Physiatry residents are increasingly interested in sports and musculoskeletal medicine careers. The American Medical Society for Sports Medicine (AMSSM) has comprehensive guidelines and a position statement on proposed standards of excellence in primary care sports medicine fellowships.1 This document provides an excellent framework for sports medicine physicians to develop and improve their sports medicine fellowship curriculum. The Accreditation Council for Graduate Medical Education (ACGME) also has standard program requirements for sports medicine fellowships.2 ACGME-accredited sports medicine fellowships can improve their training programs by enhancing the experience of fellows in aspects of physical medicine and rehabilitation (PM&R) that pertinent to sports medicine and musculoskeletal care. This approach can help a multidisciplinary approach to the care of an athlete and persons with musculoskeletal disorders.
The purposes of our article are to present a history of sports medicine training for physiatrists, to provide a broad overview of how to establish, administer, and measure success of a ACGME-accredited sports medicine fellowship program (henceforth referred to as sports medicine fellowship program) so it meets ACGME and AMSSM standards, and to provide recommendations on enhancing fellowship training. Our recommendations are endorsed by the Association of Academic Physiatrists.
History of PM&R Sports Medicine
Sports medicine and PM&R have shared roots. Frank Krusen, MD, who is considered the father of physical medicine, was one of the first sports medicine team physicians. In 1926, he was appointed team physician for the Temple University football team and later established their first Department of Physical Medicine. Dr. Krusen, similar to many of his predecessors and early leaders in the field, was drawn to PM&R because of his interest in physical education, exercise physiology, and athletics.3
In the 1940s and 1950s, Bernard M. Baruch, a New York–based philanthropist and financier, recognized the need to return war-injured persons to a state of optimal function. His efforts were largely responsible for the expansion of the field of PM&R. Mr. Baruch established a committee of medical and scientific experts, including Dr. Krusen, who worked with the American Medical Association toward the development of the medical specialty of PM&R in 1947.3
For the next several decades, PM&R made great strides in creating programs to help those with severe neurologic and physical disabilities. However, there was a growing interest among PM&R physicians to treat musculoskeletal disorders and sports medicine injuries in the outpatient setting. To address this need, in 1994, Physiatric Association for Spine, Sports, and Occupational Rehabilitation was formed as a council within the American Academy of Physical Medicine and Rehabilitation to give voice to physiatrists interested in sports and musculoskeletal medicine and to create a platform for more advanced training and education. Dr. Jeffrey Saal was the first president of Physiatric Association for Spine, Sports, and Occupational Rehabilitation.
In 1999, the American Medical Society for Sports Medicine (AMSSM) initiated the certificate of added qualifications (CAQ) for nonoperative sports medicine physicians who had completed an ACGME-accredited fellowship. This is separate from a CAQ that exists for orthopedic surgeons. In 2007, the American Board of PM&R (ABPMR) granted subspecialty certification in sports medicine, allowing PM&R physicians from ACGME-accredited sports medicine fellowships to sit for the CAQ. There was also a “grandfathering” period where physiatrists who were practicing musculoskeletal/sports medicine but did not complete an ACGME-accredited sports medicine fellowship could take the CAQ. Other specialties that are eligible for this CAQ include pediatrics, internal medicine, emergency medicine, and family medicine.
In the 2019 Sports Medicine fellowship match, there were 23 PM&R ACGME-accredited programs in sports medicine and a total of 31 available ACGME fellowship positions.4 There were 298 total certified primary care sports fellowship positions available, of which 227 were certified by family medicine.4 Many of these internal medicine- and family medicine-based programs are now accepting PM&R applicants, thus increasing the potential number of fellowship positions and opportunities for PM&R residents interested in sports medicine training.
Key Components of a Sports Medicine Curriculum
This section will provide guidance on how sports medicine programs can meet ACGME requirements and AMSSM recommendations.
Core Program Curriculum Development and Dissemination
The curriculum requires appropriate design, teaching methods, analysis of results, review, and modification based on periodic evaluation. It also requires input from learners that would aid in making the fellowship experience relevant and of high quality. The core program curriculum should be distributed to the fellow and faculty annually.2 The program must integrate medical competencies in the curriculum as follows:
- Patient Care and Procedural Skills: Care provided by the fellow should be compassionate, appropriate, and effective in treatment of medical problems and in the promotion of health. Fellows must be competent in evaluation, management, and rehabilitation of acute and chronic injury and illness associated to exercise and sports participation, perform medical, diagnostic, and therapeutic procedures essential for the area of practice, and understand return to play criteria and doping regulations.
