some issues that we have to deal with at the collegiate arena. I know as orthopedist, holy cow here, we tend to focus a lot on surgery and injury treatment and assessment. But I'm going to talk about some of the issues we have to deal with at the college level. So I'll be focusing on some organizational structure and some guiding principles and concepts. So I don't have a conflict. So one of the challenges of the collegiate athletic health care is just how large it is. At my institution, we have 36 teams, 1,000 athletes, something like seven or eight training rooms, and numerous practice and competition venues. How in the world are you going to provide good health care in this complex arena with the increasing demands being placed on us and how quickly things are assessed and communicated nowadays? So you obviously need a medical team to do this. One person is not going to be able to do this. And as an orthopedist, you're a key element in that team. And you also need team players who accept the concept of functioning as a member of a team to provide good care in this complex setting. So there's increasing mandates, consensus statements, and guidelines. We have athletic associations, medical societies, NCA, conferences, institutions, federal, state, government, all getting involved in what we do. I've been doing this long enough. I remember in the 90s. I'll use concussion as an example. In the 1990s, we, the docs at our school, we used our best judgment to take care of any concussed athlete. We did what we thought was best at the time. No one was telling us what to do or checking how we were doing it. Well, several years ago, the NCA comes in and says, oh, you need to do mandatory education. You need to educate people about concussion. My conference says, oh, we want to see your concussion policy. So now we have someone reviewing our policy. And my own institution then came and said, well, our liability lawyers think we need some kind of neuro expert on or near the sidelines for our games. So all of a sudden, all these different people getting involved in our business, how to take care of the athletes. I'm not saying it's a bad thing, but it's making it more complex. So societal expectations are changing. The student athlete and family expectations are greatly changing. Families are much more involved in what's going on with their children now than when I first started doing this. I got parents calling me all the time. How's my son looking practice today? And I said, well, first of all, it wasn't that practice. You may want to call your son. Well, my son doesn't want to talk to me at knucklehead. Well, he's not a minor. You better just talk to your son. Anyway, calls like that are coming in. The parents are involved. And as Tim alluded to, this NIL, I can't even, I've had numerous discussions of this over the last six months. We're not even sure how that's going to impact what's happening at the collegiate level. But no question, it is changing the game. So a lot of athletic department administrators say, I know I need to provide athletic health care. I don't really understand it. But our doc and our trainer seem like good people. I don't hear many complaints. So we must be OK. I think that's a very common approach by a lot of athletic department senior leadership. But times are changing. These historic patterns of athletic health care delivery are inadequate. If you're using an old or antiquated structure, this does not allow for modern function, which has been required. And this is changing quickly. So health care delivery to collegiate athletes is not just a necessity. It needs to become a priority, or you're going to be burnt at some point. So it's rapidly changing. Being reactive and not proactive just increases the risk for both the student-athlete and your institution. So waiting until you have a problem, then reacting to it, instead of being proactive, to show the society, the parents, the world, the lawyers, et cetera, that you are anticipating, do what you can to minimize the impact. That's what needs to be done. So new athletic health care paradigm. It's not simple as, hey, I've got some good people. I've got some resources. Hey, the doc seems like a good person. The trainer seems like a good person. I've got a nice training room. You've got to address some organizational structure. You need to have a clear, accountable reporting structure that ensures independent medical care. And I'm going to come back and talk more about independent medical care here in a bit. You need policies and procedures. They need to be written, updated, accessible, and followed. How many schools, and those of you that are at colleges, do you really have all your policies really written? Or is it, ah, it's kind of understood. We all know that's how we do it around here. Well, if it's not written, and it's not updated, and it's not reviewed, you're setting yourself up for a problem. The culture. Now, this is not an easy thing to change, but it needs to be student-athlete-centered, has to have accountability, has to be inclusive, foster a team concept, and has to have transparency. And you need a mechanism in place to ensure that people are compliant with your policies and procedures. If you have them in place, your policy procedure is in place, but you don't have a mechanism to make sure people are following them, again, you're exposed. And a foundational concept of this is independent medical care. So I'm going to come back to IMC here in a minute. So senior leadership may say, hey, has my institution stayed current? OK, Dr. Cady, I understand what you just said. Hey, you're right. We'd better