Hi. I’m Art Caplan, of the Division of Medical Ethics at the New York University (NYU) Langone Medical Center. Welcome to Close-Up With Art Caplan. This is an interview show where we have an opportunity to meet and talk with some of the leaders of healthcare in the United States and around the world. We have a very interesting subject today.
I want to welcome Dr. Brian Hainline, the first Chief Medical Officer of the National Collegiate Athletic Association (NCAA). There apparently hasn’t been a Chief Medical Officer before. Dr. Hainline began his career as a graduate of the University of Chicago, as a neurologist and a neuro-oncologist. He then found his way into working with pain and pain relief as a more general neurologist. How did you go from that to the NCAA?
Brian Hainline, MD: It’s a long road. I always dabbled in sports medicine, even when I was practicing neuro-oncology. I coauthored a book called Drugs and the Athlete and I was interested in drug use among athletes. I’m a former student athlete; I played tennis at Notre Dame. That kept me in the game, and then I was getting burned out with neuro-oncology. It’s a very tough field, and I was beginning to feel that it wasn’t for me.
A colleague and friend, Orrin Devinsky, runs the Comprehensive Epilepsy Center at NYU. He was at the Hospital for Joint Diseases at the time, because that’s where the epilepsy center started. He gave me a frantic call one night and said, “Brian, I’m getting bombarded with all of these consults about pain and orthopedic neurologic injuries, and I know you’re getting a little frazzled with neuro-oncology. Why don’t you come over and start a clinical and sports neurology section at NYU Hospital for Joint Diseases?”
I thought about it. It made sense. I was ready to get into general clinical neurology, and no sooner had I accepted the job when I got a call from the US Open Tennis Championships. They experienced a near-death in 1991 when a player had heat stroke. I was asked whether I would become Chief Medical Officer for the US Open. These 2 things happened around the same time. That is how life works sometimes, and ever since then I have been doing some aspect of sports medicine. Then the NCAA job was created — it kind of dropped out of the sky.
Dr. Caplan: Why did the NCAA decide that they needed someone in this medical position?
Dr. Hainline: It came from their president, Dr. Emmert. He has been in that position for a couple of years, and he has been trying to return to the roots of the NCAA. When it was created in 1906, the NCAA was all about the health and safety of college athletes, especially college football players. There were many deaths. He saw that health and safety were really not first and foremost at the NCAA. He created this job, and I interviewed for it and had a good interview.
Dr. Caplan: Do you have a staff and a budget or is it just you?
Dr. Hainline I have a staff of 7 and a budget, but like everyone else, I am always hoping that the budget will increase. I have been very well integrated not only within the full-time staff of the NCAA but, more important, among the membership. That is really what the NCAA is; it’s the 1100-plus colleges and universities that have varsity sports.
Concussion: It Isn’t Just Football
Dr. Caplan: Let’s jump into an issue that people think about as soon as we mention the NCAA, sports, and medicine, and that is concussions. Did that issue fuel some of the concern at the NCAA about bringing health to the fore? Given your background, is that something to think about?
But for the NCAA, it is a very important issue and we have to establish leadership in concussion. There is no simple answer. If you were to ask any serious scientist about concussion, the scientist would have to admit that we don’t even understand the natural history of concussion.Dr. Hainline: Concussion is certainly the elephant on the table. It’s a very important issue. There has been a lot of press with the National Football League (NFL). The NCAA has been getting a lot of press about this issue. It is a critically important issue and, in fact, it has not been at the forefront for neurologists. It was only 4 years ago that the American Academy of Neurology started a sports neurology section. I was one of the founding members.
Dr. Caplan: We hear a lot about concussion in football, but is that really where the main problem is, or do we have a much bigger problem with concussion?
Dr. Hainline: It’s much bigger than football. Football is what everyone talks about and that is primarily because of the NFL and the Congressional hearings that Roger Goodell participated in.
Dr. Caplan: It was a big legal settlement.
Dr. Hainline: Right, but it’s across all contact collision sports. It’s a very interesting question that we as a society need to ask: “Are sports really worth it?”
Dr. Caplan: Do you mean in terms of risks?
Dr. Hainline: What is the gain from sports and what is the possible risk? In certain contact collision sports, no matter what you do, there is always going to be a risk for concussion, and that risk will be 5%-10%.
