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Lynley Anderson and Steve Jacksonin elite, commercial sport

Competing loyalties in sports medicine: Threats to medical professionalism

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International Review for the Sociology of Sport

48(2) 238 –256© The Author(s) 2012

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DOI: 10.1177/1012690211435031irs.sagepub.com

Competing loyalties in sports medicine: Threats to medical professionalism in elite, commercial sport

Lynley AndersonUniversity of Otago, New Zealand

Steve JacksonUniversity of Otago, New Zealand

AbstractThis paper explores the ways in which the environment of elite-level and, in particular, commercial sport produces expectations and pressures on sports doctors that may compromise their professional standards. Specifically, this paper addresses the pressures and demands that emerge from varying groups and individuals with whom doctors have relationships within the world of elite sport including: the athlete, coach, management, media (including broadcasters) and sponsors. Using grounded theory and drawing upon qualitative data collected from semi-structured interviews with 16 sports doctors the study explores the ethical concerns of medical practitioners working with elite athletes and teams in New Zealand. Key emerging themes include: the complex environment within which sports doctors work, including the limited control over their work environment, the pressures arising from the commercial interests of sport, the issue of competing obligations, and emerging threats to medical professionalism.

Keywordselite sport, ethics, New Zealand, sports medicine

Introduction

In 2009 UK sports doctor Wendy Chapman was suspended by the British General Medical Council for deliberately cutting the inside of the mouth of Harlequins’ rugby player Tom Williams. Newspaper reports suggested the player asked the doctor to make

Corresponding author:Lynley Anderson, Bioethics Centre, Division of Health Sciences, University of Otago, PO Box 913, Dunedin, New Zealand. Email: [email protected]

435031 IRS48210.1177/1012690211435031Anderson and JacksonInternational Review for the Sociology of Sport2012

Article



Anderson and Jackson 239

the cut in order to fake an injury by using a blood capsule so that a specialist kicker could replace him and win the match (Rees, 2009).The blood capsule was allegedly given to him by team physiotherapist Stephen Brennan (he was subsequently struck off the physi-otherapy register by the Health Professions Council; this was overturned on appeal to the High Court in 2011). Although it could be argued that the injury was minor, with no likely long-term effects, outsiders might wonder how members of two respected health professional groups could support such blatant cheating. While not excusing the actions of the doctor and physiotherapist, we can better understand their actions by considering the contemporary cultural and economic context of elite and professional sport and the threat this might pose to medical professionalism.

Consider, for example, the fact that the highly synergistic relationships between sport-ing bodies, global media networks and corporate sponsors have had a dramatic impact on the structure, organisation, production and consumption of sport (Andrews, 2004, 2006; Burstyn, 1999; Giulianotti and Robertson, 2007; Harvey et al., 2001; Horne, 2006; Maguire, 1993, 1999; Rowe, 1999; Rowe and Gilmour, 2009; Scherer and Jackson, 2010; Shogan, 1999; Wenner, 1989). However, these complex configurations also influ-ence a range of other institutional and interpersonal relationships associated with sport. For example, the power of global sport cartels increasingly shapes who is empowered to report the news and business of the industry and more significantly how this information is presented to its audience. Likewise, major sports seek to control, and in their view arguably need to control, as many aspects of the business as possible including person-nel, both athletes and all other labour – coaches, managers, public relations and support personnel. One of the increasingly important, yet least understood relationships is that between the team owners, administrators, athletes and a diverse range of medical support personnel, and the ways in which these relationships impact on the provision of health care.

Elite, professional sport is highly contested and occurs within a complex sociocultural context where sponsors, owners, management, coaches, and others have an interest in the pursuit of excellence and the success of athletes and teams. These interests have the potential to generate pressures that can negatively impact on the health of athletes, the ability of sports doctors to provide quality medical care, and to practise ethically. As Safai (2005: 109) has argued: ‘it is necessary to ask some hard questions about the ideol-ogy of excellence in relation to the health and healthcare of athletes, particularly with regard to the elite sport system’s greater focus on performance than health’. Arguably, one particular issue that needs to be addressed is the nature of contemporary sport culture into which medicine is embedded and, in turn, the emerging source and degree of pres-sure on sports doctors. As one sports physician states, ‘Our professional commitment to sport cannot exist in isolation of any analysis of the environments in which it is deliv-ered’ (Pipe, 1993: 899).

This paper explores the context of elite, professional sport and the concomitant demands, pressures and expectations it places on the sports doctor using an interactionist approach to analyse data from sports medical practitioners. The study draws on data from a previous larger qualitative research project that looked at the ethical concerns of sports medical clinicians working with elite athletes and teams in New Zealand (Anderson, 2005, 2007, 2008, 2009). Specifically this paper addresses the pressures and



240 International Review for the Sociology of Sport 48(2)

demands that emerge from varying sites and relationships including from the coach and management, the athlete, sponsors and the media and broadcasters. Hence, while the data emerging from this study are drawn from participants’ views of micro-level relationships with other key personnel within sport organisations, these relationships are in effect structured and influenced by wider macro factors.

