Jan 29, 2015Lines on the Sidelines
It’s no secret that coaches will sometimes challenge your decision on an athlete’s return to play. When should you draw a line in the sand?
By Dr. Kimberly S. Peer
Kimberly S. Peer, EdD, ATC, FNATA, is an Associate Professor at Kent State University. She serves on the CAATE Ethics Committee and the NATA Committee on Professional Ethics and is co-author of Professional Ethics in Athletic Training. She is a Past President of the Ohio Athletic Trainers’ Association (OATA), a member of the OATA Hall of Fame, and has been honored with the NATA Most Distinguished Athletic Trainer Award and GLATA Outstanding Educator Award. She can be reached at: [email protected].
As football season was kicking off last fall, The Chronicle of Higher Education (1) released results of a study and presented an article about what happens when athletic trainers for football disagree with the head coach regarding concussion return-to-play decisions. The report revealed that athletic trainers in the NCAA’s Football Bowl Subdivision are regularly pressured in this area and that some have lost their jobs when they refused to back down.
While the article hopefully spurred discussion among university administrators about reporting lines and the overreach of football coaches, athletic trainers in the trenches were not surprised by the study’s findings. From those who share the sidelines with big-name coaches to those at the high school level, sports medicine professionals know that some coaches will challenge return-to-play decision, regardless of the sport. And in some cases, butting heads with coaches can have career-altering ramifications.
So how can athletic trainers best handle these difficult scenarios? What are some strategies to pursue when your judgment is questioned by a coach? How do you weigh the ethical dilemma that arises? Confronting such a situation is not easy by any means, but thinking about it in advance and having a game plan ready can help.
LAWS & GUIDELINES
The very nature of sport itself creates many ethical challenges–from cheating and gambling to commercialization to character development(2-5). As athletic trainers, we are not alone in having to deal with moral issues in athletics. That’s one reason there are guidelines in place to keep us honest to our profession and organizations to back us when our judgment is questioned. To start, athletic trainers are bound by specific licensure and/or certification guidelines. In states with licensure, the law governs the scope of practice and a violation results in legal action. In states where there is no licensure, the Board of Certification defines scope through the Role Delineation/Practice Analysis(6). This document spells out the domains and tasks relevant to the athletic trainer. The Board of Certification also has a Standards of Professional Practice document that clarifies professional practice standards, including ethical conduct.
Further, the NATA has an established Code of Ethics that defines ethical behaviors and mechanisms for reporting violations and the Committee on Professional Ethics to investigate violations. Recently, there has been a surge to increase accountability of members to report anyone who is practicing athletic training without the proper credentials, bolstered when the Strategic Alliance of Athletic Training issued a joint statement entitled, “Legal and Ethical Responsibility to Report Unregulated Practice.”(7)
In essence, if a coach or any other athletic professional oversteps their boundaries in regards to an injured student-athlete, they may technically be practicing athletic training without a credential. Return-to-play decisions often fall in this area if a coach or administrator overrides the athletic trainer’s finding.
Knowing there are laws and national governing bodies on your side can ensure an athletic trainer does not feel alone when challenging a coach regarding an athlete’s recovery. But the individual still has to think through how they wish to proceed. A bit of ethical theory can help to understand the considerations to weight when moving forward.
In the book Moral Courage(8), author Rushworth Kidder presents four paradigms for evaluating most situations: honesty versus loyalty, individual versus community, short term versus long term, and empathy versus justice. These paradigms help us to resolve issues by framing them in one or more of these perspectives. For example, if you are discussing with a coach a return-to-play decision for a star athlete who had a recent ankle injury, he or she may be looking at the situation from a community perspective (team) and short-term perspective (win). An athletic trainer, on the other hand, has an individual and long-term (potential future disability) perspective. Both viewpoints could be viewed as ethical. So what do we do when our views collide? Kidder suggests examining three elements when developing moral courage: Principles: The first component asks us to think about the values and principles that guide our behaviors. When we are faced with ethical dilemmas, we try to resolve them by framing them as “right versus right” or “right versus wrong.” Right versus right decisions occur when moral values are violated in order to do something we feel is justified or important. We may violate ethics to achieve a worthwhile goal.
Right versus wrong decisions appear to be much clearer, but they are not. Wrong is defined as a violation of law or acts of moral turpitude, and most of us draw a line in the sand to define our own level of tolerance for committing a wrong. Where we get into trouble is when we move the line in the sand to please others, avoid consequences, or remove conflict. For example, a return-to-play decision for a star player in a high-stakes game may be more of a dilemma than making the same call for a third-string player in a scrimmage. Coaches and administrators might pressure you to consider each athlete individually. But both athletes should be considered in exactly the same way. If the right decision is to hold an athlete out due to the injury circumstances and the evaluation of objective data, then their status or the stakes involved should be irrelevant.
