This fall thousands of college football players will line up to participate in one of the country's most popular and violent sports. In any given week, hundreds of those players will come off the field with concussions or other serious injuries.
Determining when those athletes return to play is the job of athletic trainers and team physicians, who are charged with keeping players out of harm's way.
But new research suggests that the medical staffs responsible for protecting college athletes often don't have the authority to do so.
Nearly half of the major-college football trainers who responded to a recent Chronicle survey say they have felt pressure from football coaches to return concussed players to action before they were medically ready. The respondents included 101 head athletic trainers, head football trainers, and other sports-medicine professionals from the highest rung of college football, the NCAA's Football Bowl Subdivision.
It's unclear how many trainers have succumbed to the pressure, but previous studies suggest that concussed players are not getting enough rest. According to a 2010 NCAA survey, nearly half of responding institutions said they had put athletes back in the same game after a concussion diagnosis.
Those findings were publicized this summer as part of a federal-court case challenging the association's handling of concussed players. The plaintiffs—four former college athletes, who are seeking class-action status—say the NCAA failed to protect them from head injuries. The association has denied the claims.
The subject is so sensitive that few athletic trainers are willing to speak publicly about it, for fear of losing their jobs. But more than 100 submitted anonymous comments to the Chronicle survey, conducted with the National Athletic Trainers' Association. Many trainers voiced concerns about coaches' invoking their personal wishes regarding athletes' medical care.
"Too many medical decisions are made by individuals outside of the medical profession," wrote one athletic trainer in the Mid-American Conference. Others told of coaches' steering players to outside medical providers who rubber-stamp their calls.
Two former athletic trainers in the Pac-12 Conference described how they had lost their jobs after clashing with coaches over concussion treatment.
"It was scary," said one trainer, who left a prominent California university over the conflict. "It was uncomfortably close to infringing on the medical well-being of the athlete."
Trainers say they've tried to resist coaches' demands, but that's not always easy. In at least 11 big-time programs, trainers or directors of sports medicine report directly to a football coach, The Chronicle has found. That arrangement could force the medical staff to choose between player safety and their own job security.
When trainers push back too hard, they often face repercussions. More than a dozen Division I athletic trainers have been fired or demoted in recent years, The Chronicle has learned, often over questionable return-to-play calls.
In the past nine months, head football trainers have lost their jobs in at least four FBS programs: Florida, Texas Tech, Temple, and Western Kentucky.
Temple's former head trainer, Dwight Stansbury, who had worked at the university for nearly 20 years, was let go in January, about a month after the new head coach, Matt Rhule, took over. According to a job posting for that position, the new head athletic trainer has two bosses: a senior associate athletic director and Mr. Rhule.
The survey findings disturbed Kevin M. Guskiewicz, a leading concussion researcher from the University of North Carolina at Chapel Hill. "Any institution that places a coach in a supervisory role over the athletic trainer or allows a coach to put pressure on medical decisions is just asking for trouble," he says.
Concerns like those have led nearly a dozen medical groups to take a closer look at the relationship between medical-staff members and coaches. Many football coaches played with concussions themselves, and have trouble relating to new guidelines that urge medical staffs to run baseline and post-injury tests and to rest players for longer periods after head injuries. The recommendations changed last year as researchers have suggested possible links between repeated head trauma in football and chronic traumatic encephalopathy, a degenerative disease that can lead to permanent brain damage.
Coaches may need more education on those changes, says Stanley A. Herring, a professor of neurosurgery at the University of Washington.
"Part of participating in team sports is to be tough," says Dr. Herring, a team physician for the NFL's Seattle Seahawks and a consultant to the Huskies' football team. "But no one has a tough brain."
Skepticism about concussions goes beyond coaches. One Division I athletic director in Illinois thinks concussions are a "bunch of hype spurred on by the media," one survey respondent wrote. According to that university's head trainer, the athletic director and the coach have objected when medical staff tried to hold out concussed players.
Elite athletes also underreport head injuries, recent studies have shown, in some cases because they don't want to lose playing time or risk having their scholarships revoked.
"Coaches want to win and athletes want to compete," Dr. Herring says. "The challenge is to find the right balance between playing with some discomfort and playing when it's dangerous."
Before the 1990s, new football coaches typically made peace with athletic trainers from previous staffs, and many trainers survived multiple coaching changes. But as the money has gotten bigger, and the expectations to win have intensified, coaches have been given wider latitude in building their staffs.
Many now consider athletic trainers to be part of their team. That setup has helped a handful of trainers earn six-figure salaries and steady employment—so long as their bosses keep winning. Many other trainers find themselves fighting for their jobs.
Ted S. Warren, AP Images
A trainer who worked with Mike Leach (right) at Washington State moved into another job after complaining about dangerous workouts.
Bill Drake, a former head football trainer at Washington State University, moved out of that job in midseason last year after expressing concerns to two senior administrators about "dangerously excessive" workouts, according to e-mails obtained from a public-records request. The worries, which were first reported by the sports site Deadspin, led to separate investigations by the university and the Pac-12 Conference. They found no wrongdoing.
