Heads Up, Part II: Independence

[This is the second part of a three-part series on concussions. See Part I here. The final installment will run later this week.]

One of the absolutely essential areas to consider when assessing and treating athletic concussions is the independence of doctors and medical personnel. Generally, injuries are assessed by team medical staff, which is problematic. As in any industry, there are certainly good and bad team doctors out there, but the unique position of a team physician means any less-than-honest ones can cause a lot of harm. These doctors and trainers are paid by the teams, not by their patients, and teams' interests don't always coincide with their players' best interests. Sometimes, it's in the team's favour for a player to return more quickly than he probably should. The classic example of this is James Woods' brilliant portrayal of Dr. Harvey Mandrake in Any Given Sunday, still one of the best sports movies of all time in my opinion. Here's a clip of his confrontation with head coach Tony D'Amato (Al Pacino) after it's discovered that he was mistreating players on the owners of owner Christina Pagniacci (Cameron Diaz), who promised to reward him financially for doing so. (Warning; some NSFW language)



Of course, this is a Hollywood movie, not a documentary. Still, there's more truth behind this portrayal than many would expect. Much of the movie was based on the book You're Okay, It's Just a Bruise: A Doctor's Sideline Secrets. That book was an expose of the shady side of medical treatment in the NFL, written by Robert Huizenga, who worked as a doctor with the Raiders for eight years.*

*Huizenga later testified in the O.J. Simpson trial and various congressional hearings, including this year's hearing on brain injuries on football, which has kick-started much of the recent progress on concussions. Lately, he's also appeared on The Biggest Loser.

Huizenga's book set off a massive controversy about football injuries and the methods of treatment used, and he also frankly discussed the prevalence of steroids in football. This 1991 interview he did with Sports Illustrated shortly after he left the Raiders* is fascinating, as is this 1994 article about how the Raiders mistreated Curt Marsh, where Huizenga is quoted. Both articles lay much of the blame at the feet of former Raiders' team doctor Robert T. Rosenfeld, upon whom Woods' character was reportedly based. The medical parts of Any Given Sunday may seem unrealistic at first, but there's a surprising amount of evidence backing them up.

That doesn't mean that this sort of thing is necessarily still going on. There's much more scrutiny of injuries and treatment these days, which would make this kind of skullduggery considerably more difficult to get away with. However, there's still a huge conflict of interest when medical personnel are responsible for treating players, but are paid by the organizations that employ those players. This conflict hasn't been solved; in fact, more evidence of it came out recently with the resignation of Dr. Ira Casson and Dr. David Viano, the heads of the NFL's concussion committee.

These doctors, both on the payroll of the league, had denied any link between concussions and pro football for years despite overwhelming scientific evidence to the contrary, and were conducting their own severely flawed study in an attempt to try and disprove the relationship between NFL careers and long-term brain damage. Their resignation is a very positive step, as is the announcement that the NFL will work with Boston University on its concussion study; BU professors have done much of the work in this field and have the academic independence necessary for believability. They've already been very critical of the NFL's policies, so this isn't going to turn into a whitewashing study along the lines of the one the league was conducting.

Another very positive step is that the NFL will soon require teams to consult with independent neurologists on concussions. There are still questions on how exactly this will work, and Mike Freeman points out that these neurologists may not be as independent as many of us would like, but this is still a move in the right direction. Other leagues will hopefully follow suit and move to independent specialists as well.

There are a couple of simple options that could dramatically improve independence, though. The key problem is still that these neurologists will be paid by the team who employs the player they're treating. It's not as bad as in the case of full-time team doctors, as their entire employment income doesn't come from the team, but it's still problematic. Freeman suggests the players' association paying these specialists, but that might be a tough sell to the NFLPA; for one thing, it shifts the costs of medical treatment from owners to players, and for another, not every player will use the services of these specialists. If the NFLPA would go for it, this would be a good solution, but it would be difficult to implement and would have to be negotiated through a collective bargaining agreement.

However, what could be done without significant problems would be to shift the doctors and specialists' employers from individual teams to the league as a whole. There still would be some issues, but the conflict of interest is significantly reduced. For example, consider the recent neck injury to DeMarcus Ware, which I talked about in Part I of this series. I'm not sure if he was evaluated by a specialist or just the regular team doctor, as he reportedly had no concussion symptoms. Under the present system, though, either would have been paid by the Cowboys. The Cowboys had a significant interest in Ware's ability to play Saturday against the Saints, and he wound up being crucial to their victory. That doesn't necessarily mean that the team interfered with these doctors at all, or that their diagnosis of Ware was at all impacted by finances, but in a situation like this, there's at least a potential conflict of interest. Even if an actual conflict of interest didn't develop, it still doesn't look good from the outside.

If the league as a whole was paying these specialists, the potential for a conflict of interest greatly decreases. The Saints have at least as much interest in Ware not playing as the Cowboys do in him playing, and there are 30 other teams that have no real stake in the outcome. Moreover, medical personnel and specialists could be put in their own unique branch of the NFL, separate from the teams (much as referees are); accountable only to the head of the medical division and the commissioner, not individual teams.

There still could be problems if the league encouraged doctors to let players return early across the board, but this is where the media responsibility I discussed in Part I kicks in. Governments sometimes employ people who investigate the government itself, such as ombudsmen, auditor-generals or people in the Justice Department. When those governments attempt to interfere with those positions (for example, the Saturday Night Massacre during the Watergate scandal), it's the role of the Fourth Estate to bring this information to the public. The sports media should act in the same way, as a check on the power of the league. This would also be much easier with league-wide medical departments and policies.

One final crucial part of independence is that it has to work both ways. It's obvious why coaches and owners shouldn't be involved in medical decisions, but it's less obvious why players shouldn't be allowed to decide if they'll play or not. This is just as important, though. The macho, team-focused culture of sports means that players can't make good decisions about if they should play or not; if they do what's best for their long-term health, they get blasted as wimps and bad teammates.

A key example of this comes from Hines Ward's ridiculous attack on Ben Roethlisberger after team doctors decided that Roethlisberger should sit out the Steelers' game against the Baltimore Ravens. Fortunately, in that case, the decision was out of Roethlisberger's hands; if he had the option to play, he probably would have played, which could have had serious conseqences if he was hit again. You can't blame him when his teammates react that way. If he had chosen to sit out, he would have been blasted even more by teammates and the media, and might have acquired a reputation as a bad teammate, which could have damaged his future earning potential. This is why so many players play through serious injuries, and why all injury decisions, not just those around head injuries, need to be made by doctors, not players or coaches.

The environment of professional sports makes it impossible for athletes, coaches or teams to make the right call on their own. It needs to be out of their hands. This is why independence for doctors is so crucial. The NFL's made some promising steps on this front lately; let's hope this continues, and that other leagues follow suit.