I’m finally catching up on the last of my August interviews today with three interviews featuring outstanding doctors who worked as part of Team USA, the Olympic delegation for the United States at the Games of the 33rd Olympiad in Paris and the 17th Summer Paralympic Games.
Above is my interview with United States Olympic and Paralympic Committee Chief Medical Officer Dr. Jonathan Finnoff. (Just click the play button to get it started. You can find the full transcript of our conversation at the bottom of this page.)
Many of you may recognize Dr. Finnoff from a preview of this interview that I posted a few weeks back here on Inside Medicine; Dr. Finnoff made a little bit of news during this interview by providing statistics on how many athletes became ill after swimming in the River Seine in Paris (it was around 10%, which is far higher than rates reported in recent previous Olympic open water events).
Beyond that, our interview covered some areas that I was excited to delve into, including a focus on how Team USA physicians prepare for both the Olympic and Paralympic Games, the latter of which comes with its own set of unique and sometimes unpredictable challenges. So please check out the video (above) and the transcript (below).
The other two interviews I conducted with Team USA doctors were held on site in Paris during the Olympic Games in early August (the café in a hotel where some of the athletes, coaches, and physicians were staying was nice enough to let me set up shop for those. I hope you enjoy the ambience). You can find those over on MedPage Today…
What It's Like Providing Care for Mental Health at the Olympics. In this interview with Dr. Jessica Bartley, we spoke about how athletes prepare both for competition and the period after, which can be marked by a period known as the Post-Olympic Blues. Here’s the link to my conversation with Dr. Bartley.
How Docs Can Volunteer for the 2028 Olympics in Los Angeles. You won’t find a more enthusiastic supporter of Team USA and the Olympic movement in general than the lead physician for Team USA, Dr. Gloria Beim. (Her Instagram featured some of the best views of the sports you’ll find, and they make a pretty compelling case for volunteering!) In this interview, Dr. Beim provided a lot of insight into both on how medicine is practiced during the Olympic Games, and how doctors can get involved. So for any Olympic-hopeful physicians, there’s good information for how to get started in here. Here’s the link.
Hope you enjoy all of these as much as I enjoyed meeting and speaking with these experts.
Transcript: Q&A with Dr. Jonathan Finnoff
Faust: Hello, Jeremy Faust, Editor-in-Chief of MedPage Today. I'm so excited to be joined today by Dr. Jonathan Finnoff.
Dr. Finnoff is the Chief Medical Officer for the United States Olympic and Paralympic Committee. He's board certified in Physical Medicine and Rehabilitation and in Sports Medicine. Paris is his 10th Olympic and Paralympic games.
Dr. Finnoff, thank you so much for joining us here.
Finnoff: It's my pleasure. Thanks for inviting me.
Faust: So right now you're between the major events. In Paris the Olympic Games have concluded, and you're gearing up for the Paralympic Games, also in Paris. You're back in the States and you're going back to Paris, is that right?
Finnoff: That's exactly right. Yep.
Faust: Talk to us about the transition, because these are two very different events with different medical challenges.
Finnoff: Yeah. It's interesting because for most countries, their National Olympic Committee and their National Paralympic Committee are two separate organizations. So they have one team that's there for the Olympics, and then when they leave, they have a completely different team come in with different personnel, different management, the whole thing. So it's not just the athletes, it's everybody.
In the U.S., we are the U.S. Olympic and Paralympic Committee. And so it's the same management team overall, the same organization that is running both games. Thankfully because of the size of our delegations, we actually keep the same place in the Village. So we were able to just clean up our clinic, lock it, and we go back in and unlock it and move right into the same space, and we use all the same equipment and same supplies.
We have different personnel coming in, still the same leadership, but this is a huge time commitment for people to go back and forth between the U.S. and Paris. So we do have different volunteers coming over for the Paralympic Games versus the Olympic Games.
Faust: And I imagine that the diversity of athletes in the Paralympic Games means that every games would be slightly different, as opposed to maybe the Olympic Games [where] we know that soccer players turn their ankles. But I imagine in the Paralympic Games there are really different challenges.
Finnoff: There are. In general, a lot of the Paralympians have multiple comorbidities, and those comorbidities result in a lot more medical complexity.
So, for instance, if you have a spinal cord injury and you have insensate skin, then decubitus ulceration is a far more frequent occurrence, of course, than in your Olympic athletes. And on top of that, that person might also have intermittent catheterization, so therefore they're more susceptible to a urinary tract infection. Because of recurrent urinary tract infections, they might have some underlying renal disease.
