An interview with consultant orthopaedic surgeon and author Professor Bill Ribbans
Continuing our series of interviews with inspirational members, we talked with top orthopaedic sport surgeon Professor Bill Ribbans, on the launch of his new autobiography.
We asked Bill, whose career has spanned 40 years, what motivated him to write the book. One strand he describes as a testament to the love affair with his little market town, Northampton, one of only six places in the country that have first-class football, rugby and cricket. He describes the privilege he feels to have been able to return to the place where he grew up, and provide some support to the organisations there.
What was the focus when writing the book?
The main purpose of the book was to look back over the last 40 years, from 1980 when I was first involved in looking after sports people. I was lucky enough to look after some leading sports people but, like most of us, much of the work was looking after ‘weekend warriors’.
My hope is that, having looked back over everything, I can just make the point that doctors, physiotherapists—and all the other health practitioners involved in sport—can’t work in isolation. However brilliant the technician, we know there is more to looking after our players and athletes than working in the bubble of performing the best operation. To use a mechanical analogy, it has been a privilege to look under the bonnet of Olympic champions; trying to deal with the electrics, but realising we have to consider there’s a computer (the brain) that’s controlling everything…
How has sports medicine changed?
Sports medicine has only been established as a career pathway for the last 15 years – it has essentially evolved from a series of cottage industries. There wasn’t a coherent organisation, and people’s knowledge of sports injuries was pretty limited, 40 years ago. We didn’t have MRI scans, didn’t have arthroscopy; diagnostics that we regard as bread and butter today.
Now, we’ve gone to the other extreme, with major sporting organisations such as premiership football clubs spending millions a year on healthcare.
My concern, which I highlight frequently in the book, is that I wonder whether as doctors, physiotherapists and strength and conditioning coaches – we ever sit back and critically look at the unforeseen consequences of what we’re achieving? Because many of the injuries which would have forced people into retirement 40 years ago, we are now very much better at sorting out. The strength and conditioning coaches (who hardly existed 20 years ago), are making athletes so fit and strong that we may just be putting people back for the next big ‘hit’ and injury.
No strength and conditioning coach is ever going to say ‘I think I’m too good at my job – I’m making these athletes so fit and strong that I’m just turning them into human battering rams’.
Do we ever look at everything and ask ‘are we doing this in the athlete’s very best interests?’ Athletes receive the benefit of the glory and income, but by patching them up and getting them back on the field, are we increasing their risks of long-term damage? I think the answer is yes.
Taking rugby as an example
Rugby was always a dangerous sport. But pre-1995 when it was amateur, and everyone had to get up for work on a Monday, it was just about kept within safe limits. The moment we told players they were all going to be paid, and they could go down the gym six days a week and turn themselves into these enormous leviathans, it tipped, in my view, into a sport that is inherently dangerous. In his forward to the book, Sir Ian McGeechan supports the view that all administrators in the sport need to take responsibility for player welfare.
Sporting authorities and organisations have been very slow to adapt to the need to support player welfare. They’re all performance machines, there to create winning teams, winning athletes.
There have been some high-profile athletes opening up about issues such as disordered eating – do you think sport needs to do more to support athletes psychologically?
These athletes have been very brave to come out. There are definitely cases of coaches wanting to push athletes beyond where they should be. What’s changing, and how we as clinicians can help, is the move to a multi-disciplinary approach. We have to be part of this ethos of whole team working.
So many of the patients I see have injuries with hidden messages underneath. They may be worried about contracts, worried about competition. And it’s not just the older athletes – it’s the younger athletes being forced through academies, forced through dance schools. Sometimes you see the youngsters coming in and they’re just not getting better from an injury you really thought they should be getting better from. And if you get a moment to talk to them alone, they actually want out. They’ve been pushed to swimming club, pushed to become professional dancers, and now they’ve had enough of the activity that totally emersed them at the age of 13. They want somebody, such as the surgeon or the doctor, to say ‘you should stop’ – which is then a relief, as they can say to their coach or their parent that ‘actually, the doctor said I’ve got to stop’.
What is the next step for the holistic sport medic team having the awareness of these issues, and working together to resolve them?
Firstly, we’ve just got to be more aware of these subtle messages, that sometimes we may not pick up in a busy clinic.
Sport is a vastly different atmosphere to the way in which most clinicians work, whether in hospital, or GP practice. We’re often just an add-on, bolted on to try and get athletes back to play – and that blurs priorities, as we are seeing at the GMC hearings with Dr Richard Freeman, former British Cycling and Team Sky doctor. This blurring between performance and welfare worries me – I’m concerned that doctors are getting pushed into this almost before they’ve realised it is stumbling into the ‘grey zone’ between welfare and performance.
Change has also got to come from the organisations – there must be more understanding of welfare, and it needs to come down from board level. There should be a board representative of every body or organisation that has responsibility for welfare. I also think that there needs to be a view as to where the clinicians lie between performance and welfare, because so many, particularly physios, are actually under the control of the managers and coaches. The ideal situation would be some distance – and it’s very difficult, because there can be little obvious lines of responsibility in these sporting organisations.
Even when there is a clear demarcation, there are managers with large egos who will just ride roughshod through it, and sack or bully physios and doctors. That needs a corporate cultural change, because doctors and physios can’t achieve the needed progress by themselves. There needs to be some recognition of healthcare professionals’ independence, and their need to have the holistic welfare of athletes at heart, particularly when you start to get down to the academies. It needs us as senior, experienced clinicians, who have been at the coalface for a long time, to stand up and say ‘this has got to change’.
In the corporate world, welfare seems to have risen much higher up the agenda since Covid-19, with a change of role focus from HR Officer to Chief Wellbeing Officer. Do you think this might happen at board level with sporting bodies?