The New Zealand context

This study focuses on New Zealand, in part because it serves as a unique site for the analysis of medicine in sport for at least three key reasons. First, we note New Zealand’s largely self-perpetuated reputation as ‘the great little sporting nation’ (Jackson, 2004) and the historical conditions that facilitated the strong links made between sport and national identity. The sport of rugby, in particular, has played a key role in the develop-ment of New Zealand national identity (King, 2003). Historically, the national rugby team, the All Blacks, came ‘to be accepted… as the purest manifestation of what a New Zealander was’ (Phillips, 1987: 109). Today New Zealanders retain a strong sense of self from sporting success. Sport New Zealand (SportNZ) state that, ‘Sport is integral to New Zealand’s culture and way of life. It helps define who we are as a nation and how we are viewed by the rest of the world’ (SportNZ, 2012).

This offers some insight into the cultural importance of sport in New Zealand. Second, New Zealand is a unique site of analysis given that it has had a structure of specialist vocationally trained sports medicine physicians for more than 10 years. This sets New Zealand apart from most other nations who are still attempting to establish or have only recently established a similar structure. That sports medicine is a recognised speciality indicates that the practice is structurally robust. Finally, New Zealand is somewhat unique, at least with respect to Western societies, in light of its small population (four million) and correspondingly its small community of sport doctors (approximately 26). This situation may contribute to higher levels of social interaction, shared values and, of particular importance to this study, the need for great care in protecting participants’ identities.

The health care system in New Zealand has a similar structure to that found in the UK, (Australia, Canada, Scandinavia, and other social welfare states) with the bulk of health care provided by the state. One major difference in the New Zealand health care scene is a no-fault compensation system run by the Accident Compensation Corporation (ACC). This system provides public funding for all injury resulting from accident, and also removes the right for accident victims to pursue a legal remedy. For example, if an athlete suffered a spinal injury from a tackle in rugby, then future health care and loss of earnings (to some degree) would be covered by ACC. If that same person suffered the same injury while driving to the match, this too would be covered regardless of fault. ACC is funded primarily ‘from levies on people’s earnings, businesses’ payrolls, the cost of petrol and vehicle licensing fees as well as Government funding’ (ACC, 2010).

Before proceeding, we wish to distinguish between a sports doctor and sports physi-cian. A sports doctor is a registered physician, most likely a general practitioner, who has an interest in and role in sport. Sports physicians are also registered medical practitioners but they have completed a four-year fellowship in sport and exercise medicine, and




become Fellows of the Australasian College of Sports Physicians. Sports Physicians are therefore specialists who practise largely on a referral only basis. In New Zealand sports doctors and physicians are both funded via ACC claims and private fees.

Sociological understanding of medicine in sport

The sociological analysis of the work of medical clinicians in sport is receiving increas-ing scholarly attention (Berryman and Park, 1992; McEwan and Taylor, 2010; Malcolm, 2006, 2009; Safai, 2004, 2005, 2007; Theberge, 2008, 2009; Waddington, 1996). In par-ticular, scholars within the broad realm of sport studies have focused on the experiences of athletes in dealing with pain and injury (Coakley, 1998; Howe, 2001, 2004; Maguire, 1999; Nixon, 1993; Young, 1993; Young et al., 1994). However, few authors have explored the work of sports medicine and the experience of sports doctors. Scholars writ-ing about athletes’ experiences have identified a ‘culture of risk’ which is accepted and normalised as part of both the sport ethic and sport environment (Coakley, 1998; Maguire, 1999; Nixon, 1993; Safai, 2003; Young, 1993; Young et al., 1994; Young and White, 1995). Safai (2003) suggests that the sports ethic is reinforced and perpetuated by a net-work of coaches, managers, and sports medicine personnel, which Nixon refers to as ‘sportsnets’. Sports doctors are included as part of the ‘sportsnets’ as they too are thought to be complicit in the role of negotiating the acceptance of risk (Safai, 2003: 130).1

Of those authors writing on sports medicine, Malcolm (2006) has explored the power held by sports doctors. He suggests that while medical authority exists in other areas of medicine, sports doctors (at least those involved in rugby at the club level in the UK) have a ‘relative lack of influence and low status’ (Malcolm, 2006: 391). Malcolm sug-gests that this low status can, in part, be attributed to the professional structure of medi-cine in sport, the nature of the workplace and the relationships with other health professionals within sport. Malcolm utilises the work of Freidson (1970) and others to examine the power structure at play for doctors involved in sports medicine. Most recently McEwan and Taylor (2010) have explored the ongoing workplace negotiations and positioning of sports health professionals using a Bourdieusian analysis.

