A position as team physician may be linked to either a local, regional or national ski-team.

Accordingly, the extent of the physicians involvement will depend on the level of service expected from the team, the resources available for medical assistance, the number of athletes to serve and of course the time and interest that the team physician is willing to dedicate to the job.

Furthermore, the physician's training in a particular medical specialty and his/her area of interest in sports medicine will also have a significant impact on the approach to the team physician job.

If engaging as physician for a local ski team, the medical services may be limited to office-based diagnosis and treatment of acute illnesses and injuries. Additionally, monitoring certain blood parameters like hemoglobin and ferritin concentrations, and a few appearances with the skiers at regional competitions may also be needed. On the other hand, serving as team physician for a national ski team often requires extensive involvement with both athletes and coaches, sometimes resulting in a full time job during parts of the sports season. In this position, challenges in several non-medical tasks like group dynamics and team work must be expected as much as traditional medical work in areas of sports related illnesses and injuries, exercise physiology, nutrition, travel medicine etc. Therefore, when involved with national team athletes and coaching staff, personal qualifications may become just as important as professional qualifications for the total medical care of the athletes.

Success criteria for team physicians work

• Personal dedication and determination
• Good availability and accessibility
• Well organized work routines
• Attitude of cooperation and team approach
• Broad professional qualifications
• High ethical standards

Qualifications

When a position as team physician is vacant, it is important that the selection process for a new candidate is fair and based on professional and personal qualifications. Selecting the physician on the basis of good qualifications rather than good "connections" will assure that future cooperation and support from other colleagues in the field of sports medicine is not jeopardized. A physician for a national team should have a combination of broad clinical experience in general medicine as well as both theoretical knowledge and practical skills in various areas of sports medicine. Even though the special skills and knowledge used as a cross-country team physician may be earned through "field experience" when traveling with the team, a good understanding of the many traditional clinical specialties of medicine is very important. Additionally, specific knowledge of areas within exercise physiology, nutrition, hematology, pharmacology, doping, etc may also be needed.

It is recommended that a team physician for international level athletes have completed basic clinical training in one of the clinical medical specialties as well as having participated in national programs for continuing education in sports medicine. Since the team physician in most instances serve as a primary care physician for the athletes, it is not sufficient to be updated on a specific area of medicine like orthopedic surgery, rehabilitation or cardiology only. A team physician must be prepared to face medical challenges beyond the proficiency of what a specialized hospital practice can give. Therefore, a broad and solid background in general medicine is quite necessary.

Having advocated the need for all-round medical qualifications in a position as team physician, it is important to emphasize a fundamental principal in medicine: One shall always recognize his/her limits of medical competence and not take on medical responsibilities and tasks with insufficient experience, at the risk of jeopardizing the health of an athlete. The ability to ask for assistance, advice, and a second opinion on medical issues is as important as having highly developed skills and knowledge in any field of medicine. This personal qualification is also highly valued by the athletes, because it assures them that you are always seeking the best solution to any problem that may arise. Being open for other colleagues evaluations of a medical problem will only improve the athletes confidence in you. However, with the exception of non-sport medical problems, the final decisions on the best diagnostic and therapeutic strategies must remain in the hands of the athlete and team medical staff

Continuing education for the team physician and other medical staff is an important issue. All fields of medicine constantly face new theoretical knowledge, new clinical routines and new medical technology. It is impossible to stay on top of the development in all areas of clinical medicine, and even in the limited field of sports medicine the drift towards sub-specialization makes it hard to keep up with the latest knowledge. Nevertheless, there is an expectation from the athletes and coaches that only the best and most effective medical treatment for any ailment is acceptable for the elite athlete. Furthermore, endurance sports like cross-country skiing is often challenging normal physiological limits in there strive to improve performance, thus encountering possible negative health effects of exhaustive exercise. This makes the field of exercise physiology particularly important to a cross-country team physician. For the same reasons, the physician must possess basic knowledge in sports-nutrition, including areas like micronutrient supplementation, re-hydration procedures and sports drinks, etc. The team physician should have a strategy on which areas of sports and general medicine to seek further proficiency in, and argue for a budget to attend relevant educational conferences. In most countries both basic and advanced courses of sports medicine are given through a continuing educational program. International seminars with issues specifically related to endurance sports are also arranged fairly regularly and should be attended periodically.