review what we do at my institution. Well, a lot of places, well, let me back up. If you're doing things the same way now that you did even as recently as five years ago, I'm going to say likely you're not current. Likely you're not current. So you may say, I need a program assessment. Well, beware of the internal review. A lot of schools say, gee, I see what you said, Dr. Cady. I agree. We might review what we're doing. We're going to do an internal review. Well, internal reviews are incredibly flawed, right? First, you've got the human relationship issue and a personal bias. Maybe the athletic director and the head team doc have been friends for 15 or 20 years. They've liked each other, supported each other for 15, 20 years. Is this personal bias going to interfere with an objective review of the program? Obviously, it will. There's a tradition and inertia issue. There's the assumption that, hey, a policy that's greater than five years old is probably OK. No, any policy that's over five years old, I'd even say three or four years old, needs to be reviewed. Are the people who actually created the system doing the review of the system? Obviously, confirmation bias. You can't have that done. And it's a trap of, you know what? I don't hear too many complaints, so I think we're doing OK. That's a little bit like, I don't wear a seatbelt but haven't had a problem, so I think I'm OK not wearing a seatbelt. It's not a problem until it's a problem. And you can be trapped in your own world. This is the way we do it here. This is the John Doe college way. We've been doing it this way, and that's the way we do it. Well, these are all flaws of doing an internal review. And there's also the assumption that, ah, good people. You've got to meet our head doc. You've got to meet our head trainer. These are good people. And they assume that good people equals a good system. Ideally, you want a good system. I'm going to use organizational structure. You want good structure and good people. That's the ideal situation to have. So in the future, you want to minimize your athlete and your institutional risk. You need to be proactive. You know, encourage people to consider having an external review, doing some proactive education, make sure it's clear, inclusive, annual, and well-documented. You have to review your structure, your culture, your policies to make sure you meet best practices. And you have to have some kind of assessment system in place to make sure you're compliant with your internal policies and external guidelines. So that's a lot of work right there. It can be daunting. So what is independent medical care? Well, oversight of athlete health and safety. All right, that's easy to say. But what exactly is it? And why does independent medical care exist? Well, there's inherent conflict. In competitive athletes, the conflict is our society loves and rewards winners. We love competition. And we love to win. This creates great pressure to win. And every elite athlete pays a price to perform at the highest level. I'm going to pause here for a second. So anyone who's pushing themself to perform at the highest level, they're paying a price, all right? There's a cost to that. Real quick anecdote, I remember I met the medical team that worked for some of the Navy SEALs teams. I said, gee, it must be interesting to work with such a healthy group of personnel. I was quickly corrected. They said, Dr. Kading, the Navy SEALs are not healthy people. They're incredibly capable. They can perform incredibly well. They're chronically sleep deprived. Their cortisol levels are chronically high. Their testosterone levels are actually low from chronic stress. These are not healthy people. But they can perform at a high level. So being able to perform at a high level, you pay a price. So that just raises the question, when is that price too high? And who determines when that price is too high? So the goal to win is often not in the individual athlete's best interest. How hard do you push the athlete to perform at a high level so the team can win, and they're paying a price? So if society rewards winning, how do we protect the best interest of the athlete and the integrity of our institution if the institution is both the competitive entity and the one providing the health care? The institution wants to win, but they're providing the health care. So there's an inherent conflict there, all right? So the challenge is, how do we manage this conflict of interest between winning and the best interest of the athlete? Well, independent medical care. So medical care should be as independent as possible from coaches, administration, and any other outside influence. So independent medical care is not easy, especially when the stakes are high. It's not the traditional mindset. Coaches are hired and fired when the stakes are high on whether or not they win or lose. If your job depends on you winning, by nature, you're going to want to control everything around you that affects your ability to win. You want to control the equipment. You want to control nutrition. You want to control medical care, the trainer, everything around you. You need to control those things because you need to win. So anything that can impact your ability to win, you want to control. So you have that. Everyone in here has worked with any kind of coach, especially a higher profile coach that's on the hot seat. You've experienced that. And everyone around you is willing to pay a price to win, right? Coaches, stay late. Stay there until I'm there till midnight, 1 in the morning, getting ready for my game plan. The players are put next to you. Everyone's paying