Waddington (1996) and Hoberman (2001) have also explored the relationship between sport and medicine. According to Waddington the relationship between medicine and sport arose from two particular social influences. The first involved an expansion of the scope of medicine beyond the traditional sphere of illness to areas of life not traditionally reliant on medical care, including athletic performance. The other significant change occurred within sport. Sport became increasingly competitive after the Second World War when the political aims of nation states came to be realised through sport. As a consequence:

comparisons of the number of Olympic medals won… took on a new significance, for the winning of medals came to be seen as a symbol not only of national pride but also of the superiority of one political system over another. As many governments came to see international sporting success as an important propaganda weapon in the East-West struggle, so those athletes who emerged as winners came increasingly to be treated as national heroes with rewards – sometimes provided by national governments to match. (Waddington, 1996: 6)




The other force that has impacted upon sport has been the commercialisation and commodification of sport. Media interest, broadcasting deals and corporate sponsorship have raised the funding levels of sport exponentially. The increase in competitiveness and commercialisation marked by the rising importance of winning has subsequently turned athletes and sports organisations towards sports science and almost by default to sports medicine to seek ways of optimising performance. Both Hoberman and Waddington discuss a shift over time from sport being a rich vein for research into human physiology for medicine and medical science, to a post-Second World War era where the desire for athletic and sporting success has slowly become an increasingly higher priority within sports medicine. This fundamental shift is problematic, not only professionally but ethi-cally as well. As demands for success grow, so too does the pressure intensify on the sports doctor to deviate from accepted medical practice and ethical values. Next, we discuss the culture and values of professional medicine and their relationship to contem-porary sport.

Medicine and the place of medicine in sport

Medicine has long-established values and professional codes that confer an obligation on doctors to behave in certain ways; instilling a commitment to promote the health and welfare of an individual patient and a prohibition against causing harm. On the other hand many would argue that the central concerns of contemporary sport, especially at the elite level, are strongly associated with commercial aims and the desire to win. It is not surprising therefore that sports doctors will at times experience some ethical disquiet about the practice of medicine within such an environment. Ultimately, the sports doctor is located at the interface between two powerful groups in society, each with very differ-ent aims and ends. As the title of this paper suggests, this often leads to competing loyalties.

Ultimately, understanding the place of medicine in sport requires consideration of the value of the role of medicine to sport. Medicine can offer sport assistance in two ways: first, the skills and knowledge of medicine can facilitate care and provide access to sec-ondary and tertiary medical services; second, the social power and authority medicine brings to the field (Brody, 1993).

The degree of authority medicine brings can be utilised in many ways including vali-dation of sporting practices that threaten the health of the athlete (e.g. doctors pushing athletes to their physiological limits and beyond), or sporting bodies accepting sponsor-ship from companies promoting unproven health products (expecting medical personnel endorsement). Medical services can therefore be understood as a valuable commodity making them an important component in the business of sport. Hence, the knowledge and skills of sports doctors can add value to the sporting product.

Consequently, within the context of a commercial sport system the medical profes-sional could face undue pressure (Hafferty, 2006). Historically, professionalism in medi-cine rests upon the pillars of humanism, altruism, accountability and excellence (Stern, 2006). Arguably all of these are implicit or explicit tenets of sport and are perhaps most clearly articulated within the espoused values of the Olympics. For example, humanism




contains ideas such as integrity, honour, compassion and empathy. Altruism has at its heart the idea of placing the interests of the patient ahead of that of the physician. Accountability is a broad concept and includes participating in assessment of compe-tence, ‘adhering to medicine’s time-honoured precepts’, and being open and honest about conflicts of interest. Finally, excellence involves maintaining competence in clini-cal knowledge, ethical values, the law, and communication skills (see Stern, 2006). In much the same way, Olympic values and professional medical values are aspirational statements that members of the respective communities are expected to uphold. Because these values are generally aspirational, they may be more difficult to uphold in the face of the commercial interests in sport, or they may be neglected in such an environment. At this point we briefly refer to the objectives and values of elite commercial sport and their implications for sports medicine.

Commercial interests in sport

The methods by which large corporations influence and control the organisation and practice of sport is evident in the ways in which sports are marketed, promoted, spon-sored, televised and reported (Andrews, 2006; Coakley, 1998; Jackson et al., 2005; Real, 1998; Rowe, 1999; Slack, 2004).

The sports that are most likely to attract sponsors and media interest are those that appeal to a market of spectators with current or future disposable income – that is, males in the 18–34 year-old age group, a group ‘prized by corporate advertisers’ (Andrews, 2004: 8). This makes top-level sport a unique and potent form of culture because it is both a commodity in and of itself, and a powerful medium through which to market other commodities. Not surprisingly, those who pay enormous fees for broadcasting rights to major sporting events seek to exert as much control as possible in order to ensure the production of entertainment spectacles attractive to audiences. In turn, the emerging commercial pressures trickle down to various organisations and their personnel to perform.

This raises an important question central to this study, namely, how are the commer-cial interests in sport manifest with regards to the provision of contemporary sports med-icine? The financial interest of sport organisations in the success of a professional team is obvious: winning teams attract fans, television contracts and sponsorship. As the effec-tive labour force for sport organisations, athletes are central to success and this highlights the important role of the sports doctor (and other medical team members) in maintaining athletes to a match-fit level. It is exactly these expectations that can impose a great deal of pressure on the sports doctor trying to negotiate and balance the often conflicting aims of maximising performance and profit on the one hand and duty of care on the other.

