Establishing a Sports Chiropractic
Practice
By Keith G. Rau, D.C.
Caring for athletes is the dream of many chiropractors. There is a longing to
be a part of the big time, to fix the chronic injury that your favorite player
has struggled with and to help the athletes perform at their peak. It is hard
to imaging that chiropractors across the country have not said at least once,
“if only I had a chance to adjust that player, they’d be right back
on the field and wouldn’t have that problem again.” We know we are
the missing link to the local star’s recovery and the prevention of future
injury. Few doctors will ever have the chance to work with a professional team,
there simply are not that many, but many could increase their presence in the
sports world.
Those of us who worked for years with the athletic teams at Life are frequently
asked how to establish a sports-oriented practice. Many students that speak
with us desire to open a sports-oriented practice while many practicing DCs
wish they could work with more athletes, especially the local professional team.
Developing a sports chiropractic practice is a complex task. There are also
many misconceptions and misunderstandings regarding the care of athletes ranging
from the knowledge necessary to the money that will be made. To be successful
the doctor must first determine what they really want to do and the implications
of that choice. Second, they must have or develop the necessary skills and contacts,
and lastly, they must work hard and learn to function as part of a health care
team.
Getting Off To A Good Start
Before jumping into anything it is good to ask and answer the right questions.
We have all moved in a direction and later realized that it was not at all what
we thought it would be. The primary questions that need to be asked and answered
are “What do you want to do?” and “What are the implications
of that answer?” To help you come to helpful answers consider these questions:
What sports do you enjoy or want to work with?
Opportunity
Perhaps the best opportunity and most rewarding work can be done with your local
youth teams. They always need help. This would include soccer, hockey, baseball,
softball, basketball, football, gymnastics and cheerleading. There are most
likely hundreds, if not thousands, of children participating in your community.
If you have a child involved you have an instant in. If not, you could sponsor
a team.
There are also many recreation leagues and clubs such as skiing, triathlon and
running. You might speak to their meeting and volunteer to help at their events.
During an ICA program several years ago, Stephen Collins, D.C., discussed his
care for the youth football teams. With the help of some Life West students
he performs hundreds of physicals in the pre-season, donating all the proceeds
back to the league. As a result he reported a huge number of new patients in
the months after the exams. (Check with your state law and boards before doing
sports physicals.)
Besides experiencing the joy that taking care of these young athletes brings,
the inevitable happens. They grow up and become high school athletes, some go
on to compete in college and finally, if you do this long enough, the pros.
At each step you have an instant “in” into that level.
Time
The time commitment varies tremendously with the sport but it is never short.
Typically, to cover a competition you would need to be there sometime before
to render care, during to deal with injuries or other problems and then afterwards
to “patch things back up.” If you think working a pro game would
be exciting (and it is), you should also consider the time involved. To cover
a game of the Georgia Force of the Arena Football League we would arrive approximately
two or three hours before game time and depart approximately two hours after.
Add in the game and travel time you have an eight to 10 hour commitment. I personally
love working track meets but it was not unusual to leave for the track to 8:30
a.m. and return at 10 or 11 p.m.. Either of these will take a big chunk out
of a weekend.
Legalities and Malpractice
Informed consent, permission to care for minors, record keeping and appropriate
referral do not change on the field. It is a major pain to keep records but
it must be done. It is also important to inform your malpractice carrier of
your involvement. Many carriers require you to inform them if you are going
to do anything beyond the information you provided on the application. Failure
to do so could result in no coverage.
In addition, if you decide to travel with a team outside of your home state
you should consult with the state board to determine the existence of “travel
to treat” or temporary license provisions in the law. Georgia has a travel
to treat law initiated as a prelude to the 1996 Summer Olympics which is briefly
summarized on the FCLB website with the following:
“Licensed, in good standing, for sports or specific performing arts event.
Limited to members, coaches, and/or official staff of the team or event for
which that chiropractor is designated. In the event that services are requested
by a specific athlete or performer, the practice of chiropractic shall be limited
to services performed for that individual only. Also limited to that venue of
the event or designated treatment area. Board has authority to audit, review
or inspect the venue and chiropractic services. Must practice within Georgia
scope and comply with Georgia rules and regulations. Cannot use electrical therapeutic
modalities unless in compliance with Georgia laws and rules.” Refer to
Georgia Rules 100-13.01 Travel to Treat; Visiting Practice for complete details.
Kansas allows you to practice under another doctor’s license on a temporary
basis. We put this to good use during the NAIA Outdoor Track and Field Championships
in 2002 where a group of us cared for the athletes competing. In this case the
board was contacted via email and then phone leading to a conversation with
their attorney who clarified the requirements. It ended up being very simple
and user-friendly. State board and law information may be found at www.fclb.org/directory/index.htm.
Follow the link to the state in question.
The bottom line in regard to standards of care is that you must apply the same
standard in and out of your office. If you are a Pierce or Gonstead practitioner,
for instance, then while working with a team you need to follow the same steps
of care including instrumentation and X-ray on every patient for whom you care.
