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Athletes' View of the Preparticipation Physical Examination
Attitudes Toward Certain Health Screening Questions
Peter J. Carek, MD, MS;
Michelle Futrell, MA, ATC
Arch Fam Med. 1999;8:307-312.
ABSTRACT
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Objectives To determine the value student-athletes place on the preparticipation physical examination (PPE) in ensuring safe participation and to determine whether these athletes would accept a station-based PPE that emphasizes health-related issues.
Design Survey.
Setting Athletic departments of 2 small southeastern colleges.
Participants Population of student-athletes enrolled in these colleges.
Main Outcome Measures Athletes' views on the necessity of the PPE to ensure safe participation in athletics, willingness to pay a fee for the currently free examination, appropriateness of the PPE as a setting for counseling by physicians regarding age-specific health screening issues, and PPE as the only routine health maintenance contact with a physician during the year.
Results A majority of athletes (66%) believed they could safely participate in athletics and avoid severe injuries or death and minor injuries without undergoing a PPE. Most athletes believed the PPE prevents or helps to prevent both major (89%) and minor (76%) injuries. Male and female respondents would not be uncomfortable with a physician or other health care provider asking questions regarding health-related issues. However, many athletes (especially women) believed that the PPE is not a place for specific questions (questions related to sexual activity and health, eating disorders, smoking, and personal and family use of alcohol).
Conclusions Most student-athletes do not see a value of the PPE in regard to safe athletic participation; most athletes believe that the PPE prevents or helps to prevent injuries when there is no clear evidence to support this assumption; and athletes are receptive to most preventive health screening, but do not feel comfortable with certain issues being raised (ie, gynecologic health, eating disorders, and alcohol and nicotine use). With specific modifications aimed toward the needs and comfort level of the student-athlete, the PPE may provide an opportunity to present health-related education and counseling by means of unique and innovative materials to a group of adolescents and young adults.
INTRODUCTION
THE PREPARTICIPATION physical examination (PPE) has become the standard of care for athletes of all ages as they prepare for athletic participation. These assessments are intended to identify medical and orthopedic conditions that may affect safe and effective athletic participation.1-4
While the effectiveness of the PPE in detecting physical abnormalities serious enough to limit athletic participation has been demonstrated,5-10 the PPE may not predict or help prevent many athletic injuries.11 The medical value of these examinations has little outcomes-based evidential support. In addition, the PPE has been found to have an unfavorable cost-benefit ratio even if costs are carefully controlled.9 Finally, the ability of the PPE to meet specific legal and insurance requirements is often variable and inconsistent.
Determining general health, counseling of health-related issues, and assessing fitness level for specific sports are stated as the secondary objectives of the PPE. Although many authors have included the assessment of general health and fitness in their recommendations for the PPE, few have specifically delineated a portion of the examination "flow chart" in which to discuss and counsel athletes in health-related issues.1, 5, 10, 12-14
The medical history contributes significantly to any participation decision. A complete history will identify approximately 75% of problems that affect athletes.5, 9 The Preparticipation Physical Evaluation Task Force has developed a history form that emphasizes the areas of greatest concern for sports participation. Several questions important to general health maintenance in the adolescent population are also included. A detailed sex-specific questionnaire covering topics relating to current health issues affecting the adolescent and young adult population might be included as a method of uncovering areas of additional concern. This format has been found to greatly increase the implementation of preventive counseling or care by the physician in non-PPE settings.15
Recently, several authors suggested that the objective of identifying possible health-related issues and risk factors be considered just as important as identifying physical limitations.16-17 The PPE serves as one of the potentially few times when many of these risk factors might be uncovered and addressed, especially in the collegiate student-athlete who is at high risk for many unhealthy behaviors.18 Joffe et al19 showed that the adolescent population is willing to be educated, as 70% of males and 78% of females reported that they wanted their physicians to present them with information on various health topics. Although the PPE is not intended to substitute for an athlete's regular health maintenance examination, previous data demonstrate that more than 78% of athletes use the PPE as their only health maintenance contact with a physician or other health care provider during the year.5, 9 Krowchuk et al20 previously recommended expanding the scope of the large-group, multiple-station format PPE after determining that many parents planned to use the PPE as their student-athlete's only scheduled contact with a health care provider.
