Primary Care Sports Medicine Fellowship

AMSSM Proposed Standards of Excellence

Abstract

The American Medical Society for Sports Medicine (AMSSM) recognizes a need to provide direction and continually enhance the quality of sports medicine fellowship training programs. This document was developed to be an educational resource for sports medicine physicians who teach in a 1-year primary care sports medicine fellowship training program. It is meant to provide high standards and targets for fellowship training programs that choose to reassess their curriculum and seek to make improvements.

INTRODUCTION

Primary care sports medicine fellowship programs are designed to provide comprehensive training in preventing and treating musculoskeletal and nonmusculoskeletal conditions in athletes and active individuals. High-quality education should be the goal of all fellowship programs.

The Accreditation Council for Graduate Medical Education (ACGME) provides the foundation of minimum standards to accredit training programs. However, there are currently no criteria established to describe benchmarks for quality improvement (QI) or standards with which to achieve excellence. The purpose of this document is to outline a vision with targets for fellowship programs to aim for the highest level in the educational training program.

This is not meant as a requirement list that all programs must meet to be considered excellent, as every program will have its own strengths. The goal of this document is to provide guidance and examples of what programs can do to enhance areas they may choose to improve (Appendix 1).

STRATEGIC PLANNING, PROGRAM PHILOSOPHY, AND OVERSIGHT

A program of excellence should have a written document detailing their mission, vision, values, and strategic plan. Fellows, faculty, and key stakeholders should be keenly aware of the program priorities, to be able to concretely describe the impact on educational and service missions.

• A. The program should be able to define its core values, how they were chosen, and how often these are re-examined.
• B. Strategic documents should be re-evaluated every 2 years.
• I. Strategic goals and objectives should be translated into outcomes/competencies that are measurable (metrics).
• II. The overall plan, metrics, and competencies should be communicated to key stakeholders and the sponsoring entity.
• C. A program should be able to quantitatively and qualitatively describe its impact on the community and local health care system, which may assist in obtaining future resources.
• D. Organizational Structure
• I. The program should have an organizational chart of the sponsoring institution, affiliated department, and participating sites that include elements of reporting relationships, financial accountability, and specific job titles.
• II. The program should be able to describe how educational program decisions are made and communicated to those who are vested in the program.
• E. Accreditation and Affiliation
• I. The sponsoring and participating institutions are responsible for ensuring that all ACGME requirements are successfully met and that there is support necessary for quality assessment and improvement.
• II. The sports medicine fellowship program must function as an integral part of an ACGME-accredited residency program in emergency medicine, family medicine, internal medicine, pediatrics, or physical medicine and rehabilitation. Some programs may receive funding from orthopedic departments, but currently, this specialty cannot serve as a sponsor for primary care sports medicine fellowship programs.
• III. To avoid conflict and marginalization, the mission, vision, and values of the affiliated department must align with the global direction of the primary care sports medicine discipline.

FACULTY

A program of excellence will allocate sufficient faculty time for fellow evaluation, mentoring, curriculum design, lecture/conference, scholarly activity, QI, institutional citizenship (Graduate Medical Education Committee and other committee meetings), and program administration that does not directly generate clinical revenue. Similar to the output that is measured with clinical productivity, metrics should be defined for nonrevenue generating full-time equivalent (FTE) at both the individual and group/program levels.

