ABSTRACT

In contrast to previous discussions of definitional difficulties regarding sports medicine (see Chapter 3), the necessarily narrower field of professional sport entails a relatively coherent body of medical provision, for if we focus on the healthcare provided by sports teams and NGBs it is reasonable to conceive of sports medicine as a form of occupational healthcare. This is one area of sports medicine that can meaningfully be defined by patient demographics. In this respect Kotarba (2001) argues that different types of occupational medicine can be distinguished in relation to their organizational

structure and working culture. Structurally, ‘the quality and complexity of occupational health care is a function of the relative value of the work to the employer’ (Kotarba 2001: 767). Consequently, the most highly valued employees receive individualized and preventative healthcare (e.g. lifestyle management, health club membership, etc.), while the lowest merely have access to periodic screening and health assessments designed to ensure a person possesses the necessary physical capacity to carry out the expected duties. The work culture, however, is seen to dictate the ‘style, tone and meaning of occupational health care delivery’ (Kotarba 2001: 767). Occupational medicine does not simply attend to the physiological needs of workers, but is more broadly shaped by the norms of the workplace subculture, e.g. the emphasis on optimal, advanced and ground-breaking performance as opposed to routine and quantifiable productivity. On this basis Kotarba (2001) identifies three main types of occupational healthcare. Elite occupational healthcare is the most medically advanced available and potentially the most expensive. Culturally, it is highly individualized such that the worker is seen as a patient-client who makes an irreplaceable contribution to workplace productivity. Typically, elite occupational healthcare is deemed to be complex and is thus provided by a medical practitioner who specializes in the field. Managed occupational healthcare is provided to workers who are not deemed to be particularly special and could be replaced relatively easily. Culturally, it will reflect this rationale, concerned to balance the expense of delivery against the savings accrued from having a healthy workforce. Typically, managed occupational healthcare is provided by a medical generalist (e.g. a GP) who works for, and reports to, the organization rather than the individual. Finally, Primitive occupational medicine is made available to the least valuable, most easily replaced and low-skilled workers. Culturally, healthcare is seen as benevolence or charity. There is no pretence to health optimization, just a desire to ‘patch up the worker in an incidental manner – when care is available and when there is an immediate need for care’ (Kotarba 2001: 768). For these reasons, primitive occupational healthcare is typically delivered by an ancillary health worker, such as a nurse or physiotherapist. Applying this tripartite model to Amer ican sports medicine, Kotarba suggests that elite occupational healthcare is available to the leading performers in individual sports such as golf and tennis and those in major league team sports (NBA, NFL, etc.); managed healthcare is the norm within less wealthy team sports (e.g. Amer ican men’s soccer leagues and the women’s NBA); and semi-professional or amateur sports performers only have access to primitive care. Two key issues arise from Kotarba’s (2001) model. First, each form of occupational healthcare suggests notions of medical power that falls some way short of the traditional conceptions of medical professionalism which underpin the medicalization thesis. In particular, the importance of economic

interests in this model provides direct parallels with Johnson’s (1972) Marxist-oriented analysis of professions. Elite occupational healthcare is similar to what Johnson describes as the patronage model, in which (medical) consumers define both their own needs and the manner in which those needs are served, ultimately leading the (healthcare) professional to become the ‘client’. Managed occupational healthcare (and to a lesser extent Primitive) is similar to Johnson’s definition of the mediative model, in which a third party (here the sports organization) arbitrates between (medical) producer and (athlete-patient) consumer, assessing the validity of consumers’ needs and the manner in which the producer will attend to those needs. No model of occupational healthcare defined by Kotarba matches what Johnson describes as the classic form of professionalism, the collegiate model, in which the producer defines the needs of the consumer and the manner in which these needs are served. Suffice to say, occupational healthcare may represent medicalization in the sense of jurisdictional expansion, but medicalization that is neither driven by nor enhances the autonomy of the profession. Second, if the ‘medicalization through rational pursuit of athletic success’ hypothesis is correct, sports medicine would: (a) increasingly come to resemble elite occupational healthcare; (b) be most advanced in the most commercial sports; and (c) develop concomitantly with the intensification of commercialization processes. This chapter uses Kotarba’s hierarchy of occupational medicine to evaluate studies of the medical and healthcare provision in sport. Initially, we examine studies of primitive occupational healthcare in sport, augmenting Kotarba’s US-based research with other Amer ican, Canadian and British studies. Subsequently, we explore models of managed occupational healthcare, focusing on medical provision in the wealthiest sport in England (football), and under conditions of heightened financial investment in post-professional rugby union. Third, we explore evidence for the existence of elite occupational healthcare, charting the provision for Olympic athletes in both Britain and Canada. As we will see, the empirical evidence demonstrates that while primitive occupational healthcare clearly exists in amateur and semi-professional sport, Kotarba’s belief in the existence of elite and/or managed occupational healthcare in professional sport is largely a matter of conjecture. We conclude by drawing on studies of the integration of medicine and science in sport, which provides a segue into the subsequent chapter focusing on the everyday practice of sports medicine. Ultimately, though, the absence of elite occupational healthcare in sport highlights the peculiar dynamics of the medicalization of sport, largely determined by people within the world of sport rather than medicine and, in particular, structured according to the cultural norms of the former.