Family physicians have historically comprised the majority of practitioners who embark on a fellowship in Primary Care Sports Medicine (PCSM). Over the past several years, however, fellowship training has become increasingly available to physicians from many different specialties, as follows: emergency medicine (EM), pediatrics, physical medicine and rehabilitation, and internal medicine (4). Just as individual fellowship programs differ in training experience, one’s specialty and respective residency training can change the way physicians from diverse backgrounds approach fellowship. As we explore the differences between family medicine (FM) and EM training, these differing perspectives become apparent. On the surface, the primary difference between residency in FM and EM is continuity of patient care and management of the critically ill and injured patient, respectively.
While it is inherent to focus on the differences between specialties, we should not forget that the Accreditation Council for Graduate Medical Education (ACGME) sets some of the same core training requirements for all residency programs irrespective of specialty. Furthermore, all residency programs are required to allow their residents to appraise their specific program, including faculty teaching and supervision, educational content, and overall program quality. Clearly defined supervision roles need to be in place for all residents. Likewise, programs must continuously evaluate their residents’ performance, including certificate examination success rates, professionalism, personal responsibility, and patient safety (1, 3).
One of the primary focuses of FM residency training is continuity of care. Residents are expected to take primary ownership of their patients, managing their care over time in the following multiple clinical settings: outpatient clinics, urgent cares, nursing homes, and inpatient wards and also during personal home visits (1). The FM resident receives excellent training in organizing regular follow-ups and reevaluations of their patients over time, which gives them the continuous opportunity to modify treatment plans based on their patients’ responses. This comprehensive patient care experience allows for an easy transition into the realm of PCSM fellowship, as fellows must evaluate athletes in numerous care settings — medical clinics, training rooms, sidelines of team sporting events, and mass community events. In fact, evaluation of patients in multiple care settings is an ACGME core PCSM fellowship requirement (2).
Additionally, the family physician is trained to approach patients as more than their respective chief complaints or disease processes, recognizing that each patient functions not only within a health care system but also within a family and a community (1). Understanding their patients’ social and cultural backgrounds can aid the FM graduate in establishing rapport and compliance with a plan for care. This aids in guiding an athlete’s recovery as he or she functions within his or her respective community.
Contrastingly, while EM residency training does require some variation in patient evaluation settings, this is fairly limited to the emergency department (ED) and intensive care unit (ICU). Continuity of care is obviously not an emphasis in training, and emergency physicians are not always afforded the luxury of patient follow-up or reevaluation. Thus, residents are often taught that they cannot always defer imaging studies or laboratories to the next visit. Oftentimes, this is because a large portion of their patient population is uninsured and has no outpatient follow-up available. Nevertheless, the importance in managing health care costs is constantly reinforced throughout EM training, and residents repeatedly encounter patients who express concern about the costs that accompany a thorough workup. Thus, residents become proficient in prioritizing chief complaints and deciding which diagnostic studies are emergently necessary (3).
EM residents are adeptly trained at evaluating acutely ill and injured patients and coordinating an immediate plan of care, whether that is admission to the hospital for further workup, consultation with a specialist, or reevaluation by the patient’s primary care provider (PCP) on an outpatient basis (3). However, unless resident physicians personally follow up on their patients’ hospital or outpatient courses, any further care received or complication incurred is rarely appreciated. This is a clear deficit that the EM graduate faces when transitioning into longitudinal care of athletes during PCSM fellowship. That said, numerous residency programs have instituted requirements that residents follow up on a specific number of patients admitted and discharged each month of training. This is a wise skill that many EM graduates have developed over the course of their training or career.
With the current overcrowding of ED, EM residents learn that in order to keep up with the overwhelming volume of patients they evaluate, it is imperative to implement concise history taking, focused physical examinations, and succinct patient counseling. Cultural considerations and empathy are not lost on emergency physicians, as good physicians across all specialties recognize that patient rapport is important in ensuring patient compliance with recommendations; however, with the brief interaction afforded in the emergent setting, this is frequently lost on those patients who expect more attention from their physicians.
The PCSM fellow is responsible for coordinating patient care with a multidisciplinary team, including trainers, coaches, teammates, family members, and other physicians. This is crucial to garnering compliance with the prescribed treatment regimens and rehabilitation and also is an ACGME fellowship requirement (2). While every specialty gets some level of training in coordination of patient care, the amount of experience is varied. All residents learn to confer with specialists for complaints outside their scope of practice whether via outpatient referrals or while caring for patients on their inpatient services. However, FM residents are afforded the opportunity to get a great deal of subspecialty training and are able to manage a wide variety of patient issues from obstetrics to chronic pain management to procedures such as vasectomies and sigmoidoscopies (depending on the physician’s comfort level). Not every FM graduate is able to manage every issue, but the broad nature of the specialty allows exploration of that which interests the physician, although this is somewhat program dependent.
