As an Athletic and Rehabilitation Therapist (ARTC) there are many different relationships involved in the completion of the job and a successful team and clinical environment. These relationships involve other professional medical practitioners, Patients, Clients and Of course athletes. The objective of these relationships is to understand specific physical, mental and emotional demands of physical activity, exercise, everyday living and sports training.
A different relationship exists between ARTC’s, patients, athletes, medical practitioners, sports organisations, professional colleagues and team managerial staff. ARTC’s are the primary liaison between the athlete and team coaches. The ARTC should have the final say whether or not a player is fit for playing no matter how important a player is to the team. It is a common problem in amateur sports where the coach overrules the ARTC’s medical opinion and plays an injured player to benefit the team rather than benefitting the Athlete as an individual.
The relationship between the athlete and the ARTC is one of the most important in a team environment. There needs to be a level of communication, listening and empathy between the two. If this is not the case the athlete will not trust the ARTC and recovery from injury will be inhibited because an athlete needs to feel that their concerns are being taken in to consideration when they are being treated. While this relationship needs to be transparent and honest the athlete needs to know that the ARTC knows best and is obliged to exercise professionalism at all times. The ARTC also holds the position of having to being honest to the coach about the injury for the sake of the Athletes best interest. The athletes right to privacy is also protected by the ARTC. While it is important to have a close and professional relationship with and an injured athlete it is also very important to keep it a therapeutic relationship and to avoid an intimate relationship with the patient and not to cross and boundaries.
In the field of practice the ARTC will work with other healthcare professionals of various disciplines. An interdisciplinary medical team is a key element of a functional practice of sports medicine. For the athletes best interest it is important the if an athletes problems is beyond the level of your expertise you should refer them on to another member of the medical team. It is crucial that at a sports venue it is the ARTC’s responsibility to give priority to the athletes health and wellbeing and determine whether or not they can or not return to the field of play. It is key that the result of the competition should not influence the decision of the ARTC and that no third party should influence the decision either.
As and ARTC you have a responsibility to your patient to act in their best interest and the position you hold as an ARTC should never be used to gain advance for a sexual or intimate relationship. Patients should always be treated with dignity and respect no matter of race, disability, sex, sexual orientation, social status, or political views. Children should also be treated in a protected environment and should always have a guardian with them in a clinical and sport setting. The child’s wellbeing is always the priority and if the ART has concerns about abuse or neglect they have the responsibility to contact appropriate authorities without delay. The Child must also feel that you are a trustworthy person so that they can talk and build a strong professional relationship with. Once care is undertaken by the ARTC they are then obliged to provide continuity of care throughout the duration of the injury no matter if the ARTC withdraws their services from the team they are ethically bound to the responsibilities.
Drugs in Sport.
Performance enhancing drugs (PED) are becoming very common in the modern sport setting with a recent survey saying that every high level athlete saying that they know at least one other high level athlete taking PED’s. There are very serious repercussions for athletes that are caught doping. This is also the case for any healthcare professional that is seen to be assisting the athlete to do so. An ARTC for example will lose their job, licence and will spoil their name for assisting an athlete to dope.
There are many types of drugs and methods used to enhance an athletes performance. There is a full list of prohibited drugs on the WADA Website. There was a survey done in 1997 where 200 Olympic athletes were asked if they could take an illegal drug to ensure winning and no chance of getting caught would they take it. 3 out of that 200 said that they would take it. This shows that ethics varies over time and it all depends on an individual’s personality on what he/she thinks is ethical or not.
There are arguments for and against the use of drugs in sport. But it is fair to say that the use of PED’s taints the name of good sportsmanship and the individual. The argument for the legalisation of PED’s is that, like high tech equipment, research and training that some teams have, PED’s also enhance performance and some teams don’t have these methods of improving performance so PED’s should be an option.
The arguments against drugs are by far stronger than their counterparts. Drugs distort the nature of sports by changing the focus of it to winning. Honest athletes builds character by learning how to win lose and draw but drugs counteract this by enhancing performance to win every event.
It is in important that an ARTC has an idea of prohibited substances in the 3 main categories:
– At all times
– In Competition
– In particular sports
The most common PED’s are
• anabolic steroids: enhance strength and muscle mass
• human growth hormone (HGH): improve performance and muscle mass
• EPO or blood doping: increase red blood cells (oxygen carrying cells)
• gene doping: changes genetic makeup of athlete to make more desired genes
If a ARTC becomes aware of a member of their team they are obliged to intervene in the matter. If they don’t they are subject to punishment as well by governing bodies.
