Despite the athlete’s preference, at the highest level of professional elite sport, there are often wider performance implications and contextual pressures that impact upon athletes . Sports are primarily a social process bound by a number of contextual factors that may (in)directly and (sub)consciously have some influence on any athlete’s decision-making process; including health status, participation risk, family, teammates, management, sponsors, and supporters . These mediators can have a strong influence on players and their performance, as well as their attitudes to pain and injury . These social influences have shaped an athlete’s attitude towards Sports Science and Medicine practices, and practitioners as sources of authority , and the worth of output monitoring in general (for example, in field sports such as football it has recently been reported that some athletes disdain load monitoring practices as superfluous .
An important component of SDM is to inform and engage patients about the risks and benefits of the available treatments. In a clinical setting, this seems plausible whereby the patient understands how the condition impacts upon their life and how they feel about risk . In a professional elite sport setting, however, this may not be afforded since the coach ultimately decides whether an athlete is selected to compete, and there are many mediating factors that can influence these decisions. Such different roles and experience may govern the way an athlete and coach perceive situations differently . In one example, emerging evidence exists that suggests a conservative approach to ACL injury is a viable option for athletes as part of their journey back to sports performance. However, there may be the general belief amongst backroom staff that the problem has not been ‘fixed’, and therefore, athletes are unlikely afforded the period of time to really consider their choices. Rather they are easily enticed into thinking that surgery allows for the rehabilitation to begin quicker and return to play sooner compared to pursuing a conservative option.
The dynamic of the stakeholders in a professional elite sport setting is very different to that of a physician and patient in a clinical setting. Despite the best intentions to remain neutral, it is plausible that in certain circumstances whereby the situation affects possible performance, some practitioners may oppose their normal procedure . Therefore, any decision may be largely influenced by the increased challenges associated with inter-relational performance pressures associated with key stakeholders and the athlete . While it may often be proposed as an option, evidence indicates that the elimination of biases by simply telling patients about the existence of a particular bias and asking them not to be influenced is not actually effective .
While practitioners believe they are offering their athletes the autonomy, power and options by ‘involving them’ these are likely offered within an eco-system of constraints that are pinned to the club or practitioners’ ‘philosophy’ and within a bandwidth of conformity to what practitioners consider best practice. From this, it is clear there are many components of SDM that demonstrate its complex and multi-faceted nature amongst the main stakeholders (coach, practitioner and athlete) .
For all stakeholders to truly provide their preferences, there needs to be a non-judgmental, even playing field and where possible no agendas or conflict of interest reside. For example, the completion of the ‘exit assessment’ before returning to play is the apparent objective confirmation of being ready to return. However, evidence does suggest that athletes often return earlier and are more fearful despite being signed off ready to play . Conversely, an athlete may feel ready to return before being signed off but is held back, which may call into question a patient’s ability to truly make informed choices alluding to preferences. What is more, we also argue that this very observation casts disparagement on the ability of practitioners to frame SDM as an objective, meaningful practice that they might deploy whilst claiming non-contaminated input from the athlete. It is the extreme alternative to assume that the elite athlete is ‘free’ to proffer a neutral contribution to any SDM process, let alone when said athlete finds themselves in a position of vulnerability (such as suffering a significant injury).
Anecdotal evidence shows that athletes rarely question coaches’ decisions or practices. Furthermore, coaches and athletes are likely to succumb to the social norms that can act to subconsciously influence their treatment choices. This arrangement significantly calls into question the ability of both parties to make neutral informed choices surrounding an athlete’s rehabilitation—yet for many who promote SDM this is not a consideration. The biases caused by how the information is collected and framed are always at play , and it is important to understand that uncertainty, error, and regret are inherent in every decision made .
It may be true that some athletes may be more confident or well versed in understanding analytics generated regarding their output or bodily functions and will want something closer to decision analysis—in other words, computer software that calculates the best option based on weighting probabilities with their personal utilities . This circumstance is likely to be more common, particularly since analytics is so evident in all other aspects of a player’s life in professional sport; indeed, many athletes now develop in ‘data rich environments’ . Indeed, in a world of increased sophistication whereby many decisions are made and greater stock is placed on data-driven decision aids (rather than solely subjective opinion), then it is reasonable to assume that many athletes are more confident and fluent in understanding the implications of analytics. Regardless, we feel that is very important that an athlete’s familiarity with analytics does not lead to the assumption that he or she should routinely be considered competent enough to fully understand the intricacies of, for example, complex medical considerations.