Dilemma: A middle-aged man attends your surgery complaining of tiredness and a reduced sex drive, and asks you to prescribe him some testosterone. You are concerned that he wants the drug to enhance his performance as an amateur cycling enthusiast. How should you handle his request?
Allegations of doping by athletes has once again been in the headlines – but as the example above illustrates, the problem does not just affect elite sportspeople. The increased availability of advice and prescription medication over the internet has made doping more accessible to both amateur and professional athletes alike.
GPs treating sportspeople at all levels of sport need to be aware of the potential for abuse of prescription medication as well as the risk of prescribing prohibited substances.
The issue of athletes taking prohibited substances is complicated and fraught with dangers for the unsuspecting. Athletes are responsible for ensuring that they do not take anything that could be seen as a performance-enhancing drug – if they are subject to anti-doping regulations, prescribing is best left to doctors with special expertise and training in the World Anti-Doping Code.
In dealing with your patient’s request for testosterone, you must follow the GMC's guidance on prescribing, which says 'you should prescribe medicines only if you have adequate knowledge of the patient’s health and you are satisfied that they serve the patient’s needs'.
If, after careful discussion with the patient, you do not consider the treatment would be of overall benefit to him, you do not have to provide it. You should explain your reasons to the patient and explain other options such as seeking a second opinion.
Treating sportspeople can also pose other unique challenges for GPs, including the following.
Good medical practice
The usual rules of good medical practice apply whoever your patient is. As a GP, the medical care you provide a professional athlete is likely to be very similar to your day-to-day work.
However, you will need to take into account that sportspeople may have concerns specific to their sport and in some cases, you may have a lower threshold for referral to a specialist. Be sure to always act within the limits of your competence and seek a second opinion where necessary.
There can often be considerable pressure placed on doctors treating sportspeople, both by the club or employer and the patient. At all times, the interests of the patient must be paramount and you must always act with integrity. This is reinforced by the GMC, which says you must make the care of the patient your first concern.
The Faculty of Sports and Exercise Medicine has also published a professional code, which says that decisions on the fitness of a patient who is a professional sportsperson to perform physical activity should be determined on clinical grounds, and under most circumstances should not be influenced by third parties such as coaches, management, or family members of the patient.
In a more recent statement, the faculty also said that 'to discourage a doctor's duty of care to an athlete shows a disregard for player welfare and good medical practice'.
Treating sportspeople may also require a commitment to travel and work in the evenings or at weekends, so make sure this does not conflict with the care you offer other patients.
As a GP you may be asked to attend a sporting event to provide medical cover. Before accepting this position you should clarify with the organisers exactly what medical cover they require and satisfy yourself that you have the specific skills and training needed.
It is important that you meet any certification requirements for that particular sport and have adequate professional protection. You should also establish what equipment will be available and whether it is functioning and appropriate, and familiarise yourself with relevant emergency procedures.
Maintaining patient confidentiality
There may well be media interest in the health of elite sportspeople, and you and your staff should be mindful of inquisitive journalists or fans. Athletes have the same rights and expectations as any other patient in respect of confidentiality, and any disclosure to a club or employer can only be made with the patient’s express consent.
Minimising your liability
Medical Protection advises GPs not to enter into a written or oral contract with an employer (such as a team or club) to provide GP services. Your relationship must be with the patient and not the club, and any professional fee notes should be addressed to the patient and not their employer.
GPs should also only accept referrals from other independent healthcare professionals, and not from clubs directly or from other healthcare professionals working for them.
Finally, if you are interested in working with a sporting team or sportsperson, you must ensure you have appropriate indemnity arrangements – regardless of whether you are being paid or not. Clubs and sports associations may provide indemnity or insurance for clinical negligence claims and you should make sure you are clear on those arrangements before undertaking any work.
However, it is important that you contact your medical defence organisation well in advance to inform them of any changes to your scope of practice, and they will be able to confirm, on a case-by-case basis, whether you have appropriate protection in place.
- Dr Marika Davies is medicolegal adviser at Medical Protection