatively, if a national Anti-Doping Organization’s TUE meets the criteria set in the international Standard for Therapeutic Use Exemptions, the international federation has to accept it. The application has to be submitted to UKAD in case of national competition. The UKAD website contains all information and grants access to all forms necessary (UKAD, 2016). When applying for a TUE the following three major points have to be considered. 1.The use of the prohibited substance is needed to treat or prevents “significant impairment” caused by a medical condition; 2. There is no effective, alternative, non-prohibited treatment; 3. The treatment in question is not necessary to treat the results of a previously used doping violation. In this case all three apply, an application can be submitted. TUEs should be applied for in advance or can be granted retroactively if applied for within 5 days of a positive analytical finding. For a retroactive application, there has to be a valid medical reason why the drug had to administered without the formal decision on TUE. For example, severe asthma, allergic reaction. Treatment guidelines suggest that prompt steroid treatment is needed to prevent severe complications in temporal arteritis (Hayreh et al., 1998), so in this case I believe, a retroactive standard TUE application would be applicable in case of interim doping test. Testing positive with a valid TUE does not qualify as doping violation. A comprehensive range of medical documentation regarding the condition at hand has to be included with the application. History, relevant diagnostic results and evidence to lack of alternative treatment. After obtaining written, signed consent from the athlete, I would contact the specialist as soon as possible to get access all relevant information to submit the application. It might be beneficial to certify in advance if all relevant diagnostics are available, before application.
There is no reason why this shooter could not compete legally at international level, and does not need to worry about a doping test regarding her oral corticosteroid therapy if her application for a TUE is granted.
Question 3
Brain concussion can be defined as a “stunning” of brain cell, secondary to trauma without permanent damage to the skull or the brain parenchyma, resulting in vague symptoms due to minor brain dysfunction (Davis, 2013). Manging the concussed player as the team doctor, was always a complex matter that raised many debates (Partridge, 2014). There has been an increase in legal claims filed against sports doctors, therefore appropriate steps and guidelines have to be created to facilitate correct treatment of athletes in emergency situations (Kane and White, 2009). Clinical negligence is defined by a “breach of legal duty of care” towards the patient, and consequently causing injury or harm, assuming there was a duty of care in the first place (Mind.org.uk, 2013). Treating the injured athlete is indisputably the primary duty of the sports doctor. In this case administering a new, homeopathic product might be considered negligent, unless advised by a reasonable body (Bolam Test) – described in a widely accepted evidence backed guidance. The said guidance also has to be logical in order to be called responsible or reasonable (Bolitho test) (Rull, 2015). Negligence might also arise from superficial pitch-side physical examination, misinterpretation of the symptoms and providing inadequate advice (Kane and White, 2009). It is debated until today if homeopathy has got any effect at all. Two large meta-analysis studies found no evidence for homeopathic preparations other than placebo effect (Linde et al., 1997; Shang et al., 2005). So it is questionable if the severe adverse reaction was secondary to the administered treatment, but very difficult to prove otherwise as even unlicensed medicines are considered to have side-effects (NICE, 2016). Non-exhaustive list of severe adverse reactions: death, disability, life threatening conditions or need for hospitalisation (FDA, 2016), severe headache can be categorised in latter. If regarded as adverse reaction, the doctor has a duty to report it through the appropriate channels. The patient has agreed to the treatment, but it is not clear if all alternative treatment options were discussed and detailed. It is debatable if the patient had exhaustive information at hand to make his agreement valid informed consent and there was no mention of possible side-effects either. This stresses the importance of documentation in every area where acting as medical professional, regardless of context and also accentuates the need for an open and honest attitude towards the athlete. Achieving a harmonic patient-doctor relationship based on trust and evidence based medical guidance can prevent litigation and misunderstandings. The most common symptom following a minor to moderate head injury is headaches; the continuing problems experienced by the player may very well be due to the primary injury. In this case onward specialist referral and hospitalisation was the correct next step form the part of the physician. Although symptoms might be long-lasting, it rarely is the case (Rutherford et al., 1979). As it was an illegal tackle the player inflicting the injury might have injury liability similar to Ben Collett’s case in 2008, where the opponent’s club was eventually held responsible for the loss of earnings of a potentially “outstanding” footballer, who’s injury broke his promising career (BBCnews, 2008).