Success is also important to coaches and management with respect to their own career and financial future. Given the rapid turnover of coaching staff and management it is clear that they are under enormous pressure to produce winning teams (Waddington and Roderick, 2002: 122). It is that pressure within the culture of elite sport that creates the potential for excessive demands to be made of both athletes and sports doctors. One of the most common ways this is manifest is when a player is pressured to return to the field before they are medically ready (Macauley, 1997; Polsky, 1998; Roderick et al., 2000).




Coaches have been known to create conditions that make playing with an injury the norm in some teams through a range of techniques including bullying, ridicule and isolation from other team members (Roderick et al., 2000). One retired athlete describes his coach’s attitude to playing hard and with injury: ‘In my day if you weren’t bleeding by halftime the coach would say, “What’s wrong with you? You’re a poof”’(Reid, 2005).

One consequence of the stress on coaches and sport managers is the subsequent pres-sure they put on doctors to maintain players at peak fitness (Apple, 2002; Orchard et al., 1995). At times, such demands may influence the doctor to breach his or her professional standards. According to Macauley (1997: 1), ‘In this highly competitive sporting market doctors may find their professional independence threatened by pressures to treat, reha-bilitate, inject, or operate in a manner that they find unacceptable’. While it might be easy to assume that the doctor should put the care of the athlete first, refusing to comply with the demands of management may impact negatively on the doctor’s re-employment.

Furthermore, athletes attempting to be the best in their sport will often be willing to take on severe training regimes and diets and will almost certainly be willing to take on risks of harm (Magdalinski, 2009). At times, athletes may request the assistance of the doctor in facilitating risk-taking such as returning to the game early or may request access to banned performance-enhancing drugs.2 Thus, while we might expect that the source of the greatest pressure is from management, pressure also comes from the ath-letes themselves who are subject to the forces extant in professional and commercial sport (Opie, 1991: 512; Polsky, 1998). As one New Zealand sports doctor notes:

Huge amounts of natural talent, training and single-minded determination have brought [an athlete] close to the top of his sport. Athletic prowess has also elevated him to the bottom of the commercial food chain. If you don’t recognise this, you don’t recognise a truism of professional sport. Vested interests permeate and manipulate to maximise financial reward. The promise of receiving some share of this is intoxicating and can distort risk perception. If that sounds harsh, then you are getting the picture. (Dreyer, 2004: 34)

Athletes face a range of occupational pressures, the most significant being the tenuous nature of their position in the team, their status, income and future. An athlete’s fear of losing a position in the team is heightened by the fact that there is always someone else waiting to show the selectors that they are better or that they are willing to sacrifice their bodies unconditionally by playing injured. Stated plainly by Orchard (2001):

The bottom line is that if a player stays on the field enough, his contract as a professional footballer is extended. If he spends too much time on the injury list – for example, with his wrist in plaster recovering from a wrist reconstruction – then he gets cut by the team and loses his contract. (Orchard, 2001: 212)

The utilisation of sports doctors and other health professional personnel is an obvious route to recovery and return to the field of play. However, at times athletes can put pres-sure on sports doctors to return to the field before they are medically ready (Brukner and Khan, 2001; Fullagar, 1996; Polsky, 1998). Indeed, at times, the athlete-as-patient, sup-ported by the organisation, may demand intervention that the doctor believes is in con-flict with professional standards or ethics. As a contracted employee, doctors will be




aware of their responsibility to the organisation, and in the harsh business world of top sport, contracts may be short and depend on performance and compliance with company policy (Macauley, 1997).

Methods

The ethical issues facing sports doctors were examined using semi-structured interviews with 16 sports doctors (n = 12 male, 4 female) working with elite athletes and teams in New Zealand. To be eligible for inclusion as a research participant, sports doctors had to be working with athletes or teams who represented New Zealand, or were professional athletes. These two groups (NZ representatives and professional athletes) are not coex-tensive, though there may be some overlap. Many athletes who represent New Zealand are not professional (that is, they do not get paid), while some professional athletes may never achieve a place in the national side – for example, Rugby Union players in the SANZAR (the South African, New Zealand and Australian rugby triumvirate) Super 15 league.

Following approval from the relevant Human Ethics Committee, recruitment of participants was undertaken by a ‘snowball’ technique (Patton, 1990). Each inter-view lasted approximately one hour. The interviews were transcribed and returned to the participant for checking. This stage allowed participants an opportunity to delete, add or correct material. Nearly all doctors took up the opportunity. The sensitive nature of some of this data required serious attention to the confidentiality of partici-pants, not only to protect the doctors but also their high-profile patient group. Given the interest of the media in the activities of elite sportspeople, every effort was taken to ensure that the data were anonymised. Although each of the participants worked with elite or professional athletes or teams in New Zealand, half the participants worked predominantly with amateur athletes, while three worked mostly with pro-fessional athletes.3

Overall, the participants in the study represent a group of highly experienced senior clinicians working at the very pinnacle of sport in New Zealand. They also spend a great deal of their week on sports medicine with nine of them spending their whole week working as a sports doctor. The remaining seven combined sports medicine with other specialised forms of medical practice. The number of years each of the participants had worked as a sports doctor ranged from 6–26 years, with the average being 11.6 years. The participants had high qualifications, 12 held a postgraduate diploma in sports medi-cine or musculoskeletal medicine, while seven were Fellows of the Australasian College of Sports Physicians.4 There were five other qualifications held by the group of partici-pants related to the sports medicine role, including either undergraduate degrees or diplo-mas, or Masters degrees.

