By Andrew Blecher, MD

If you are reading this then you are already well aware of the current concussion crisis in the NFL. No matter where on the spectrum your opinions lie regarding this topic, there is one question that still remains: How did we get here? Surely if something has gone wrong then there must be someone to blame for it. Was it the league’s fault? The coaches? The players? The doctors? Maybe it is the injury itself that’s to blame? Perhaps it was just the perfect storm of a number of factors that put us in this situation? To truly get to the bottom of this, it is important to have a better understanding of the doctor-patient relationship. Not just in general, but specifically as it applies to concussed athletes in the NFL. Ultimately we may not find blame here, but we should at least shed some light on the realities of the situation.

As a sports medicine physician, I have taken care of thousands of concussed athletes at all levels. Eight year old hockey players, high school soccer players, collegiate football players, professional moto-cross racers and skaters, you name it. For all of them, the doctor-patient dynamic is similar. However, for the NFL players, that dynamic is entirely different. Let’s begin by looking at the usual non-NFL doctor-patient relationship.

If I evaluate a concussed athlete either on the sideline of a college stadium or during clinic in my office, the roles are clearly defined. An injured athlete is being evaluated by an independent expert in the field of concussions. Either the athlete has sought me out in the office or the school has asked me to be there because I am good at what I do. I am not employed by the athlete or by the team. I answer to nobody and base my decisions on my training and my instinct. When I diagnose a player with a concussion I educate them and their family that they should not be participating in activities that put them at risk of further head injury until they have fully recovered from the concussion, however long that will be.

This education may not be easy. After all, the athlete wants to get back to play ASAP. The athlete considers the concussion to be minor and it doesn’t inhibit their ability to play (so they think). That’s the thing about concussions. It affects cognitive function and diminishes one’s ability to make rational, thoughtful decisions. Therefore it can be extremely difficult to properly educate the athlete about why they must not be playing.

Why is this education so important? Because I cannot go home with them and hold their hand and prevent them from going skateboarding, or skiing, or playing pick-up basketball. I might be able to hold them out of their sanctioned sport by giving them a note that says they aren’t cleared, but ultimately they must be convinced of what I am telling them in order to protect themselves. They aren’t cleared to play in a sanctioned event at their institution because of my note and because the institution doesn’t want to assume the liability. But nobody is stopping them from doing what they do on their own time in their backyard or in their driveway. So ultimately the athlete and the family must trust that what I’m saying is in their own best interest. And why wouldn’t it be? Because after all I am an independent expert who is a patient advocate who answers to nobody.

Now let’s look at the doctor-patient relationship in the NFL. Many people may believe that the NFL team doctors are the very best of the best and are carefully sought out by NFL teams and are hired by the teams to provide the best medical care to their players so that their multi-million dollar investments are well protected. Makes sense right? Unfortunately this is not necessarily the case. NFL team doctors are not paid salaries by the teams. In fact, most team doctors pay the teams for the right to be the team doctors. Yes, you read that correctly. A medical group or hospital system will often pay the team for the right to be the team physicians. Why? Because they receive a marketing package to promote themselves as the team physicians. Is this valuable? Well many physicians think so and are willing to pay hundreds of thousands of dollars a year (sometimes approaching $1 million/year) for the right to be NFL team physicians. This is not to say that some team physicians are not incredible doctors, because many times they are in fact the best of the best. However, that’s usually not how they got the job. They got the job because of the marketing rights for the group or hospital. So now who is managing the concussions on an NFL sideline? Is it an independent expert in the field, or is it whomever is the best-trained representative of the medical team that paid for the rights to be there?

If you correctly understand this situation, then you would guess that historically the doctor on the sidelines to evaluate concussions would be either an orthopedic surgeon or an internist. Respectively they might be outstanding doctors in their field, but neither of them likely has had specific training in managing concussions. Even if they had, let’s look at what that training might have entailed. For years there were many different guidelines for diagnosing and managing concussions. These were not based on any scientific evidence but instead on the opinions of various experts from the fields of neurology and neurosurgery. By and large these guidelines stated that it was OK to send an athlete back into the game if their concussion symptoms were minimal and temporary. So now let’s look at a typical NFL concussion situation and see how this plays out.