• A. Program Directors
• I. Qualifications
• a. The fellowship program director must be board-certified in their primary specialty (Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, or Physical Medicine and Rehabilitation) and hold a Certificate of Added Qualification (CAQ) in Sports Medicine.
• b. The director should have strong leadership skills and a substantial commitment to education.
• 1. Program directors should aim for at least 10 hours of faculty development per year (minimum).
• 2. Faculty development can include faculty development seminars within the AMSSM annual meeting, institutional, or other equivalent conferences.
• c. Program directors must be active in sports medicine organizations at the local, state, regional, and/or national levels. For example, program directors could participate in committees within the AMSSM or the American College of Sports Medicine (ACSM).
• II. Responsibilities
• a. The program director is responsible for the creation of the educational mission and curriculum, while also articulating the program philosophy.
• b. The director must be dedicated to the training of the fellow and nurture an environment of professionalism that is culturally sensitive.
• c. The program director should participate in scholarly activity.
• 1. Scholarly activity targets include 1 peer-reviewed publication per year, which could include original research, review articles, book chapters, etc.
• 2. Directors should deliver at least 1 state, regional, or national level presentation per year to peers.
• d. Program directors should have a leadership succession plan.
• e. Fellows should work with the program director at least one half day per week providing clinical care.
• III. Percent effort
• a. Sponsoring institutions must provide adequate Full-Time Equivalent (FTE) allocation toward the administration, nonclinical teaching, curriculum design, mentoring, QI, scholarly activity, and evaluation of the fellowship program, for which the ACGME designates a minimum of 10 hours per week.
• b. Direct patient care and/or fellow precepting should be no less than 30% of the total FTE allocation to maintain clinical expertise.
• B. Associate Program Directors
• I. Qualifications
• a. The associate program director must be board-certified in their primary specialty (Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, or Physical Medicine and Rehabilitation) and hold a CAQ in Sports Medicine.
• b. The associate director should have strong leadership skills and substantial commitment to education.
• 1. Associate program directors should aim for at least 10 hours of faculty development per year (minimum).
• 2. Faculty development can include faculty development seminars within the AMSSM annual meeting, institutional, or other equivalent conferences.
• c. Associate program directors should be active in sports medicine organizations at the local, state, regional, or national levels, which could include committees within the AMSSM or the ACSM.
• II. Responsibilities
• a. The associate program director should support the program director in the creation of the educational mission and curriculum and be able to articulate the program philosophy.
• b. The associate director should assist in clinical teaching, mentoring, advising, and didactic education.
• c. Fellows should work with the associate program director at least one half day per week providing clinical care.
• d. The associate program director should participate in scholarly activity.
• 1. Scholarly activity targets include 1 peer-reviewed publication per year, which could include original research, review articles, book chapters, etc.
• 2. Associate directors should deliver at least 1 state, regional, or national level presentation per year to peers.
• e. Associate program directors may be part of the leadership succession plan for the role of a program director.
• III. Percent effort
• a. Sponsoring institutions must provide adequate Full-Time Equivalent (FTE) allocation toward the administration, nonclinical teaching, curriculum design, mentoring, QI, scholarly activity, and evaluation of the fellowship program, for which the ACGME designates a minimum of 10 hours per week.
• b. Direct patient care and/or fellow precepting should be an expectation of the associate program director role.
• C. Core Sports Medicine Faculty
• I. Number of core faculty
• a. Program requirements dictate at least 2 core Primary Care Sports Medicine faculty (including program director) for accreditation.
• b. For each additional fellow (>1), it is recommended that there be at least one additional faculty member.
• II. Qualifications
• a. Core faculty should be board-certified in their primary specialty (Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, or Physical Medicine and Rehabilitation) and hold a CAQ in Sports Medicine.
• b. Core faculty should be devoted to ongoing faculty/professional development.
• 1. Core faculty should aim for at least 10 hours of faculty development per year (minimum).
• 2. Faculty development can include faculty development seminars within the AMSSM annual meeting, institutional, or other equivalent conferences.
• c. Core faculty should be active in sports medicine organizations at the state, regional, or national levels.
• III. Responsibilities
• a. Core faculty should support the program director in program and curricular development and be strong in at least 1 of the 4 following areas: clinical care, scholarly activity, education, or event coverage.
• b. Core faculty should assist in clinical teaching, mentoring, advising, and didactic education.
• 1. Fellows should work clinically with each core faculty member at least one half day per week.
• 2. Core faculty should lead or colead educational sessions (eg, didactics, journal clubs, etc.) on at least a quarterly basis.
• c. Core faculty should participate in scholarly activity or QI initiatives, with the target of at least one per year of any of the following: peer-reviewed funding, publication of original research or review articles in peer-reviewed journals, chapters in textbooks, or presentations (state, regional, or national).
• IV. Percent effort
• a. Sponsoring institutions should provide adequate Full-Time Equivalent (FTE) allocation toward the administration, teaching, curriculum design, mentoring, QI, scholarly activity, and evaluation of the fellowship program, which by ACGME definition is a minimum of 10 hours per week.
• b. Clinical sports medicine revenue and nonrevenue producing activities including direct patient care or fellow precepting should be an expectation of each core faculty.
• D. Noncore Faculty
• I. Clinicians from sports-related surgical and nonsurgical orthopedic specialties may participate as noncore faculty.
• a. Ideally, orthopedic specialists would include: shoulder, elbow, wrist/hand, spine, hip, knee and foot/ankle, pediatrics, and potentially other specialties such as trauma and oncology.
• b. Rotations should include operating room experience, which are an optimal time to perform examinations under anesthesia and observe proper placement of a blind needle injection.
• II. Other noncore faculty may include:
• a. Nutritionists
• b. Coaches
• c. Athletic trainers
• d. Physical/occupational therapists
• e. Pharmacologists
• f. Behavioral specialist
• g. Neuropsychologists specializing in concussion
• h. Exercise physiologists
• i. Anatomy and physiology professors
• j. Bike fit specialists
• k. Strength coaches
• l. Adaptive sports medicine experts
• m. Prosthetist/orthotist