Grounded theory was utilised for the initial data analysis of the broader project of sports medicine, given that it uses an inductive form of analysis, where the theory emerges from the data rather than starting with an existing theory and requiring the data to fit the theory. (Glaser, 1967). However, while grounded theory was ideal for the broader project, an interactionist approach is used for analysis of the data for this paper. Specifically, following Malcolm (2006), we draw upon the work of Eliot Freidson, a




sociologist from the interactionist school, who studied professions and in particular the medical profession.

Freidson suggests that professional behaviour has more to do with the situation peo-ple find themselves in rather than their training. He states:

a significant amount of behaviour is situational in character – that people are constantly responding to the organized pressures of the situations they are in at any particular time, that what they are is not completely but more their present than their past, and that what they do is more an outcome of the pressures of the situation they are in than of what they have earlier internalized. (Freidson, 1970: 90)

This does not mean that Freidson rejects the important influence of education on pro-fessionalism and professional behaviours or the personal attributes of an individual pro-fessional, but he considers that the work situation is the dominant variable in accounting for variations in professional behaviour. (Freidson, 1970: 87–88)

Freidson identifies two extreme forms of practice governance. At one extreme, physicians are subject to a colleague-dependent practice, that serves the needs of other physicians, and at the other extreme, the physician is subject to lay control. At this extreme the physician ‘is chosen on the basis of lay conceptions of what is needed, not by profes-sional criteria… And to be chosen again and survive, he must be prepared to provide services that honour the client’s prejudices’ (p. 107). Freidson suggests that professional standards are higher in colleague-dependent practice and lower in situations where a phy-sician meets lay demands (p. 107). Malcolm’s study ‘did not find much evidence to con-firm’ (2006: 386) this claim and this has also been the case in our research.

Results and discussion

The results and discussion section is a collation of the views and voices of the sports doctors that describe the pressures associated with elite sport that often give rise to com-peting professional obligations. These pressures are categorised with respect to the fol-lowing groups: coach and management, athletes, sponsors, media and broadcasting structures. The key themes addressed focus on the complex environment within which sports doctors work including the lack of control over their work environment, the com-peting obligations they face, the pressures that arise from the commercial interests involved in sport, and the threats to medical professionalism.

The results of this study confirm that sports medical practitioners work under a great deal of pressure stemming from the commercial interests of others to generate profile and income. The risk is that these kinds of pressures may distort the focus of sports doctors such that they identify less with the health needs of the athlete and get pulled towards the aims of others involved in the sporting network.

Coach and management

As identified by Waddington and Roderick, coaches are under pressure to field a winning team. The desire of the coach to succeed can be a source of pressure on a doctor to get an




injured athlete back into action before medical clearance (Macauley, 1997; Polsky, 1998; Roderick et al., 2000). This was reiterated in our research and was identified as a source of pressure by sports clinicians:

Yes, the [coach] often wants them [athletes] back on as soon as possible, of course. Especially if they’re one of the good players in the team, vital to the team. So yes, there’s a lot of pressure to rehabilitate players and get them back out there, from the players themselves, and from the coach’s point of view.

The pressure a coach can apply to the athlete to play with an injury can be immense, especially when there is a ‘no play – no pay’ payment structure as one participant describes:

The difficulty comes when the coach says I want this player to play, and goes to the player himself and says you’ve got to play, if you don’t play you’re not going to be played again, and there’s a bonus system where if you’re not playing you’re not getting paid sort of thing.

Another participant describes the way in which some coaches can limit the ability of the sports doctor to look out for the medical interests of the athlete.

Even me [as the sports doctor] trying to remove someone [an athlete] from the field of play and they [the coach] have not wanted that player removed… and I… say, ‘look [this athlete] is struggling, he feels unable to go on, he’s got this injury I think we have got to get him off’ and I was told in no uncertain terms, that he is a wimp and he has to stay on and die for the cause.

The motive for coaches may not solely be for team success but for the coach’s own interests as well (Waddington and Roderick, 2002: 122). A team that is doing well reflects well on the coach, and may contribute to reappointment, a positive salary review, or help when applying for other jobs. So coaches have a personal financial interest in the wellbe-ing of athletes.

I think that straight away you have got people that have got a financial interest, in their wellbeing clearly, and in terms of coaches, they have not just got a financial interest they have a career interest, if this player performs well it enhances not only the player’s career, but the coach’s career, and that’s clearly been an issue with me.

When asked whether not complying with coach demands could impact on their re-employment, one participant captured the mood of many of the others, stating:

Ah, yes, that did initially bother me when I was still quite wet behind the ears. To be honest with you it did concern me a little bit, but now I realise that there are a lot of teams… management styles change and coaches change and I think that if you didn’t compromise, people will eventually see the good in it. And to be honest with you, I think there are many teams. If you don’t get a job here, you can get a job somewhere else. For me it’s an issue of enjoying the job rather than feeling guilty and trying to work around issues like that.