If something goes wrong and you did not, then there could be trouble. This is
why some doctors will only adjust in their practices and never on the sideline.
If you choose to adjust outside your practice, it is important to develop and
follow a protocol. This was in part the reason that John Downes, D.C., (Dean
of the Life University College of Chiropractic) developed the techniques he
teaches in his Global Extremity Assessment course, an extension of the groundbreaking
work of Dr. Kevin Hearon. Of course, check with your state board and or legal
counsel for a definitive answer for your locale.
Getting
Paid
Over the years our general experience has been that whatever you do at the competition
is for free, but you get paid for whatever you do in your office. This may hold
true for youth, high school, college and pro teams. The great thing of working
with youth teams is that every parent wants their child to have the edge now
and then to be a starter in high school, make it to college on a scholarship,
then the Olympics and or the pros—and they are willing to pay for it.
We cannot change a child’s potential, but we can help reveal it.
Several years ago on vacation I played golf with a lovely 16-year-old young
lady who is now in her second year on the LPGA tour. Her parents paid for a
movement therapist, a massage therapist, coaching and a chiropractor to be a
regular part of her development. That may be an out of the ordinary instance,
but parents often will pay for that which they believe has benefit to their
child.
It is important to make clear the boundaries in regards to payment. The athlete
and or their parents need to understand that when they come to your office “the
meter is ticking” and that you must also pay your bills. You should be
aware that many athletes at the higher levels are used to everything being given
to them. If you expect to get paid for service, then you will have to make that
clear up front and take the chance that they may go elsewhere.
Do You Have What It Takes?
The second question to be asked and answered is in regards to the necessary
skills and contacts to work with teams. These are two very different issues.
It has long been my contention that any chiropractor can adjust an athlete,
but there is a distinct set of knowledge and skills necessary to care for an
athlete. Consider the following questions:
You may have gained the
answer to some of these questions by your own experience as an athlete. This
is invaluable and allows you to better enter into the world of the athlete you
will care for. Many athletes will immediately trust you if you have the right
body type and “speak the language.” Of course you will still have
to “deliver the goods.” If you do not have the background you will
have to gain their trust solely through your expertise and insights.
Adjusting Versus Care
In addressing the issue of adjusting versus care it is apparent that everyone,
including every athlete, that is breathing and has a spine, should be adjusted.
The care of an athlete includes so much more. For instance, you might say to
a regular patient, “You should be great but let’s check you tomorrow
to make sure,” but you should never say that to the athlete 10 minutes
before the national championship race.
Gaining Knowledge
One of my favorite phrases from teaching is in regard to experience: “The
best way to get experience is with experience.” You can read this article
and a hundred more articles and books, but until you put it to work, it is just
theory. You must prepare and you must have experience. There is no other way.
If you are already in practice then you already have a great database of experience
to draw from but you must realize that caring for athletes on the field is different
than in your office. For instance you probably see few completely sweat-soaked
bodies that are bleeding in your office. You will if you cover rugby! The good
news is that the same intelligence that got you through school will assist you
in this endeavor.
There are many resources to gain the knowledge necessary to care for athletes
including many fine texts and journals and programs like the CCEP (kevinhearon.com)
and CCSP (acasc.org) seminar series each sponsored by various chiropractic colleges.
At Life University we have found that extremity adjusting is a big part of the
success we have had. If you choose not to adjust extremities then I believe
you should find another doctor who will work with you to who can.
While the knowledge gained in the various seminar programs is necessary, it
has a downside. The more you know and the more credentials you hang after your
name the higher your standard of care and liability. In court you would not
be compared to an average chiropractor but to another doctor with your credentials.
This is not bad, but you should go into it with open eyes.
The sports chiropractor will be on the lookout for patterns of injuries and
their relationship to certain areas of subluxation. In addition, the sports
chiropractor will gain knowledge of the rehabilitation exercises that facilitate
the athlete “holding” their adjustments better, thereby helping
to prevent injury.
Though we may not like it, in the real world athletes often seek every possible
means to gain the advantage, and this includes many helpful and harmful supplements.
Gaining some knowledge of them will enable you to be a source of logic and reason
in an area fraught with peril.
Contacts
When it comes to making contacts with teams it is unfortunately often who you
know rather than what you know. Case in point: Rumor had it that one pro football
team had a pediatrician as their team doctor who just happened to be the son-in-law
of the owner. Use your contacts to their full advantage but realize that in
the long run working your way up through youth teams may be the best solution.
If you get the opportunity to present your services to a team, emphasize the
non-duplicating nature of what we do, the enhancement of performance and prevention
of injuries, and your desire to work as a part of the healthcare team. If you
get the opportunity to care for a member of the team make the most of it. You
will be watched closely by all the decision makers involved. The good thing
is “chiropractic works” and they need you whether they knew it before
or not!