General Data Protection Regulation
The general data protection regulation (GDPR) is an EU directive which was introduced to protect and preserve all documents regarding consumers and new obligations for ARTC’s and physiotherapists. These have being active since the 25th of May 2018. This GDPR entitles the patients to the right of accessing data which has been collected concerning him or her, and the right to have it rectified.
As ARTC’s are deemed to be working with “high risk” or “sensitive” personal data they attract more attention from the GDPR so greater efforts to have safe and secure processes in place will be expected. It is very critical that ARTC’s let their patients know how you handle their personal information as this increases the trust between you and you patient while also adhering to the GDPR. Consent is Crucial in in dealing with patient health information. Any data that can be used to identify a patient is said to be sensitive information this includes e-mails, videos, session notes, etc. whether they are on paper or on an electronic device.
All data should be stored correctly and securely. For any information stored on central IT servers needs to be restricted to certain amount of staff. Encryption is needed to a certain level to secure personal devises. Clinical computer systems should only ever access the internet when an approved firewall or anti-virus is in place and regularly updated and renewed. Access to systems need to be password protected and all patient information needs to be hidden from all others.
It is important to remember that the patient has to give consent to handle and manage sensitive data especially photographs and videos. Consent must be freely given and patient cannot be forced into giving consent and also may withdraw their consent at any time. An ARTC’s consent policy must meet the standard set by the GDPR and all the guidelines must be explained in advance.
Children’s Data is similar to the other rules and regulations in terms of records and record keeping but consent must be given by a guardian when the child is 13 years old and under.
Consent
Consent is very crucial in an ARTC’s clinic. The objective of valid consent is to respect the bodily integrity and the right to self-determination of patients. When it is not possible to obtain a patient’s valid consent, an ARTC should do whatever is in the patient’s best interests. If an ARTC was to treat a patient without consent it would violate their constitutional rights. If an ARTC was to touch a patient without consent they are leaving themselves open to a clinical negligence claim, a complaint to the medical council or charges of assault. Consent can be withdrawn from any treatment or research experiment at any time throughout. The three main aspects of consent are Capacity, information and voluntariness.
Capacity involves the patients “ability to understand the nature and consequences of a decision in the context of available choices at the time the decision is to be made”. If the patient is incapacitated only personal guardians, relatives and careers can give consent on the persons behalf if they believe it is in the patients best interest after doctors medical advice. In no case should an incapacitated patient be denied treatment. An ARTC must never presume a person’s capacity and must undertake proper examination and assessment. Background information from people close to the patient and other medical practitioners may prove useful in diagnosing the patients capacity. It is important that if a patient is able but cannot communicate verbally an alternative means of communication should be used e.g. a picture board. When a child is in the picture with consent the law states that a 16/17 has the capacity to refuse treatment if they fully understand but if the parents and minor are in disagreement about the decision it is best to refer the matter to the hospital legal team, HSE or an external solicitor.
Information is key in consent. If the correct information is not giving to the patient they are not in the position to decide what is best for them. The only justification for withholding information from a patient is if it will cause serious harm to the patients mental or physical health. Other than this any questions asked should be answered thoroughly and honestly. In emergency cases when time is of the essence it may not be possible to provide all the information necessary. It is crucial that the patient is given a broad outline and all the information and possibilities of the end result is mentioned.
Patients must not be pushed/forced into making a decision. This is where voluntariness comes into consent. In some cases patients might not like questioning the ARTC’s expert opinion and might not want to say no therefore it is important to emphasize that the patient doesn’t have to say yes to the treatment and has the right to withdraw consent at any time throughout the treatment. Adult patients that are under the mental health act of 2001 are particularly vulnerable, but still do not lose their right to refuse treatment.
When a patient refuses to be treated an ARTC cannot disregard or overrule the patients decision even if the ARTC believes that it is foolish and illogical. The patient must understand the consequences of refusing treatment and what the indications are.
Medical Documentation
Accurate and detailed record keeping is mandatory in providing a high quality, reliable service. These records entail highly sensitive and personal data. It is important to store this notes securely away from prying eyes of staff and other patients. The main reasons for keeping clear and reliable notes are to provide information for future sessions, either with clinical staff or other health care professionals, to provide base line data for education and research, to provide a basis for quality review and providing a basis for legal purposes.
There needs to be a continuity of care between sessions and therefore everybody that is dealing with the patient needs to know what treatment has already being completed along with the diagnosis. This will reduce confusion of the athlete between different diagnosis of different ARTC’s. it is also very important to have records for legal reasons as most lawsuits occur years after the event so detailed notes are essential for recurring memory and have a strong recollection of events.
