Originally posted on the BJSM Blog
John Orchard’s recent blog ‘On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinician’s hands’, raises some interesting points for debate. Dr Orchard laments that decisions regarding return to play following concussion were made by a coach who is ‘forced by the nature of the job to think in the short term’. Orchard says that coaches are under “ridiculous pressure to win”, and so cannot be trusted to have the long term welfare of players in mind. Furthermore, he believes that the typically short term nature of a coach’s job (that is, they may be sacked if their team is not successful) compromises their decision-making about issues of player safety – as a result, Orchard believes that coaches should not be involved in decision making about return to play from concussion lest they put players at risk of long term harm.
We wish to expand upon Orchard’s useful and provocative contributions by making several points for consideration. Firstly, we think that Orchard gives the impression (perhaps unintentionally) that coaches such as Andreas Vilas-Boas can either try to win, or can be concerned about player safety – but are unable to do both. We believe that this describes a false dilemma for coaches. The pressure to win is certainly a factor that places coaches in a potentially vulnerable state when it comes to player safety – there are going to be circumstances where this vulnerability is heightened and, if not managed appropriately, lead to harm. But implying that the “win or else” pressure precludes coaches from having any concern about player health and welfare is perhaps not the most accurate or useful way of viewing things. Giving the impression that it is not within the scope of a coach’s obligations to care about player safety may be even more detrimental to player safety. If coaches are absolved of any obligations to the health and safety of players they may see this as encouragement to push the envelope further in their decision making in the belief that it is simply someone else’s job to tell them when they’ve gone too far.
Secondly, it is not surprising that Orchard thinks return to play decisions should be the domain of the team doctor because they ‘are in a position to think longer term with respect to the player’s health later in life’. Those in charge of football teams (and perhaps even those in charge of entire football leagues) could be accused of wanting to have it both ways when it comes to team doctors. On the one hand they want access to medical expertise when it comes to optimising performance and treating injuries because such expertise may facilitate winning. Furthermore, cynics might consider that the involvement of medical professionals allows coaches and administrators to trot out the well-worn line that “the player’s welfare and safety are paramount” – if nothing else, it makes for good PR to concerned mums and dads. But in the event that those medical professionals provide recommendations that do not facilitate the team achieving its goals (or may hinder their achievement), then some coaches and administrators may be apt to ignore such expertise or seek to circumvent it. This appears to be Orchard’s concern too.
Our point is that, team doctors can’t have it both ways either. Given the obligations and goals of coaches, Orchard says that team doctors need greater scope to say who can and can’t play, and that there is a need to redress “the power imbalance on match day between the coaching and medical staff”. In other words, doctors should be the ones with the final say on return to play, and doctors should be the ones to tell coaches when they’ve gone too far. There may be good reasons for this, but we can’t forget that team doctors (like coaches) have many conflicting pressures too – from their patient, the coach, their employer, and perhaps even their medical colleagues.1,2 Not all of these stakeholders necessarily have aligning interests when it comes to each case of injury. Orchard’s call for allowing team doctors longer assessment times seems like a sensible proposal, but it doesn’t eliminate the potential for the assessor to be swayed by these conflicting pressures – just like coaches. So Orchard’s solution is fairly neat, as long as we assume that team doctors are the only stakeholders who are immune to external pressures on decision making! Player welfare is a stated priority for all stakeholders, but Orchard’s most recent post creates the impression that coaches will always lean towards winning over player safety, but no team doctor ever will. We saw this as curious because we agreed with Orchard’s earlier blog post ‘Concussion, risk assessment, and practical steps to reform’, where he suggested that doctors are indeed at risk of losing their job if they do not toe the party line.
In that post, Orchard calculated the chance of the Tottenham medical team being sacked at 1 in 5 to 1 in 20, noting that the risk is ‘demonstrably lower than the manager but far higher than a colleague working in the NHS’. He goes on to state that:
… this level of risk becomes lower if they all “stick solid” with the manager on the decision to return the player to the field and much more likely if a public statement was made to the media along the lines of “the medical team requested that the player be substituted for safety reasons but the manager over-ruled us.”
The message is that members of the medical team are also vulnerable to losing their job and might tailor their medical advice or decision-making to please those who determine whether or not they retain their job. Doctors are best placed to medically assess a concussion injury, BUT team doctors may not always feel able to make a call that goes against the wishes of the coach and their decision making may involve a compromise between what is in the athlete’s best interest and what is in their own. This raises doubts about the independence of team doctors and places them in a similar position to coaches – a point that seemed lost in Orchard’s most recent blog post.
Furthermore, in a blog post from March 2012 Orchard relayed how coaching staff at the NRL club he was working for made it clear that they would not refer potentially concussed players to him for assessment if there was a chance he would exclude them from further play. Whether or not this ever occurred is unclear, but it clearly made Orchard uncomfortable. Interestingly, when interviewed in 2012, the chief medical officer of the National Rugby League (NRL) implied that team doctors do not have any conflicts of interest affecting their decision-making about concussion:
“There have been questions about whether club doctors have a conflict of interest because they are being paid by the clubs … their number one priority is the welfare of the player. They will always make the right decision by him.” (quoted in Prichard 2012).
Echoing this sentiment, a co-author of the Australian Football League’s concussion management guidelines also appeared to discount the influence of third parties by claiming that team doctors only ever make clinical decisions with their obligation to the player in mind:
”I may be idealistic, I may be wrong, but my feeling is that the guys are going to follow what they’ve been doing which is making sure players are safe. … You have very experienced doctors working in the AFL … we’re not going to be doing anything that compromises or risks player welfare.” (quoted Lane 2011).
Orchard has raised some important concerns for the care of athletes and been refreshingly frank in confronting ethical issues facing team doctors – in this post we have sought to clarify some of these issues. There is a need for good research to elucidate the mechanisms that make coaches and medical support staff more vulnerable to decisions with the potential to compromise the wellbeing of players. This will help develop strategies for managing these issues.
1. Partridge, B. (2013). Dazed and confused: Sports medicine, conflicts of interest and concussion management. Journal of Bioethical Inquiry. DOI: 10.1007/s11673-013-9491-2
2. Anderson, L., & Jackson, S. (2013). Competing loyalties in sports medicine: Threats to medical professionalism in elite, commercial sport. International Review for the Sociology of Sport, 48(2), 238-256.
Dr Lynley Anderson is a Senior Lecturer at the Bioethics Centre, Division of Health Sciences University of Otago
Dr. Brad Partridge is a NHMRC Research Fellow at the UQ Centre for Clinical Research, The University of Queensland