But according to two sources close to the program, Mr. Drake butted heads with Mike Leach, the Cougars' head football coach, after failing to clear concussed players as fast as he and other coaches wanted. According to Mr. Drake's e-mails, Washington State kept concussed players out for an average of 8.2 days. (The NCAA does not mandate how long players should stay out or keep track of return-to-play times following concussions.)
Last year, 21 Cougars' football players suffered concussions between the start of the season, in August, and late October; in previous years, the team had averaged about 12 concussions annually. That increase—a result of more awareness about head injuries among players and coaches, Mr. Drake told colleagues—contributed to tensions with the coaching staff.
"There were so many athletes held out, it was a shock to the entire coaching staff," a person with knowledge of the situation told The Chronicle. Some coaches were convinced that trainers were being too soft on players, this source said, an approach that those coaches believed had contributed to the program's losing ways. (Neither Mr. Drake, who moved into more of an administrative role, nor Mr. Leach would comment on the record.)
Mr. Leach was fired by a previous employer, Texas Tech, after allegedly mistreating a player with a concussion and refusing to apologize for it. The coach has denied the allegations, saying he was dismissed over a contract dispute.
A concussion diagnosis made during competition is often hardest for coaches to accept. A few years ago, a former football trainer in the Big East Conference says he took away a player's helmet during a game after he was diagnosed with a concussion.
The trainer says the head coach confronted him on the sidelines, asking what would happen if he gave the athlete someone else's helmet.
"If something bad happens," the trainer says he told the coach, "you're on your own." (The player did not go back into the game, but the trainer later lost his job.)
Similar stories are playing out beyond the football field. Last fall, when a soccer player at the University of South Florida was concussed during a game, another sideline dispute ensued.
The student, who was a key player, reported feeling well enough to return to the field, but the medical staff held him out, says Barry Clements, a senior associate athletic director, who was briefed on the incident.
He says the head coach, George Kiefer, questioned an athletic trainer, asking, "Are you sure this guy can't go? He's saying he can go!"
The player was not returned to the game. But weeks later, the university changed the team's trainer. Mr. Clements, a certified athletic trainer who helps oversee the sports-medicine staff, says the move had nothing to do with the disagreement.
"In the heat of the moment, something occurred," he says. "But we would never make a change because a coach wanted a change."
In some ways, return-to-play decisions have become more complicated in recent years, as athletic trainers fret over getting sued.
In addition to standard concussion-assessment forms, many colleges now use a computerized neurocognitive tool to evaluate suspected head injuries. Among other things, the tests measure players' balance and coordination, and look for physical and mental deficiencies based on previous scores.
Those tools give trainers and physicians a pretty clear idea of whether players have concussions, but athletes can still fool the tests. For that reason, some coaches aren't convinced that they're worth doing.
"You're just trying to cover your ass," one head football coach in the Southeastern Conference told his head trainer last season, the trainer told The Chronicle in an interview. "Those tests are worthless."
But in many cases, the bar for passing a sideline concussion test still seems low.
Last October, Robert Woods, a wide receiver for the University of Southern California, took a helmet-to-helmet hit against the University of Utah that spun him off his feet. After pushing himself up and staggering across the field a few steps, he fell face down on the turf.
A few minutes later, he passed a concussion test by answering three questions, he later told reporters:
What is today's date?
Who is the president?
What's 100 minus 7, minus 7, minus 7?
He missed just one play before going back into the game.
Mr. Woods recently signed a contract with the Buffalo Bills. But some players who have returned soon after big hits have not fared as well.
Steven Threet, a former University of Michigan quarterback, took a helmet-to-helmet blow in 2008 that led to a bout with retrograde amnesia. He doesn't remember the Purdue University player who hit him or the penalty flags that flew. He can't recall what tests he was given on the sidelines or what happened moments later. But he says he can watch a recording of the game and see himself head right back into the huddle.
Mr. Threet, who transferred to Arizona State University at the end of that season, suffered at least four concussions playing college football, the last one leading to 10 months of debilitating headaches. He has since quit the game. Although he believes he received good medical care, he worries about the potential long-term problems that players face when they return too soon following a concussion.
"If they would just allow it to heal," Mr. Threet says, "it's so much easier to deal with."
Gareth Patterson, AP Images
At Western Kentucky, Coach Bobby Petrino (shown after a motorcycle accident) questioned medical decisions made by a trainer who was later fired, the trainer said.
Controversy has surrounded Bobby Petrino for years. The former head football coach at the University of Arkansas won 21 games in his last two seasons there, earning the Razorbacks an appearance in a BCS bowl. But he was fired in April 2012, after wrecking his motorcycle with his mistress on board and later lying about her to the university.
When Mr. Petrino was hired as head coach at Western Kentucky University, in December, Danny Cobble, the head football trainer, showed up at his news conference to express support.
"I was excited about the opportunity to work with him," Mr. Cobble says. "I thought, 'This man is a winner. There's no way I can't work with this guy and learn something I could do better.'"
