Medical Supervision of High School Football in Chicago
Does Inadequate Staffing Compromise Healthcare?
Pietro M. Tonino, MD; Matthew J. Bollier
THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 2 - FEBRUARY 2004
BACKGROUND: Football has the highest injury rate among high school sports, yet few studies have assessed medical staffing of high school games and practices.
OBJECTIVE: To gather information from Chicago public high schools to evaluate medical supervision of varsity football games and practices.
METHODS: Athletic directors of all 77 Chicago public high schools were faxed questionnaires to complete. If questionnaires were not returned, investigators called athletic directors, and the survey was then completed over the telephone and the results tallied.
RESULTS: A total of 59 (76.6%) of the surveys were completed by the schools. Of the 47 schools with football programs, 10.6% had a physician on the sideline at games, 8.5% had an athletic trainer present, and 89.4% had a paramedic available. No high school reported having a physician or paramedic present at football practice, and only one school had an athletic trainer available. Hence, in all but one school, coaches were the only staffers available at practice to deal with medical problems. In 89.4% of the schools with football teams, coaches were certified in first aid and cardiopulmonary resuscitation.
CONCLUSION: Comparison of this study with a similar one done in 1980 reveals that, despite greater recognition of athletic injuries, appropriate medical supervision during games and practices for high school athletes is still lacking. Better care of high school football players may be achieved by the use of certified athletic trainers. In addition, physician involvement may be improved by increasing musculoskeletal training for physicians in medical school and family medicine training.
The ability to diagnose and treat injuries in college and professional athletes has improved during the last few years, but this has done little to improve care for the largest group of athletes, the high school athletes. Estimates reveal that more than 1,000,000 high school students play football in the United States.1 The injury rate among high school football players has been reported to be between 21% and 50%,1-3 and football has the highest injury rate among high school sports, with 1.97 injuries per athlete.4 DeLee and Farney5 found that the incidence of injury among Texas high school football players was 0.506 injuries per athlete per year. Given this level of injuries in high school football, one might assume that physicians are available to provide adequate, timely care at games. However, studies3,6 demonstrate that, depending on state and school size, between 27% and 82% of high schools do not have a physician at high school football games.
The schools that are able to provide physicians or athletic trainers are usually larger schools in wealthier areas.3 In 1980, Porter et al7 studied medical coverage of athletes in 191 private and public high schools in and near Chicago and found that 42.4% of all schools surveyed had physicians present at home football games, compared with only 12.5% of Chicago public schools. Of non-Chicago public schools, 57.1% had a full-time athletic trainer, compared with only 2.5% of Chicago public schools.
We sought to examine the adequacy of medical coverage during varsity football games and practices in the Chicago public schools. The information gathered will foster a better understanding of steps that can be taken to improve injury detection and treatment at the high school level, an important (but not, of course, sole) part of comprehensive medical care.
We designed a questionnaire to evaluate available medical coverage at home football games in the Chicago Public School System (table 1). The survey requested information about personnel available to assess medical problems at home football games and at practices, and it also sought information about cardiopulmonary resuscitation (CPR) and first aid certification of these staffers.
We obtained a complete listing (including telephone and fax numbers) of all 77 high schools in the Chicago Public School system from the Office of High School Development. We faxed questionnaires to athletic directors of the schools and asked them to return the completed form. Schools whose surveys were not returned were contacted by telephone.
Of the questionnaires faxed to all Chicago public high schools, only 11 (14.3%) were completed and returned. The remaining 66 athletic directors (85.7%) were called, and 47 athletic directors completed the phone surveys, giving a total of 59 (76.6%) completed surveys. Twelve of these schools (20.3%) had no football team.
Of the 47 (79.7%) schools that had a football team, 5 (10.6%) had physician coverage of home varsity football games; 4 were family physicians, and 1 was an orthopedic surgeon. Of the schools with teams, 4 (8.5%) reported that athletic trainers were present at home varsity games, while 42 (89.4%) had paramedics at these games. No schools arranged for an ambulance to be on site during games, but they had ambulances on call. Of the schools with football teams, 42 (89.4%) of 47 schools had coaches who were certified in CPR and basic first aid.
At football practice, no school had a physician or paramedic present. Only 1 of 47 (2.1%) schools that had football teams had an athletic trainer present at practice to deal with medical problems. In 46 of 47 (97.9%) schools, coaches were the only ones available at practice for medical problems.
In 1980, Porter et al7 reported that 12.5% of Chicago public schools had a physician available at home football games, and 10% of Chicago high schools had an athletic trainer on staff. Our study demonstrates that these numbers have not changed much in the ensuing years.