Moving the line in the sand violates our own principles. As athletic trainers, pressure from coaches and administrators skew our perceptions of right versus wrong because we are part of the team as a health care provider and truly want the team to succeed. But honoring our principles means standing our ground to protect the athlete–every time. Danger: The second element involves recognizing the risks. All decisions have risks associated with them, and some have higher risks than others. What we have to do is determine which risks are worth taking based on our values and principles. For example, not standing our ground in a return-to-play decision can expose us as not having strong principles. On the flip side, disagreeing with a coach can sometimes mean the loss of a job and decreased standing in the community. Both situations have inherent risks, and it’s up to the individual to decide which outweighs the other.
Endurance: The last component of moral courage involves enduring the hardships, which involve the factors of experience, faith, character, and intuition. Experience is a powerful teacher and informs our decisions daily. It is most powerful when combined with thoughtful reflection about the lessons learned prior. Faith is what we firmly believe in. Character is that component of yourself that evolves from doing things consistently over time. Many have compared character to an old oak tree. The oak stands tall and strong and withstands the storms but is quickly brought down with a chainsaw. Like the oak tree, our character takes a long time to establish but can be destroyed with one bad decision.
Lastly, intuition is often referred to as a “gut feeling,” and is the hardest to trust. Many of us know deep down when a decision isn’t right, but we sometimes override that feeling or rationalize our behavior. As athletic trainers, it’s imperative that we trust our instincts. Enduring the pressures associated with a delayed return to play is where the athletic trainer has to really dig in and take a stance. We are the health care providers, and we are the ones trained to protect the athlete. Sometimes we must have the courage to go the distance when tough decisions need to be made.
How do guidelines and theory work in practical terms? Consider this scenario: You are an athletic trainer treating an athlete who has recently experienced a meniscal injury of the knee. The player’s physician has given a “go-as-can” status. The athlete has performed rehabilitation on a consistent basis but still has intermittent pain and is fearful of reinjury. The team is slated to begin conference play in a week, and the coach is pressuring you to get the athlete back on the field. You explain the reservations of the athlete and the limitations seen in rehabilitation, but the coach argues the athlete is healthy enough to return–as reflected in the physician’s release.
Clearly, this situation is not life or death. However, it is riddled with ethical elements that will impact the relationships between the athlete and coach, athlete and athletic trainer, and athletic trainer and coach. To start, it is imperative to consider the rules and regulations that govern our profession. Athletic trainers work under the direction of a physician and are bound by either law or standards to their scope of practice. In this situation, the athletic trainer is following the directions of the physician, which is to allow the athlete to practice “as can.” However, that does not mean the athlete is cleared to play, and this may need to be explained to the coach.
The dilemma evolves further because the coach is pushing the athletic trainer to get the athlete back as soon as possible. But if the athlete is unable to return either psychologically or physically based on objective measures, the athletic trainer should consider the primacy of the patient and be cautious in returning him or her too soon. Being persuaded by a coach to go against objective measures relative to physical or mental readiness to play is clearly an ethical violation.
What if the coach insists that you return the athlete and a contentious situation arises? This is where thinking ahead of time about ethics and the elements of moral courage can help. To start, what are your principles–do you feel it is okay to allow the athlete to return if he or she is not ready? What are the dangers to think through? And can you call upon experience and intuition to help you make your decision?
It’s also important to stay calm, focused, and objective. Emotions typically lead us into discussions that have little relevance to the topic at hand. Keeping feelings out of the conversation and standing your ground will help diffuse the situation. If the interaction continues to escalate, it may be useful to walk away. Explain to the coach that you are going to leave the argument and that you will gladly talk to him or her at a later time when emotions are calmer. It is okay to leave the conversation, especially if you are being demeaned or challenged in public.
If you do this, be sure to follow up with the coach in a timely fashion. It is recommended that you have a colleague or supervisor with you. Documenting the interaction and conversations for future reference can also be helpful. Let’s look at a similar situation through a different lens. What if the athletic trainer is adamantly against an athlete returning to play based upon objective testing and functional criteria, yet the physician clears the athlete? This is more complex, as the athletic trainer works directly under the direction of the physician. The best solution would be to discuss the objective findings with the physician and try to reach a compromise regarding the athlete’s return. This can be done through open communication and thorough documentation and discussion of findings. Should the physician remain adamant that the athlete is ready to go despite your recommendations, a second opinion is always an option. There are certainly some risks associated with this method, but if the patient is the top priority, we are obliged to provide him or her with a second opinion. This is exactly what moral courage is all about–standing up for what you believe in even in the face of impending consequences.
Know yourself, trust yourself, and believe in yourself, because when you do, you will not be swayed by peer pressure. Listen to your intuition–if it feels bad, it probably is. Losing yourself is far worse than any consequence that could emerge.
THE RIGHT THING
Athletics is an area where ethical dilemmas often occur. Emotions are involved, and the stakes can be high. But in life, the stakes are even higher. When dealing with serious injuries, such as concussions, there is no room for error. While it is discouraging that so many athletic trainers fear for their jobs when they do not support a coach’s desire to return an athlete to play, it is important to be true to our profession. If we are certain that it is not in the best interest of the athlete to return, then it is critical to stand strong and advocate for their proper care despite the risks involved to us personally and professionally.
