Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're going beyond the game, being a team physician and handling the pressures of Division I sports. Joining me today is Dr. Kevin Farmer. He's a Professor in the Department of Orthopedic Surgery and Sports Medicine and team physician at the University of Florida.

Dr. Farmer, thank you so much for joining us today. When people hear team physician, and especially at the collegiate or even professional level, what do they not fully appreciate? If you were telling people about this role, help us understand the role of a team physician. And at such a high level, how would you define this role within these organizations?

Dr. Kevin Farmer: Thank you for having me. I appreciate the opportunity. I think, you know, when people hear team physician at the D1 level or the NFL level or professional level, they think it's just a lot of fun and glory, and you come in on game days, and that's about all you do. But that really is just a very small token of what we do on a day-to-day and a week-to-week basis.

I mean, being a team physician, you're really tasked with, first and foremost, looking out for the health and the well-being of the athlete, both in the short term, such as getting them back for a game. And in the long term, worrying about their futures and not doing something that may jeopardize their health long term. And you do that in the aspect of having to work both with the team, with coaches, with parents, with agents, and kind of synthesizing all that information and all their input, to help kind of make a decision or give them information to make a decision that allows them to decide on what path they want to go as far as treatment.

So really, you're herding a lot of cats, so to speak. You're trying to get everyone on the same page and make a decision that's both in the best interest of the athlete but also, to some extent, in the best interest of the team. And it's a tightrope you have to walk in many cases.

Melanie Cole, MS: Well, it certainly is. And before we get into a little bit more about those unique pressures and balancing athlete health, as you're saying, with team performance, I'd like to know if you've ever had the opportunity to treat upper-level athletes. Briefly discuss your experience a little bit and tell us about UF Health's partnership as the medical provider for the United States Olympic and Paralympic Committees.

Dr. Kevin Farmer: Yeah. That's been a great partnership. You know, there are a lot of Olympic athletes that train in the state of Florida, and that train at the University of Florida. I think at one of the more recent Olympics, they said that if University of Florida was its own country, I think we would've been like top 10 or top 12 for medals for countries. So, we have a lot of athletes here at University of Florida that are Olympic athletes, not just American Olympic athletes, but athletes from other countries. And so, that partnership, I think, has been very beneficial that these athletes don't need to leave the state. They can stay here, get their care and then get the proper rehab and therapy afterwards.

And so, these athletes are high-profile athletes. They're under time constraints. They're trying to get back so that they can be prepared to qualify for the next step and stay in the mix because, you know, there's always someone else trying to get that spot. But I think that relationship with UF Health and the Olympics has been mutually beneficial. And we've had a lot of high-level athletes that have done well and had good outcomes with us. And once the word gets around, that the athletes are comfortable to stay here and don't feel they have to leave to go to other states or other areas, because we can provide that high level of care here in Gainesville.

Melanie Cole, MS: Well, thank you for telling us about that, Dr. Farmer. And so, I'd like you to speak about the Transfer Portal and the Name, Image, and Likeness, the NIL, how that deals and changes the physician-athlete relationship within the NCAA. Do you see differences in continuity of care or medical documentation with increased athlete movement? Tell us how that transfer portal affects the care of college athletes.

Dr. Kevin Farmer: Yeah, it's a great question. And something that's become more and more of an issue for us in the last five years. You know, unlike the NFL or other professional organizations that effectively have shared electronic medical records, we don't have any of that. And so at this point, there's no SCC shared medical records or medical records amongst different conferences.

And so, it's not uncommon for me to operate on an athlete. And then, find out next day or the next week that they're transferring to a different school and then not to really get any kind of follow-up or any kind of discussion or anything to make sure that they have the care that I would want them to have. And so, vice versa, to get an athlete that shows up for physicals with us that had surgery a week ago that I didn't know about at a different school, and now they're kind of our problem. And so, in that situation, who pays for the rehab afterwards? You know, how do we make sure that they're following the rehab plan that the surgeon wanted, that I wanted before they left?

And so, it takes a lot of initiative amongst ourselves. We have to reach out to the other teams. We have to find out where they went. A lot of times, we don't even know where they transferred to. We don't hear about it. And so, there's a lot of effort on our part to make sure that there's some line of communication to make sure these athletes are taken care of appropriately. Because at the end of the day, you know, every year I'm at the NFL Combine with the Dolphins, if one of my athletes comes through that I did surgery on and then they transfer and I lose track of them, they're going to come back to the Combine and my name is still going to be on that chart for the one who did the surgery. And if they have a poor outcome because they didn't follow the postoperative plan, I'm the one that looks bad.