Finally, the athlete's perspective of the PPE has not been extensively examined. In a study by Laure,21 36% of the athletes reported having had poor-quality preparticipation sports visits. According to these athletes, medical history taking was "poor," and physical examination "restricted to blood pressure measurement" and/or "chest listening" and "not targeted enough to past athletic injuries." This study did not address the athletes' knowledge and understanding concerning the effectiveness of the PPE in preventing injuries. Though not well studied, this type of information is necessary to ensure that the athlete participates in the station-based PPE on the basis of an informed and educated decision and that the PPE fulfills the needs and desires of the athlete.
Therefore, the purposes of this study were to determine the value college student-athletes place on the PPE in ensuring safe participation during athletics and preventing injuries and to determine whether college student-athletes would accept a station-based PPE that emphasizes health-related issues of the adolescent and young adult population.
SUBJECTS AND METHODS
The team physicians and members of the athletic training staff of the College of Charleston and Charleston Southern University, Charleston, SC, annually conduct a station-based PPE for college student-athletes aged 18 through 25 years participating in athletic programs sponsored by their respective schools. These students served as the subjects for this study. These PPEs are mandatory for any student planning to participate in intercollegiate athletic activity. Therefore, subjects in our study represent the population of student-athletes enrolled in these schools.
These examinations are held in scheduled sessions during a 2-week period on the campuses of the College of Charleston and Charleston Southern University, and the student-athletes are assigned to a particular session. As part of the routine examination process, standardized PPE forms are distributed to individual athletes before their examination session. The student-athlete is expected to complete the historical information section before reporting for the PPE session. After registration, the athletes are examined by means of a station-based PPE format. Individual stations performed the following tasks: review of historical information and clarification of positive responses; measurement of height, weight, and blood pressure; and examination of the head and neck, heart, lungs, abdomen, and musculoskeletal system. Clearance for participation is determined on site by the team physicians after the completed historical and physical examination information is reviewed. Any follow-up care is arranged as needed.
The study questionnaire was designed for this project. The questionnaire was modeled after previously used surveys and reviewed by several primary care and sports medicine physicians for appropriateness. The questionnaire was also reviewed by several college-aged individuals for readability and understanding. Test-retest reliability was not measured. A letter was attached in front of the questionnaire packet explaining the purpose of the study and inviting the student-athlete to participate. In addition, the test advised the potential subjects that their participation in the study was voluntary, that all responses would remain confidential, and that they should not identify themselves by name on the questionnaire. The study questionnaire was distributed as the athletes reported to their assigned PPE sessions. Completed questionnaires were returned and the athletes were allowed to proceed with the PPE. Athletes not wishing to participate in the study were asked to return the incomplete form and were then allowed to proceed with the PPE.
The initial portion of the questionnaire gathered basic demographic information, including the subject's age, sex, and race. The body of the questionnaire was developed to determine the student-athlete's views on the following issues: necessity of the PPE to ensure safe participation in athletics, willingness to pay a fee for the currently free examination, appropriateness of PPE as setting for asking or counseling by physicians regarding age-specific health screening issues, and PPE as the only routine health maintenance contact with a physician during the year. The age-specific health screening questions were derived from those outlined as recommended for physician intervention during periodic health examinations specific to the adolescent and young adult population by the US Preventive Services Task Force. These questions were divided by sex, and the student-athlete was asked to respond only to questions pertaining to his or her sex. The study protocol was approved by the institutional review board of the Medical University of South Carolina.
Descriptive statistics were used to characterize and summarize the data obtained. The information was then analyzed by the Epi Info statistical program (Centers for Disease Control and Prevention, Atlanta, Ga) and examined for significant differences between subjects based on sex and race. Analysis was completed with a  2 test for noncontinuous variables and a t test for continuous variables. Significance was defined as P<.05.
RESULTS
A total of 716 college-aged student-athletes attended the station-based PPE during their respective schools' scheduled sessions (307 women and 409 men). Five hundred sixty-three completed questionnaires (79%) were returned and used for analysis.