- Medical Knowledge: Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral science and its application in sports medicine.
- Practice-Based Learning and Improvement: Fellows are expected to systematically analyze practice using quality improvement methods and implement changes to improve their clinical care. They should independently use sports medicine scientific literature and incorporate evidence-based information into patient management.
- Interpersonal and Communication Skills: Fellows must have skills for effective exchange of information and collaboration with patients, families, health professionals, and members of the sports medicine team. They should be able to lead team-based patient care and communicate clearly while protecting patient confidentiality.
- Professionalism: Fellows must demonstrate a commitment to carrying out their professional responsibilities and adhering to ethical principles, such as beneficence and nonmaleficence. They should exhibit compassion, integrity, accountability, respect for others, and patient autonomy.
- System-Based Practice: Fellows must understand the context of healthcare systems, provide cost-effective medical treatment, and use available resources to provide optimal sports medicine care.2
Clinical Program Requirements
The fellowship should have a detailed clinical program with specific activities documented in a weekly or monthly schedule. This program should include sports medicine and musculoskeletal clinics, continuity clinics, musculoskeletal ultrasound clinical training, half day of clinical experience in the core specialty, orthopedic operating room experience, activities to develop procedural skills, training room, and team/sports event coverage. Training in musculoskeletal ultrasound should be carried out throughout the year and requires both didactic components and clinical experiences in diagnostic use of the technology and for guidance of clinical procedures.1 Clinical activities in sports and musculoskeletal medicine must represent a minimum of 60% of the fellows’ time in the program.
The academic program should allow the fellow to achieve core knowledge in sports injury management, primary care of the athlete and individuals who exercise, develop expertise in prescription and supervision of rehabilitation programs of patients with sports injury, and understand basic concepts of exercise physiology, sports psychology, and nutrition. The sports medicine fellowship curriculum should contain conferences, seminars, and workshops. Protected research time should be included in the weekly program of the fellow.
Sports medicine fellows may benefit from additional exposure in the evaluation of acute medical and orthopedic emergencies and how to prioritize chief complaints to make emergent treatment decisions. Team and sports events coverage and training room activities are mandatory and allow the fellow to develop expertise in this area. In addition, electives in emergency medicine or another acute trauma environment may help broaden their skill set to feel comfortable functioning independently as a team physician.
Progression of Fellow Responsibility and Curriculum Assessment
Levels of supervision should progress from direct to indirect supervision and finally to oversight of the fellows’ activities. By the end of training, the fellow should reach the milestones expected at the time of graduation and be able to practice confidently and independently.
Evaluation of the clinical and academic curriculum should take place every year with involvement of the faculty from different core specialties/disciplines and fellows.
Enhancing Sports Fellowship Training by Achieving Competency in PM&R Skills in Sports and Musculoskeletal Care
Sports fellowships can incorporate these unique aspects of holistic care emphasized by the PM&R discipline. Functional assessment of patients with sports and musculoskeletal disorders that elucidates functional impairments is one such aspect. Function-based treatment approach may include specific functional rehabilitation programs, assistive devices, and assessment of environmental factors in the patient’s home. Few other specific aspects of PM&R that can be incorporated into sports medicine fellowship training include a physiatric physical examination, which includes a musculoskeletal, functional, and neurologic evaluation, assessment of environmental factors such as accessibility in a patient’s home, need for orthotic and prosthetic devices, pain management, gait analysis, electromyography/nerve conduction studies interpretation and performance, and management of psychosocial issues in musculoskeletal disorders. Spine care and nerve injuries are commonly encountered in musculoskeletal clinics and management of such injuries is another aspect that can be incorporated. It is also important for fellows to be trained in the care of athletes/patients with disabilities who frequently have musculoskeletal issues and training in assessment of assistive device needs. The fellows may also be educated on the International Classification of Functioning, Disability, and Health as it relates to patients with musculoskeletal issues. Fellowship programs should strive to mprove fellows’ knowledge about and attitude toward the promotion of physical activity and exercise in diverse populations.5
Program Requirements and Recommendations
Section IV.A.2.a). (2) of the ACGME requirements for procedural training during sports medicine fellowship state6:
“Fellows must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice. Fellows: must demonstrate competence in the diagnosis, and timely referral for operative treatment of sports-related injuries, including hematomas, stress fractures, surgical sprains and strains, and traumatic fractures and dislocations.”