And so, you have to make sure you make the effort to communicate and find out where they're going. And, likewise, if we get somebody from another school that's had surgery, I try to reach out to the team physician there to get some information. But it is not ideal. Unlike the other professional leagues that have figured this out, we have not figured that out at the Division I level, and we need to find a way to figure it out, because as the athletes get put in this back-and-forth situation, and we need to make sure that we get this down where we're all on the same page, we all have the ability to get the records easily and can continue to take care of them no matter if they transfer or not. And I suspect in the next five to 10 years, we'll have that. But right now, that is not where we are.

Melanie Cole, MS: That is so interesting, Dr. Farmer. And when we think of professional free agency model that's so affecting athlete care these days and we think of the mental health strain from high stakes negotiations and the scrutiny on social media, that's a big one, the pressure, I'd like you to speak a little bit about the physical health to determine injury risk, how the teams assess draft prospects as the medical evaluations are considered one of the most crucial elements of the combine that really can determine a player's draft stock more than even sometimes on-field drills. Walk us through the medical evaluation process at the Combine. What's actually happening behind the scenes?

Dr. Kevin Farmer: At the Combine level, every athlete will get a grade, so an orthopedic grade and a medical grade. And so, the primary care doctors do the medical evaluation, heart, lungs, labs, all those different things. And then, the orthopedic doctors for each team will do the evaluation and give them an orthopedic grade. And teams do it differently, but it's effectively A, B, C, D, kind of an F. And so, that grade based on, if they've had a meniscus tear and have had part of that trimmed out, do they have cartilage injuries, that gives the teams an idea what is the long-term risk of this athlete.

If somebody has bone-on-bone arthritis in their knee, they're probably going to get a D or maybe even a failing type grade. So that way, when the team looks at them, they know that there is a risk with taking an athlete that may not have a long-term perspective because of some underlying injury. And so, you know, at some point, the talent level and the medical grade, they go head-to-head. And you make a decision on which of those is more important. If the talent exceeds the medical's concern, then they'll get drafted and it doesn't affect it.

But if the medical concern is enough where it doesn't exceed the talent, then those are the people that unfortunately probably fall down in the draft, because the higher you're drafted, the more guaranteed money you get. And so, if there's a concern that you may not last a year or two because of the underlying issue, then a team doesn't want to invest money in you upfront.

Now, the same thing happens now to some extent at the Division I level. We never had that issue. But now, because of revenue share agreements, all these kids are guaranteed, at least in football—are guaranteed some amount of money—and that varies amongst the schools based on how they divide up the revenue shares amongst the different athletes and the different teams.

And so, now that these kids not only get a scholarship, now get some sort of guaranteed money, now their health history comes into play. Whereas in the past, it maybe wasn't quite as big of an issue. Now, if somebody's had a bad injury or missed the previous season because of an injury, we often get asked to weigh in on that. What's the likelihood this kid could play four more years? You know, is it worth us investing whatever amount of the revenue share that they're going to invest in somebody that's got a long injury history? So, that was something in the past that we didn't have to really deal with, that now you're really having to weigh in, because now there's a monetary tie or monetary number to each one of these athletes—good or for bad, depending on how you look at it, but there is a monetary tie now to these athletes.

Melanie Cole, MS: So, Dr. Farmer, then, is there both hospital and on-site testing? And is there a standardized assessment for injury risk before the draft when we think of these specialized scans that would have to take place in the hospital, and then orthopedists looking at injured areas, risk for injury? Tell us a little bit about that.

Dr. Kevin Farmer: At the NFL Combine, it's been done in Indianapolis now for the last 20 years, and I don't see any way that they could possibly move it out of there. They've talked about moving it just for kind of a moving road show like they do the NFL Draft, but it's so well organized and set up in downtown Indianapolis. I don't see any way you could do that in a different town because they have Lucas Oil, so the Colts Stadium is connected to the convention center. All of that is hardwired into the University of Indiana Hospital System so that we all have access to imaging. So, an athlete comes in initially, they get an intake evaluation by an athletic trainer.

 Often, they will already have most of their injury history just from communicating with the college teams and the college athletic trainers. So, they'll know they missed last season because of a knee or they missed this season because of a foot. And so, they'll get X-rays and typically MRI right then at that point at the University of Indiana Hospital system.