The mean (±SD) age of the respondents was 19.5±1.56 years (range, 17-33 years). Forty-three percent were female and 57% were male. Seventy-eight percent were white and 22% considered themselves nonwhite. Seventy-one percent of the athletes attended the College of Charleston.
A majority of athletes (66%) believed that they could safely participate in athletics and avoid severe injuries or death and minor injuries such as sprains and strains without undergoing a PPE (Table 1). A significantly lower number of nonwhite participants believed that they could safely participate in athletics without undergoing a PPE when compared with whites (70% vs 53%; 2=92.85; P<.01). Contrary to evidence about the PPE, most athletes believed that the examination prevents or helps to prevent both major and minor injuries. No significant difference was noted between sexes in their responses to these questions.
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Table 1. Proportions of Student-Athletes Responding Positively to Questions Regarding the Need to Participate in and the Benefit of a PPE*
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Overwhelmingly, the participating athletes were not willing to pay for the PPE (79% vs 21%). Of athletes willing to pay, the average amount (±SD) was $19.16±$19.78. No significant differences in this amount existed between male and female respondents. Among athletes willing to pay for a PPE, the nonwhite participants would pay an average (±SD) of $29.16±$34.16, while white participates would pay an average (±SD) of $17.00±$14.52. The difference in these 2 means was significant (P<.01).
In addition, male and female respondents would not be uncomfortable with a physician or other health care provider asking questions regarding health-related issues of the adolescent and young adult (Table 2 and Table 3). Although a majority of participants believed that most of these health screening questions were appropriate, many athletes (especially women) believed that the PPE is not a place for specific questions (Table 4). These questions related to sexual activity and health, eating disorders, smoking, and personal and family use of alcohol.
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Table 2. Responses of Female Student-Athletes to Whether They Would Be Uncomfortable With a Health Care Provider Asking Specific Questions During a PPE*
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Table 3. Responses of Male Student-Athletes to Whether They Would Be Uncomfortable With a Health Care Provider Asking Specific Questions During a PPE*
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Table 4. Health-Related Questions With Which Women Would Feel Significantly (P<.01) More Uncomfortable Than Men if Asked During a PPE*
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Interestingly, only about one third (191 [34%]) of the participants stated that the PPE would be the only contact they would have with a physician on a routine nonemergency basis during the year. No significant differences were noted between sexes (men, 117 [37%]; women, 74 [30%]) or races (white, 149 [34%]; nonwhite, 42 [33%]).
COMMENT
The major findings of this study included the following: (1) Most student-athletes did not see a value of the PPE in regard to safe athletic participation and would be unwilling to pay for it. (2) Most student-athletes believe that the PPE prevents or helps to prevent injuries when there is no clear evidence to support this assumption. (3) Student-athletes were receptive to most preventive health screening but did not feel comfortable with certain issues being raised (ie, gynecologic health, eating disorders, and alcohol and nicotine use).
Our finding that a majority of college-aged student-athletes (66%) believed that they could participate safely in athletics and avoid serious injuries or death and minor injuries, such as sprains and strains, without undergoing a PPE is consistent with previous studies that found a low disqualification rate during the PPE and suggests these athletes find little overall value in this examination. This finding may also be consistent with the individual athletes' previous experiences. As the participants in this study were college-aged, most of them had participated in some form of PPE and had qualified for sports participation without incident. As would be anticipated, a majority of them subsequently participated in athletics without sustaining a major injury.
Interestingly, most of these same athletes believed that the PPE prevents or helps to prevent both major and minor injuries (89% and 76%, respectively), a belief that is not always supported by available literature. Again, this finding may be based on the individual athlete's experience of successfully completing a PPE and subsequently participating in athletics without sustaining a major injury. In addition, this finding may represent a misunderstanding and lack of knowledge concerning the scope and known benefits of a PPE. These data suggest that athletes inappropriately assume the value of the PPE in helping to prevent injuries. Furthermore, the relative value the student-athlete places on the PPE in preventing injuries as compared with other factors (ie, conditioning, flexibility, environmental conditions, coaching, rules, etc) was not addressed in the present study.