It’s ice hockey for women and men, soccer for women and men, softball for women and baseball for men, plus wrestling and lacrosse. Football is just one of them. In fact, even in our internal data, the highest incidence of concussion is in women’s ice hockey.
Dr. Caplan: That’s interesting. So the elephant isn’t even where most people think it is.
Dr. Hainline: It’s not where they think it is, and quite frankly, most people don’t want to talk about women’s ice hockey. Everyone wants to talk about football.
The Mental Health of Student Athletes
Dr. Caplan: If you were looking beyond concussion, what else is on your plate that you are starting to pay attention to?
Dr. Hainline: Mental health is a huge issue. Neurobiologically, the ages of 18-22 are highly vulnerable. If you talk to any university president, he or she will say, “I’m concerned about mental health.” There is a high risk for depression, anxiety, and bipolar illness.
There is a lot of experimentation in college. There is drug and alcohol use. There are specific concerns about student athletes; some people identify themselves strongly as being athletes, and if they become injured, then where is their sense of identity? We had a 3-day mental health task force and are in the process of putting everything together in a book. It is going to be out in June, and we are going to launch it in the context of mental health awareness.
Dr. Caplan: Is that a bigger issue for athletes than it is for regular students in college?
Dr. Hainline: It’s different. If you look at depression and anxiety, most sports offer the student athlete protection from depression and anxiety. Moreover, in some sports (for example, lacrosse) there is more high-risk behavior, such as alcohol, nicotine, and marijuana use. There is something about who plays lacrosse and risk-taking behavior.
Dr. Caplan: We all know about rugby: “Let’s have a lot of beer after the game ends.”
Dr. Hainline: Yes, there is a cultural aspect to it. But with student athletes, there are other risk factors, according to data from the Olympics. These are very hard-working kids. They have given their lives to their coaches and others. Other issues, such as sexual abuse, have to be addressed. Issues such as binge drinking during the off-season are important mental health issues.
The data are still somewhat inconclusive, and we are still sorting out the difference between students and student athletes or between women’s basketball and women’s swimming, because those are different cultures, too.
A Pressing Need for More Data
Dr. Caplan: Do you think that we know enough about the health of student athletes when they first come to college? Do we have an adequate baseline against which to measure?
Dr. Hainline: We don’t have an adequate baseline. That is another project. If you were to ask what pie-in-the-sky project we could create, it would be longitudinal data from youth all the way to college and beyond. We are actually working on that possibility. We are collaborating with the National Institutes of Health and others who are very interested in this.
A simple solution would be to develop a universal, preparticipation physical examination, with a unique identifier that could be uploaded in such a way that it’s HIPAA compliant, and then we would have a universal database. We could begin to understand these issues. Look at the New York City Public School Athletic League; there are 35,000 kids and no athletic trainer.
Dr. Caplan: For the whole system?
Dr. Hainline: Yes. Where are the medical records? Many of these kids go to college and they play sports. Much is lacking, and it’s a societal issue.
Dr. Caplan: Do you think that people in primary care pay enough attention in high school, or junior high school, to the healthcare needs of athletes? Do we have some work to do on that front?
Dr. Hainline: We do have work to do. Most primary care providers are very busy, and I’m not convinced that they understand some of the most important elements of healthcare.
Overtraining and Early Specialization
Dr. Hainline: What are those important elements? It’s how much time is spent in training vs recovery. Overtraining has become epidemic in our society.
Dr. Caplan: The “playing baseball all-year-round” kind of thing.
Dr. Hainline: We call it “specialization.” It is the idea (which is not supported by the data) that if you specialize early, you are more likely to become a great player. What actually happens is that you are more likely to develop overuse injuries and become burned out.
Many primary care providers don’t understand the pressures that go with being an elite athlete or a specialized athlete. They don’t understand recovery or the temptations for drug use. They don’t understand that kids won’t be forthright about their injuries because they want to keep playing. They won’t even be forthright about their concussions.
Dr. Caplan: I’m not sure that they are forthright about anything at that age. I understand. It’s difficult, unless you really push or find ways to encourage them to come clean, to figure that out. It’s an excellent point.