Compensation Differences Between MDs and DCs
You should also realize that many orthopedics are actually paying for the privilege
of working with pro teams. Team management is aware of this and every business
attempts to cut its overhead as much as possible. So the question arises of
why should we pay you when the MD is paying us? Other than the obvious that
your athletes need a chiropractor, it is unfortunately comparing apples and
oranges. The MDs may come to games and give some free office visits, but they
are hedging that with the surgeries that will inevitably come, they will get
paid. Even at Life University, with the finest chiropractic and athletic training
care provided to our athletes, significant injuries occurred which required
surgery. After a few surgeries the MD recoups the money spent on advertising
or the services rendered at no charge.
On the other hand, when the DC renders an adjustment the athlete has received
our best. If they do not get paid for the adjustment there is nothing else.
There are a number of DCs that are paid by teams or through the teams insurance
while others have worked out creative ideas such as getting credit for “gifts
in kind.” The reality is that the care of college and pro teams will most
likely not make you rich, but if you market your experience to the community
properly you should see a good return on the investment of your time.
This is a problem that is not going away anytime soon. Coaches, athletic directors
and owners know the MD is not getting paid to be at the game, so why should
the chiropractor? Teams must come to recognize the value of what we do and chiropractors
must be careful regarding how much they give away. Chiropractors willing to
give it all for free take away from those who are attempting to get paid fairly.
It’s A Team Effort
Once you are working with athletes you must learn to work as a part of their
healthcare team and coaches. This does not mean compromising your principles
but it may mean swallowing your ego and deferring to someone more knowledgeable
or qualified.
The certified athletic trainer (ATC) is the gatekeeper for the health care of
teams at the high school level and above. This means that no matter how good
your relationship may be with the principal, athletic director, owner or coach
you will only truly succeed with the ATC on your side. The good news is that
when exposed to quality care and professionalism most ATCs will embrace what
we do. We have seen several make the move from cynic to booster.
The team model we use at Life is one based on mutual cooperation and respect
with regard to each others’ expertise. The absolute key is that each professional
does what they are best at without competition or contention. The MD does not
tell the DC how to adjust. The DC does not tell the ATC how to tape and the
ATC does not tell the MD which surgery to do. On the other hand as trust and
respect grows, a warm and wonderful interplay of ideas will develop. The DC
may suggest a particular exercise or tape job they are familiar with to the
trainer. The ATC and MD may learn to have a sense that there may be a need for
the DC to adjust. The trainer may be convinced of the presence of an injury
that has defied detection by the doctors, requiring the doctors to humble themselves
and press on to find the problem. This synergistic atmosphere is one that is
a delight to work within.
When joining an existing team it is best to ask lots of questions, listen carefully
and move slowly to integrate yourself into the team. Obviously, the personalities
of all the parties will guide this process, but it is easier to keep your foot
out of your mouth than trying to remove it later. Again, there is no need for
compromise, but often “discretion is the better part of valor.”
In an effort to codify the relationship, a former trainer at Life, Brendalou
Melchiorre, MS, ATC, developed an Injury Guidelines (available online at todayschiropractic.com).
We use these guidelines to train our staff and lay the framework of our expectations
and required cooperation. Our 26 national championships in five years is evidence
of the success it brought.
Coaches
Working with coaches can be one of the most rewarding and/or the most challenging
parts of the experience. Having had the privilege of both sides of that coin,
it is best that you must simply “enjoy the journey.” The very nature
of your position makes you part counselor, part bus driver, part intermediary,
part friend, etc. The first year with any team, no matter your level of experience,
will present many “opportunities for growth.” Working for years
with the same coaching staff can build great camaraderie that greatly benefits
the athletes.
Return-to-Play
If you are the sole doctor involved you will be called on to make determinations,
in conjunction with the ATC, regarding return-to-play. This is one of the most
challenging tasks, stretching you clinically and personally. It is often the
athlete that is the biggest problem; the “I’ve got to go back in”
type of thinking is common. On the other hand, I have experienced a wide degree
of attitudes from coaches in these cases, from quiet acceptance to belligerence.
There have been times when there was room for compromise. For instance, one
of our runners was not fully recovered from a stress fracture at the time of
Nationals. We all agreed to let her compete with the understanding of the effort
that she could exert, and that time-off would be required after the meet. She
won her event but unfortunately suffered for a long time as a result.
As the doctor you must be willing to stand up for and then live with your decision.
The consequences are quite different during the second game of the season with
a part-time player versus the championship meet with a star. The entire situation
is much easier to deal with as the health care team. Nevertheless, in this litigious
culture the owner and coaches must consider the consequences of attempting to
override your decision.
Coming to grips with what you want to do, building the skill sets necessary
and not giving up until the doors open can take you places you never could have
imagined. The sky is the limit when caring for teams, national and world championships
await you along with the promise of increase performance and less injuries.
Set your goals high, work hard, be persistent and give it time and you can realize
those dreams.
Dr. Keith Rau is on the faculty at Life University and has taught and assisted
at many extremity programs. He was formerly the head of the Sports Chiropractic
department and the team chiropractor for Life’s cross country and track
and field program. In addition he has worked with high school, college and pro
teams as well as other elite athletes. You may reach him at (770) 426-2785 or
krau@life.edu. He maintains a part-time practice in Marietta, Ga., (770) 419-2917.
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