Although most of our participants appeared to value the PPE for injury prevention, this belief was not translated into monetary value, as nearly 80% of the participants were not willing to pay for a PPE. Furthermore, individuals who assigned a monetary value for this service were willing to pay only a modest fee. In the schools surveyed, a mandatory PPE is available at no charge to the athlete, which may have affected the response to this question. In addition, many students may not have experience with actual health care costs and may believe the cost of an office visit with a physician is within the range of their responses. Although the response to this question may be difficult to interpret because of the above-noted issues, these students should be placing a monetary value of the PPE based on their individual experiences with purchasing other goods and services.
The data obtained suggest that the value, in terms of both need for a PPE before safe participation in athletics and willingness to pay for this examination, was significantly greater for nonwhite participants. This finding is difficult to explain and may reflect both personal experience and cultural biases.
Finally, a majority of these athletes believe that most health screening questions could be appropriately asked during the station-based PPE. However, many athletes believe the station-based PPE is not a place for some questions relating to sexual and gynecologic health, eating disorders, and alcohol and nicotine use. The concerns regarding the inappropriateness of these questions may be related to a lack of interpersonal relationship between the athlete and the particular health care provider, surroundings less than ideal for conveyance of confidential information, activities in opposition to college and societal rules and regulations, the student-athlete's experience of not having these questions asked during previous PPEs, and the desire to discuss or not discuss these specific issues with others. These issue may have affected the responses of the female participants in this study to a greater degree than the males, as suggested by the differences noted in Table 2. Despite these concerns, we believe these data support that most college-aged student-athletes would accept a station-based PPE that emphasizes health-related issues of the adolescent and young adult population. To implement such a PPE, the concerns of the female student-athlete in regard to specific questions being asked need to be addressed. Further study should address these concerns.
We found that nearly two thirds of our athletes (66%) anticipated having another nonemergent contact with a physician during the year. This percentage contrasts with previous reports that a majority of athletes use the PPE as their annual contact with a physician. This difference may have resulted from the manner in which the question was phrased. This figure is supported in one of the colleges, in which the student health service reported an average of 2 visits per student during the previous academic year (in this particular health service, unlimited visits are covered by an annual student activities fee, which is included in their tuition package). Although the present study did not address whether the participants seek medical care for routine health screening, the additional encounter affords physicians and other health care providers the opportunity to provide such screening in addition to counseling on health-related topics.
Certain limitations of this study deserve mention. First, the subjects in our group were from small colleges (public and private), and the sex and racial distribution in this sample might not be representative of all student-athletes. In addition, several of the contact sports (ie, football and wrestling) are not part of the athletic program at 1 or both of the participating colleges. As a result, the generalizability of our findings to other groups of athletes is limited. Second, although the questionnaire was distributed to entire populations of athletes participating in the PPE, the results may be biased, as we were not able to obtain a 100% response rate; however, the response rate obtained (79%) was excellent for a voluntary survey. The effect of nonrespondents on the results would have been variable and probably would not have altered our findings. Finally, although the questionnaire was reviewed for content appropriateness, understanding, and readability, test-retest reliability was not assessed. In addition, the questionnaire could have been further tested.
Despite these limitations, our findings demonstrated that college student-athletes, while stating that they believe that they can safely participate in athletics without undergoing a PPE, believe that the PPE prevents or helps to prevent major and minor injuries. With these findings, we recommend that the scope and limitations of the PPE be presented and explained to the participating athletes to have informed participation in this medical supervised activity.
Furthermore, our findings demonstrated that college student-athletes would accept a station-based PPE that emphasizes most of the health-related issues important in the adolescent and young adult population. This acceptance has not been previously demonstrated. The examination format should be modified to allow for confidential and personal issues to be presented, reviewed, and discussed. The PPE is an excellent opportunity to provide some health-related education and counseling with the use of unique and innovative materials to a group of adolescents and young adults. The specific format in which these services may be provided requires further study.
AUTHOR INFORMATION
Accepted for publication May 26, 1998.
Reprints: Peter J. Carek, MD, MS, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun St, PO Box 250192, Charleston, SC 29425.
| Editor's Note: Perhaps a first screening question should always be, "Will you see a physician for general or preventive care this year other than this sports medicine examination today?" Then, preventive items should be addressed for those who answer no.—Marjorie A. Bowman, MD, MPA
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From the Department of Family Medicine, Medical University of South Carolina, Charleston.
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