that price to win. And that can result in a pressure on the medical staff to support the team, be a team player. You've got to help the team win. And that pressure on the medical staff is obviously a bad situation. So what are some good examples of independent medical care at the college level? The medical staff should not be selected by the coach or the administration. How many programs is that true, and especially where there's bigger money and a higher pressure to win? How many times did the football coach or basketball coach have major input in who's hired to be the part of the medical team, whether it's athletic trainer or physician? That should not be happening, strictly speaking, for IMC. And you sit and think about this in the real world and you see why IMC implementation is not easy. Medical staff performance should not be graded by the coach or administration. The coach should not say, hey, that was a good doc. He got that guy with a whatever, bad knee, ankle, back in the game, and we won the conference championship. It's not the medical staff's job to keep the coach happy. A lot of people think it's my job. All right, keep the coach happy. That's what I do. No, no, that's asking for trouble. That's not independent medical care. And the medical staff should not be bonus for winning. No, going to the playoffs, winning something, you're working extra hours, but you shouldn't be incentivized financially for the team winning. So the NCA, and there's an interassociated consensus statement on the best practices of sports medicine management secondary schools. I think Tim mentioned, regarded some of these. And I'm going to go through these real quickly. They have 10 guiding principles for IMC from this consensus statement. It's published. Google this, you'll find it. Physical and psychosocial welfare of the individual student athletes should always take the highest priority of the athletic trainer and team physician. Any program that delivers health care to the student should have a medical director. This is a pretty basic thing. But if you don't have a medical director, who's the medical team actually kind of reporting to? Is it the athletic director, university president, the head coach? No, you need a medical director. Medical team should always integrate the best current evidence and preferences and values of the student athlete. Clinical responsibility of the student trainer should always be performed consistent with protocols, verbal orders, and standing orders of the team physician. In 47 states, the clinical practice ability of athletic trainers is actually under the assigned team physician. They actually perform their scope of practices under the team physician. So that should be clear and understood. Decisions that affect long-term health of student athletes should only be made by properly credentialed health care professionals. Decision-making should be well-documented. And coaches must not be allowed to impose demands that are inconsistent with guidelines of sports medicine professional organizations. Athletic trainers' responsibilities and employment status should be through a formal role that includes the medical director. Perhaps the coaches have some input, but you have to have a medical director involvement at the very minimum. Athletic trainers' employment status should not be primarily judged by the administration personnel who lacks health care expertise, such as a coach. Institutions should adopt an administrative structure for health care delivery that minimizes the potential of any conflict of interest. So this conflict of interest, is this conflict overt or intentional? No. I think we've talked through why it exists. This conflict is often unintended. It permeates society. Athletes, coaches, parents, fans, administrators, staff, they all want to win. Health care personnel can be biased by this desire to win. It's the culture of athletics. You need to be aware of it. You must work to minimize this phenomenon. The implementation of IMC can be challenging. IMC does not easily evolve from historic patterns of how health collegial and athletic administrations have been. These old, educated organizational structures do not flow naturally into what we want for modern function. Organizational structure is critical to IMC function. So that's my point. If you look at your school, you need to look at your organizational structure. We'll talk a bit more about that. Make sure it's optimized to promote IMC. You need to identify a chief medical officer or a medical director. Ideally, it's a physician. Medical personnel should report to medical personnel. Coaches are not medical personnel. Some administrator might be. You can have a physician administrator. You can have an athletic trainer, physical therapist, as an athletic department administrator. Collaboration with and support of the administration is crucial to success at IMC. How about your health care resources? It's unique to each institution. There's no one rubber stamp way to implement IMC at every school. Are you at a school associated with a large medical center? Are you a small liberal arts school in the middle of a small town in the middle of a rural America? You have very limited resources. So how you implement IMC will be different at each institution. But you should try to follow those guiding concepts. How about communication transparency? Student athletes must understand the concept of IMC. They should understand that the physician is separate. The medical staff is separate from administration and the coaching staff. Everyone must be aware of the concept of IMC. That includes your administration's