Being part of the team of physicians from Changi General Hospital's (CGH) Department of Sport and Exercise Medicine (SEM), providing medical care for national athletes in major games is an important scope of practice. The team works with the Singapore Sport Institute (SSI) to provide medical care for our national athletes participating in major games, such as the Olympics, Paralympics, Asian Games, Southeast Asian Games and ASEAN Para Games.
Travelling with a team of athletes as the team doctor presents considerable challenges. While people may think that travelling as a team doctor is a holiday, the reality is quite different. A lot of preparation is needed, with planning that spans many months before the event. When working in a foreign environment, prior knowledge of the local medical standards, climate, infrastructure and risks is needed. Often, the schedule can be hectic and the work hours can be long as we are with the team 24/7. The working conditions can also be difficult at times, such as working out of the team room or hotel room, or out in the field without the clinical security of the hospital/clinic.
Assembling the team
The role of a chief medical officer (CMO) is to oversee the medical needs of both athletes and officials of the team in sporting events. Varying from event to event, the CMO coordinates a multidisciplinary medical support team comprising doctors, physiotherapists and sport/rehabilitation trainers, together with sport scientists, nutritionists and sport psychologists. The composition of the games medical team depends on a host of factors, including the spread and distribution of events both geographically and schedule-wise, the injury and medical risks of the events, as well as accreditation numbers for medical and support personnel stipulated by the games organisers.
Physiotherapists and sport trainers often serve as the first point of contact between the athlete and medical team. During each games, they not only provide necessary physiotherapy treatments for the athletes, but also on-site medical support. Our allied health team members help facilitate video consultations, especially in remote locations, and schedule athletes for subsequent physical consultations. Prior to the event, assigned allied health professionals will also engage with respective team managers, coaches and athletes to work on the athletes' current injuries, as well as musculoskeletal maintenance and injury prevention measures.
Pre-games preparation
Adequate planning is instrumental for a successful trip. Gathering insights and information on the destination through research and reconnaissance is of paramount importance. Information on the environment and climate, such as the temperature and humidity, will determine the team's training and hydration strategies. The country's endemic diseases and food and water hygiene standards will require appropriate travel health practices such as determining the team's source of drinking water or required vaccinations, as requirements vary considerably between countries. With this information, a list of precautions in the form of a travel advisory is developed and disseminated to athletes, officials and team members.
The CMO is responsible for developing the medical plan, which describes the structured details of the team's medical coverage. A clear and concise medical plan takes into account the local medical infrastructure, as well as environmental and geopolitical factors. The accessibility, proximity and capabilities of the available local medical facilities are also important considerations. Multiple medical facilities are often considered when covering large teams in major games with multiple sport and venues. Event details, medical manpower, medical operations and infrastructure, and logistics are included in this document. Deployment details with coordinating instructions, medical contingencies and protocols, as well as critical incident plans are also included.
Based on the historical data of the sporting event, we can also anticipate likely injuries and illnesses, and thus train to deal with various possible situations, and rehearse for scenarios such as coordinated pitch-side medical responses. From the data, common injury management protocols are developed and medical logistic requirements are spelt out as well. At the same time, the games doctors and physiotherapists hold regular coordinating meetings to deliberate any injury or medical issues the athletes may have, given that they may not be the athletes' regular care provider.
The event itself is a culmination of hard work that goes behind the scenes. Before travelling for major games, national athletes would have already completed medical screening, which is mostly done at the SEM clinic at CGH. Given the number of athletes and tight timelines between qualification for the games and the event itself, administrators and clinicians in both clinics at SSI and CGH coordinate to facilitate timely and seamless medical screening. This ensures that athletes going for competitions are medically cleared to participate in their sport. The process also facilitates early treatment of any incidental medical illnesses or musculoskeletal injuries prior to departure.
Athletes are required to complete a drug and medical declaration, which documents medications and supplements consumed by the athletes. This information is crosschecked to ensure that their medications or supplements do not contain banned substances. Supplements are screened through batch testing by the nutrition team to check if they contain banned substances or are also safe for consumption. Medications are checked to ensure that they are not in the current World Anti-Doping Agency (WADA) list of banned substances.