What about in dealing with elite athletes or college athletes? Do you think that the level of care they receive is adequate? Do they have access to what they need in most schools? Are there special problems? For example, some athletes will say, “I don’t have money to eat. They gave me this scholarship, but I’m kicking around here without the ability to do very much.” Many universities have student health services, but are they meeting the students’ needs?
Dr. Hainline: It depends on the level. When people think about the NCAA and college athletics, most understand the NCAA to be the 3.5% that they see on TV.
Dr. Caplan: Yes, the Southeastern Conference (SEC) game of the week, for example.
Dr. Hainline: The big 5 conferences — the powerhouses, the Pac-12, the SEC big 10, or the Atlantic Coast Conference — are what most people see. In fact, most of the NCAA consists of Division III schools such as NYU. NYU has an incredible athletic training department. They have great access, but none of the programs have focused on the mental health of student athletes.
Some schools have a psychologist, but the psychology of the student athlete is not given as much importance as, for example, the overuse injury. We can do better there.
For the most part, a formula is followed. If you have this many sports and this many student athletes, this is how many athletic trainers you should have. For the most part that rule is followed, but if you talk to athletic trainers, they feel overworked and they sometimes feel underappreciated, because it’s a lot of pressure. There is another type of societal pressure on them to win all the time.
Pressure to Keep Athletes on the Field
Dr. Caplan: Do you reach out to the people who act as team physicians or consultants? They experience an enormous push-and-pull in terms of keeping athletes playing but also looking out for their health.
Dr. Hainline: It’s a very important point. It comes down to the foundation of what medical care should be, and that falls to the team physician and the athletic trainer. They are the foundation of care for student athletes. The primary role falls to the athletic trainer, who reports to the team physician. And what has to be ensured is that their reporting line does not conflict with what’s happening on the athletic side. The team physician and athletic trainer have to know that when they make a decision, it is made in the best interest of the student athlete and that their jobs are not at risk.
Dr. Caplan: Do you think that the primary focus still has to be on health, and that it has to be protected more than it is right now?
Dr. Hainline: It has to be protected enormously, but there is also an educational component. The great coaches understand that if a student athlete is healthy, he or she is more likely to perform better. For example, consider women distance runners. They had a high incidence of disordered eating because they wanted to be thin. They weren’t fueling their bodies enough. We showed unequivocal data that during a continuum of not eating properly, the athlete won’t perform as well. There are many instances like that, so we need to educate the coaches as well. Performance, health, and safety can work together.
Dr. Caplan: Would you say that trainers, who are sometimes caught between coaching pressure and the desire to look out for the athletes, need to be supported in making health the top priority?
Dr. Hainline: They need to be supported unequivocally in that domain. Last June we had an interdisciplinary conference with National Athletic Trainers’ Association and many medical groups. We are coming out with a statement about the importance of independent medical care. You have to ensure that there are no conflicts of interest. The trainer has to be able to say, “I make a medical decision that is in the best interest of this athlete, and my job is not at risk.”
Healthy Athletes Perform Better
Dr. Caplan: Does that lead to better performance?
Dr. Hainline: Absolutely. Many coaches are starting to understand that a healthy athlete is more likely to perform better. Furthermore, we don’t talk enough about women. We talk too much about guys playing football. Coaches sometimes put pressure on women distance runners (who have disordered eating, not eating disorders) to stay thin. We need to educate everyone: the coaches, the athletes, the trainers, and the parents. Being healthy improves performance.
Dr. Caplan: You haven’t been in this job a long time, but during that time, what keeps you awake? What issue do you worry about the most?
Dr. Hainline: When I started the job, even though I’m a neurologist, I didn’t appreciate how poorly concussion is understood. That keeps me awake, because I see all of the consensus statements out there. There are 42 definitions of concussion right now. Not one of them is purely evidence based.
As a result, we are going to form a partnership with the Department of Defense, because they have the same concerns and it’s the same type of population. We are going to be launching a joint study. I’m pretty confident that it will help to answer the question, “What is the natural history of concussion?” We need to take a step back and find out.
Dr. Caplan: While we are trying to get good tests and helmets with sensors, we don’t even really know what concussion is?
Dr. Hainline: We don’t even have baseline prospective, longitudinal clinical data.
Dr. Caplan: That is both depressing and exciting. It shows why they need you there. Let me thank you, Dr. Hainline, for spending this time with us on Close-Up with Art Caplan.