The political adage “sunshine is the best disinfectant” is attributed to a statement made in 1913 by future Supreme Court justice Louis Brandies. His insightful comment emphasized “transparency” as the best protection against special interests promoting a hidden agenda that will influence the outcomes of organizational operations. The administrative leadership of all athletic programs would surely proclaim a strong commitment to student-athlete health and welfare, but to what extent are their operational procedures transparent? By what process are medical personnel (i.e. team physicians and athletic trainers) selected or terminated? Historically, the process has been determined by athletic directors and coaches who lack the expertise to properly judge the qualifications of medical personnel. Thus, one might question the basis on which selection and termination decisions are made. Do financial donations or payments for recognition as an exclusive provider of sports medicine services influence the choice of a team physician? To what extent are past personal relationships with coaches weighted more heavily than the professional qualifications of existing medical staff? What is the real rationale for dismissal of an athletic trainer when a new coach is hired? Does it relate to concern about the quality of services provided to student-athletes? If not, what is the rationale for replacement of medical personnel that commonly coincides with a change in head coach? Is such a decision based on any performance metrics? Although an “at will” employment contract legally allows for termination without cause in such cases, is an arrangement of this nature ethically defensible?
The critical determinants of healthcare service quality were designated by Dr. Avedis Donabedian in 1966 as: 1) structure, 2) process, and 3) outcome. Structure refers to administrative leadership and resource availability, which determine the range of possible processes that can be implemented to achieve prioritized program outcomes. Interactions among these factors reflect organizational culture, which often has hidden influences on the behaviors of program personnel. For example, the clinical decisions of team physicians and athletic trainers may be consciously or unconsciously affected by the dogmatic views of coaches who expect utilization of processes that are consistent with their long-held beliefs about best practices.
Donabedian (1966) model of medical care quality.
The extremely high rate of recurrence of sport-related ankle sprain and ACL injury, as well as progressive development of related disability, represent adverse outcomes that may be partially attributed to ineffective injury management processes. Evidence-based practice offers the greatest potential for continuous improvement in outcomes, but a very high level of professional development is necessary to effectively implement such an approach to sport injury management. An organizational culture that places greater value on program loyalty than the best long-term interests of student-athletes certainly increases the likelihood for poor outcomes, particularly those that are not manifested until years after participation in a competitive sport. Growing evidence of the potential for long-term effects of concussion and repetitive head impacts on degenerative brain conditions and psychiatric disorders raises serious concerns about the possibility that non-medical considerations may have influenced care processes.
Despite the fact that member institutions of the NCAA have affirmed a commitment to an administrative structure independent of coaching staff to provide for the “unchallengeable autonomous authority” of teams' physicians and athletic trainers to have final decision-making authority with regard to student-athlete care, organizational culture can exert subtle influences that are hidden from public view. Athletic programs that truly prioritize the health and welfare of student-athletes should adopt a policy of complete transparency in all administrative aspects of sport injury management that might be influenced by a conflict of interest. Such a policy could provide student-athletes, as well as their parents, with greater assurance that high-quality injury prevention and treatment services will be provided by team physicians and athletic trainers who are unencumbered by pressures to meet the expectations of any powerful special interests within the organization.
This blog was written by Gary Wilkerson, EdD, ATC, FNATA
University of Tennessee at Chattanooga
Associate Expert, The Rehberg Konin Group