A survey of college athletic trainers revealed concern about coaches' influence and pressure to make calls not in the best interest of student-athletes. (4:49)

About 19% of college athletic trainers reported in a recent survey that a coach played an athlete who had been deemed "medically out of participation," according to results released Tuesday by the National Athletic Trainers' Association that reveal concerns about college coaches having too much influence in medical decision-making.

NATA president Tory Lindley said such actions put athletes at a "major risk."

"To think that we're in 2019 and that would still happen is really concerning," he said. "It should be concerning for everyone involved in that institution. It should certainly be concerning to the parents, and certainly concerning to the athlete."

The findings come almost three years after the NCAA passed legislation specifically prohibiting coaches and athletic directors from influencing medical decisions and requiring a reporting structure in which athletic trainers and team physicians would have final say on return-to-play determinations.

The survey findings also coincide with a spate of recent high-profile incidents where athletes either died or suffered serious injuries or complications during workouts, including the heatstroke deaths of Maryland football player Jordan McNair in June 2018 and Garden City (Kansas) Community College football player Braeden Bradforth in August.

Two former Oregon football players are suing their university after they and a teammate were hospitalized after a workout in January 2017 and diagnosed with rhabdomyolysis, which is a breakdown of muscle fibers that can lead to kidney damage. The University of Houston is also investigating how several of its women's soccer players suffered rhabdomyolysis after a January workout.

NCAA legislation prohibits coaches and athletic directors from influencing medical decisions. Aaron M. Sprecher via AP

Murphy Grant, chairman of NATA's Intercollegiate Council for Sports Medicine, said the demands on student-athletes during practice and play have been growing, from the intensity of summer conditioning workouts to the mental stress of increased competition.

"As those stresses get high, so does the intensity of training, so do some of the health issues that we're dealing with," Grant said. "From an athletic training standpoint, we want to make sure that we're providing that quality care without having to look over our shoulders on what's going on or feeling any type of pressure."

According to the survey, about 36% of respondents reported that a coach has been able to influence the hiring and firing of sports medicine staff. And of athletic trainers who reported that happening, 58% then reported being pressured by a coach or administrator to make a decision "not in the best interest of a student-athlete's health."

Although athletic trainers can feel pressure in specific situations, Lindley said the pressure actually "manifests itself in a culture" over time, and much of that has to do with the structure of the sports medicine staff -- and who is in charge of hiring and firing.

The 2016 NCAA legislation states, among other things, that each school should establish a structure that "provides independent medical care and affirms the unchallengeable autonomous authority of primary athletics health care providers," namely team physicians and athletic trainers.

The survey, which allowed respondents to remain anonymous, draws attention to several concerns that Lindley said athletic trainers rarely discuss publicly.

"It's really difficult for an athletic trainer to come forward and talk about the gravity of those situations," Lindley said, because they're worried about losing their jobs. Several athletic trainers contacted by Outside the Lines for this story declined to speak on the record, with some saying they were worried about being stigmatized if they said anything negative about a coach or program.

One athletic trainer, who asked to remain anonymous, said a coach at a former job in a Division I program once intervened with some football players who were scheduled to have shoulder surgery. The coach wanted the players to participate in spring ball, and he approached them individually and talked a couple of them out of the procedure, which had been advised by the medical staff, the former athletic trainer said.

"It was totally inappropriate," he said of the coach's involvement.

play 1:39 Spears: 'It should be a crime' to play athletes not medically cleared Marcus Spears and Bobby Carpenter react to the amount of influence that college coaches have in the medical decision-making of athletes.

"If in fact athletic trainers have the ability to make independent medical decisions, they in turn should be evaluated on their abilities to make those decisions by another health care provider," Lindley said, and not coaches or non-medical staff.

Lindley, who is also Senior Associate Athletic Director for Health, Safety and Performance at Northwestern, said it's appropriate for coaches to get information on players' treatments and updates on when they're expected to return to play, but a coach asking a question of an athletic trainer is "drastically different" from a coach questioning an athletic trainer's decision.