In combination these comments highlight the powerful links between the commercial aspects of sport and how they shape management and coach attitudes and behaviours towards their athletes. The stresses on coaches and others for sporting success will trans-late into stress on the sports doctor, at times encouraging them to act in a manner outside of accepted professional standards. In some respects these views highlight another dimension of competing loyalties: management and coaches may find themselves torn between proving their own value in a highly competitive sport-business environment, ensuring the viability of their franchise and their desire to protect the welfare of players – this is something worthy of further investigation. It is also worth noting the role of masculinity within this culture; most elite professional coaches are male and their own experiences and training in sport is likely to influence how they view sporting bodies, injuries and the culture of risk (Burstyn, 1999; Young, 1993, 2004).

Athlete funding

Intense commercial interest in sport has a relatively short history in New Zealand com-pared to some other countries. For example, rugby has only been professional since 1995 (Jackson et al., 2001). Many sports continue to struggle with low levels of funding, while others are particularly well funded. This resonates with comments by sports doctors (and others) in the literature (Brukner and Khan, 2001; Dreyer, 2004; Macauley, 1997; Opie, 1991; Orchard, 2001; Polsky, 1998) who are aware that athletes can put direct pressure on sports doctors to return to sport before they are medically ready in order to retain contracts.

The influence of sponsors

Attracting sponsors is one way of improving the funding of individual athletes and teams. At first glance, the sponsorship of sport could be considered to be a reciprocal arrangement between a sports body or individual athlete and a company, with both benefiting from their joint participation. However, Slack and Amis (2004) are quick to point out that while this is indeed true, such a simplistic understanding of the relationship between the two parties fails to appreciate the true nature of sponsorship relationships. In the vast majority of cases the relationship between the sponsor and the athlete is unequal. The athlete may be expected to play more frequently, and if they fail to play, then spectators will be less likely to watch – a key concern of sponsors. One doctor spoke about how aware they were of the need for a sponsored athlete to be both selected (putting pressure on coaches) and to be seen despite potential injury (putting pressure on the athlete, coach and sports doctor).

Doctor: …they have to use players that are more marketable and so there’s pressure on to have those players out there for the public to see. So, yes.

Interviewer: Right. And the coaches acknowledge that?Doctor: Oh, yes, marketing’s a huge part of the game now.Interviewer: Right, so [a player] and [the player-sponsored product]?Doctor: Yes, so she needs to be on court. Yeah, so it does come into it.




Interviewer: And that would influence you as well?Doctor: Well, it makes you very aware that you’ve got to get them up and going

and back out there – yeah, so it’s marketable. And for them, it’s often their income – it will be in the future, as things get more professional.

Ultimately sponsors are paying for visibility and brand awareness, whether through corporate signage at the stadium, logos on uniforms or via celebrity athletes. This has two key implications: (1) the sponsor’s name will be seen on the team members’ uniforms, in effect making the athletes walking billboards; and (2) it is assumed that the athletes will be using their products, thus providing both brand exposure and a form of endorsement.

Twelve of the 16 participants raised the issue of sponsorship by footwear companies as causing problems for the athlete and sports doctor. The problem arises when sponsor-ship involves the whole team, and all players must wear a particular brand of sport shoe even though the product may not suit an individual’s feet.

Some companies will go to great lengths to try and find suitable footwear. But where this can’t be done, sports doctors may be involved in altering a rival manufacturer’s product to look like the sponsor’s product. This involves removing the logo from the new footwear and painting on the sponsor’s logo. One doctor describes the surveillance the sponsor does to check athletes are wearing the right product.

Doctor: We try and actually blacken the boots out completely. But we get told off for that.

Interviewer: Who from, the sponsor?Doctor: The sponsor. Yeah, they pay people to watch the games to check

people are wearing the right stuff.Interviewer: I didn’t realise that.Doctor: Yeah, there’s big money. There’s millions of dollars involved, so

they do – yeah, we get phone calls after the game, so-and-so wasn’t wearing the right boots – [we] get in trouble. So we’re monitored.

In these instances sports doctors are using subversive actions in order to look out for the interests of their patients. Other subversive activities reported by participants included empty-ing the sponsor’s drink product from the sponsor’s bottle and replacing it with another prod-uct. Here, the sports doctor is under pressure from various sources, including players who do not have a legitimate medical reason for not using a sponsor’s product; as such the doctor is actually involved in a commercial negotiation rather than medical treatment. The influence of sponsors points to another element of a form of surveillance over the image and practices of athletes and teams and those charged with supporting them. The above examples demonstrate the far-reaching effects of commercial interests and the ethical dilemmas these can pose.

Media and broadcasting concerns

While the relationship between sport and the media has been well explored (Andrews, 2006; Real, 1998; Rowe, 1999; Slack, 2004; Wenner, 1989), the relationship between the media and sports doctors has not received the same attention. Elite sportspeople have




become celebrities in New Zealand, and public interest runs high. When a particular athlete is injured or becomes ill, one of the main sources for information is the sports doctor, either directly or indirectly through the manager or appointed team media liaison officer. Some doctors indicated that ‘you get pestered by the media the whole time’. This scrutiny and close and regular contact with the media sets doctors apart from their peers in other medical settings.