They have osteoporosis because of lack of weight-bearing movement. So when they crash, they break a lot more things and they can't feel it. If their spinal cord injury is above the T6 level, they can have autonomic dysreflexia, where your blood pressure and stuff goes a little bit crazy and it can cause somebody to have a stroke or to die.
You have all of these things in somebody who, if you're a triathlete, normally you might crash on your bike, but with these other comorbidities, you have a crash on your bike and you've got all these underlying problems, so it becomes much more complicated.
Faust: At the games, I certainly noticed that there were varying approaches to risk management around COVID. And I imagine that the Paralympic athletes may have a different approach, or there are various approaches across the board with different athletes.
Do you sense a difference in terms of the questions the athletes are asking? Whether they want certain protocols, or just things like whether they're masking up into their events?
Some of this may not really even be medical as opposed to just strategic. I mean, there were athletes who, quite frankly, you could argue lost a medal because they didn't get themselves to their starting event without COVID.
Finnoff: Yeah, absolutely. We have pretty consistent protocols for our infectious disease. We follow the CDC guidelines.
So if somebody has a respiratory illness, then we have a certain period that we don't have them staying in the same room as another athlete because we don't want the other athlete to get sick. We'll transport them separately, we'll have them wear masks when they're indoors around people. So we follow CDC guidelines on that and GI illness and stuff.
But we do encourage athletes to be up-to-date on vaccinations, use hand sanitizer, wear face masks when they're doing travel with lots of people, just to minimize their risk of getting an infectious disease because absolutely that will affect their performance. And different athletes take that to heart to different levels.
Faust: Can you tell me a little bit about moving from the Olympic Games to Paralympic Games? I did discuss with some of the experts on your team about the sort of psychological stressors and the mental health strain of this moment. You know, you're training your whole life or for many years to get to this place.
I'm wondering about in the Paralympic Games whether it's just the exact same thing or whether there's something different about it, because I really don't know. I can imagine both answers, right? It's the same thing, or there is a different kind of vibe or different needs. What's your assessment of the difference between events for the athletes in terms of the psychological piece?
Finnoff: Are you talking about the psychological piece during the games or more the transition after?
Faust: Oh, both. I was specifically thinking about the games themselves, but I'm also very interested in the sort of post-Olympic blues as well.
Finnoff: Number one, psychological services -- which is a combination of clinical mental health provision as well as mental performance, which is sports psychology -- we provide those services. I would say that we're a world leader within that infrastructure for our athletes, both on the Olympic and the Paralympic side. It's something that we take very, very seriously.
The first sign that we really had that full spectrum was at the Tokyo Games. We had just over 200 interactions with our psychological services personnel during the Tokyo Games, which I would say was an incredibly stressful environment. The delay for a year, all of the things surrounding going to the games and what you could do and couldn't do at the games and so on.
We had over 800 at this games, and this was a wonderful games with minimal restrictions and so on. But what that shows to me, Jeremy, is that we have this service that people believe in and they feel is appropriate, and there's less stigmatization or negative stigma associated with it. It's probably related to some high-profile athletes coming out and talking about their experiences and how positive working with psychological services providers has been for them. And so we see a lot of athletes using our psychological services providers during the games.
We work a lot in the lead-up to the games because [for] a lot of people, their dreams kind of end when they don't make the team. So we want to make sure that we're there at the Olympic and Paralympic trials to help those who did not succeed. And maybe they're going for it in four more years, but maybe this was their shot.
We work with them through their successes and failures during the games, and then also after the games in that transition. The post-games blues is a very real thing. And it's not just for athletes that are transitioning out of sport, it's also for athletes that have gone through and had this big experience and then it's done and what is the next big thing, whether it's in their career, whether it's outside of sport. It happens.
So we have peer support groups, we have one-on-one psychological services, we do all sorts of different things to help athletes with their different psychological stressors.
Faust: Yeah. And I think it really has been great that some prominent Olympians have been so forthcoming to make it so that whether you're Michael Phelps or whether you're Simone Biles or whether you're someone who we haven't heard of because they're not on the medal stand all the time, it's okay to address these issues and not hide from them. I think that's been really important.
Finnoff: Yeah.
Faust: Any insight on the events that were held and in the Seine River, and I don't know whether or not there are plans to have events in the Paralympic Games in the Seine. I thought the idea of doing it was kind of beautiful and amazing, but I think the execution was touch and go.
So I'm curious about both your reaction to how it went in the Olympic Games and if you can inform me as to whether there are plans for the Paralympic Games.
Finnoff: Yeah, so there is going to be an event in the Seine in the Paralympic Games, the triathlon. In the Olympic Games it was triathlon and open water swimming.