It’s the third quarter and the quarterback gets sacked. He is slow to get up and wobbles a little bit. He comes over to the sideline and says he has a headache but otherwise he feels fine. His team is down by a touchdown and he wants to get back into the game. Should he? And if not, who is going to stop him? Does the athletic trainer or the team doctor have an obligation to examine the athlete?

Well, historically the answer is not really. If the athlete doesn’t seek out medical assistance then he may not get it. If he is minimizing his symptoms and wants to be tough and get back out there (which of course is the culture of the game because continuing to play after getting your bell rung is a badge of honor) then he might not present to be evaluated or may even go so far as to refuse to be evaluated because he states that he is completely fine. Remember, the concussed athlete does not make good decisions due to the concussion itself. If the athlete happens to be lucky enough to be evaluated by the team physician, then hopefully he will have a thorough physical exam and cognitive evaluation and the diagnosis of concussion will be made. Was that always the case? We can’t say for sure, but even if it was, then what? The physician must decide whether the athlete can return to play. With any return to play decision the physician takes two important things into consideration: 1) Is the player at risk of further injury by playing? 2) Is the player at risk of long term or permanent damage by playing? Historically there have not been solid answers to these questions. Guidelines have said that if symptoms are minimal and temporary (which of course they will be because the athlete is minimizing them) then return to play is OK.

What’s the real danger of returning to play anyway? Is it Second Impact Syndrome? Typically that is the correct answer, but no NFL player has ever suffered Second Impact Syndrome. In fact, Second Impact Syndrome is so rare that arguably there are less than 20 true occurrences that have ever been reported, and they all occurred in adolescents, not grown men. So we never really knew for sure that there was a risk of worsening the injury by returning an NFL player back into the game on the same day. There were also no good long-term studies that told us without a doubt that there was a risk of permanent long term damage either. So the athlete wants to play, the team wants the athlete to play and now the doctor must determine if it is OK to play. Well there is no written evidence-based guideline for the physician to rely on to give a reason not to play. Even if the physician’s instinct might be extremely conservative and want to hold the player out, does the physician really want to be the only doctor in the NFL who is doing this? As they say, NFL stands for “Not For Long” and the physician might find himself no longer on the sidelines if he is holding all of his team’s players out against their will and the wishes of the team. After all, the doctor is easily replaceable with someone else who wants to be part of the marketing package. So with no real reason to hold the player out and many pressures to put them back in (including the athlete’s own desire to go back in) . . . . back in they go.

Maybe the athlete will take a few aspirin for the headache, but that’s where the treatment ends. And what about the educational part where the player gets taught about his condition? No time for that because the clock is running and the game is going on. How about after the game? Well the player finished the game just fine and just has a headache and does not want to be bothered by the medical staff with education about head injuries. The player might not even trust the medical staff’s opinion anyway since the athlete believes that the medical staff works for the team. The athlete didn’t seek out that specific physician for an opinion so how can he trust him to be an independent patient advocate looking out for his best interest? And is the athlete going to now go see his own personal doctor to be evaluated for the concussion? Of course not. Many of these players didn’t even have personal doctors and even if they did they would be minimizing their symptoms and wouldn’t feel the need to go. So unless they had family or friends who forced them to go get evaluated, it wasn’t going to happen. So where should the educational part have come from? Should it have been mandated by the league? Who would have provided it and who would have really listened? With no educational part to the concussion management protocol, the athlete goes right back to practice and on to the next game.

This is how for years NFL players with mild concussions were able to keep playing and keep putting themselves at risk for the next head injury. It wasn’t until all of these players got older and their permanent long term effects became well-documented that we were finally able to recognize the true seriousness of concussions. We now know that these injuries have cumulative effects. We now know that it is not OK for a concussed athlete to ever go back into the game. We now have league guidelines for head injuries and we have independent experts in the field of concussion who thoroughly evaluate all concussed players. We now have the tools to save the athletes from themselves. Younger players are learning from the older players and the culture is slowly changing. Should all of these revelations have occurred years ago? Absolutely. But they didn’t. So whose fault was it? The player, the doctor, the league, the culture, the concussion, the perfect storm? ……..You decide.

Dr. Andrew Blecher is a Board Certified Sports Medicine physician at the Southern California Orthopedic Institute. He provides concussion management for both amateur and professional athletes. You can follow him on Twitter for the latest concussion information: @the_jockdoc. This post first appeared at NFL Concussion Litigation.