Keeping notes will also help in research of new proposed treatments ideas. Notes will help to determine whether treatments work or not. This research would have to occur over a 5 year period to make it a legit case. Whereas the notes need to be kept for 7-8 years for legal reasons post event. This notes may need to passed on to different organisations, with the patients consent, e.g. sports teams, military, insurance companies and some employers. Maintain a complete and accurate record of each patients personal medical information. If an ARTC is working with high profile athletes, they should first get consent from athlete of what information can be released to the public and press.
As previously stated in the GDPR section all visual, auditory, hand written and electronic notes need to stored correctly and securely. All entries into the notes should be initialled by the ATRC that has entered the notes. Notes that put into a patients file should be straight forward and easily understood. The notes should include injury info, history, treatment, all findings, a referral note if necessary, details of consent and follow up appointments. Some ARTC’s use SOAP notes as form of keeping record. SOAP notes are very helpful and can save time in clinic.
S-Subjective
O-Objective
A-Assessment
P-Plan of Treatment
Review/Summary of Code of Ethics
ARTI:
The Code of Ethics of Athletic Rehabilitation Therapy, Ireland (ARTI) states the principles of ethical behaviour that should be followed in the practice of Athletic Rehabilitation Therapy. It is intended to establish and maintain high standards and professionalism for Athletic Rehabilitation Therapy in Ireland. All ARTI members should respect the rights and dignity of all, along with maintaining high standards and professionalism. All members should not engage in conduct that contradicts their laws and regulations of ARTI. Members must also accept responsibility for their scope of practice and their clinical team.
ISCP:
The Irish society of chartered physiotherapist states in their code of ethics that all members should care for their patients in a respectful manner and not to be prejudice. The dignity of the patients and rights should be respected and should act professional at all times. It is also important that the physiotherapist takes part in CPD courses and stays up to date with the latest treatments and technology. It’s crucial that physiotherapists know their limitations and only treat activities that are in their professional competence.
NATA:
The National Athletic Trainers’ Association Code of Ethics states the principles of ethical behaviour that should be followed in the practice of athletic training. It is intended to establish and maintain high standards and professionalism for the athletic training profession. The principles are representative of the spirit with which athletic trainers should make decisions. The principles should be take into consideration the circumstances of a situation that will determine the interpretation and application of a given principle. When a conflict exists between the Code and the law, the law should prevail
Lawsuits/cases critiqued
• In 2014 a 13 year old boy was running a cross country race on a track when he ran into a bench that was on the lane that was placed on the lane he was running on. He fell over the bench and suffered a displacement fracture of his radius and the wrist joint. The boy’s mother sued the school and the ARTC saying that they were negligent and it was their job to create a safe environment for the students. In the court this claim didn’t stand fit to the jury as the race took part off the school grounds and out of school hours. This meant that the student was a voluntary competitor in the in the race and it wasn’t the discretionary right of neither school nor ARTC’s fault the environment of the race wasn’t safe.
• Another case in 2014 that went to the courts, was that of the death of collegiate football player from California. This player suffered a hypertrophic cardiomyopathy (excessive Thickening of the heart) due to an off season conditioning drill that the ARTC and coaches had the team doing. The medical team acted promptly when the young man collapsed but there was little they could have done to recover him. He suffered from a sickle cell trait which NATA recommend that anybody that suffers from a sickle cell trait be monitored closely, and this is the cause for possible negligence. There has being no mention of money in this case but previous cases of the same nature have received anywhere from $200,000 to $10 million. This is an ongoing case that has yet to reach a verdict.
• In 2009, a D.C. United Soccer player suffered a concussion in a game and continued to finish the game. After this he suffered blurred vision, brain and cognitive damage, memory loss and trouble sleeping when he approached the medical team they offered little help and said they would monitor him. This event led to an early retirement. In 2012 he then sued D.C. United, the coach and the medical team for negligence in the care and treatment of the injury. The plaintiff is suing them for $10 million dollars for medical negligence and $2 million dollars for causing marriage difficulties with his wife. This case was dismissed as the plaintiff and the club came to an agreement.
• A high school footballer has recently put in a claim against his athletic therapist that was over him in 2014 where he sustained a concussion in a football game. The plaintiff is saying that the ARTC did not fulfil the requirements of dealing with the concussion properly and giving the all clear to play another game shortly after which led to the hospitalisation of the football player. The Plaintiff has being living with a permanent brain injury since the incident back in 2014 and in January 2018 he took legal action. This case in ongoing and is in the courts at the minute.