White: What's Up, Docs?

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By Jeff White
jwhite@virginia.edu

CHARLOTTESVILLE — It won’t ever be held up as an example of Jeffersonian architecture. Disregard the building’s utilitarian design, though. What’s important is the work done inside by John MacKnight and Danny Mistry.

If you’re a UVa student-athlete and need to see a doctor, you know where to go: the clinic that sits between University Hall and Onesty Hall near the football practice fields.

MacKnight and Mistry are co-medical directors for UVa athletics, and they serve as primary-care physicians for the 700-some young men and women who make up the University’s 25 varsity teams.

As for the nurses who assist the doctors?

“You’re looking at us,” MacKnight said, smiling.

“We do it ourselves,” Mistry said.

Officially, the clinic is open from 8 to 10:30 a.m. and 1 to 5:30 p.m. each weekday when classes are in session at UVa. That’s misleading.

“We’re on call every night and every morning,” Mistry said. “It doesn’t matter. We’re always on call.”

Which is fine with Drs. MacKnight and Mistry.

“We have their cell-phone numbers. They’re so willing to help,” said Lauren Elstein, a fourth-year field hockey player who has exercise-induced asthma.

“Both guys are phenomenal doctors, and they’re incredibly caring. I’m so spoiled. I’m actually wondering what I’m going to do next year.”

MacKnight earned a bachelor’s degree from the University of Delaware in 1988. He graduated cum laude from Jefferson Medical College in 1992 and completed his internal-medicine residency at UVa in 1995.

Mistry has a bachelor’s from the University of Madras (1995) in his native India. He earned a master’s in exercise science from the University of Massachusetts in 1994 and his M.D. from UVa in 2002.

Put them in a room together, and they could double as a comedy act, so easy is their rapport. Their friendship has deep roots. When Mistry was a resident at UVa, his mentor was MacKnight.

“And so to be practicing with your mentor on a daily basis is great,” Mistry said. “I’ve learned more about the logistics of good medicine from him than I’ve learned from anybody else in my career.”

During working hours, Mistry usually can be found in the clinic. MacKnight spends about 75 percent of his time at the Fontaine Research Park, where he has a standard internal medicine practice as part of University Physicians Charlottesville.

“The other time is spent either here or over in the McCue [Center] in orthopedics,” MacKnight said in the clinic, where he and Mistry stuck around one evening to field questions from VirginiaSports.com.

Q. How many people are you responsible for?

Mistry: “We see all 700 student-athletes. Any primary-care issue related to a student-athlete at UVa. This is the daily clinic.

“We don’t direct the athletic trainers. The athletic trainers are directed by Ethan [Saliba]. So he’s the head athletic trainer who’s in charge of all the administrative aspects of sports medicine. John and I just run the primary-care sports medicine clinic. So if our athletic trainers have someone who’s sick, they send them to us.”

Q. What are your backgrounds as athletes?

Mistry: “Cricket, and track and field as well.”

MacKnight: “Nothing at the collegiate level, but I’m a football, basketball, baseball guy.”

Q. When one student-athlete gets sick, does the whole team usually end up sick as well?

Mistry: “Yes, it spreads. More than in the student body.”

MacKnight: “They spend a lot more time together, with a lot of activities that really dictate that they’ve got close proximity, between meetings and practices and certainly traveling on the road and staying in the same hotel together. These guys spend five hours a day together, and social time, too. They have their own kind of social structure, as athletes often do.

“We see an interesting cascade. On Monday you see three kids with a problem. That means on Tuesday you’re gonna see seven more, and on Wednesday you’ll see 10 more. It just blossoms out. And it’s interesting, when you’ve been here awhile and you know the teams that like to hang out together, you know the individual people who like to hang out together, you know the houses where the kids live for multiple sports, you can absolutely see the trickle-down effect. You kind of know what’s coming.”