Sporting organisations are getting much better at welfare. The early of stages of Covid have forced them to change from performance vehicles to welfare organisations, which they were not very well equipped to do. Taking Northamptonshire cricket as an example—who have actually been brilliant and taken these issues on board—they don’t actually have an HR department, or any facility for occupational health.
The majority of the money in sport is invested in players and performance. But the clubs have got to change their strategy and appreciate that, in the long run, this will help team performance.
With the knock-on effects of the Covid response—such as empty stadia and other restrictions to earnings—threatening the viability of clubs and organisations at lower levels, do you think this will have implications for welfare?
I think it’s going to have a terrific impact because, outside the Premiership and Formula One racing, it’s almost certain that sports people’s salaries are going to be affected, and there will be increased concern about providing for their families. But I hope that the new Premiership rescue package that’s been announced will be distributed in a way that makes it accessible.
What it also means, of course, is that there is a risk that clubs are going to be coming back with smaller squads. We know—because we have had students looking at research into playing while injured in the lower reaches of the football divisions—that the smaller the squad, the higher percentage of injuries and more athletes playing with injuries. But even at Premiership level, when you look at what is going to be required of footballers in the next 2-3 years because of the concertinaing of fixtures, it is undoubtedly going to shorten some player’s careers.
What about the medical defence and litigation impact of that? Will all these additional pressures have a knock-on effect with regards to the vulnerability of medical professionals to claims?
There is no doubt that in society and sport, we are increasingly litigious, and this has an impact on our insurance. Some of the spinal surgeons are already paying over £100k per year, and that doesn’t even cover them to look after premiership footballers. This is why SEMPRIS has been so welcome. They are the only insurance organisation that are able to offer the level of cover that doctors and other clinicians need to look after these people, because the well-established organisations such as the MDU, MPS still have a £10 million ceiling on one claim. We know how much footballers earn in a year – if they’re earning £4-500k per week, you can see that within six months, they will have gone through the clinician’s ceiling.
This is what happened when West Bromwich brought the claim against their team doctor a number of years ago – not only did they want to sue the surgeon for the fact that the player didn’t get back to playing, but they also wanted to sue for the loss of player transfer value. Fortunately, they lost the case, but it’s not been ruled out that this couldn’t happen in the future.
The nature of sport and sports medicine, whether you are a doctor or a physio, is that things can happen quite quickly. I remember being at the ECB annual conference about four years ago and we had a barrister speaking, who said “if you’ve not written it down, you’ve not done it”. Traditionally, note keeping about what happens during the game and afterwards is poor, and very little is recorded. This barrister looked at all the doctors and physios in the room and said “I’ll destroy you in court; I will be your absolute worst nightmare; and the next day, I’ll walk past you in the street and I won’t even remember you”. It was a chilling reminder!
How then, does this not become an impossible barrier for young SEM practitioners entering the industry?
I think there is ever-increasing awareness, because there are high-profile cases occurring, and people should learn from that. For instance, someone coming from the NHS would have accurate note keeping inculcated into them. The inherent danger is that as time goes on, this gets sloppy.
To be fair, football, rugby and cricket do have good central databases for inputting injury and illness information, and that has been very useful. Obviously if a player then moves to another club, the records are available to the next club that employs them. This has been a dramatic improvement over the last 10-15 years. A lot of organisation and time is still required to do it, but it’s got to be done!
Concussion, dementia, disordered eating – these have all been high-profile concerns over the last couple of years. What do you see as the next time-bomb waiting to happen with athletes?
I think there are still going to be a minority of youngsters in sport who have contracted what they regard as relatively mild Covid, but who may have ongoing symptoms. Obviously, I’m not a respiratory or cardiology physician, but we know that some of the scans of the lungs of young people who’ve had Covid do show significant scarring.
When the difference between appearing in the Olympic 100m final and being beaten in the semi-finals is only 1 or 2 %, you don’t need your lung capacity to be a little bit off. So I do think there is going to be some young athletes who may have performance restrictions because of long-Covid effects.
The other big risk is for the Olympic-based sports that are mostly funded through the lottery and UK Sport. We all know that the economy has got to pay for the pandemic response at some stage. With the recently announced change to the Government spending cycle from year to year instead of four-yearly, you’ve got to wonder if Olympic sports are going to be hit, both in terms of the amount of funding they will get and their ability to plan. If you don’t know how much money is going to be available for coaches, athletes, doctors, physios to take you through the next Olympic cycle, it is going to make you wary about who you employ. So there is a lot of concern.
Bill’s book, Knife in the Fast Lane, has been published by Pitch publishing. It is semi-autobiographical, semi-commentary on the last 40 years of looking after sports people from Olympic champions to weekend warriors. It contains a chapter on the early effects of COVID-19 on elite sport and Bill’s involvement. The book is supporting the charity Prostate Cancer UK.
#SEMPRISinspirations
Knife in the Fast Lane: A Surgeon’s Perspective from the Sharp End of Sport by Professor Bill Ribbans
(ISBN: 1785316885)
About SEMPRIS
SEMPRIS was launched in 2010 in response to requests from doctors for an indemnity scheme that provided comprehensive protection against the unique third-party risks involved in the treatment of professional sportspeople. To our knowledge, these risks are still not covered by any other Medical Defence Organisation or Insurance Scheme.
In addition, SEMPRIS covers all aspects of independent private practice, including all non-sport related practice and professional issues not covered by the NHS.
Members benefit from the expert legal support and representation offered by SEMPRIS Support. In addition to providing legal advice on all issues arising from professional practice, the service is the primary point of contact for discussing or notifying us of a ‘circumstance’ or claim against you.
The service will now provide full and accessible risk management, offering advice, education and updates to members on best practice and mitigating risk within private practice.
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