"Coaches might question an athlete's toughness," Lindley said. "Might say, 'She's just not tough enough. Don't you think this ankle sprain has taken long enough?' And those types of conversations are some of the more benign but impactful ways in which health care providers feel pressure. A coach should not have any type of an opportunity to provide an opinion on whether or not those decisions are being made correctly. They lack the medical expertise to provide an opinion."

About 1,800 college athletic trainers responded to one or more questions in the survey -- which NATA emailed to its more than 9,200 collegiate members. Of those who responded, 43% said they worked in Division I sports. That closely represents the overall percentage of Division I athletic trainers among the association's total collegiate membership.

Lindley said the survey was designed to test how well schools were complying with the 2016 independent medical care legislation, and he found the results "concerning."

About a quarter of the respondents reported that they did not feel as though they had "medical autonomy" -- the unchallengeable authority to "determine medical management of athletes," at their institution. And about 52 percent reported that their programs follow the NCAA-legislated independent "medical model" of care, the association reported.

NCAA chief medical officer Dr. Brian Hainline said all schools are "obligated to comply" with the legislation, and those that don't should self-report an NCAA violation. An NCAA spokesperson was unable to provide information on whether any schools have self-reported, saying "the NCAA cannot comment on the type of self-reported violations, due to member-created confidentiality rules regarding the infractions process."

New NCAA recommendations, effective Aug. 1, further try to bolster the medical supervision of the strength and conditioning staff who design workouts to improve athletic performance. Strength and conditioning coaches, who typically get paid substantially more than athletic trainers, are often considered part of the coaching staff with direct lines to the head coaches. Although the NCAA requires they take part in a certification program, they are less regulated than athletic trainers who, in most states, must be licensed as medical professionals.

Kansas is removing its strength and conditioning staff from athletic department supervision. Tim Warner/Getty Images

The new recommendations state that strength coaches should report to sports medicine or sports performance supervisors, and not head coaches -- a move that is designed to align them more closely with athletic trainers. Questions about strength coaches have been a factor in some of the recent incidents involving college athletes who have died or been hospitalized after a workout, and they've resulted in strength coaches being fired or suspended.

In the spring, Outside the Lines surveyed the 65 schools in the Power 5 conferences about their strength and conditioning staffs; of the 57 that responded, almost all of them had strength and conditioning staff within the athletic department, and about 20% referenced some reporting line to a head coach. Just a few noted that medical staff did have some role in the supervision of strength and conditioning staff.

In May, Kansas became the one clear exception, announcing that it would take the NCAA's rules a step further and completely remove its strength and conditioning staff from athletic department supervision and make them report -- along with the athletic trainers -- up through the University of Kansas Health System. They are supervised by primary care physician Dr. Larry Magee and orthopedic surgeon Dr. Jeffrey Randall, who work daily onsite in the athletic facilities. Dr. Randall said the change in structure stemmed from the university's chancellor, Dr. Douglas Girod, a practicing head-and-neck surgeon.

"[Girod] wants physicians in charge, and just to make the whole process go better," Dr. Randall said. "If the coaches and the athletes and athletic trainers trust what you're doing, then the whole process goes better when it stays focused on the athlete, and for that trust to happen, you have to be here."

Even for a sports medicine staff, it's a unique move. According to the NATA survey, about 80% of respondents noted that athletic trainers were employed by the athletic department, although they could have reporting lines through other entities, such as a medical school, private health care group or student health center. In the Outside the Lines survey of the Power 5 schools, fewer than 10% indicated a primary reporting line mostly outside of athletics, although several responded that medical decisions were overseen by a team physician, who was often jointly or solely employed by a medical entity outside athletics.

Grant, the NATA collegiate committee leader, is the director of sports medicine at Kansas. He said the school had been providing medically supervised care to its athletes, and the change was not in reaction to any problem or incident at KU, but that the school wanted to set an example.

"We know that we have the physician backing, and the medical backing of any of the decisions that we make. They support the decisions. The decisions to return to play are coming from our physicians as well, and the support is there," he said. "For my job, me personally, and even my staff, it gives us a little more ease."