In January 2017, the National Athletic Trainers' Association (NATA) Board of Directors restructured and expanded the NATA College/University Athletic Trainers' Committee (CUATC) into the Intercollegiate Council for Sports Medicine (ICSM). The ICSM was developed to bridge the gap between the different groups within collegiate athletics (such as between Division I schools and junior colleges) to foster more conversation from ATs with varied backgrounds.
Murphy Grant, Senior Associate Athletic Director and Athletics Health Care Administrator at Wake Forest University, is also Executive Chair of the ICSM. As an AT dedicated to student health and safety, he spoke to us about the evolution of the medical model and the landscape of different models of care.
The NATA participated in a recent episode of ESPN's Outside the Lines that discussed medical models and models of care. The term medical model describes when athletic trainers and other health care providers have supervision of a physician and that physician works through a hospital and/or student health. (As described in 2017 Journal of Athletic Training article: “In these models, athletic training services are housed outside of the athletics department and conjointly with either an academic system or student health services [medical].”)
Prior to the ESPN episode, we (the ICSM) designed and distributed a survey asking collegiate athletic trainers questions regarding the delivery of health care on their college campus. The results were eye opening: the survey revealed many athletic trainers felt pressured by coaches to play student athletes in a game or to practice while injured; there were also instances of coaches playing student-athletes after they were deemed “out” by the AT or physician.
This information made us really think about the healthcare that is being provided and what the best practices for an ideal model was, and what should it look like. So in conjunction with a group of collegiate administrators, conference administrators, athletic trainers, and physicians, we met and discussed what type of information was currently out, what research was done. As the group continued to meet we decided to move from a direction or term of “medical models” to “models of care.”
We did that because not every institution has an association with a medical school/center or even a student health center. We wanted to explain what is necessary to provide quality patient care while also maintaining medical autonomy.
At the University of Kansas, where I previously worked, the department moved into a medical model, where the athletic trainers and staff involved with strength, conditioning, and nutrition became employees of the University of Kansas Health System and no longer employees of the athletic department. That was a “medical model.”
At Wake Forest, the opportunity presented another model of care: I am a healthcare provider, but I'm also a senior-level administrator. That means in my current role I have very little patient care responsibilities, but all of the athletic trainers, strength and conditioning coaches, and nutrition and sports psychology professionals report to me as a health care provider, as opposed to the senior administrator (who doesn't have a medical background), or a compliance director (who doesn't have a medical background). So we identified the different ways to implement a model of care where the reporting lines don't lead to coaches and/or administrators who don't know medicine or the health care aspect of our role.
Absolutely. In my current role, I can have the candid and sometimes difficult conversations with the coaches regarding a student-athlete's health, safety, and ability to play, and it takes pressure off the athletic trainer and/or the strength coach.
It can be an uncomfortable position for the athletic trainer, who works side-by-side with the coach, to have those kinds of conversations, so this gives the person who oversees this department (at Wake Forest, me) an opportunity to step in and address any issues at a high, administrative level. Medical autonomy is important when it comes to the care that is provided. Here is a way to separate that and support/grant medical autonomy so ATs and physicians can make return-to-play decisions without pressure from coaches.
That's true—and that's one of the reasons why I looked into this position. My athletic director here believes in and understands the importance of health care for the student-athletes. I had a great time at Kansas for 13 years, but the Wake Forest role was important as I have continued traveling all over the country to discuss models of care and health care for student athletes, which I've been doing for many years already. Since I started at Wake Forest in August 2019, I've spoken with several other schools about my role, our structure, and how it's working—as well as how we're able to make it work.
Not every school has a medical school attached to it, so having the opportunity to explain ways to develop a structure that provides high-quality, independent medical care and medical autonomy is important.
Every institution is different, but as a whole, most coaches can raise issues they face with an administrator. And that administrator goes to the athletic director or they try to incorporate and involve the director of sports medicine on these campuses. Now, in this new model, concerns about health care can be discussed with a person in an administrative oversite role (whom is a licensed health care provider) like the one I have—but they have to understand that having these conversations, whether it's with someone at the hospital or someone like myself, results in the best plan from the health care standpoint of the student athletes. That approach might not always be in line with what the coach assumes is the right path.
The NATA developed a document called Best Practices and the Implementation and Structure of Medical Care for College Athletes that will be shared at every level of collegiate athletics throughout the country. It discusses the patient-centered model of care—including medical evaluation and supervision, medical autonomy and decision making—plus how to build this model, similar to what we've built at Wake Forest.
If you choose to have a connection to a medical center, maybe you build it through there, but what's important is getting the word out on how this model provides quality care, protects the student athlete, and gives athletic trainers and physicians medical autonomy.
Will the model change the current level of care? Hopefully, that level of care is already really high. What the model can do is avoid communication issues and situations where medical providers don't feel pressured that their jobs are on the line if they don't play an athlete and do what is in the best interest of the student-athletes' health.
Coaches and ATs, we're all on the same team, and we share the goal of protecting student athletes. I've had conversations with coaches where I say, “You all travel all over the country, even internationally, to recruit athletes and to talk up our institution. You're sitting in front of these parents and telling them that their kids are going to get a great education and play a sport at a high level, and that you're going take care of them. Well, the athletic training staff is on your team and wants to take care of them as well. So it's important to trust and support us because we're here to take care of the athletes you're recruiting and bringing into the institution.”
These conversations are opening up their eyes to see it that way—as opposed to viewing that AT as the bearer of bad news: this athlete can't practice or play today. That's just one of the many things ATs do.
The question is, how do we all engage to do this together? I think this is a start. So in 2020 we're looking to circulate the best practices document and continue conversations about the different medical models and continue to build a system around the country that is both supportive of all individuals involved in student health—the AT, sports performance, nutrition, sports psychology—but also continue to provide the highest levels of care to the student athletes.