Q. Your clinic moved here from the McCue Center several years ago. What has this facility allowed you to do?

MacKnight: “It’s been a great thing. What it allows us really to do is to try as best we can to put under one roof all of the important facets to take the best care of our student-athletes. There are a lot of institutions where they have excellent providers, but they’re all over the place. So we’re able to really compartmentalize our care in a place where the student-athletes have easy access to it, and make it a very comfortable environment for them.

“We see them quickly and minimize the roadblocks to getting them the care they need, and that’s big, particularly because it is so time-sensitive and sport-sensitive. If that particular sport’s in season, you don’t have a lot of time to waste, so you relish the opportunity to have it all here together.”

Q. Who ultimately decides when a student-athlete is healthy enough to practice?

MacKnight: “Coaches are coaches, and coaches want their players. But our coaches are great. Particularly because Danny and I have been here for so long now, the coaches have a really good sense of what our algorhithmic approach is to things, and Danny and I have really gone out of our way to have a great sense of consistency. If you have a given problem and you have this set of parameters if things are going wrong, then this is the way we’ll manage this. The coaching staff, and certainly the athletic training staff, has become very comfortable over time with the way that we approach things.

“They always want their kids, but in the end, once you lay out the scenario and say this young man is too ill to participate today for reasons X, Y and Z, then the focus changes from ‘I want them right now’ to ‘Do what you can to make them better as fast as you can, and when they’re ready to go, let me know, and we’ll take it from there.’ Early on there was a learning process there, but now that we’ve become really comfortable with each other, it’s really pretty seamless, actually.”

Q. What’s the procedure if a student-athlete gets sick after your office hours?

MacKnight: “We stop here at 5:30 p.m. The way that we set the system up is that the primary contact person for each of the student-athletes is their respective athletic trainer. So they would contact the athletic trainer, who then would sort of make the determination with respect to what they need to have happen. On occasion the athletic trainer will meet the student-athlete back here. It might be midnight, but they say, ‘Before we send you to the emergency room, let me take a peek at you and see if what you’re telling me really is worrisome.’ And then they’ll give us a call and say, ‘Here’s the scenario. Do you want to see them? Do they need to go to the emergency room? Can I pat them on the back and tell them to go home?’ That kind of thing.

“As Danny said, we’re available basically 24/7, so we really depend heavily on our athletic trainers to be our eyes and ears and our hands to help manage this big population, because we can only be in so many places at once.”

Q: What is the common problem you see?

Mistry: “Colds, flu. It just depends on the season. It’s varied.”

MacKnight: “The patient population we see here is a microcosm of the patient population I see in general internal medicine to a certain degree. It’s illnesses, it’s acute kinds of things, most of which are self-limited and more easily fixed. Then you’ve got your asthmas and your thyroid diseases and your hypertension and those kinds of things, too. Much lower incidents in our [student-athlete] population in general, but you still see those things, and I think the thing that makes it fun to manage those things here is that you’ve always got the looming game, the looming trip to participate in.

“Otherwise the nuts and bolts of taking care of them isn’t all that much different than any other place. But when you [consider the fact that the student-athlete may say], ‘Oh, by the way, I have to get on a plane tomorrow morning and I won’t be home for three more days,’ that changes your approach pretty significantly. That’s part of the challenge. That’s what makes it fun.”

Q. How often are you working against a deadline?

Mistry: “Almost always. But the flip side to that is that by and large, especially at the D-I level, you have a patient population that wants to be better. They’re thinking, ‘How can I get better and get on that field?’ So your challenge is their challenge. It’s kind of a joint challenge, and that’s exciting.”

Q. How many first-year student-athletes do you see in a typical school year?

Mistry: “About 250, because we have a lot of walk-ons. Roughly 250 new student-athletes each year.Typically it’s about 200 in the summer and 50 additional in the fall.”