They do have historical data from the IOC standpoint on how many people have gotten sick, specifically [from] gastroenteritis, after various open water types of events. It's hard to compare apples to apples because both in Rio and in Tokyo they were in saltwater, which is very different than freshwater in a river in a city, but the preliminary results from the IOCs injury and illness surveillance data is that they have about a 10% infection rate in those who swam in the Seine, versus in the past it's been between a 1% and 3%.
So it's definitely higher, substantially higher, but it's still not that high. One in 10 athletes got gastroenteritis. Some were more serious, others were not. Thankfully within Team USA, it was less than that.
Faust: So 10% had some kind of a GI illness. Were those because of the nature of the bacteria or other pathogens that might be there? Were those routinely treated with antibiotics? Versus if I as an ER doctor see a mild gastroenteritis in my Boston ER, I'm not giving antibiotics unless there's some really high-risk exposure.
Finnoff: Yeah, it was variable. One of the nice things is that you can do rapid PCR tests and get an idea of what pathogen it is and then decide whether this is something that requires antibiotics or not. Also the severity of their symptoms and whether they have another competition or not comes into play.
So within Team USA, we did use antibiotics on the individuals that did have gastroenteritis-type of symptoms related to the Seine. But on some teams, they did sometimes and did not on others based on the pathogen.
The other thing is that there was variability between teams in terms of pre-treatment, to try to prophylactically prevent infections from happening. But as you know, if there are a lot of different pathogens, which antibiotic you use, is it going to be broad-spectrum enough to eliminate the risk of all of these -- which it won't. You also have your own risks associated with antibiotic use, which can cause photosensitivity, gastrointestinal discomfort and distress just from changing your flora. So there's all sorts of different things.
We did not, based on infectious disease doctor's recommendations, we did not prophylax and we had really minimal problems with gastroenteritis.
Faust: Alright. That's a really interesting story, and a unique challenge to the games. I would love to delve into what the go-to were, but it sounds like you were driven by PCR, so you pretty much knew what you were treating there. That's pretty interesting; thanks for sharing that.
I want to move on to a discussion about injuries before competition. I asked some of your colleagues in Paris how you make these decisions as to whether someone is well enough with an injury to play or recovered enough from say COVID to compete.
I would just imagine that in the case of the Paralympic games, it might be a little more up to the athlete because they might have a better read on their own unique situation. Is that a fair assessment?
Finnoff: That's an interesting question. I would say that we always have shared decision-making.
The time that shared decision-making kind of goes out the window is if the person is impaired, so say they have a head injury, then they're not able to make that decision for themselves. That's why concussions are a little bit different than most other medical conditions.
But shared decision-making is a really big important part of sports medicine where you talk about this is the risk associated with your injury. These are the recommended treatments, these are the risks; if you proceed with competition, can you participate at the level that you need to? Would it be better for you and also for the team to have a late athlete replacement moving into that position?
So there are a whole bunch of different things that go into that decision, but certainly if it puts their health significantly at risk or those around them, then the decision would be made for them not to participate.
Faust: Yeah, and I was really interested in the Noah Lyles case, because a lot of people commented that they felt that him competing put others at risk. And as someone who studied COVID a lot, I don't think that he put anyone at risk in the event. I mean, this is an open-air stadium. It's very, very difficult to spread the pathogen in that situation. But the place where you might spread it was waiting in the ready room or in the sort of infrastructure leading up to that.
How cognizant and mindful were you and your staff about those issues?
Finnoff: Very. So again, we follow CDC guidelines. And the CDC explicitly states that people should isolate when they have a fever and they have escalating symptoms. When their symptoms have improved for 24 hours and they no longer have a fever [while] off of fever-lowering medications, they no longer need to be in isolation, but they should wear a mask when they're inside around other people.
We follow those guidelines and that's what Noah followed.
Faust: Alright. The criticism there is people test positive for a lot longer than that CDC guidance, notwithstanding,
Finnoff: Correct. Yeah. So we follow CDC guidelines, and the CDC guidelines are not based on when you test positive. CDC guidelines are based on when you're symptomatic and when your symptoms are improving and your fever has resolved.
Faust: Alright. Well, I'm glad that you're paying attention to it. I think that, obviously it wasn't like Tokyo where everybody was getting tested every minute, so you had a different set of challenges.
I could not help but notice a very viral story out of Paris about a U.S. athlete who basically implied that there was better healthcare in the Olympic Village than there is at home. Going around and getting like a free pap smear and all kinds of things.