The AMSSM published a recommended sports ultrasound curriculum for sports medicine fellowships in 2015.7 This document provides detailed recommendations for both diagnostic and procedural ultrasound skills that may be included in sports fellowship training. Commonly performed ultrasound-guided procedures may be practiced first on unembalmed cadavers when such set-ups are available. Fellows should receive formal didactic education as well as mentored clinical experience in musculoskeletal ultrasound. Fellows are advised to keep logs of all ultrasound training(s) and procedures. In a more recent position statement from AMSSM,1 Asif et al.1 proposed standards of excellence for a 1-yr sports medicine fellowship. In several sections of this article, recommendations for procedural scope, volume, and competence were put forth that programs can consider in their curriculum development. These cover a broad scope of procedures and do not include spine interventional procedures (other than ultrasound-guided sacroiliac joint injections).
Teaching of Fellows to Achieve Procedural Competency
Procedural training is a combination of on the job training and related didactic instruction under the supervision of a skilled professional. Asif et al.1 suggest that procedural training should include didactic instructional sessions, didactic practice sessions, mentored clinical experience, and supplementary and continuing educational options. To accomplish these goals, one full-day per week of musculoskeletal ultrasound clinic under the supervision of an attending trained and proficient in musculoskeletal ultrasound procedures may be considered by sports fellowship programs. Both diagnostic and interventional procedures should be performed with direct hands-on supervision, guided needle handling skills, feedback, and teaching in real time.
List of Recommended Procedures
A comprehensive list of procedures sports fellowship programs may consider incorporating in their curriculum is available from the AMSSM.1 Optional procedures that may enhance skills of sports fellows include orthobiologic procedures, flouroscopically guided injections of the spine and peripheral joints, electromyography/nerve conduction velocity, and percutaneous procedures such as extracorporeal shockwave therapy, ultrasound-guided percutaneous tenotomy, and muscle compartment pressure measurements. These additional procedures should be considered optional.
Evaluation of Procedural Competency
Components of skills teaching and performance evaluation that can be incorporated into fellowship training include written or oral examination to assess indications of specific procedures, simulation-based training, use of anatomic landmarks or ultrasound guidance to perform procedures, use of a standard checklist for specific interventions, standard faculty training on teaching skills and procedures, direct observation of performance, number of procedures required to achieve proficiency, and evaluation of results of the intervention. Key elements of a competency evaluation system include clear definition of the elements of the evaluation process, definition of the standards of training required before performing the procedure, collection of outcome metrics, feedback on procedural, safety and patient care skills, and an effective process of correcting deficiencies identified in the evaluation.8
Assessment of Milestones
The milestones provide a framework for the assessment of the development of the fellow in key dimensions of the elements of physician competency in sports medicine. They are designed for use in the context of residents and fellows in ACGME-accredited programs.9 Milestones can be demonstrated progressively by fellows from the beginning of their education through graduation and unsupervised practice of their specialty.9 Milestones are arranged into numbered levels, from 1 to 5, starting at a novice level and progressing to an expert in the specialty (Table 1).9 Milestones are designed for programs to use in the semiannual and final review of fellows’ performance and reported to the ACGME twice a year. Level 4 of the milestones is considered the graduation target, but it does not represent a graduation requirement.9 An example of a milestone progression for patient care is presented in Table 2.
Assessment of progression in the milestones for each subcompetency may have different components, which include case presentations, direct observation of clinical performance and procedures, structured oral or written examinations, evaluation of journal club presentations, lectures and grand rounds, participation in scientific activities, research productivity, and interaction with staff, patients, as well as the sports medicine team. Feedback for the assessment can be provided by faculty supervisors, staff, and academic/research mentors.