Medical logistics
A huge component in preparing for major games coverage is medical logistics. In the process of assembling the medical bags, the appropriate medications and their quantity need to be planned and procured. This will depend on the country the team is going to, its endemic diseases and hygiene standards, as well as medication availability in the country. It is also important to be aware of the customs regulations that vary from country to country. Import documents for the medications and equipment will need to be filled out and submitted ahead of time. In selecting medications, being up to date with the WADA list of banned substances – knowing whether the medications are banned, in or out of competition – is important.
Anti-doping
The team physician must be familiar with the drug-testing rules for the particular competition, including testing procedures. The medical support team needs to constantly remind athletes that they must not take any medications without approval and be aware that common over-the-counter medications or supplements may contain banned substances. There have been many instances of athletes being caught for unknowingly committing doping offences. There are also times when we are required to accompany a podium athlete for drug testing, especially when the athlete is a minor. It is thus important to know the appropriate doping control procedures, as there are times when they may vary or even be inappropriate.
Qualities of a team doctor
There are often many difficulties when looking after a team on the road. The team physician will need to be up to date with their knowledge on primary care as well as the skills needed to deal with competition injuries. Acute medical illnesses such as upper respiratory tract infection and gastroenteritis are common on the road, but we may occasionally need to manage chronic medical conditions as well, as a significant part of the contingent includes staff and officials who are likely to be less athletic and may have multiple chronic health conditions.
Covering major games is akin to doing a call over a few weeks, and hence an element of endurance is required of the team doctor. Although the absolute number of tasks is less than that of a usual call, we have to remain on standby for any potential emergencies that may occur. It is common to cover a match onsite till late at night and subsequently travel with athletes to the competition grounds early the next day. Apart from the long hours, movement of the team may be restricted to the games accommodations and competition venues, often in events held where geopolitical or security risks are high, which can prove very mundane and sometimes repressive.
The CMO leads the medical contingent and is in charge of task delegation. It is much like in a resuscitation scenario, where the roles, responsibilities and tasks of team members are clearly defined. The CMO must identify team members' strengths and how to best utilise their talents. Team members like physiotherapists or trainers often have long experience covering a particular sport or team, and therefore have in-depth knowledge in field coverage and injury management.
The team doctor must also be flexible and adaptable. With the team on the road, the team doctor may have to treat the athlete in public areas, such as in the field or in the arena, open to media and public scrutiny. Wherever possible, arrangements are made for assessments and treatments to be done in a room or in an area with screens for privacy. However, due to logistical constraints, it is usually not possible to have an ideal setup similar to what we are used to in the hospital. The teams' allocated medical centre in each games is often a retrofitted space, and we have encountered situations at major games where allocated building structures were incomplete. Some common occurrences included building defects or a lack of furniture, and sometimes even sewage leaks. In the 2024 Paris Olympics for example, we had to shift our medical centre multiple times due to unforeseen circumstances. On the bright side, the moves gave us better insights into how to best utilise each different space, as well as some swift "pack and run" practice. In terms of accommodations on the road, there have been events where available accommodations were lacking and we had to make do with sleeping on mattresses on the floor. These instances highlight the need for the travelling team physician to be flexible and adaptable.
A team physician must always maintain a professional relationship with the athlete and coach. The relationship is complex, involving the health of the athlete, the needs of the team, and the coach's role in supporting the team. The team physician's primary responsibility is the athlete's health, but at the same time, the team's goals need to be supported. Decisions must not be based on the desired outcome of the competition, but on the athlete's health risks and consequences. Some athletes may also hide or play down their injuries for fear of being dropped from the roster. Being transparent with open communication is important in such situations, to help athletes understand that we are not there to stop them from competing, but to help them get fit and playing again as soon as possible.
Conclusion
Medical cover for major games is an experience that differs greatly from our routine clinical care. The work in front and behind the scenes thoroughly exemplify how it "takes a village to support an athlete". Although it can be tiring, it is a highly enriching experience, and the camaraderie forged during the journey is something that lasts way beyond the games itself.