Job contract and responsbilities

When accepting a position as team physician, a number of responsibilities and obligations usually may be attached to the job. It is recommended that this is formalized in a job contract covering the following issues:

• The legal party (club/federation) that you are contracting with
• The athletes or team(s) you are responsible for
• Main responsibilities and tasks you are expected to cover
• Additional medical personal you are in charge of
• Number of hours pr week or days pr month you are expected to be actively working
• Accessibility outside these hours i.e. "on call"
• What authority do you have concerning eligibility for training and competitions?
• Who do you report to administratively?
• What kind of budget do you have?
• Annual compensation or wage pr day/week
• When and how it should be paid
• Clothing, equipment or other goods that you are entitled to
• Consequence of either parties failure in fulfilling obligations of the contract
• Number of months from dismissal notice to final termination of the contract
• Right to renewal of the contract
• Date for initiation and completion of the contract
• Signatures of both parties on two copies

Legal issues connected to a job contract are too often overlooked or postponed in the initial phase of working with a team, because medical issues are much more pressing. Then, perhaps months later, conflicts may surface,-- that be medical, administrative, economic, or personal,-- and questions about what was said and promised at the beginning of the engagement arises. This may evolve into an unhappy situation if only minor disagreements about personal or economic compensations are at stake. However, more serious conflicts may lead to a more dramatic situation where the health of an athlete could be compromised. Therefore, just like in any other job agreement, a solid legal contract should be worked out and signed by the parties before starting up the work as a team physician.

The type of responsibilities that comes with a job as a team physician may vary considerably according to what level of service that is expected from the team, but also according to the level of involvement that the contracting physician is able and willing to provide. However some main areas of responsibilities that most likely will go into such a job are briefly summarized in the following:

1. To have the overall responsibility for the athletes health in the following settings:
   1. While attending training at home or in organized camps,
   2. While traveling and competing as a member of the contracting team.
2. To initiate any medically sound procedure that could prevent or reduce the risk of sports related illnesses and injuries.
3. To provide swift and correct diagnostic routines and medical treatment for any acute illness or injury among the athletes.
4. To monitor the athletes health and risk of illness/injury along with their training load and total life stress and take preventive action if signs of deteriorating health and performance occurs.
5. To initiate necessary treatment for acute illnesses and injuries that occur among the non-athletic members of the team while on tour.

These and perhaps other areas of responsibilities should be discussed with the team manager and the appropriate statements brought into the contract accordingly. This will make the team physician work more predictable and all parties will thus have the same understanding of which duties and authorities that comes with the job.

Management and organization

As indicated in the professional title, the team physician is part of a team, consisting of athletes, coaches, managers, technical assistants, waxers, etc. The internal organization of a national cross-country ski team may differ somewhat from one nation to another, but normally the physician is administratively subordinated a non-medical team manager. At the same time, the team physician may carry the leadership of a medical staff consisting of assistant doctors, physiologists, physical therapists, nutritionists, massage specialists, etc. In such a position it is necessary to follow "the line of duty" concerning both medical and non-medical issues. Furthermore, regardless of differences in team organization, it is imperative that all members of the team are clear on the areas of responsibility and authority and who reports to whom. This requires effective lines of communication between all team members, including the athletes. See Chapter 7, section 3, Group dynamics.

A typical national team in cross-country skiing may consist of 8-10 skiers, 3-4 coaches, 5-6 waxers, 1-3 team physicians and 3-4 physiotherapist, a physiologist, and a team manager. The team physician may also serve additional teams of skiers and their coaching staff. Therefore, awareness of team dynamics and communicational skills is needed both among the medical staff and in the sports team as a whole. Many teams have experienced that close co-operation between the medical and coaching staff is of vital importance for the success of the individual athletes. Similarly, a team approach among the members of the medical staff to the athletes` health problems is just as important in order to optimize treatment and rehabilitation. Regular medical staff meetings and briefings are recommended both at "home-base" and on race tours. This will secure a proper flow of information on the health status of each athlete and good coordination of the selected treatment strategies.