But their relationship was full of turmoil. Mr. Cobble says the coach frequently questioned his willingness to do things Mr. Petrino's way, and was prone to criticizing him in front of fellow staff members.
When Mr. Cobble was hired, in 2009, he was told he reported to Bill Edwards, director of athletic training and sports medicine. But he and Mr. Petrino had arguments over his reporting line, he says, with the coach believing that he worked for him.
Mr. Cobble says the coach also questioned his medical abilities, was impatient with return-to-play times, and pushed back on physicians' decisions.
Things boiled over, Mr. Cobble says, after a doctor ordered surgery for an injured player. When Mr. Cobble shared the news with Coach Petrino, he says the coach suggested treating the injury with cortisone. The player got a second opinion but ultimately had the surgery. (Through a spokesperson, Mr. Petrino declined to comment.)
In early April, e-mails between Mr. Cobble and Andy Wagner, director of football operations, which The Chronicle obtained through a records request, describe communication problems among players and staff. A few weeks later, Mr. Cobble was called into a meeting with Mr. Edwards, his supervisor, and Todd Stewart, the athletic director, to discuss his future with the program. He was subsequently fired.
He wishes that Mr. Stewart, who would not comment on a personnel matter, had done more to stand up for him.
"He had a choice," Mr. Cobble says, "and truthfully, I think he went with the million-dollar deal instead of what's right."
While many trainers want to distance themselves from coaches, others have embraced the idea of working for them. Arnold Gamber, who was head football trainer at Auburn University for about 10 years, starting in 1999, worked directly for Tommy Tuberville, a head football coach there. (He says that his bosses also included medical professionals, but that Mr. Tuberville wrote his reviews.)
Mr. Gamber was comfortable working for the coach and feels he never shortchanged players. But he understands how people could see a conflict of interest.
"Was I loyal to Tommy? Yes. But my main goal was to the kids," he says. "Really deep in my heart, I know that's why he kept me around."
But some players felt he didn't have their best interests in mind. In 2009, Austin Chaz Ramsey, a former starting lineman for the Auburn football team, sued Mr. Gamber in federal court, arguing that the athletic trainer had ignored a doctor's orders and pushed him into a strenuous rehabilitation program too soon after back surgery. According to court filings, the exercises caused Mr. Ramsey to reinjure his back, requiring additional surgery and other complications that prevented him from playing football again. A judge found no proof that Mr. Gamber had done anything improper. But a similar complaint filed by Mr. Ramsey against Auburn and one of its former strength coaches is pending in Mississippi state court.
Soon after Coach Tuberville resigned, in late 2008, Mr. Gamber lost his job, too. Ten months later he landed back in the game, thanks to Mr. Tuberville, who had just taken over at Texas Tech. But when the coach left for the University of Cincinnati, last December, Mr. Gamber did not try to follow him.
This summer he started a job at the University of West Florida, a Division II program in Pensacola.
The idea that coaches have too much power over medical professionals has prompted nearly a dozen health associations to revisit their guidelines in recent weeks.
In July the National Athletic Trainers' Association, in collaboration with five medical groups, including the American Medical Society for Sports Medicine, released a stern set of recommendations.
The guidance makes clear that members of the sports-medicine team should not report to coaches, and describes the legal duty of team physicians to guide return-to-play decisions.
At least 36 states require athletic trainers to report to medical professionals when making medical decisions. Those who don't could lose their certification.
The groups also recommend that colleges create policies governing the hiring and firing of athletic trainers. And the proposals put pressure on athletic directors to avoid ceding authority to coaches on personnel decisions involving medical staff.
In late July, six medical associations, including the American Orthopaedic Society for Sports Medicine, updated a physician consensus statement, emphasizing that trainers must report to a team physician on medical issues. The document also flags ethical conflicts, including coercion from coaches and administrators.
The NCAA has also joined in, endorsing the trainers' guidelines and sending a strong signal about how quickly players should return to the field.
"Under no circumstances should a student-athlete diagnosed with a concussion return to a sports activity the same day," its concussion guidance now states.
The association has added language to its Sports Medicine Handbook clarifying proper oversight in medical decisions. It hopes to ensure that athletic trainers and other sports-medicine officials avoid repercussions when their return-to-play decisions do not align with the expectations of coaches.
But Brian Hainline, the NCAA's chief medical officer, cautioned that the association's powers are limited.
"We can say, 'This is how we believe medical care should be delivered,'" he says. "That said, the NCAA is not the NFL. We can't just shift and say, 'Now everyone's going to do this.'"
Given the persistent concerns with concussion management, some critics believe the NCAA should rethink its responsibility.
"This is such an urgent problem that the national governing body needs to step up," says Chris Nowinski, executive director of the Sports Legacy Institute, which studies the effects of brain trauma in athletes and advocates on their behalf. "This is a clear situation where athletes need to be protected, and they're not being protected."
He would like to see the NCAA expand its oversight of institutions and police the rogue offenders. "They're the only group that could punish offenders," he says, "and make the punishment so large that you'd never hear a coach question a medical decision again."
Jonah Newman contributed to this article.