Both EM and FM residency trainings provide daily opportunities to coordinate patient care not only with other physicians, such as admitting hospitalists, surgeons, other specialists, and PCP, but also with ancillary staff, such as nurses, technicians, phlebotomists, respiratory and physical therapists, and social workers. All take part in implementing the plan of care for patients within the acute care or outpatient setting. As a physician in either specialty, it is important to maintain direct, concise communication and foster an environment of continuous support.
The ACGME has set clear criteria to ensure that EM residents get superlative training in managing a broad range of medical and trauma emergencies in all age groups. This includes developing certain procedural skills needed to treat emergent patients. There is a distinct list of emergent procedural skills at which all EM residents must demonstrate proficiency prior to graduation. These include laceration repairs, dislocation and fracture reductions, and airway management, to name a few. In fact, residents must demonstrate that they have performed a specific number of each required procedure and managed at least a baseline number of medical and trauma patients — both adult and pediatric — prior to graduation (3). While the FM graduate definitely has some experience in the urgent and emergency care settings, where procedures are frequently encountered, this is not a primary focus of residency training. Each FM residency program has developed a list of procedural skills it deems important and has a system in place to monitor competency (1). This has the potential to produce greater variances in the specific procedural skill set of the FM graduate.
The pressure that comes with evaluating an injured athlete on the sidelines without many available resources — all while coaches, teammates, and fans are watching and waiting for an immediate diagnosis — is not well simulated in either residency. While EM training offers much more experience in pressure-filled, time-sensitive medical situations, resources such as imaging modalities, electrocardiogram, bedside ultrasound, and laboratory studies are frequently available depending on the emergency department setting. Musculoskeletal training is a core requirement of FM residency training; however, the extent of experience depends on individual residency program requirements and each resident’s motivation to get involved (1).
Event and sideline management are important experiences that prepare both FM and EM graduates for fellowship in PCSM. The more exposure a physician incurs throughout residency and fellowship training, the more comfortable that physician becomes at medically managing patients in a nonhospital setting. PCSM fellowship offers many opportunities to participate in event medicine (2). In addition to athletes, the sports physician must be prepared to deal with unexpected patients, such as fans, coaches, and other bystanders. In the vast majority of sporting events, musculoskeletal injuries and other acute medical issues are predominantly being treated in the medical tents or on the sidelines. While both EM and FM graduates are experienced in managing these issues in a clinical setting, PCSM fellowship expands that training to community events outside the hospital.
While most sporting events are focused on participating athletes, they can quickly turn into mass casualty disasters, as the recent Boston Marathon bombing demonstrated. Disaster management is not yet a core requirement of PCSM fellowship training (2), and its hopefully exceedingly rare occurrence may never elevate it to requirement status, but a unique aspect of EM residency training is disaster medicine, during which residents undergo simulations where they learn to triage patient care based on medical acuity, direct large teams of medical personnel, and manage patients in less-than-ideal settings. On average, the FM graduate has much less training and exposure to disaster management, if any.
Irrespective of the standardized ACGME requirements for each specialty training program, there also are many differences among residency programs within the same specialty. This definitely influences the overall future practice of FM and EM residents and their transition into PCSM fellowship. Historically, fellowships are offered through the FM specialty, and thus, it is assumed that most FM residents have had more exposure to the field of sports medicine and managing musculoskeletal injuries over time. This is not true across the board, as FM training can vary among programs. Specific residency programs often have differing emphases, from musculoskeletal care to obstetrics to inpatient hospital care to rural medicine, and provide its graduates with differing skill sets.
Likewise, EM residency programs can offer somewhat differing training experiences based on its patient population, hospital setting, and faculty experience. This encompasses the amount of exposure to trauma, ultrasound, and advanced airway management. Some experiences, however, are driven by individual resident interests. Elective rotations are a requirement and allow exploration of subspecialty training, such as sports medicine, critical care, and administration.
The goal of EM and FM residency is not to prepare physicians for the world of sports medicine. PCSM fellowship faculty should recognize that the needs of each new fellow will vary based on respective residency training and any previous self-directed sports medicine experiences individual graduates have had. For example, the FM graduate will most likely need to dedicate more time to acute injury evaluation, dislocation reductions, and disaster management, while the EM graduate will likely need to focus more of their time on continuity of care, garnering patient compliance, and fostering a strong patient-physician relationship. Applicants of PCSM fellowship, regardless of specialty training, must demonstrate a commitment to gaining musculoskeletal diagnostic and treatment skills. The seasoned fellowship director and faculty will foster the unique talents of each fellow and identify and strengthen areas of weakness to develop a superlative sports physician.
Residency training impacts every physician’s perspective and approach toward PCSM fellowship training. Every fellow starts with a different foundation of knowledge and skill set, but fellowship training — combined with a dedication to continuous learning and development of skills — can help bridge the gaps between physicians of differing specialties. The diagnosis and treatment of shoulder impingement quickly become second nature to all, just like management of diabetes is to the family physician and myocardial infarctions are to the emergency physician. The goal should always be to embrace the diversity of our complete sports medicine community and learn as much as we can from each other’s experiences and expertise.
The author declares no conflicts of interest and does not have any financial disclosures.