administrators, your sport administrator. The coaching staff needs to understand what IMC is and that this particular institution, your school, values IMC. Policies should be clear and transparent. Questions regarding IMC must be addressed in a very timely fashion. So administrative support is key. IMC success requires senior administrative support. It's critical to avoid conflicts and confusion regarding IMC. And it's a culture they must work to develop. Independent medical does not mean the medical team exists in a silo. They're independent. They're over here by themselves. And they're responsible to the student athlete's health. If anything goes wrong, it's their fault. It does not mean the medical team is the sole responsible for the health, safety, and well-being of the student athlete. Medical oversight is seen in many areas of collegiate athletes. They need to have a self-environment, self-training, practice, not just competitive venues, at the value of the athlete's well-being. No one in the organization can abdicate responsibility. So the administrator can't say, well, that's part of the medical team. No, they have an obligation. That's been documented in these guidelines. And even I think there's some legal precedent of that. So independent medical care is the foundation for optimal athletic health care. It protects both the athlete and the organization. Organizational structure is critical for IMC. Implementation can be challenging. Understand that. Accept the challenges and start to work to overcome them. IMC should guide the oversight of all aspects of health and safety of your student athlete. IMC ensures the medical personnel should have unchallengeable autonomy and authority to make medical decisions for the athletes. IMC decreases the risk to the athlete and liability exposure to the organization. It's a good thing, just not easy to achieve. Now I'm going to shift a little bit here to the interassociation recommendations for those consensus statements. Dr. Peter Indelicato has represented AOSSM for many, many years on a lot of these documents. A recent one that came out was Preventing Catastrophic Injury and Death in College Student Athletes, Requirements and Solutions here. This was endorsed by 14 major medical organizations, 18 foundational statements, addresses six critical areas, and was adopted by the NCAA Board of Governors in 2019. Now some of the background. The number of non-traumatic fatalities are twofold. Those are traumatic fatalities in college sports. So trauma, some kind of collision, if someone ends up having a cervical spine injury and death, those are not the major reason of death, cause of death in the college athletes. It's non-traumatic fatalities. Non-traumatic exertion related death is directly related to the conduct and construct of workouts intended to prepare student athletes to play sports. It's heat. It's rhabdo. It's sickle crisis. These things are all preventable. So what about the guidelines of protective equipment? Equipment must meet national standards. Every member school should establish policy to ensure annual certification, recertification, and compliance as appropriate with all protective equipment standards. Those of you out there at schools, universities, do you have an established policy, written policy on your equipment? Or is it simply, yeah. We know equipment's important. We look at it. If it's bad, we replace it. No, we got a good equipment, people. Do you have a written policy? Optimization and conditioning. A minimum expectation is all strength and conditioning sessions, regardless of what time of year they occur, should be evidence or consensus-based, sport-specific, intentionally administered, appropriately monitored, irrespective of the phase of training, and not punitive in nature. That's key. When we grew up, I grew up, if the coach wanted to have some discipline to punish a player, have him run some extra, whatever, gassers, do some push-ups, whatever, that's not allowed. You cannot use physical activity as a punitive measure. So is it evidence-based? Is it monitored? Make sure it can never be punitive. All training conditioning sessions should be documented. And any training or conditioning session has to be approved by a credentialed strength conditioning professional or by the head sport coach at institutions who do not employ a strength conditioning professional. And the strength conditioning professionals, they're being credentialed, increasing movement to have them credentialed. And every conditioning or strength session has to be approved by one of these credentialed strength conditioning coaches. Is it documented? I suspect, in a lot of places, it is not. Has it been approved by a credentialed strength conditioning person? All training and conditioning sessions should have plans that are reproducible upon request and shared with the primary athletic health care provider, the trainer or the physician. A disciplinary system should be developed and applied to the strength conditioning professionals and sport coaches who fail to follow these guidelines. This is the national consensus statement. This is what's out there that lawyers will point to saying this is the standard. So do you have plans that are reproducible? If someone asks you, hey, what were your wrestling workout plans last season? And do you have a disciplinary system in place? I'm guessing you don't. Emergency action plans. Obviously, they're venue-specific. They have to be transparent. They have to be rehearsed and documented. They have to document that you've rehearsed your emergency action plans. What about the responsibilities of the athletics