The NFL has a Concussion Problem

The NFL has a concussion problem. The league may not be able to fix it, but all experts should glean an important lesson from the crisis which could dismantle the entire sport.

The NFL’s concussion problem continues. On Sunday, December 10, 2017, Tom Savage, the quarterback for the Houston Texans, was hit in the offensive backfield was left twitching on the ground. He exited the game briefly but returned minutes later. Once back on the field, it was evident to officials that Savage was suffering the effects of a neurological injury. He was removed again and taken to the locker room for evaluation. A week later Savage did not return to the field for the Texan’s next game. Savage’s brief return to the field has renewed suspicions that the league is unable or unwilling to protect players from brain injuries.

For several years the NFL has been under scrutiny for brain injuries among players. In 2013 the NFL reached a $1 billion settlement with former players who suffered ill health attributable to brain injuries. The league has also changed several game rules in hopes of reducing head injuries. They have instituted stiff penalties and fines for high risk forms of tackling and hitting. The league has also created an independent scientific advisory board to identify and support leading research in concussions and brain injuries. They have announced $100 million in funding toward scientific research in brain related injuries. They have educated coaches and trainers to help identifying injuries.

One action the league has taken since 2013 is the introduction of neurological experts. Independent head-injury experts are now on the sidelines of each game with concussion assessment authority. This includes trained medical experts in the press boxes who help identify players who may have suffered a head injury. The neurological experts are authorized to remove players from the field, perform prolonged injury assessments, and withdraw players from games regardless of what the players, coaches, or team doctors may say.

Of course, neurologists on the sideline of a football game cannot eliminate head injuries on the field. They can, however, assist players when an injury occurs, and reduce the chance that an injury becomes worse. The most important treatment for concussion is rest, which is antithetical to NFL culture. It is unlikely therefore that players, coaches, or team staff, who are motivated to win games can consistently protect a players’ long-term health and the league’s best interest.

This of course is where the NFL’s independent neurologists have an important role. Given adequate authority and autonomy the neurologists can protect players from the catastrophe of wide spread debilitating brain injuries. Quickly diagnosing head injuries and prescribing treatment, which in most cases means the player’s removal from the field, may be bitter for the teams and the fans, but highly beneficial to the players and league.

Ergo, the mistake with Tom Savage was an important event for the NFL and an important lesson for all other experts more broadly.

One role that experts often play is the position of expert sentry. Sentries pass judgment and approve or deny entry. Due to their unique training or experience, experts are frequently put into this gatekeeping position where they are authorized and expected to guard an organization from unwanted people or things. Organizations have used expert sentries throughout history and in almost every industry. Corporate recruiters who make hiring decisions are expert sentries. Judges who approve or deny search warrants are expert sentries. Doctors who select patients for clinical trials are expert sentries. And of course, neurologists on the sideline of NFL games are expert sentries.

Of course, experts also wear other hats. NFL neurologists, for example, don’t just say to athletes, “Yes, you may play.” Or, “No, you may not.” They prescribe treatment. They council with other doctors and trainers. They do what they can to ensure the health and safety of the players. But in the narrow role of sentry their decisions are binary. They decided if someone is in or out, approved or denied.

As simple as a binary decision may appear to an outsider, there are often weighty factors which contribute to any sentry’s decision. Because of complexities and the lack of immediate information, it can be difficult for sentries to ensure their decisions are reliable and consistent. Sentries may occasionally deny admission to one person who should have been admitted, while granting admission to another person who should have been denied. Binary decisions carry the risk of false positives as well as false negatives, and both types of errors can be vexing for the best experts and their organizations.

For sentries, one type of error is almost always more desirable than the other. In the NFL, for example, when a neurologist decides that a player has a brain injury, when in fact the player does not, the diagnosis is a “false positive” and the player is unnecessarily removed from a game. In this case the health consequence of a false positive is benign. There is no risk of hurting a player by treating him unnecessarily for a concussion. Of course the false positive does carry other negative implications but not regarding the player’s health.

False negatives in the NFL (falsely judging a player to be fit for play when he is actually seriously injured) can have catastrophic consequences for the players, the teams, and the league. Long-term health problems and premature death are just a few problems connected with concussion. The lopsided difference between a false positive and a false negative should lead to a diagnosis bias in favor of false positives. NFL neurologists should be expected to err on the side of caution and remove players from games on the suspicion of concussion, even if one does not exist, and should not allow players to return to games unless they are certain the player is fully healthy. This is why Tom Savage’s return to the game in Houston is so alarming. The decision was in error and the diagnosis bias was insufficient.

All experts who serve as sentries are subject to error, both false positives and false negative. And, as important as it is for sentries to make the right decision, it is even more important that sentries make the better of the wrong decisions. It is better to remove a healthy NFL player from the field than to allow an injured player to compete. It is better to wrongly ground an airplane than to wrongly put an airplane in the sky. It is better for a court of law to wrongly acquit than wrongly convict. Both decisions are wrong, but one error is more egregious than the other. One decision is the right-wrong and other is the wrong-wrong.

Taking a page from the NFL playbook, experts need to know when they are playing the role of sentry and what their binary decisions can be. They need to understand and abide the decision bias, and avoid above all else, making the wrong-wrong decision. The players need expert sentries to protect them from themselves. And, the league needs expert sentries to ensure the long-term viability of the entire sport.

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