What was your reaction to that, and how are we preparing for hosting the games in 2028?
Finnoff: So, a few different things.
I would say that if you're looking at the average person walking the street here in the U.S., the access to free healthcare at the Olympic Village is beyond anything that anybody in the world is going to normally have. Everything you have access to and it's all free.
However, I think that that athlete -- I would love to have a chat with them, because there's probably resources that they have that they're unaware of. We provide elite athlete health insurance to our top about 1500 athletes, and it's a Cadillac program that's better than what you could get through a workplace, because the athletes are not our employees and so we don't have to follow the same federal guidelines and we're self-insured. We give them better insurance than you can get any other time.
We have medical network partners where we will fly the athletes to those medical network partners and they get free healthcare. We put them up for free. Anybody who is EAHI eligible, so that elite athlete health insurance, also has access to the medical network. All of those athletes have access to the sports medicine clinics at the training centers. All the national governing bodies have medical teams working with them, so the medical infrastructure around our elite athletes is actually pretty amazing.
But some of our athletes still don't understand all the resources that they have. And so that's something that we are working on is, how do we do a better job onboarding people, educating them on their resources, and making it so there are no barriers to them accessing those resources?
We also have a medical assistance fund and a mental health assistance fund where any out-of-pocket expenses get reimbursed. So it's really pretty impressive.
Faust: Alright, thanks for addressing that.
Now as we go to 2028, we will be hosting the Olympic Summer Games in Los Angeles. I imagine that every Olympic Games, something happens where you learn something and say, "Oh, I have to make a note for that for next time." What's something that you learned so far in the Paris experience that you'll say, "Here's something that we'll do a little differently, a little better when we host in LA?"
Finnoff: Two things. Number one, the USOPC does not run the LA Games. That's the LA 28 Organizing Committee. And so I will not even really be involved other than maybe just giving them my opinion. They will have their own medical team welcoming the world, the 206 nations, to LA and providing healthcare to all of them. I'll be the chief medical officer for Team USA going there.
So for Team USA specifically, there are actually a number of different things that we learned, some of it being from an infectious disease standpoint, some of the complexities and logistical challenges that we have to try to keep our teams healthy, and what we need to have in place -- so extending some of the resources that we had. We had a baseline, but I would like to have more resources to be able to support those athletes in need.
I think that we'll change some of the ratios of our staffing. We bring orthopedic surgeons, sports medicine physicians, physical therapists, athletic trainers, chiropractors, massage therapists, and psychological services providers along with our exercise physiologist, strength and conditioning, and sports nutritionists. And I feel like all of those are important, but we keep really good data on how much each of those different resources is being used. We're looking at that and looking at the ratio of our staffing versus the utilization of those different things, so we're going to make some adjustments based on that.
And then strictly an interesting logistical one for myself and Amber Donaldson, who is the medical director for the Games and I serve as the Chief medical officer, we had a time in our overlap with the games where both of us were not there for a very short period of time. Always one of us has to be at the Games whenever there's an athlete there. And so that's something that we're going to make sure does not happen in the future.
So it's a big, huge time commitment, but we're there and we love what we do.
Faust: I told all of your colleagues, if you need any ER doctors, I know a few and we're ready to serve, but I know there's a process for that. People have been asking and we'll refer them to the different opportunities to get involved. Do you want to talk about that at all?
Finnoff: Yeah. So from a volunteer standpoint, the best way of considering getting involved in the Games -- with Games on home soil at LA, since they're welcoming the 206 nations there, they have to have a huge medical infrastructure in place. They have to staff all the venues, they have to staff the polyclinic, they have to have crews for ambulances and stuff. And it's way beyond what the normal capacity is in LA. They're going to need thousands of medical volunteers.
That's probably the easiest way to go to the Games is to volunteer through LA 28, so I'd check on their website.
If you want to come with through the USOPC, then we want to have physicians who are board certified in their base specialty and in sports medicine, minimum of three years of experience in elite sports, having gone through the volunteer process at the U.S. Olympic and Paralympic training centers and done really well and gotten great ratings, and then gone to some minor games. So the Youth Pan Am games, the Pan Am games, the beach games, and then if they're doing great through all of that, then we invite them to the Olympic Games and Paralympic games.
Faust: Alright. So it sounds like my best chance to make it is as an athlete, and those odds are zero. I think I'm in trouble.
Alright Dr. Finnoff, thank you so much for joining us today and for all your work in this really interesting and excellent cause.
Finnoff: It's my pleasure, Jeremy. Thanks for your time.
Q&A with three Team USA Olympic doctors.