And then, at the Combine, we have access to view all those, to see the reports. And they also have MRI units in the Lucas Oil Stadium if we need to get more MRIs. And so, it's not uncommon for an athlete to get five or six MRIs as part of the Combine evaluation, just based on their injury history. And then, that goes into the evaluation and deciding on what their orthopedic grade is.

Melanie Cole, MS: So then, let's talk about your game day responsibilities. What does that look like for a team physician from start to finish? How do you prepare for the unpredictability of acute injuries and then some ongoing chronic injuries?

Dr. Kevin Farmer: Part of it is the preparation before. So, you know, make sure that you have all the potential medications, anti-inflammatories, those kind of things, you have those stocked and refilled. So if you do need those pre-game or in the game, that you're ready. You make sure you have X-ray available and set up. We typically have X-ray brought into the stadium for game day so that it's right there immediately available just off the field. You know, you make sure you have an X-ray tech available. Make sure all those kind of things are lined up. You would've already met with paramedics and EMT before the season to make sure you have a plan in place, where they're going to be positioned. What's the plan if somebody has to get spine boarded and put into an ambulance? All those things are all worked out. We call it an emergency action plan. We've gone over that. We've rehearsed it. Everyone's on the same page. So, those are the first steps, the first line steps. And then, on game day, you know, typically, my game day I get in about two and a half hours before the game, give or take.

I try to be there before the home and visiting team get there. So about two and a half hours before the game. You know, you get set up, I talk with the athletic trainers, who's having any ongoing issues that we may need to discuss plans before the game, who's having any problems that are on the fence that may not be able to play. You get those things lined up. If anyone needs to be evaluated before the game starts, be ready for them. And then, obviously, the game usually lasts about three or four hours. So, that's seven, eight hours that you're there. Usually , around another hour afterwards and make sure there's no evaluations afterwards, you don't need any X-rays. The visiting team doesn't need any X-rays. You know, also, I skipped one part. We do a timeout about an hour before the game with all the visiting team physicians and medical staff so that they know where X-ray is, where paramedics are, what's the plan as far as the emergency action plan if we need to get somebody in the ambulance and taken to the hospital so that they're all on the same page.

And so, then, in the night, you know, an hour after the game, you're able to go. And then the next day, you come in and you do injury checks all over again and make a plan for the upcoming week. So, game day weekends is a lot more than just what you see on TV. There's a lot more that goes into it that keeps you pretty busy.

Melanie Cole, MS: Well, I imagine that is true. This is such a great topic to talk about of interest to so many people. You have a cool job. I mean, Dr. Farmer, let's put that right out there. You have a really cool job. And so, as we wrap up, what are some of the most important aspects and personality traits? And I love this question, because I want to hear from you about what you feel are your best personality traits that make it so that you can not only handle the pressure and the scrutiny, because social media and all of that, as we said, but the pressure of keeping these athletes healthy.

And if somebody wants to break into the sports world as a team physician, as I imagine, many young upcoming physicians would like to do, what do you find are some of the important traits that you yourself have, and what advice would you give to these clinicians that are interested in entering this field?

Dr. Kevin Farmer: Yeah. I think, first and foremost, it's communication. The ability to communicate well with the rest of the team. End of the day, it's a team approach. And so, that's got to be first. You know, number one is, you know, your ability to communicate with the athletic trainers, the athletes or family, the coaches. I think that's critical. I'm a former athlete myself. And so, I think having that experience can be very helpful, understanding a team approach and working well with a team. But also, developing sort of thick skin. As you said, there are going to be some shots fired on things on social media that people may not have really the understanding of what's going on, but they're still going to fire some shots. And you just got to let those things roll off your shoulders.

And, you know, as long as you're doing what's in the athlete's best interest and doing the right things, then nothing to worry about. So, I think being a hard worker, being used to being in a team environment, working well with a team, having support, I think it's critical to have support at home.

As I mentioned, these are long days and long weekends and having support at home that allows you to do that, I think, is critical because you miss out on a lot of different things in your personal life that maybe if you weren't doing those things, that you'd be able to do. And so, I think having good support and a good social system I think is very important. But I think end of the day, being a hard worker, doing what's in the best interest of the athletes and being able to communicate well and work well within a team are probably the most critical aspects to being successful as a sports medicine physician.

Melanie Cole, MS: Thank you so much, Dr. Farmer, for joining us. What a great episode this was. Thank you for joining us. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org.

And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole.