Three years ago, the NCAA and sports medicine leaders worked to establish new rules that would limit the influence coaches have on the hiring, firing and supervision of sports medicine personnel -- part of a larger effort to ensure athletes receive sound medical care.
Violate the rules and schools risk being cited for NCAA violations.
But medical independence concerns remain, according to an Outside the Lines investigation. In one case, at Texas A&M, newly hired high-profile football and basketball coaches appear to have directed who will provide medical care to their players, according to documents obtained by Outside the Lines; it is "a direct violation of NCAA policy," said one sports medicine industry leader.
In 2016, based on input from the National Athletic Trainers' Association and other sports medicine agencies, the NCAA approved new rules aimed at guaranteeing medical independence for athletic training and sports medicine staff in the Power 5 conferences; last month, the rest of the Division I schools voted to approve the official piece of legislation as well.
The rules require sports medicine staff -- team physicians and athletic trainers -- to have "unchallengeable authority" over the medical treatment and return-to-play decisions for injured athletes. While it is common and accepted for head coaches to hire and fire assistant coaches and certain support staff, the new rules draw a line when it comes to medical staff, insisting that the employment, supervision and decision-making of team physicians and athletic trainers be made independent of coaches.
"The coach must be completely de-coupled from medical decision-making," an NCAA briefing document states, "and primary athletics health care providers must be in an environment in which making such decisions are free of any threat from coaches."
NATA president Tory Lindley said athletic trainers are influenced in their decision-making when they know a coach is responsible for their employment.
"Until there's zero evidence it still exists, there's going to be concern," he said. "It's the ultimate compromise in medical autonomy."
Dr. Brian Hainline, chief medical officer of the NCAA, told Outside the Lines that while coaches can have input and make suggestions on sports medicine staff, the hiring and firing decisions should be independent of coaches because allowing coaches to bring in their own medical staffs can create a conflict of interest.
"It sort of sets up the possibility of a relationship where I'm answering to the coach, and I shouldn't be answering to the coach. I should be answering to the call of medicine," Hainline said.
In January 2018, a month after Texas A&M hired Jimbo Fisher for $75 million over 10 years to replace Kevin Sumlin as head football coach, then-Texas A&M athletic director Scott Woodward signed off on two letters terminating the employment of Phil Hedrick, the school's associate athletics director overseeing athletic training, and Owen Stanley, its head football athletic trainer.
The letters state that Fisher was hired on Dec. 4, 2017, "and will want to hire his own staff, as in the industry standard."
Outside the Lines showed a copy of one of the letters to Hainline, who was instrumental in the 2016 passage of the NCAA's independent medical care rules.
"This is not the industry standard today, and it's not consistent with independent medical care legislation," Hainline said.
That might have been "just how things [were] done" several years ago, Hainline said. But in the years leading up to 2014, when the NCAA and sports medicine groups started to work on drafting the medical independence rules, he said there was an awakening to reject that status quo: "It's not right that coaches come in, and they bring in their medical team, and ... they have that sort of control over that medical team."
Lindley, of NATA, said Texas A&M's move was a "direct contradiction of NCAA policy. I'm not sure what industry they're in, but last I checked, they were an NCAA member institution."
In April, Texas A&M announced the hiring of Buzz Williams as men's basketball coach. The school fired the men's basketball athletic trainer, Matt Doles, who had been with the program for 14 years.
Outside the Lines obtained an April 9 email from Justin Moore, senior associate athletics director, regarding the men's basketball athletic trainer position, in which Moore writes that Williams "is bringing his guy with him from Virginia Tech." And indeed, athletic trainer Eddie Benion left Virginia Tech, where he worked with Williams, and is now Texas A&M's men's basketball athletic trainer, making almost $100,000, or about 55% more than Doles, according to records provided by the university.
After reviewing the email, Hainline said that sort of action was "not consistent with the legislation."
"This is an example where that understanding is not consistent with what we had put out. So even if it's just ... one, that's too many," Hainline said.
Asked about the NCAA's medical autonomy rules, Texas A&M team physician Dr. J.P. Bramhall told Outside the Lines that the "guidelines we are given are not rules." But Hainline said NCAA legislation is indeed a "rule" that member institutions are supposed to follow. In June, Hainline told Outside the Lines that schools that don't follow the rules should self-report an NCAA violation.
Bramhall told Outside the Lines that he believed Texas A&M was in compliance with the medical autonomy rules because athlete medical care and return-to-play decisions are made by sports medicine staff, and he said he reviews the medical qualifications of new hires.
But Bramhall said hiring and firing decisions are administrative, and "that's not me." He referred questions about the firing of the three athletic trainers to the school's senior associate athletics director, Moore, who did not agree to an interview. Texas A&M officials did not make anyone else, including Fisher or Williams, available to answer questions.
Instead, the university released a statement that reads: "Persons in staff positions at Texas A&M are at-will employees. Administrative and employment decisions are the responsibility of Athletic Administration. Dr. Bramhall and/or our medical staff are consulted and [sic] is involved in the screening process related to hiring of athletic training staff. The Director of Sports Medicine analyzes and has ultimate oversight of the health and wellness of our student-athletes."
Outside the Lines also reached out to Woodward, who is now the athletic director at LSU, but he declined to answer questions. An LSU spokesman released a statement on Woodward's behalf that said, in part, "Personnel decisions are made for a variety of reasons, none of which can or should be discussed publicly. However, throughout my career, I have been consistent in my belief and actions on the health and wellbeing of student-athletes."
Bramhall said he had no medical reason to get rid of the athletic trainers. "They were all performing outstanding. They were all very qualified individuals in their field," he said. The last annual performance reviews for Doles and Stanley, which Outside the Lines obtained through a public records request, were positive and noted that each athletic trainer "exceeds expectations."
Hedrick, who served as an administrator overseeing other athletic trainers, received a review in May 2017 that stated he needed to improve communication with his staff and that he and his supervisor "will work together to put a plan in place to improve this issue." Those records for Hedrick noted an allegation of harassment, but the university refused to release a report with additional details to Outside the Lines.
In an interview with Outside the Lines, Hedrick said he had made inappropriate comments in the training room in what he said was a joking manner. Hedrick said the notes from the May 2017 review and the allegation were not brought up at the time he was let go in January 2018, and it was not mentioned in any of the termination paperwork provided to Outside the Lines.
Texas A&M officials would not answer questions about how the current football athletic training staff was hired, but Hedrick and other former Texas A&M employees said Fisher's top pick for head athletic trainer turned the job down, and it was eventually given to Dan Jacobi, who came from Mississippi State.
One Texas A&M athletic trainer who worked under Fisher and spoke to Outside the Lines only on the condition of anonymity said it was clear who made the decision.
"It was 100% the football staff. They had the say in who they were going to hire," he said. "In our big sports, the coaches have all the say in how they want to build their program."
He said he didn't agree with how the program had changed under Fisher, whose practices were more aggressive and physical than those under Sumlin.
"I never felt like we put a guy out there who was going to do harm to himself by practicing or participating, but there were times when I felt like guys should have been held out longer," the school's former athletic trainer said.
"They gave Jimbo Fisher the keys to the city ... especially when he was given the go-ahead to let go of the training staff and bring in his own guy," he added. "That is just more added pressure on the athletic trainer when they're brought in. I think that was immediate from day one."
Hainline said he could not say if Texas A&M was being investigated by the NCAA. He said the NCAA's enforcement division had received reports citing violations of the independent medical care legislation, specifically related to athletic trainers "being concerned that he or she made a medical decision and then didn't have a job." He said he couldn't say how many reports but that there were fewer than 10 across the country.
"It's not like it's flooding enforcement, but they're there," Hainline said.
Hainline said the NCAA's challenge is how to enforce the rules, and "We aren't there right now." He said health and safety matters are different than issues of amateurism and eligibility, for which the organization has a structure to address with enforcement. The NCAA is actively working on a way to enforce the medical autonomy rules.
In the meantime, Hainline said schools still are obligated to follow the rules, though no penalties for not doing so have been set. The NCAA has made several efforts to educate athletic department officials, he said.
Hainline said information about the rules and a list of frequently asked questions went out to "every president, every athletic director, every athletics healthcare administrator, every compliance director ... and then the team physicians and athletic trainers. ... The expectation was everyone should know this."
Yet it is unclear how much athletic departments actually understand about the intent of the legislation.
Outside the Lines reached out to the National Association of Collegiate Directors of Athletics to gain overall perspective about how schools were interpreting the legislation. In a text message, CEO Bob Vecchione said no one from the organization could comment because "there is no real data at the AD level identifying progress within the industry, so not having data, there is reluctance to discuss."
Some schools have publicized their embrace of the medical autonomy rules and have changed the structure of their sports medicine programs as a result. One such example is the University of Kansas, which has its sports medicine and strength and conditioning staff report through the University of Kansas Health System and outside of the athletic department. The NCAA doesn't dictate what structure schools adopt, but in August it did enact a further requirement that strength and conditioning coaches report to sports medicine or sports performance supervisors and not head coaches.
In June, NATA released the results of a survey of college athletic trainers in which about 36% of respondents reported that a coach has been able to influence the hiring and firing of sports medicine staff. Of athletic trainers who reported that happening, 58% reported being pressured by a coach or administrator to make a decision "not in the best interest of a student-athlete's health."
Two months later, in August, former Penn State team physician Dr. Scott Lynch filed a lawsuit against the university and its health center alleging he was removed from that role with the athletic department because he challenged football coach James Franklin, who Lynch said was trying to interfere with return-to-play and treatment decisions of injured athletes. Franklin and the university have denied his claims, and a statement from the school states, in part, that protecting the health and well-being of students, including athletes, remains the "single most important priority at Penn State."
Outside the Lines also spoke to six other current or former athletic trainers from other schools -- who spoke only on the condition of anonymity -- who said they either left their positions on their own or were let go by the school because of a coach's decision. They said schools were not following the medical independence rules and were allowing coaches to dictate the hiring and firing of athletic trainers and even sometimes team doctors.
One former Division I athletic trainer said that shortly after a bowl game in January 2018, his supervisor called him into a meeting and told him he was being let go, because "coach wanted to make a change."
"I asked what the reasoning was, and they had no reason," he said.
Another Division I athletic trainer said the head coach at his school was calling players and trying to talk them out of surgery.
"It set off an alarm bell for me; this guy might be gunning for me," he said, noting that soon afterward he was forced out.
"If the head coach feels you're not doing the job he wants or getting along with the head coach, he's going to start complaining to the athletic director. The AD, the first one or two times might say, 'You've got to work through this,'" the current DI athletic trainer said. "But eventually the AD is saying, 'Hey, this relationship is not going to work. I'm not going to get rid of the head coach, especially if he's winning. It's very easy to get rid of the athletic trainer.'"
Some players also say they know when the athletic trainers are beholden to the coaches.
Former Tennessee linebacker Darrin Kirkland Jr. said he was still rehabbing his knee post-surgery in November 2017, when, after the Vols dropped to 0-6 in SEC play, the school fired coach Butch Jones. Jones was replaced by Alabama defensive coordinator Jeremy Pruitt. Kirkland said he was worried how the transition would affect his recovery.
When Kirkland returned in January after the holiday break, he said, "Things were picking up really fast" under Pruitt's new coaching staff, and he added that he was "very uncomfortable" with how quickly he was going back into full practice.
"I was extremely nervous and didn't know how my leg was going to react," Kirkland said. "I'm wearing a big brace. Still swelling, still in pain, still not able to do the things that I'm normally used to."
In February 2018, Kirkland said he reinjured his knee during team workouts and had another surgery. Although he recovered enough to play the 2018 season, he said the cumulative effect of the injuries prompted him to retire from football this past spring. He now works as a mortgage loan officer assistant near Washington, D.C.
"If I had more time for my knee, I feel like I would've been healthier long term, you know," he said. "Probably would've healed up. Probably would've still been playing ball, honestly."
Although Kirkland said the change of pace and expectations under the new coaching regime forced him into activities he said he believed caused his reinjury, he said he doesn't blame Pruitt for what happened and that he understood the pressure put on the athletic trainers.
"It's a huge challenge because you have your player patient care that you're trying to combat. But they also have a greater job that you're trying to focus on a program, winning games," Kirkland said. "It's definitely just a lot more than just saying, 'That a guy is healthy or he's feeling OK and he can do whatever.'"
Former employees with Tennessee's sports medicine staff told Outside the Lines that in those first months, Pruitt tried to pressure athletic trainers and interfere with how sports medicine staff managed injured athletes. They said he would yell at them to hold off on immediately tending to fallen athletes.
"He wanted us to wait until he decided it was OK. He thought that the players were too soft and sometimes they needed a second to get up and shake it off. But that's not his decision to make," one former employee said. "Jeremy [Pruitt] had enough juice behind him to where if he really wanted to, he could get things his way. If you invest this much money in a coach, that's their guy."
Another former employee confirmed Pruitt's request but said that in the interest of athlete health, the athletic training staff didn't always comply.
During the spring of 2018, according to interviews with sources and reports from online sports blogs, Pruitt arranged for then-head football athletic trainer John Burnside to be fired and for two orthopedic team doctors with Knoxville Orthopaedic Clinic to be removed from responsibilities within the football program.
"It was foot on the throat, right off the bat," one former employee said. "A lot of pressure, and pretty much letting us know pretty early on that he didn't want any of us to be there and he was looking for a reason to let everyone go and bring on his own staff."