Dealing with the media is easier for some sports doctors than others and doctors use different approaches. Some simply repeat facts that the journalist already knows, others say very little. As one doctor put it, ‘we give them enough to keep them happy’. Two sports doctors identified that reporters were known to make up stories about player inju-ries and one reporter told a physician, ‘if you don’t tell me, I’ll make it up’.

However, the relationship between the media and the team is more than just the provi-sion of information about the players; the media create the interest in the team, which in turn enhances the value for sponsors. Confirming this, one doctor stated that, ‘informa-tion has to be released to the media because the media are what create our sponsorship arrangements which is eventually what pays our wages’. However, the right of players to confidentiality of personal health information is potentially compromised by the need to generate a high profile to attract the sponsors.

Talking to the media raises concern regarding an athlete’s confidentiality as illustrated by the following remark:

in the last six years national and international competitions have really become a professional entertainment business, and a lot of media representatives feel they’ve got a right to the information about players, and there’s a lot of pressure on us to release information quickly about injuries

In sum, the media are another source of pressure on the sports doctor and maintaining athlete confidentiality is of concern.

In attempting to attract viewers and media interest, competitions have been created which are designed to push athletes to the edge and sometimes beyond their physical and psychological limits. Doctors may find their involvement with such endurance races dif-ficult, especially when the boundaries of good health are breached. One doctor describes their experience after a large number of competitors became unwell at a particular endur-ance event.

… when I was [working for an endurance race]… one athlete in five… who started that race finished up sick in the medical tent at the end of the day. So these are healthy, superbly healthy, superbly fit human beings, many of them young, and the race… caused one in five of them to end up needing to see a doctor, caused 16 of them to have to go to hospital, caused two of them to have to go to intensive care, and one to be unconscious for four days in hospital. So this was the race that did this, and the nature of the race and what they did during the race. So that bothered me enormously, hugely at the time – not my involvement in it – but here was this event that was way beyond the realms of good health.

Some might consider the statement ‘way beyond the realms of good health’ naïve from what appears to be a highly qualified person. After all, it is well known that an elite




and commercial sport breaches the boundaries of good health (Nixon, 1993; Roderick et al., 2000; Safai, 2003; Young, 1993). Despite their qualifications and experience (or perhaps because of their previous experiences in non-sport areas) maybe some sports doctors find the juxtaposition of practising medicine in an environment of elite sport philosophically troubling.

Commercial motivations central to elite televised sport also have the potential to limit the ability of sports doctors to care for injured athletes. For example, television broad-casting contracts that schedule televised games back-to-back will restrict the time avail-able for doctors to assess and treat injured athletes.

… at Super Twelve5 games you don’t get an injury break. In NPC6 rugby you can take a player off for ten minutes and assess them. In Super Twelve you don’t have that; you’ve got to make a call there and then whether the player stays on or comes off. And once they’re off they can’t come back on. Although, you can bring them off for a blood injury… so if you can find a little bit of blood and get the referee to agree that they can come off, it gives you a chance to assess whatever else. And probably the commonest thing that you really want a minute or two for is where they’ve had a knock to the head. You want a couple of minutes to see that that’s going to clear, and they’ve not got visual disturbances and they’re not completely fluent in their processing… whether they really need to be off… and so you do sometimes keep a player on, and you’re really watching them closely for a few minutes until you’re sure that they are fine. Or until you realise that they’re really not fine.

By restricting time to assess the injury on field, the length of the game is not disrupted and match completion time is more predictable. But this can threaten the ability of sports doctors to provide quality care. One doctor gave an example of a game scheduled for the hottest part of the day in Brisbane thought to be related to maximising television ratings. These are also examples of the limited control sports doctors have over their workplace environment.

Recent literature on medical professionalism lists commercialism as one of the major threats to professional ethics (Stern, 2006; Van Mook et al., 2008) Human nature, self-interest, pressure from peers and commercialism are well recognised challenges to pro-fessionalism (Van Mook et al., 2008). Discussion about commercialism is often limited to the examples of managed care and corporate medicine; however we posit that the commercial elite sport environment within which a sports doctor works is immersed is equally problematic for maintaining professionalism. Given Freidson’s theory that the behaviour of professionals (and in this case, doctors) is more a product of their present working environment than what they have learned in the past, the findings above are concerning.

However, commercial pressures are not the only factor that contribute to threats to medical professionalism. The complexity of the commercial world of elite sport, including the inherent web of interconnected relationships, also contributes. Firstly, the employment structure of the sports doctor often aligns him/her more strongly to team management and may place expectations via the employment contract that encourage deviation from traditional obligations, creating a conflict of obligations for a sports doctor. The central issue is the divided loyalties of the clinician. Each clinician who has a contract with an employer has an obligation to




that employer, and to the patient. As this study has demonstrated, these obligations can conflict.