In todays society with an array of medical and paramedical services being offered to the public, it is necessary to have a policy on how the athletes should interact with this multitude of health businesses. The high profile athlete is particularly attractive for promotion of specific health services, methods of treatment or health products. Furthermore, in most countries each person has the right to choose his/her own "therapist" to deliver a specific treatment or health service. However, in this "free market" of medical services it is important to be aware of the downsides and pitfalls of free enterprise, both for the athletes and the medical support team. Thus, it is recommended to have a policy of allowing the athletes free access to all health care services outside the medical support team; but at the same time, insisting on being continuously informed about all new health problems and who is responsible for the diagnostic- and treatment process. In other words, as the team physician you have the right to know but not to determine what medical services that the athletes are choosing. If the team physician should disapprove of the athletes choice of medical services, the parties involved must quickly resolve this problem and reach a mutual agreement. In order to have a well functioning medical team both at home base and during traveling, it is important that the team physician always remain updated on each athletes health situation. This "freedom with responsibility" policy should be an acceptable --middle of the road-- solution between restricting the athletes to use only the medical support team and on the other side allowing a liberal "supermarket shopping" of medical services without quality control.

Handling a variety of health problems within a sports team requires an extensive network of quality medical services. The team physician needs good accessibility to common diagnostic and treatment facilities and preferably a personal relationship with colleagues in various fields of medicine. This is not a strategy for acquiring a superior health care system for athletes compared to the general public. In many instances a short conversation and piece of advice from a medical specialist is the only service needed. However, for elite athletes it is of paramount importance that a minimum of time is spent out of training. It is a common experience for team physicians that the traditional health care system has a general lack of knowledge on sport medicine and athletic care. Therefore, the network of medical services outside the sports team must be carefully chosen among those health professionals that at least have a minimum of insight and interest in sports and athletic performance. Unfortunately, a "mirror image" of ignorance and lack of insight may turn up on the athletes` side as well . In some situations athletes do not show the proper respect for good medical evaluation and ignore expert advice just because it is given by medical expertise without a background in sports medicine. As a result, the athletes may end up with undesirable and possibly dangerous outcomes of their illness or injury. Therefore, one of the most important tasks for the team physician is to bridge the gap between the medical and athletic expertise, both inside and outside the sports team.

Practical preparations

When starting as a new team physician, it is important to gather as much medical information about the athletes as possible from the previous physician and the other medical staff. Each athletes health condition should be evaluated at the beginning of the training season, and based on the outcome of this evaluation, the team physician should initiate necessary measures to reduce or eliminate each individuals health problems. Keep an updated medical file/log on each athlete, but adequately stored as confidential information. Furthermore, remember to bring in the necessary specialist statements if an athlete is on medication with restricted use during sports activities. The task of educating the athletes and establish optimal routines in the following area may be one of the most important jobs for the team physician.

Teach the athletes about

• Risk factors for common injuries and illnesses related to cross-country skiing
• Important preventive measures towards these illnesses and injuries
• How to cope with initial signs and symptoms of illness and injury
• How to adjust their training while injured or sick
• How to practice optimal recovery regimes between their training sessions
• Banned substances and methods in conflict with present doping rules
• How to check medications, nutritional supplements and other substances
• How to deal with adjustment of time when traveling long distances east or west
• How to deal with adjustment to hypoxia when training above 1500m altitude

Make arrangements with the head coach or sports manager in due time before the season to evaluate and discuss each years season plan for training, traveling, and competitions with regard to all health matters. Then, organize a sufficient coverage of various health personal for the scheduled events. Adequate medical equipment including necessary medications should be prepared in due time before traveling with the team. Moreover, proper routines for monitoring the athletes training state and life stress, including relevant blood tests should be discussed with both athletes and coaching staff. Preventing overtraining syndromes with potential harmful health effects is a mutual responsibility of the coaching and medical staff.


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