Risk / tolerance approach in return to play decision making – the right approach?

This month’s Editorial in CJSM by Levy and Delaney highlights the issue of the role of the Team Physician in the process of the Preparticipation evaluation.

Team Doctors are often called upon to make a decision about the suitability of an individual for return to play. In this role, the burden of responsibility for the decision making process is likely to lie with the clinician, at least in the first instance, whether or not the team manager and the player decide to follow their advice.

Few would argue that the clinician is best placed to make a definitive ‘medical’ decision on return to play decisions since they are likely to have the most educated opinion about decisions related to the health of the player within the team environment. However, the question of where the responsibility should lie with the ultimate decision made is a contentious one.

In the context of return to play decisions, the clinician offers a medical opinion based on the suitability of the player for a return to play, taking into account the potential risks to the individual. These may include a worsening of a pre-existing injury or medical condition, together with the  potential for further injury or illness as a result of a return to participation in sport.

The factors governing medical decision making in these circumstances are many, and include the clinician’s prior level of medical knowledge, defensive practice and risk-taking in clinical decision making, conflicts of interest (for example doctor versus fan and player versus team), pressure from external sources on return to play, the availability of sports risk modifiers, and the clinician’s perception of the risk ratio of benefit to harm for the patient. On occasion, the clinician must also consider the potential risks to others involved in sport of a participant’s return to competition, for example, with motor vehicle racing in the case of a driver with epilepsy.

Return to play decision making from the coach’s point of view may be governed by a different set of variables including contract issues, perceptions about the importance of the next game and the importance of the particular player to the team, the availability of other players, pressure from internal and external sources, and differences in perceptions about clinical risk to benefit ratios.

Similarly, from the player’s point of view, important factors in their decision making on return to play include their understanding of their own injuries or medical conditions, individual risk-taking behaviour, contract issues, and pressures from internal or external sources.

The key difference in decision making between these three different sources is that the clinician is morally and duty bound to consciously consider the welfare of their patient in the first instance and to prioritise this in their decision making process, whereas the coaching staff may have an entirely different set of priorities, and the player may well put other factors in front of their own health.

Who should have the final say on return to play decisions?

As described in this month’s CJSM Editorial by Levy and Delaney , the authors take a novel ‘risk / tolerance’ approach in the preparticipation evaluation setting, starting with a clinical assessment of risk made by the team medical staff based on four different risk category classes, which are in turn based on subjective criteria of the medical team’s perception of risk to an individual of participation in sport. This risk category class is then shared with the management and with the player, and the management then make their own decisions based on this information.

The authors argue that this is a transparent system which can serve to inform and to help everyone involved, and removes the clinician’s absolute responsibility in the decision-making process.

However, a question one might ask is it simply passing the buck? Taken to its logical conclusion, this could result in a return to play for a player whom the medical staff consider is medically unsuitable for play. Is this the right approach?

Creighton and colleagues previously published a 3-step decision-based return to play model in an attempt to clarify the processes that clinicians follow both consciously and subconsciously when making return to play decisions, and to provide a structure for this decision making process.

Could Levy and Delaney’s risk / tolerance approach model logically follow on from the 3-step decision-based return to play model described by Creighton and colleagues? Would this work in Practice? Do any of our readers currently adopt a similar approach, or is this just a simplification of a far more complicated decision-making process?

CJSM would like to hear your thoughts.


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1) Levy, David ; Delaney,  J.Scott. A Risk/Tolerance Approach to the Preparticipation Examination. Clin J SportMed. 2012;22:309-310 

2) Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model. Clin J SportMed. 2010;20:379-385

3) Shrier I et al. 2010. The Sociology of Return-to-Play Decision Making:A Clinical Perspective. Clin J SportMed. 2010;20:333-335

Photograph – Josef Schmitt – Germany FC National Football Team Doctor. Wikimedia Commons

About Chris Hughes
Associate Editor, Clinical Journal of Sport Medicine

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