The evolution of sport and exercise medicine (SEM) has been a story of unparalleled opportunity and unpredictable success. From humble beginnings treating the ailments of athletes using skills derived from physical medicine, we have seen SEM flower, initially as a form of medicine dealing with musculoskeletal trauma and more recently with exercise medicine in its broadest sense. This is where SEM offers its greatest potential, dealing with the increasing social and medical burden imposed on western society by the sequelae of physical inactivity such as type 2 diabetes, obesity, and the metabolic syndrome.
Other nations have taken a divergent approach to the recognition of SEM physicians. In Scandinavia, SEM as a medical specialty has been recognized for more than 20 years; in the United Kingdom, the specialty of SEM was only recently recognized, with the impetus for recognition driven by the forthcoming London 2012 Olympics. In North America, 1- or 2-year fellowships are available under existing specialty boards (eg, orthopedics and family medicine) or with the assistance of SEM organizations (eg, Canadian Academy of Sport Medicine [CASM]) or as a consequence of additional training opportunities in academic primary care training centers. In Canada, physicians can acquire a Diploma from CASM attesting to special interest and abilities in SEM but not conferring specialist status. It remains an extraordinary situation that in a number of countries where the need for specialist sports physicians is arguably the greatest, SEM is not recognized as a distinct specialty in its own right.
Australia has taken a very different path toward specialty recognition than is the case in the United Kingdom where the new Faculty of SEM, under the auspices of the Royal College of Surgeons of Edinburgh, has had to rapidly develop a training curriculum; find training posts within an overstretched public health system; endorse training supervisors; and develop a credible assessment and examination process before any training can actually commence. By contrast, the Australasian College of Sports Physicians (ACSP) began in 1984 to develop a comprehensive curriculum, evolve a 4-year specialist training program, and has progressively refined its examination processes.
This year, after a comprehensive assessment of its training and assessment processes conducted by the Australian Medical Council, the Federal Minister for Health and Ageing has approved the new specialty of SEM with the ACSP as the recognized provider of specialist training in that field. As a result of this process, the College has been granted the maximum accreditation available, signaling a new era in Australian SEM practice. There are annual reporting requirements and other bureaucratic paths to be trodden; however, the saga of the specialization pathway for SEM in Australia is finally reaching a conclusion, some 15 years after it commenced. It must be said that the extraordinary length of time to gain recognition has been out of the College's hands and largely due to repeated governmental changes in the processes that permit a new specialty to be recognized in Australia. Now is a suitable time to reflect on the gains, losses, and lessons of the last 15 years.
What has been gained from the process? First, over the period the College has been pursuing recognition, there have been significant advances in the knowledge and breadth of the discipline, which in turn now makes SEM a more “robust” specialty that is far better equipped to deal with the challenges of exercise medicine as a tool for public health rather than being narrowly focused on sports trauma.
Second, the College has developed and matured as an organization. Some of this maturity has been tempered by experience. But the fires of governmental accreditation have led to much greater reflection on the College's internal processes and refinement and clarification of its aims.
Third, new medical specialities are increasingly multidisciplinary and patient focussed rather than hierarchical and organ based. The growth of integrated comprehensive approaches to contemporary health problems can be harnessed to improve clinical care while enhancing opportunities for research and public health policy development. The specialization journey has allowed ACSP to forge strong ties with other disciplines who share common interests, including sports physiotherapy, sports nutrition, and exercise science.
Fourth, closer attention to the SEM training curriculum has meant greater engagement with overseas SEM organizations to harmonize content knowledge within training. These efforts will likely continue to progress further. The tangible benefits to College trainees as a consequence of this international engagement and coordinated curriculum mapping will mean a more transportable skill base. This will facilitate easier movement of sports physicians between countries.
Finally, SEM physicians in Australia have learned that sometimes “the struggle doth availeth” (with apologies to A.H. Clough). Although the formal process has tested the will, and the long struggle hardened the commitment of those involved, SEM physicians have learnt that a strong belief, a rational goal, and clear direction can overcome the most daunting bureaucratic hurdles.