Medical professionals at games. A lack of medical coverage at high school football games and practices persists in the Chicago public schools. Only 10.6% of responding high schools reported having a physician present at home football games. In addition, only 8.5% of schools had an athletic trainer at games. In contrast, one study in California reported that 71.2% of high schools surveyed had a football team physician, and 68.8% of schools had an athletic trainer solely assigned to the football team.2
We found that the number of Chicago high schools with paramedics present at home football games has increased substantially since 1980 (53.7% in 1980 versus 87.5% in our study). Other studies have shown that the percentage of high schools with paramedics providing game coverage is much lower. Vangsness et al2 reported that medical coverage of home football games in California was provided by a physician 72.2% of the time and a paramedic or physician assistant only 17.6% of the time.
The percentage of Chicago schools with an athletic trainer available at practice has not changed significantly since 1980. We found that only 2.1% of responding high schools reported having an athletic trainer available at practice. In 1980, 2.5% of Chicago high schools had a full-time athletic trainer covering boys' programs.7 In contrast, 82% of South Carolina high schools surveyed had a trainer assigned to the football team.3
Even though more injuries occur per unit time during games, studies3,7 reveal that 70% of high school injuries occur during practice. None of the high schools that we surveyed reported having a physician present at practice. Other studies1,2,7-9 have shown a similar lack of medical coverage at practices and scrimmages.
Why so few physicians? Several factors are responsible for the lack of physician availability at games and practice. Many physicians who previously would agree to volunteer are instead now concerned with limiting their liability.1 Several team physicians for professional athletes have seen their malpractice premiums quadruple in recent years.10 Physicians who cover high school athletes have also had their premiums increase, and many cannot afford the additional cost.
Another reason for decreased physician availability involves a lack of musculoskeletal training. One study11 in the United States reported that 57 of 122 medical schools surveyed (46.7%) had no required instruction in musculoskeletal medicine. Similarly, in the 16 Canadian medical schools, only 2.3% of total curriculum time was spent on musculoskeletal education. The clinical training among American medical schools reveals a similar deficit: Only 20.5% of American medical schools require a musculoskeletal clerkship during clinical training.11 Consequently, many physicians are not confident in their ability to evaluate and manage musculoskeletal injuries, and many primary care physicians do not feel comfortable volunteering to cover athletic events. Increasing the amount of time spent on musculoskeletal education should generate more physicians qualified to cover high school athletic events.
Cost and paraprofessionals. Some may argue that most public schools cannot afford the added expense of a physician or even an athletic trainer. However, we found that most physicians providing medical coverage are not financially compensated by the school. Carek et al3 reported that none of the 137 high schools they surveyed directly compensated a high school team physician for providing medical coverage. This finding implies that school district budget constraints should not affect the medical coverage provided by physicians.
In our study, we found that paramedics provided sideline coverage at the vast majority of football games (89.4%). Although paramedics are trained to provide early care and coordinate transportation of injured athletes to the nearest hospital, they lack appropriate training for sports injuries. The paramedic certification curriculum in Chicago-area programs devotes only a few hours to managing fractures, strains, and sprains and to training in methods of splinting. No time is spent on orthopedic clinical rotations, and trainees receive no formal training in evaluating athletic injuries or deciding when an athlete should be allowed to return to the game.
Addressing the shortfall. Only 2.1% of Chicago public schools reported having an athletic trainer present at practice, so the responsibility of medical care inevitability falls to the coach. In nearly all schools, coaches were the only ones available at practice to deal with arising medical problems. Even though we found that most coaches were certified in CPR and first aid, they are not trained to provide emergency medical care, determine when a player is injured, and assess when a player can return to competition. It is unreasonable to expect that coaches concurrently attend to their own coaching duties and decide whether an athlete is fit to return to practice or play.
Certified athletic trainers can supervise all aspects of healthcare delivery while working closely with team or community physicians.2 In addition to game coverage, they would be available regularly to coordinate return-to-play issues and facilitate communication between football players, coaches, physicians, and the administration. Athletic trainers would relieve the coach's responsibility of providing medical care and create a safer environment for the high school athletes. They are specifically trained to prevent athletic injuries by stressing the importance of adequate conditioning. They also are trained to evaluate acute injuries, provide first aid, and manage rehabilitation.
Solving the Problem
The medical coverage of high school football games in the Chicago public schools has not changed much in the last 20 years. Paramedics are responsible for nearly 90% of game coverage, but most of them lack formal education in evaluating and managing athletic injuries. At nearly all of these schools, coaches serve as the only staffer available for dealing with medical problems at practice.
With few physicians or athletic trainers serving the schools, the responsibility of determining when an athlete can return to play falls to the coach or the paramedic, neither of which is adequately trained for such decision making. Better care of high school football players may be achieved by employing certified athletic trainers. In addition, physician involvement may be improved by increasing musculoskeletal training for physicians in their medical school and family medicine training.
Dr Tonino is chief of sports medicine in the department of orthopedic surgery and rehabilitation at Loyola University Medical Center in Maywood, Illinois. Mr Bollier is a fourth-year medical student at Loyola University's Stritch School of Medicine in Maywood. Address correspondence to Pietro M. Tonino, MD, 2160 S First Ave, Maywood, IL 60153.
Disclosure information: Dr Tonino and Mr Bollier disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.