Q. What does the first-of-the-year physical consist of?

MacKnight: “We have a history questionnaire which has different facets of their medical history. Then they have a screening EKG, and we review that. They have an entire physical exam, a thorough physical exam, and then they have a drug test. Then certain contact sports have a baseline concussion test done. And we clear them only after we’ve reviewed the medical history, noted that they have a clear physical exam and their EKG doesn’t have any criteria that needs further diagnostic work before they can be cleared. It’s all about making sure they’re safe for participation.”

Q. What’s the most enjoyable part of your job?

MacKnight: “Working with that guy” — he points at Mistry — “is always a ball.”

Mistry: “Right back at him.”

MacKnight: “For me it’s two things. It’s the pleasure of working with a very unique and highly motivated group of individuals who are not only working for athletic success but for the most part are very invested in their health and their well-being, and you play a really important part in that process. Particularly in an age group that otherwise isn’t all that too tuned-in to that. You really have a nice opportunity to influence their health status for the future, and we go out of our way to try to make that an important part of what we do.

“I think the other thing is — and we’ve both had this experience any number of times — the carrot for what we do in here every day, or the pot of gold at the end of the rainbow, is to take a student-athlete who isn’t faring well, who’s sick, who has a medical condition that’s holding them back, and to really bust your tail to help them fix it and then have them go out and do something special on an athletic field. So for a team physician, because we obviously live vicariously through our student-athletes, to have somebody who’s kind of down and out, and to turn them around and fix their issue and then have them go out and really excel, that’s the best thing.”

Mistry: “And for me also, and I’m sure John seconds this, are the relationships you form with these kids. You see them coming in as 17- and 18-year-olds, you grow with them for four years, they have different needs each year as they grow. There is no doubt the first-years are more sick than any other year. There is no question about that.”

MacKnight: “That’s before they learn how to take care of themselves.”

Mistry: “But you see them grow, and by the time they come to their fourth year, they’ve learned how to deal with stuff, and the way they can lead their teams, and the lifelong relationships you form, is just such a blessing.”

Q: Do you see every student-athlete at UVa at some point?

Mistry: “Definitely for the physical exam.”

Q. And after that?

MacKnight: “It’s amazing, but there’s some folks along the way that I would have to tell you I’ve never seen. I absolutely know who they are. Some of them are quite noteworthy for their athletic endeavors, and I would tell you I’ve never seen them in the office. I don’t think it’s many over four years.

Mistry: “We see about, say, 80 percent of them through their career here [after the initial exams], and we probably don’t ever see 20 percent of them. But it’s interesting: Out of those 80 percent, there’s only about 30 percent you’d see consistently.”

Q. Given the accessibility of your clinic, are some student-athletes prone to running to the doctor too often?

MacKnight: “We try to temper that with the athletic training staff. Think about how many kids walk down that hall every day. Danny and I laugh about this. We’ll be working on our computers or something, and we’ll hear them walk past the door. We hear the footsteps, and then they get, like, halfway down the hall and they stop. And it’s like they’re thinking, ‘Should I? There’s nobody waiting. I think I’ll go see Dr. Mistry.’ And they come right back. There’s no barrier.

“On the one hand, it’s a great thing, that there are no barriers, and again you don’t want to create roadblocks, and we fashion ourselves as likeable guys. We’re obviously very interested in the well-being of the kids, so they don’t mind coming in here. Some of them are more aggressive consumers than others, so we try to temper that a little.”

Q. What are some of the challenges facing student-athletes?

MacKnight: “There’s so much stress. To understand the stress of the student-athlete, unless you’re a student-athlete, you can’t. And they’ve got so much on their plates, so balancing everything they do, their social lives and their athletic lives and academic lives, they tend to be a little sicker, because high-performance athletics creates poor immune systems. It’s well-established. If you exercise at high intensity for a longer period of time, your immune system is not going to work as well as people who perform moderate intensity exercise on a regular basis. It’s almost counter-intuitive that if you’re exceedingly fit, you tend to be more sick. So what we see is a sicker kid, but they also have the ability to recover quicker, because, A, they’re motivated, so the mind-body thing is, ‘I need to be better fast.’ That really helps. But we’re also kind of aggressive with our care. We don’t wait two days and three days before [acting]. We don’t have time.