There have been losses over the past 15 years. First, and most important, dealing with the specialization and accreditation process has consumed the energies of virtually all Australian SEM physicians at a time when they might have been better harnessed to deal with other key issues in the field, such as the delivery of injury prevention and safety guidelines, health promotion, and public health policy development. That Australian SEM physicians have been able to contribute substantially to these fields throughout this period is a tribute to their tenacity and commitment. One can only wonder what might have been if these processes had only taken 5 rather than 15 years.
Second, ACSP and its secretariat have been enmeshed in the bureaucratic processes required to maintain the momentum of accreditation and have dealt with government departments in which these processes were new, uncertain, and constantly changing. This has meant that other tasks have had to be lowered in priority. The executive officer of the ACSP, Ms Christine de Villeneuve, deserves particular commendation for ensuring that the accreditation process moved forward while simultaneously administering the range of other College activities.
Third, the recruitment of new clinicians to the field has been significantly affected. At the time when medical-workforce pressures have been at their greatest, young doctors have been actively discouraged from entering the field of SEM simply by the uncertainty that existed as to whether the speciality would be recognized and their training under ACSP auspices would be accepted. That some young doctors have had the belief to risk their careers by pursuing training in SEM is astonishing; it is also a tribute to the passion of the ACSP Fellows who teach and inspire them.
Fourth, opportunities to generate research in SEM have been limited by a lack of access to public research funding as existing guidelines preclude the support of nonaccredited areas of medicine. A generation of SEM researchers have had to rely on the “soft” funding available from individual national sporting organizations (who are understandably only interested in research pertinent to their sport), from programs within the Sports Institute networks (whose own budgets have been steadily shrinking), and from a variety of other sources. Although Australasian SEM physicians have contributed admirably to many fields of SEM research, the focus of the College has not been available to lobby governments to redress this research funding imbalance.
The Fellows and trainees of the ACSP can be very proud of the fact that they have created a new specialty in Australia, nourished it, and raised it to adulthood. It must now take its place in the world and fulfill its potential. A number of urgent issues confront SEM in Australia and must be addressed. These include SEM training and the interface with mainstream medical specialties; the role of SEM within the public health system; the changing nature of the medical workforce in Australia; and the need to raise the profile of SEM among both the medical community and the public.
To date, SEM training in Australasia has been provided solely in private SEM practices, within the Department of Defence, and in the various sport institutes around Australia. Broadly speaking, this system has been very successful in terms of ensuring high quality training but also has a number of limitations. This system can only produce a small number of SEM physicians, a number that is insufficient to fill current and projected medical workforce needs. Furthermore, the training process is reliant on the voluntary contribution of time and energy by SEM physicians, other medical practitioners, and numerous allied health personnel for its teaching faculty. All health disciplines are facing a shortage of clinician teachers due to rising numbers of trainees, increasing clinical demands, diminishing resources, and in some cases, an ageing group of core trainers. Finally, there is a growing demand for experienced SEM physicians worldwide, which has the potential to reduce the pool of teachers in Australasia. We have seen, in the past few years, a continual exodus of ACSP Fellows and registrars to countries such as Canada, United Kingdom, Ireland, and the Middle East where academic and private sports medicine enterprises create a seemingly insatiable demand for graduates. These problems require innovative solutions including funding for some areas of SEM training by the Australian government.
The Australian health care system is a unique mix of private and public medicine. The public system provides free medical care, in general via the public hospital system and a number of other facilities. Sport and exercise medicine practice in Australia is almost entirely practiced in the private hospital system. Only a handful of public hospitals offer any form of SEM care beyond emergency department treatment of acute sports injuries. If this imbalance is not addressed, then a significant portion of the Australian public will have no access to specialist SEM care. Similarly, if effective exercise prescription does not become a routine part of the holistic care of all public hospital admissions, then the patient is disadvantaged, money is wasted, and the burden of chronic disease increases. If SEM does not have a presence in the public system, medical students, interns, and resident staff continue to have limited or no exposure to the field resulting in less interest in it as a career path and more importantly less understanding of the critical role of physical activity in preventative medicine.
Finally, the fundamental message of SEM needs to be conveyed to our medical colleagues and to the general public. Sport and exercise medicine is not just about elite athletes, it is for every individual-“exercise is medicine.” How this message is conveyed and how effectively it is heard will have a profound effect on the health of Australians in the future.
Sport and exercise medicine in Australia has finally arrived, and … a journey begins.
*Apologies to Pliny the Elder-“out of Australia there is always something new.”
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