The clinical competency committee and the program director are responsible for evaluation of the fellows’ progress in the subcompetencies and achievement of the milestones expected at the mid-year of training and at the completion of the fellowship. Decision about readiness to graduate remains under the jurisdiction of the program director.
Establishing Milestones for Measuring Procedural Competency
Programs should first assess the procedures and degree of expertise that they train their fellows in. This should help establish expected procedural volume, learning objectives, and competency goals for training. The level of supervision for each procedure can provide a starting point to determine the trainees’ expertise at the beginning of their program and toward the end of the program.
The ACGME sports medicine milestones that relate to procedural training are patient care subcompetencies in medical management and team coverage and athletic care.6 Medical management does not include any direct reference to procedural training. However, it is possible to extrapolate to procedural milestones given the current framework. An example is as follows: generate a basic procedural plan (level 2), modify procedure to the athlete’s medical condition and comfort (level 3), and use evidence-based decisions to provide procedures in complex clinical situations (level 4). Team coverage and athletic care specifically refers to supervision level with procedural milestone establishment. For instance, level 2 requires direct supervision and level 3 requires indirect supervision for minor sports-related procedures.
Minimum procedural volumes for an ACGME-accredited training program are modest. Establishing programmatic “minimum” and “aspirational” procedural volumes and competency can be helpful in giving the trainee ongoing guidance throughout the year. This also helps inform the clinical competency committee of the expected volume. Procedural documentation should occur on an ongoing basis throughout training to ensure accurate and complete procedure counts. This should be reviewed by the program director, clinical competency committee, and fellow at least at the midpoint and end of the training year.
Musculoskeletal/Sports Research During Fellowship Training
Research is key to discovery of new treatments and for the survival of a medical specialty. Research is also important in the value-based healthcare environment where procedures and treatments for patients with musculoskeletal or sports disorders need to be supported by data to enable reimbursement.
Fellows should preferably work with a faculty member that spends a considerable amount of their time doing research so as to enable effective mentorship. The goal should be to understand and perform the process of research from inception of the idea to its publication. Statistical/data analysis support for completion of the project is desirable for the fellow. A research mentor should also commit to regular meeting times (preferably weekly or at least once every other week) to guide the fellow through the project. The fellow should perform the literature search, be part of meetings to discuss analytical strategies and data analysis, and have the opportunity to write a manuscript as a lead author or make substantial contributions toward its writing. The research should specifically not be limited to case reports or series. Because most fellows will eventually not perform research in their careers, this research requirement provides proficiency in critical appraisal of an article so as to decide whether the data presented can be applied to one’s practice.
Few trainees will wish to go beyond the previously recommended research requirements. In such cases, it is paramount that the fellowship directors encourage and facilitate a research mentor who can guide the trainee on mentored career development awards. Ideally, candidates with strong research interest should pursue a 2- or 3-yr fellowship (as is usual for most medical specialties). This only applies to specific candidates who wish to pursue the physician scientist path and should not be a requirement.
Postfellowship Career Paths
Fellowship graduates can pursue a variety of career paths including private practice settings or academic medicine, self-employed or a salaried position, and working for multidisciplinary practice. The fellows should carefully consider in their decision to accept a job the patient population to be served (spine vs. sports related), inpatient and outpatient call coverage responsibilities, their desire for an academic environment (teaching and research), and the amount of sports events coverage expected by the practice.
The future of sports medicine subspecialty training is exciting. With the emphasis on musculoskeletal medicine and functional impairments during residency training, PM&R physicians are well equipped to pursue sports medicine fellowship training and careers. In addition to providing a framework for meeting ACGME guidelines, we provide recommendations for enhancing the current fellowship curriculum by including training in PM&R-based medical and procedural skills relevant to sports medicine and musculoskeletal care. Incorporation of these unique aspects of PM&R in sports fellowship trainings will strengthen the skills of sports fellows for better patient care. Given the multidisciplinary nature of musculoskeletal and sports medicine, it is key that fellowship programs (regardless of the department that they are accredited through) have faculty members that represents these disciplines and accept applicants with residency training in PM&R, internal medicine, family medicine, pediatrics, and emergency medicine. Working alongside our partners in orthopedics is also key to our access to patients with musculoskeletal disorders and to provide a model for value-based healthcare delivery where nonoperative musculoskeletal care can be streamlined.