The Spot

No, FIFA and Jill Ellis, Team Doctors Are Not Neutral Arbiters of Concussions

USA’s goalkeeper Hope Solo helps teammate Morgan Brian after she collided with a German player during their 2015 FIFA Women’s World Cup semifinal match at Olympic Stadium in Montreal on June 30, 2015.

Photo by NICHOLAS KAMM/AFP/Getty Images

The U.S. women’s national team’s 2-0 victory over Germany in the World Cup semifinal on Tuesday was, in many ways, glorious. The Americans passed better, ran faster, and defended more fiercely than they had all tournament, thoroughly outplaying the top-ranked team in the world. Carli Lloyd’s textbook penalty conversion, followed by her assist to Kelley O’Hara for the team’s second goal of the evening, left no doubt that the Americans deserved their win.

But the triumph was bittersweet, thanks to a gruesome cranial collision between American Morgan Brian and German Alexandra Popp in the 28th minute and the medical decision that ensued. With Popp bleeding profusely from her hairline and Brian looking dazed, there was a real possibility that either or both players had suffered a concussion. But after being examined by their respective team doctors for a few minutes, both players continued playing for almost the entire game. (Brian is also expected to play in the final on Sunday.)

This was a bad outcome from a medical perspective. Women are at higher risk of concussion than men, possibly due to the structure of their necks, and soccer is the most dangerous sport for women in terms of brain injuries. Concussions are extremely dangerous both in the short term and in the long term. People with concussions must avoid strenuous activity for days or weeks after the initial jolt, since you’re at higher risk of additional concussions when you’re recovering from a concussion. A second concussion can cause a rare, fatal condition called second impact syndrome. In the long term, repeated knocks to the head are associated with chronic traumatic encephalopathy, which causes memory loss, depression, and dementia.

Diagnosing concussions isn’t easy. It takes up to 15 minutes for a doctor to properly evaluate a player for a concussion by asking her questions about her symptoms. Scientists are at work on a blood test that can objectively diagnose a concussion within a few minutes, but we are still years from having that technology available on the field.

What can change now is the way players, coaches, referees, and doctors respond to head injuries. The problem with soccer is that the rules of the game seem almost uniquely ill suited to the proper evaluation and treatment of concussed players. This is in large part because coaches have only three substitutes per game, and once a player is subbed out, she can’t come back on. In basketball, an injured player can be subbed out, examined, treated, and subbed back in; in soccer, the stakes of removing an athlete from play are much higher.

So coaches are basically incentivized to keep injured players in, so they don’t waste one of their substitutions. Meanwhile, team doctors—who are charged with determining whether players should stay on or come off, based on a very cursory examination—are incentivized to make their bosses happy by keeping the player in. This is not to say that team doctors are bad people or bad doctors; just that their job involves a fundamental conflict of interest. Referees’ top priority, meanwhile, is to keep the game going, and players—well, players have maybe the worst incentives of all. For most of their careers, elite athletes are told to push through pain and discomfort, to subjugate their own needs to the needs of the team, and to win at all costs. As we’ve seen in the NFL, this can be a disaster when players face brain injuries. But you can’t expect players to suddenly prioritize their long-term health over their thirst to win, just because they’ve been hit in the head.

So this is what soccer is up against: No one on the pitch has any incentive to ensure that players who’ve been hit in the head are properly evaluated and treated. The easiest and most effective way to change how head injuries are handled would be to make the desires of coaches, players, refs, and team doctors irrelevant. In an ideal world, there would be an independent, unbiased doctor on site with the authority to order players off the pitch for a thorough evaluation. To avoid interrupting the game too much, and to avoid penalizing the team of the injured player, coaches could be allowed to temporarily put in a substitute player while the injured player is being evaluated. If the player is deemed healthy enough to keep playing, she would be allowed to return to the game; if not, the substitution would be permanent. Either way, the involuntary substitution wouldn’t count as one of a coach’s three regulation-time subs.

But let’s be serious: FIFA is terrible at taking steps to protect players’ safety, and that’s unlikely to change anytime soon. In the real world, without changing any rules or protocols, is there anything that can be done to protect players?

It would help if coaches—who arguably have the most power in situations where a player is injured—stopped passing the buck. USA coach Jill Ellis and Germany coach Silvia Neid did just that after the collision between Brian and Popp on Tuesday. “I have absolute faith and trust in our medical team to do the right thing. I would never question our doctors,” Ellis told the New York Times’ Jeré Longman. Neid went even further, saying, “If the player says to our doctor she is well, and the doctor can look in her eyes and can verify that, then I don’t know why we need a neutral physician.”

It’s willfully naïve for a coach to believe that a doctor isn’t influenced by his bosses’ and colleagues’ strong desire for a certain outcome—and it’s plain ignorant to believe that a doctor can diagnose a concussion just by looking in a player’s eyes. Given the current rules and regulations of professional soccer, coaches have the most control over what happens after a player gets hit in the head—and they should take responsibility for that decision.

They should also err on the side of safety. It’s not easy to play with 10 women, or to spend a valuable substitution, in order to take a star player off the pitch for a thorough, 10- to 15-minute evaluation—but it’s the right thing to do. And it’s better for a team, in the long run, if the players are healthy and if they know their coach is looking after their best interests.

There is also an obvious role fans can play in changing the soccer culture that brushes off head injuries: Stop praising players for continuing to play after getting hit in the head. On Tuesday night, after both Popp and Brian kept playing following their nasty collision, I saw plenty of tweets commending both players for their toughness. One Fox broadcaster acknowledged Brian “looked like she was concussed,” before immediately praising both women for continuing to play. If, as fans, we care about our favorite players, we need to root for them to come off the field after head impacts. I long for a day when an arena full of USWNT fans chants, “Take her off! Take her off!” for an American player who’s gotten hit in the head—not because they want to stop watching her play, but because they care about her too much to let her keep playing.