Secondly, sports doctors have limited control over the manner of their work. An example of this is the sports doctor who describes limited time for injury assessment because of the television broadcast schedule. Clearly, athlete welfare is secondary to other aims. Such examples indicate that sports doctors have limited control over their workplace. Instead the workplace structure is often dictated by others.

Thirdly, sports doctors are isolated both clinically and professionally. They often work alone or are part of a small medical team, so they may not have the professional support immediately at hand when faced with an ethically difficult situation.

The results of this New Zealand study are, to some extent, in line with the findings of Malcolm’s (2006) research with rugby club doctors in the UK. Malcolm (2006: 391) attributes the lack of power and influence that sports doctors have to a number of impor-tant factors including the workplace setting, the relationships that sports doctors have with others and the structure of the profession of sports medicine. While there is a sense of lack of power in this research that resonates with Malcolm’s findings, these clinicians can exercise power through subversive acts such as changing products to look like that of the sponsor, or through using the media for the benefit of the team and the sports doctor.

The relationships with others have been one of the key themes in this paper; it is those relationships that can put pressure on the sports doctor that may encourage the doctor to act differently than they perhaps would in other settings. This is in line with Freidson’s theory that the working environment plays a large part in determining the behaviour of professionals. In this case sports doctors are enmeshed in an environment that creates a strong pull to the needs and demands of a highly commercial environment. Traditional obligations learned in medical training and clinical practice may become secondary to the everyday employment environment of sport at this level, hence creating divided loy-alties whereby what sports doctors were being asked to do and what they considered to be good clinical practice are two different things.7

Sports doctors are alert to many of the pressures that exist in sport that have the poten-tial to distract their focus from patient interests or distort their professional values.

There are clearly threats to professionalism through the commercial nature of high-profile sport and through the pressures to be successful, and this may be compounded by the employment context.

Moves to strengthen medicine’s role in sport have commenced in New Zealand. Specialist status has been achieved in the field of sport and exercise medicine, and the number of sports physicians is now growing. This new role could potentially move sports medicine along the continuum away from lay control and, because physicians rely on referrals from other health professionals, towards colleague control. However, it is hard to imagine that this group will overcome many of the pressures extant in a commercial elite environment. New codes of ethics are also being written directly addressing many of the concerns raised by the employment structure and clarifying expectations (Anderson, 2009). These new codes have been written in such a way as to provide a shield to sports doctors who are asked to act outside professional expectations.




Conclusion

Understanding the place of medicine in sport requires consideration of the value of the role of medicine to sport. As stated earlier, medicine can offer sport assistance in two ways: first, the skills and knowledge of medicine are used to facilitate care and access to secondary and tertiary medical services only they can provide; second, the social power and authority medicine holds. Medical authority can bring a sense of social acceptance and validation to a range of sporting practices that can threaten the health of the athlete. Medical services can therefore be understood as a valuable commodity to sport. The medicalisation of sport whereby high-performance athletes who want to achieve the ulti-mate performance are viewed as those requiring medical attention is an important claim and one that has been challenged by a number of scholars (Hoberman, 2001; Maguire, 1991, 2004; Shogan, 1999; Walsh and Giulianotti, 2007). However, we must also acknowledge that the practice of medicine in sport is open to abuse from the very envi-ronment of high-performance sport. Sports doctors who are part of the machinery of sport will have a number of competing obligations and threats to their professionalism. Further research is required in order to better understand those interests and influences that encourage a doctor to abandon their traditional obligations to the patient and to their own professionalism. This is important, not just because we might consider that medi-cine is a valuable social good, but ultimately for the wellbeing of athletes.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Notes

1. For a full discussion on ‘sportsnets’ see Walk (1997), Nixon (1993), and Safai’s (2003) evalu-ation of the concept within the Canadian university setting.

2. While sports doctors and physicians in this study had received requests for performance-enhancing drugs, this is not the focus of this paper and will be the subject of future research.

3. Although few professional sports in New Zealand (with the exception of rugby, rugby league, and a few isolated teams and individuals) provide a full-time employment income, there are a large number of elite amateur or semi-professional sportspersons. Many of these individu-als are immersed within a highly structured, high-performance environment often based on a professional, corporate model. Thus, while this paper may tend to refer to commercialised sport, our main concern is the impact of the culture of contemporary elite sport working with both professional and amateur sports.

4. Sports medicine became a recognised specialty in New Zealand in 2000 with vocational reg-istration awarded by the New Zealand Medical Council There are currently 20 vocationally registered Fellows of the Australasian College in New Zealand, working solely as specialists in the area of sport and exercise medicine. To maintain certification sports physicians must meet certain yearly expectations for continuing medical education, teaching and research and quality assurance activities.

5. The Super Twelve tournament is a rugby tournament played between the top regional teams from South Africa, Australia and New Zealand. This tournament became the Super 15 begin-ning in 2011.




6. The NPC tournament is a rugby tournament within New Zealand based on regions. NPC stands for National Provincial Championship.

7. Murray (1986: 831) describes divided loyalties as occurring ‘when conflicting moral claims are made that cannot be honoured simultaneously’.

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