Friday, March 19, 2010

Concussions & Medical Conflict of Interests

The NFL, after fifteens years of denial and statistical irrelevancy, finally disbanded, sorry, reconstituted its concussion committee. A relentless year of exposure in the mainstream media and the cumulative result of a decade of research that contradicted the NFL findings finally resulted in this shamed response.

The new committee is chaired by two world renowned university doctors, one from UW in full disclosure mode. More importantly, the long time chair and influential member Dr. Elliott Pellman  resigned. Under his leadership the committee consistently used the same argument global warming skeptics use, not enough data to warrant action. His colleagues vehemently denied any connection between football play and the data and stories of the debilitating brain and spine injuries suffered in later life by ex-players. Asking for more data or denying there is enough evidence is a time honored way to put off decisions and avoid responsibility. Under the committee's vigilant leadership the NFL denied reality and avoided liability and did nothing for over a decade.

The key to understand is that Dr. Pellman was the New York Jets team physician. Like research doctors who own interests in drug companies, this creates a clear conflict of interest problem. Conflict of interest occurs when your self interest comes into direct conflict with your professional jugdment. Or it can guide or skew your judgment especially in grey areas of diagnosis and interpretation. The problem exists everywhere in-house professionals exist and professions have developed strong associations and standards to deal with the unyielding tensions that exists there. Having a doctor employed by a team to chair the committee to oversee injury studies fundamentally violates good professional practice. The point of the game here is that doctors stand as the front line defense of athletes against a world of pressures to compete until they are irremediably injured. Doctors' integrity and professional judgment are all that stand between safe lives and tortured lives for many players at all levels of athletics.

Let's look at the incentive pressures at each point of contact. Players face immense pressure to "play through the pain" and risk future loss of function against present gain. Professional players and college players have very short football careers. They believe they cannot afford to lose any time and must  maximize their chance to play the game they love; gain exposure or gain salary. The NFl compounds this pressure with its free market attitude toward contracts and the way it cuts players quickly and mercilessly. The career is a one shot deal for players, short, hard, sometimes glorious, but this is it. Very few players are equiped for life after football. So they play on; they hide injuries; they play through pain to minimize the reasons coaches or managers have to replace them with someone healthy.

The players' agents, who should be their conservators, know the comet like careers of their players. They push for maximum gain up front for just that reason. But their incentives are to keep the player playing to minimize any chance of losing the percentage guarantee for them. In football especially short term gains trump long term gain because of the violence of the sport and much shorter career span. An agent sees himself protecting the player's long term welfare with big contracts against almost certain injury risks. This results in interests to push the player to stay on the field as long as possible since going off risks ending the career quickly.

Coaches must win; they must win now. Pro coaches may get a year or less; college coaches might get two or three; they must win or they are gone. They need players who can deliver now. They understand and appreciate injuries. Ultimately they don't want to play subpar injured players. But the starters are often good enough that even somewhat impaired they are better than the others. The oaches need them and hold implicit threats against them. The coaches are not cruel or vicious, they have no job security and no responsiblity for players whom they cut and never see again. Pro players show up to find their bags packed for them; they seldom see coaches when they are escorted off the premise never to return. So coaches will ride a player until they player falls. They want gamers who model the toughness to others.

In the warrior culture of toughness--nothing is tougher than football--all other sports pale in comparison to its physical demands and sublimaed violence, everyone knows they need each other. A few might want a player to stay out when injured to get their position, but most urge them on to play with pain; play through pain; play for loyalty and glory. They all know they could be gone tomorrow, but so do soliders in combat. You don't abandon the band of brothers in battle.

Players, agents, coaches, culture all drive players to assault the margins of safety. To play as long as you can hobble or think and not worry about what you will be like with early dementia, impaired judgment and compromised spines in your mid forties.  Doctors stand between this. Doctors need science, data and protocols to support them and push back. The NFL and its team doctors subverted this for a decade.

Only the doctors stand between these forces and the welfare of the players. Only doctors stand as the stewards of a players' future. Too much of the medical world of football places doctors in dual roles of doctor and cheerleader. Teams bid out medical service to practices. Practices bid low or offer to be the team doctor for free in order to have the prestige of being a team doctor. Doctors paid by teams where their practice's status depends upon the team's largesse face serious stress upon their integrtiy. Many withstand it, but to sustain them, we need better economic models; better tranparency; better second opinions; limitations upon predictable demands that will be placed upn them to push someone back into the game too early.

No easy answers exist. In many ways the best model is to have university doctors who have tenure and research support doing most of the work. Most programs don't have that luxury. But the universities can help by building strong and evidence based sports medicine programs to educate doctors and provide professional networks to educate and support them. The economic model of bidding out or for free services should be abolished to eliminate the nexus between large economic gain and status. Mandatory second opinions required. Above all the medical profession needs strong and clear and evidence driven protocols to give the doctors the ground upon which to stand and protect players from management and from themselves.

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