Burnside's letter of termination from April 2018 is signed by Tyler Johnson, a senior associate athletic director, and does not give a reason for his firing. In June, the Chattanooga Times Free Press reported that Pruitt had hired new head football trainer Jeronimo Boche, who had been at Florida State when Pruitt was the defensive coordinator there in 2013.
Tennessee officials declined a request to interview Pruitt. In response to questions about the employment of Burnside and the assignment of the two doctors, as well as the allegations of undo pressure by Pruitt, athletic department spokesman Tom Satkowiak said in an email, "Tennessee disputes any notion that it violated the NCAA's medical autonomy rules at any time. We have a longstanding culture of prioritizing student-athlete health and wellness."
"Our sports medicine staff reports directly to the Director of Athletics," Satkowiak wrote, "and our coaches understand that sports medicine personnel have unchallengeable authority as it relates to student-athlete health and NCAA medical standards of care."
Satkowiak also wrote that the university maintains its relationship with Knoxville Orthopaedic Clinic and that the two orthopedic doctors "continue to provide care to Tennessee student-athletes," but he did not specify in which sport or sports. The two doctors did not respond to requests for an interview.
Even when a relationship appears to benefit an athletic trainer when a coach brings someone with him to a new job or seeks someone out, Lindley, the NATA president, said that benefit ends the day that athletic trainer starts working at that school.
"In some situations, that can be the immediate signal for, 'I brought you here, now let's make some decisions together. I brought you here, now I am going to, in our daily meetings, going to be questioning you instead of asking questions about our athletes' health and safety,''' Lindley said. "Whether it's outright or whether it's subtle, there can be that expectation to make health and safety decisions that don't match up with what's best for the student-athletes."
At Penn State, there was an official announcement in February when Lynch was removed from his position as director of athletic medicine, which he had held since 2014. The letter noted that Lynch was being replaced by someone who could be on the main campus in State College full time; Lynch had been splitting his time between State College and his office at the university's medical center 100 miles away in Hershey, Pennsylvania.
But Lynch said he actually was removed in retaliation for speaking out against Franklin, who Lynch said would, at times, ask him "not to reveal potential diagnosis to the players" and would pressure medical staff to direct injured players to specific treatment plans.
"The coaches are now smart enough to figure out, 'I shouldn't try to influence the player,'" he said. "They tried to influence the medical staff to change their decision, and that absolves the coach of the responsibility, because now he or she can come back and say, 'It wasn't my decision. It's the medical staff made that decision.'"
Lynch said that as he was preparing for his departure, he sent his supervisor a list of recommendations for the school to implement to ensure medical autonomy of the remaining sports medicine staff, including the appointment of someone outside athletics who would be responsible for hiring and firing medical personnel.
In the March 6 letter to Dr. Kevin Black, Lynch wrote, "I believe that the current situation, where the coach can attempt to influence medical care, is dangerous for the student athletes." The letter stated that Lynch was aware Franklin was calling around about another doctor who became Lynch's replacement, writing that "it's rather obvious to me that [Franklin] was doing this to see if [that doctor] was easier to control than me."
Lynch said the school refused to implement his ideas, so in August, he filed a whistleblower lawsuit alleging he was fired because he spoke up against Franklin.
Lynch wrestled for Penn State in the 1980s and was a national champion in 1984. He said his main interest is to protect the athletes by getting Penn State to implement his recommendations.
"I don't care how much money they give me," he said. "I won't go away unless they do the right thing to protect patients."
Franklin addressed the allegations at a news conference shortly afterward in August, saying, "As always, the health and well-being of our student-athletes is of utmost importance to us, but after that, we'll have no further comment."
Some of Franklin's former players, including New York Giants running back Saquon Barkley, spoke out in support of his handling of injured athletes. But Lynch said that if players weren't affected, then that was a testament to his work to protect them.
In legal filings, the school has denied Lynch's claims and requested a dismissal of his lawsuit, stating that he missed the legal deadline for filing his complaint by about three weeks, as the two sides dispute his actual termination date.
Penn State officials declined to provide anyone for an interview but released a statement in response to questions submitted by Outside the Lines, which reads:
"We are pleased our highly-regarded program moves forward under the outstanding direction of a national leader in orthopedic sports medicine. Protecting the health and well-being of students is the single most important priority at Penn State, and that is certainly true for our student-athletes as well. We reject the claims in the complaint, and will vigorously defend our program and its representatives who work tirelessly to support our student athletes."
Producer David Lubbers contributed to this report.