Recent concussion literature is redefining the rigor with which we consider head trauma and return to play. The consequences for failing to use extreme caution are severe. Although in the heat of the moment, some may believe it is worth the risk to play the athlete and get the win, retrospectively, the risks are far too high. Athletic trainers should not be concerned with a win-loss record–we should be focused on players’ lives and futures. Knowing where you stand before these situations arise is critical in making the right decision. Thomas Jefferson once said, “In matters of style, swim with the current. In matters of principle, stand like a rock.” Knowing when to stand like a rock and when to swim with the current is imperative. And when you do stand like a rock, do it with conviction. Demonstrate your moral courage and do the right thing. Nothing is worth the consequences of returning an athlete too soon.
(1) http://chronicle.com/article/Trainers-Butt-Heads-With/141333/ Accessed 1/8/2014 (2) McNamee, M., & Parry, S. (1998). Ethics and Sport. Routledge Press, New York, NY. (3) French, P. (2004). Ethics and College Sports. Bowman & Littlefield Publishers, Inc., Lanham, MD. (4) Simon, R. (2004). Fair Play. Westview Press, Cambridge, MA. (5) Shogan, D. (2007). Sport Ethics in Context. Canadian Scholars Press, Inc., Toronto. (6) Board of Certification. (2010). The 2009 Athletic Trainer Role Delineation Study. Omaha, NE: Stephen B. Johnson. (7) Strategic Alliance Releases Statement: Legal and Ethical Responsibility to Report Unregulated Practice. November 12, 2013. Accessed at www.caate.net on January 9, 2014. (8) Kidder, R. (2005). Moral Courage. Harper Collins Publishers, New York, NY.
Sidebar: IN THE TRENCHES
A high school athletic trainer, who will remain anonymous, explains his first-hand experience with a difficult coach.
Several years ago, I worked as a certified athletic trainer at a high school in which the head football coach continually questioned my judgment and put his athletes’ health in danger. Initially, I rolled with the punches, believing this coach just needed time to get to know me and my level of competence. But things only got worse. He would suggest to me he knew the athletes’ conditions better than I did and that he felt they were faking injuries. He would come into the athletic training room and publicly tell athletes that they weren’t being tough enough and didn’t need to be there. Often, a player would give me a doctor’s note that limited his participation or required him to undergo specific treatment prior to practicing. Some of these instances involved the return to practice following concussions. The coach often wanted me to ignore the physician’s directions.
Then some parents informed me that the coach was telling athletes who were injured and wanted to come see me to stay away from the athletic training room, because he figured I would just pull them out of competition, regardless of the severity of the injury. At that point, I knew I had to do something.
My first step was to document everything. This was not hard to do since I had been recording every instance when parents or athletes contacted me with these concerns–much like any medical professional would do in a patient’s chart under the subjective portion of the SOAP note. While I was compiling evidence against the coach, I continued to carry out my duties as best as I could, making sure to discuss the treatment of the athletes and participation guidelines almost daily with the team physician. I also leaned on a fellow athletic trainer at another school, who is a great friend and mentor to me, for advice and support.
I knew that I could be risking my job by issuing a complaint against the football coach, but I did not think about this much. I felt that the risks of doing nothing were far greater. What if an athlete suffered a permanent or catastrophic injury because I remained silent? If this injury was determined to be due to negligence on the part of the sports medicine team, I could lose more than my job. I could lose my license and ability to practice. Ultimately, I believed I had to take a stand against the coach to ensure the safety of the athletes. When I went to the athletic director with my complaint, I had clear documentation about the risks of the situation. I felt I explained the situation professionally. But the athletic director didn’t want a confrontation, and the superintendent didn’t want to get in the middle of our situation. The district decided to “go in another direction” with the sports medicine program and I was let go.
This was a difficult outcome to stomach, but I felt confident I could rebound. And fortunately, I landed on my feet. I was able to secure a position as both an athletic director and athletic trainer at another school, and the two jobs have worked well together. I have never regretted standing up to the coach, but I might have done a few things differently. I could have involved the athletic director sooner to show how the decisions I made were medically backed and not a personality conflict. It might have worked well to ask the athletic director for advice each time the coach ignored recommendations for limited practice or participation. It also might have helped to have the support of the team physician to show the coach and athletic director that we were united on the treatment of the athletes.
My advice to other athletic trainers dealing with this situation is to document and communicate. Write down everything that is going on and involve as many members of the sports medicine team as possible in the treatment of athletes. Communicate with the head coach and assistant coaches verbally and in writing on a daily basis–do not assume that player status or practice restrictions are communicated to the entire staff when you only speak to one coach. Finally, don’t be afraid to ask for help from others. Speak to veteran athletic trainers you know and respect as well as administrators in your school. Ask friends to be a sounding board. Know that you have the athletic training community behind you, and don’t be afraid to do the right thing.