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Survey: Collegiate Athletic Trainers Face Conflicts on Medical Decisions

Nearly half of major-college football athletic trainers and medical professionals say they've been pressured to clear concussed players before they were medically ready to return, according to a new survey conducted by The Chronicle of Higher Education.

The findings, released less than a week after the National Football League reached a settlement over concussion-related lawsuits filed by thousands of former players, highlight one of the major questions about youth-sports concussions: Are all of the adults in charge of youth-athletes always acting with the students' best interests in mind? Or, to put it another way, do some coaches place more of a premium on winning than on student-athlete safety?

Based on the Chronicle's findings, the answer appears to be mixed.

Of the 101 head athletic trainers, head football trainers, and other sports-medicine professionals from top National Collegiate Athletic Association's football teams who responded to the survey, 53 said they had "felt pressure from football coaches to return a student to play faster than they thought was in his best interest medically." Forty-two said they had "felt pressure from football coaches to return an athlete to the field even after he suffered a concussion."

It's not an exaggeration to say the latter could prove to be a fatal mistake. Numerous student-athletes, including Jake Snakenberg, the namesake of Colorado's youth-concussion law, have died from second-impact syndrome, which occurs when someone sustains a second concussion before fully healing from the first one.

Of course, coaches aren't the only ones in need of enlightenment when it comes to second-impact syndrome. Earlier this year, a Cincinnati Children's Hospital Medical Center survey of 120 high school football players found that nearly 91 percent felt it was OK to stay in the game after suffering a concussion. That same percentage said they knew that continuing to play despite concussion symptoms could result in serious injury or even death, but that cognitive dissonance apparently wouldn't dissuade them from wanting to stay in the game.

Conflicts of Interest Highlighted

So, with the possibility of second-impact syndrome looming, why would an athletic trainer disobey his or her own medical expertise to send a student-athlete back into a game prematurely at a coach's behest? According to the Chronicle survey, in at least 11 big-time college football programs, athletic trainers report directly to the football coach.

That potential conflict of interest has caused more than a dozen Division I athletic trainers to either lose their jobs or get demoted over recent years, according to the Chronicle.

"It was scary," one trainer, who left a prominent California university over a return-to-play conflict with a coach, told the paper. "It was uncomfortably close to infringing on the medical well-being of the athlete."

In a consensus statement on best practices for sports medicine management released last month, the National Athletic Trainers Association recommended that defining "supervisory relationships for each area of responsibility so that potential role conflicts are minimized and medical care is not sacrificed." (My colleague Gina Cairney wrote more on the guidelines here.)

"All involved should realize that quality medical care must supersede other responsibilities in times of conflict," the association said.

It's more common for athletic trainers to be employed by schools themselves instead of athletic programs at the high school level, according to NATA, which helps reduce potential conflicts of interest. It's unclear, however, exactly what percentage of high school athletic trainers are employed by schools compared to athletic departments.

A video from the Chronicle (below) highlights the dangers of presenting athletic trainers with such conflicts of interest:


According to Bylaw Blog author John Infante, who served as a former compliance officer at NCAA Division 1 schools, the NCAA could help mitigate these conflicts of interest. In a Sept. 3 blog post, he recommended a proposal which would do the following:

  • require institutions to designate both a team physician and full-time athletic trainer for each of their teams to oversee medical care;
  • require members to give final and unchallengeable authority to the sports medicine staff on all decisions involving student-athlete medical care; and
  • prohibit the sports-medicine department or staff from being overseen by a coaching staff member or a noncoaching staff member with sport-specific responsibilities (i.e. a director or operations).

Whether a similar proposal could ever become ratified at the high school level, it's clear that schools must do everything in their power to eliminate any potential conflicts of interest for medical professionals. No one wins when someone has to choose between saving their job or doing what's best, medically speaking, for a student-athlete.

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