RESOURCES

The program must have sufficient resources and support to become a top-tier sports medicine fellowship training program.

• A. Fellowship Program Coordinator
• I. The fellowship program coordinator is an essential part of any fellowship program and assists with duties such as recruitment, on-boarding, annual program reviews, and evaluations.
• II. The fellowship coordinator should devote at least 50% FTE toward the program.
• III. If the position is shared among other fellowships within the institution, it should only be with one other fellowship program to minimize the inability to complete critical tasks.
• B. Business Administrator
• I. A business administrator can assist in securing financial stability for the fellowship and any associated clinical productivity that is generated.
• II. Critical tasks include managing the clinical budget, assuring stable funding, and assessing the feasibility of reimbursement models.
• III. An ideal allocation may include 10% FTE.
• C. Administrative Staff
• I. Administrative staff may provide support for the faculty, fellows, and fellowship.
• II. Every faculty member should have access to administrative assistance.
• D. Other Resources
• I. Fellows and faculty should be offered clinical and nonclinical workspace, including one computer and desk per fellow.
• II. Fellows should have access to a robust online and/or physical medical library.
• III. Medical information access
• a. The clinical setting should have an appropriate Health Insurance Portability and Accountability Act (HIPAA) compliant Electronic Medical Record (EMR).
• b. An ideal EMR would include the ability to track aggregate patient information for QI initiatives and population health management dashboards.

FELLOW APPOINTMENT

Sports medicine fellowship applicants and programs should follow a standard set of guidelines for recruiting, interviewing, and matching within a fellowship.

• A. Eligibility
• I. Sports medicine fellows must be scheduled to complete an ACGME-accredited residency in Family Medicine, Pediatrics, Internal Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation.
• II. Fellows should submit applications to programs through Electronic Residency Application System (ERAS), which requires completion of United States Medical Licensing Exam (USMLE) steps 1, 2, and 3 or the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX) steps 1, 2, and 3.
• III. Fellows should register and participate in the National Residency Matching Program (NRMP) and abide by NRMP integrity standards and the AMSSM Code of Ethics.
• IV. The ideal candidate should have verifiable research, presentation, or publication experience.
• V. Eligible fellows must be able to obtain a state license in the state of the fellowship program, and it is critical for the program director to know his/her particular state requirements.
• VI. The ACGME's Milestone Handoff from residency to fellowship can be used as a tool to understand the fellow's level of education at the start of fellowship to ensure continuity from previous training. This is now part of ACGME's recommended actions for transitioning between training programs.
• B. Number of Fellows
• a. The number of the fellows in a program should be determined by the adequacy of educational experiences, which would include faculty, clinical/academic capabilities, and team and event coverage.
• b. Ideally, the number of fellows is also guided by the availability of faculty in sports medicine, orthopedics, ancillary staff, and subspecialists, as well as, expertise in musculoskeletal ultrasound.

CORE COMPETENCIES

A list of competency requirements and expectations for promotion and/or graduation should be given in clear detail at the outset of fellowship training.

