title: Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion.
abstract: BACKGROUND
  Anecdotal and qualitative evidence has suggested that some clinicians face pressure from coaches and other personnel in the athletic environment to prematurely return athletes to participation after a concussion. This type of pressure potentially can result in compromised patient care.
  
  
  OBJECTIVE
  To quantify the extent to which clinicians in the collegiate sports medicine environment experience pressure when caring for concussed athletes and whether this pressure varies by the supervisory structure of the institution's sports medicine department, the clinician's sex, and other factors.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  Web-based survey of National College Athletic Association member institutions.
  
  
  METHODS
  A total of 789 athletic trainers and 111 team physicians from 530 institutions.
  
  
  METHODS
  We asked participants whether they had experienced pressure from 3 stakeholder populations (other clinicians, coaches, athletes) to prematurely return athletes to participation after a concussion. Modifying variables that we assessed were the position (athletic trainer, physician) and sex of the clinicians, the supervisory structure of their institutions' sports medicine departments, and the division of competition in which their institutions participate.
  
  
  RESULTS
  We observed that 64.4% (n = 580) of responding clinicians reported having experienced pressure from athletes to prematurely clear them to return to participation after a concussion, and 53.7% (n = 483) reported having experienced this pressure from coaches. Only 6.6% (n = 59) reported having experienced pressure from other clinicians to prematurely clear an athlete to return to participation after a concussion. Clinicians reported greater pressure from coaches when their departments were under the supervisory purview of the athletic department rather than a medical institution. Female clinicians reported greater pressure from coaches than male clinicians did.
  
  
  CONCLUSIONS
  Most clinicians reported experiencing pressure to prematurely return athletes to participation after a concussion. Identifying factors that are associated with variability in pressure on clinicians during concussion recovery can inform potential future strategies to reduce these pressures.
authors.affiliation: Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA.|Sport Science Institute, National Collegiate Athletic Association, Indianapolis, IN.|Edmond J. Safra Center for Ethics, Harvard University, Boston, MA.
authors.forename: Emily
authors.initials: E
authors.lastname: Kroshus
authors.affiliation: Edmond J. Safra Center for Ethics, Harvard University, Boston, MA.|Interfaculty Initiative in Health Policy, Harvard University, Boston, MA.|Division of Sports Medicine, Boston Children's Hospital, MA.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Baugh
authors.affiliation: Center for the Study of Traumatic Encephalopathy, Boston University School of Medicine, MA.|Sports Legacy Institute, Boston, MA.
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Daneshvar
authors.affiliation: Center for the Study of Traumatic Encephalopathy, Boston University School of Medicine, MA.|Department of Anatomy and Neurobiology, Boston University School of Medicine, MA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Stamm
authors.affiliation: Sargent College of Health and Rehabilitation Sciences, Boston University, MA.
authors.forename: R Mark
authors.initials: RM
authors.lastname: Laursen
authors.affiliation: Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA.|Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, MA.|Department of Pediatrics, Harvard Medical School, Boston, MA.
authors.forename: S Bryn
authors.initials: SB
authors.lastname: Austin
mesh_terms: D000328:Adult; D001265:Athletic Injuries / Q000523:psychology / Q000534:rehabilitation*; D001291:Attitude of Health Personnel; D001924:Brain Concussion / Q000523:psychology / Q000534:rehabilitation*; D003430:Cross-Sectional Studies; D005260:Female; D005544:Forecasting; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000592:standards*; D000068958:Return to Sport / Q000523:psychology*; D013177:Sports / Q000523:psychology; D013178:Sports Medicine / Q000592:standards*; D013334:Students / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014495:Universities
keywords: college; conflict of interest; organizational structure; sex