“If they’re sick, we don’t wait to say, ‘OK, drink fluids for a couple of days and see if you feel better.’ It’s quick-fire medicine, but it’s aggressive medicine, too, in a safe manner. But we’re not going to put a kid out, in any circumstance, if we feel that they’re not ready to go, no matter what the contest is. We create a fine line between safety and being aggressive.”

Q. So you find your work professionally stimulating?

MacKnight: “For anybody who’s sports-oriented in the medical field, it’s an awfully tough job to beat, it really is.”

Mistry: “Yep. And it just grows by the minute. What we saw 10 years ago together, the kind of illnesses that we see today and the amount of asthma and allergies and attention deficit disorder and acid reflux. As athletes in high school train harder — and their EKGs have changed over time, because they get fitter, and the electrical activity of the heart changes — we end up doing more studies to clear them. So it’s an amazingly quick-evolving field.”

MacKnight: “My sense in the 10 years I’ve been here is that we definitely see kids who are physically different when they get here. Much bigger, they’re much stronger, they clearly are around-the-calendar-training athletes when they get here, so it’s interesting. They’re still only 17 and 18 years old, so the element of physical immaturity is there. So it’s all the more impressive when you see how well-developed they already are, and you appreciate that they’ve still got a lot of developing to do as they really kind of grow into their bodies.

“I think the other thing that we definitely see is there’s sort of a societal difference or cultural difference. Sort of the psyche of our student-athletes now is different than it was back then. The prominent role that athletics plays in their life is magnified relative to some of the kids that we saw when I first started who were a little bit more low-key about it. It’s an interesting evolution, but I think that’s the sports world in general. That’s the ESPN factor and all these things. The notoriety of sports has just boomed, and these club sports are just going crazy these days, and all the kids who are playing [on travel teams], things that really push them physically and developmentally, that’s a natural by-product of all of that.

Q. What are some of the perks?

Mistry: “You know, one thing that’s great about this job is how funny it is. Kids can just make you laugh like you wouldn’t believe. They’re waiting to see you, and the conversations are hilarious. They come in here, and even when they’re sick, they’re crying but they’re funny, and it’s amazing how you grow with them. It’s a hilarious environment to work in. It truly is, and there’s just the uniqueness of different athletes and different sports. You’ve got Olympic sports and you got football and basketball.

“But the beauty is to see the kid perform on game day. And if you look down the list of the 700 athletes, you can go back in time and remember, ‘I took care of this kid for this thing.’ And many times they leave and they call you for the records, and they keep in touch with you and want to know what’s going on, sometimes not for medical care, just random funny text messages.

MacKnight: “One of our football players, on the morning of the Maryland game [in October], was moderately sick with a flu syndrome. I don’t think he had H1N1, but he had a flu syndrome, one of our starters, and I saw him about 11 o’clock in the morning, and he really did not look well.

“We did what we could, and we got his temperature down, and we treated his symptoms, and we hydrated him before the game, and he went out and he did his thing. And I told him, ‘I don’t anticipate that you’re going to make it through the game. So I’ll just keep asking you, and when you tell me you’re out of gas, then we’ll have the coach replace you, and that’ll be that.’ I also told him that if ‘we get to the stadium and your fever is still present and you just don’t feel like you have the gas in the tank, then we’re not going to go.’ But he played the whole game. I kept checking on him, and he just sucked it up and played great. So that’s fun, because he was really dead in the water as of 11 o’clock in the morning, and he went out and played a great game, played an integral part [in the team’s] ‘W.’ And I didn’t do anything for him that anyone else wouldn’t have done, but you’re the guy standing in those shoes at that particular point in time, so when the kids show up and are able to do what they want to do, and particularly when you have a great outcome like that, and they played a nice role in that, you say, ‘Man, that was fun. That’s what it’s all about.’

Mistry: “The reward for what we do with kids is truly unmatched.”