personnel? OK, athletics personnel, I'm talking about your entire athletic department, from your AD down. Physical activity should not be used for punishment. And everyone, your sport administrators, has a duty to stop these activities. If an athletic department administrator is aware that this is happening and they don't report it, they're liable. So all training activities should be administered by properly credentialed professionals. And they must be able to respond to emergencies associated with these activities. Again, everyone in your athletic department has a duty to stop if they see abusive, punitive physical activity. So the sports medicine staff should have unchallengeable authority to cancel and modify workouts for health and safety reasons. All strength and conditioning professionals should have a reporting line into the sports medicine or sports performance lines of the institution. That's different. Traditionally, strength and conditioning personnel always reported to the coach. Now, they're required to have some line to the medical team. So the first point is about policy and culture. The second point's about organizational structure. Education training, each institution adopt requirements for education training of athletic personnel, including as a minimum, strength and conditioning professionals, your sport coaches, your health care providers, your student athletes, and even your administrators should have some type of annual education. What's your quality of your education? What's your mechanism for delivering that education? And how do you document that you gave that education? All challenges for the collegiate team physician. So let me keep moving here. I'm going to go through this a little more quickly, type of education. These, at the minimum, require that these are education areas that they should be given. So this interassociation guideline that I just referred to, you can find it on the internet. You should review the document and discuss with key personnel. Consider 12, even longer, month implementation. You're not going to do this in just a couple of weeks. And be proactive about it. Quick last couple of comments. And Tim mentioned this. I'm going to talk about communication, especially in a bigger organization. It's critical to minimize tension within a team's health care system. The model we use at Ohio State is the hub of the wheel. Tim mentioned it. The athletic trainer is at the hub. All communication has anything to do with the health and safety of any athlete goes to that team's head athletic trainer. If you're an administrator, a team physician, a coach, anyone who wants to know what's going on, they should talk to the wrestling, the volleyball, the softball trainer. And that trainer should know everything that's going on about the health care of every athlete on their team. Game day communication. You want to avoid the appearance of chaos, especially in today's world with cameras. Everything you do is being taped and videotaped and sent around the world. How will communication flow at game day? Between the athletic trainers, the physicians, the position coach, the head coach. Who do you get community to? The athlete, the coach, the conditioning staff, administration, the parents, the press, fans, friends? If you communicate with the athlete, understand the context of the athlete. And make sure you stay athlete-centered when you communicate with your athlete. When you communicate with a coach, follow your model. Make sure your athletic trainer is aware of everything you've told the coach. And beware, if in your discussion when you're chatting with the coach, that you're not inadvertently including the coach into some medical decision making that's crossing that independent medical care line. Strength and conditioning staff, as a rule, always use the athletic trainer as a conduit. Parents, be aware of the relationship with the athlete with the parent if the athlete is not a minor. If they're 18 years or older, beware what you're saying to the parent. That can come back to bite you. The press, have an organizational plan. Have a media relations person. Dr. Burfeld taught me years and years ago, the less you as a team physician talk to the press, probably the better. That's absolutely right. So avoid that trap of trying to be the star or providing inside information. Beware of HIPAA and FERPA in the college world. You're all aware of HIPAA. But as a rule, the less you talk to the press, less is better. How about fans and friends? Beware of the fan passion and the limelight temptation. You don't want to be in the limelight. Beware of HIPAA and FERPA, that they still apply. And beware of losing the athlete's confidence or trust. If the athlete finds that they're treating physicians, telling everybody what's going on, obviously you've lost and broken that patient-physician relationship. FERPA, Family Education Rights Protection Act, somewhat unique to collegiate sports. So be aware of what your athlete has signed on any kind of HIPAA or FERPA waiver. Our guys sign big waivers to allow us to use our discretion to do. But without that waiver, you have to be careful what you say about their care. But regardless of whether you have the waiver or not, use discretion when you're communicating about an athlete's situation. So in summary, have a system and a plan for communication. Understand HIPAA and FERPA. Stay athlete-centered. And avoid the limelight and the insider information trap. Use discretion. Good luck. Thanks a lot.

collegiate level

healthcare challenges

athlete healthcare

independent medical care

communication protocols

risk minimization