• A. Patient Care: Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows must be able to diagnose and provide treatment (including appropriate referral) of medical illnesses and injuries related to sports and exercise and competently perform all procedures essential to the practice of Sports Medicine.
• I. Clinical Experience: The fellowship program should ensure adequate clinical experience for fellows that would include a variety of presenting complaints, ages, sports, sexes, socioeconomic backgrounds, types of sports, and levels of participation.
• a) Longitudinal experiences
• i. Sports Medicine Clinic: The sports medicine clinic is the paramount clinical experience during fellowship training and the fellow should work/learn in this setting longitudinally with the target of >800 patient visits.
• ii. Continuity Clinic: Sports medicine fellows are required to have a minimum of one half day per week devoted to clinical care in their primary specialty during fellowship training (minimum target case load >200 patient experiences).
• iii. Training room: During fellowship training, fellows should provide sports medicine care in a training room setting (target >200 patient visits per year).
• iv. Event coverage: Fellows should provide event coverage in a variety of settings during their fellowship year.
• a. Fellows should cover a football team throughout an entire season (high school and college).
• b. Fellows should aim to provide coverage to other contact sports during the fellowship year (lacrosse, soccer, hockey, rugby, etc.).
• c. Fellows should cover at least one game in each of a variety of other sports to become accustomed with the athletic environment and potential injuries that could be sustained during the event.
• d. Fellows should provide medical coverage for at least one mass event during their fellowship year, with the goal of being a medical director/codirector for at least one mass participation event during their training.
• v. Ultrasound: Fellows should complete the AMSSM-recommended sports US curriculum for sports medicine fellowships, plus be given a ½ day per week devoted to US experience.
• vi. Preparticipation examination (PPE): Programs of excellence will have fellows perform PPEs for a variety of athletes (eg, high school, college, Special Olympics, adaptive athletes). The overall target number of PPEs for the fellowship year should be >150.
• b) Monthly rotations
• ii. Orthopedics
• a. Fellows should have the ability to rotate with subspecialists, including shoulder, elbow, wrist/hand, hip, knee, foot/ankle, and pediatrics surgeons (target 50 patient encounters per rotation).
• b. Acute injury and fracture management: Fellowship programs should offer sufficient exposure to acute fracture and dislocation management including assessment and diagnosis, splinting and casting, referral, and follow-up. Fellowships may consider exposure through rotations in the emergency department, urgent care, after game/Saturday morning clinics, or winter injury clinics (eg, winter ski clinic).
• iii. Specialty rotations: Aside from the traditional orthopedic rotations, fellowship programs should look to incorporate monthly or longitudinal experiences with other disciplines such as: sports cardiology, musculoskeletal radiology, PM&R, physical/occupational therapy, exercise physiology and performance, neurology, rheumatology, nutrition, and psychology. Meaningful experiences in each discipline would include a target of >25 patient encounters per rotation.
• II. Procedural Training in Sports Medicine Fellowship Programs
• There are no current ACGME procedural requirements for sports medicine fellowship programs with the exception of the recent addition of ultrasound training. However, because sports medicine procedures are an integral component of most sports medicine practices, they should also be included in this document. Procedural training is also not included in the Sports Medicine Milestones because the milestones are a reflection of the ACGME Program Requirements.
• Procedural training should include education in 4 ways: (1) didactic instructional sessions, (2) didactic practice sessions, (3) mentored clinical experience, and (4) supplementary and continuing education options.
• Direct observation of the fellow's procedural knowledge and technique is critical in determining procedural competency and should be performed to determine proficiency for all procedures.
• a) Sports Ultrasound
• The new ultrasound requirements have not been added to the Milestones, and there is no timeline set at this point to do so. It is recommended that program directors see the AMSSM-Recommended Sports Ultrasound Curriculum for Sports Medicine Fellowships published in the following journals:
• • Br J Sports Med. 2015;49:145–150. doi:10.1136/bjsports-2014-094220
• • Clinical Journal of Sport Medicine. 2015;25(1):23–29.
• • PM&R, Vol. 7, Issue 2, e1–e11. Published in issue: February 2015
• • AMSSM Sports Ultrasound Didactics Online https://www.amssm.org/UltrasoundOnlineDidactics.php
• b) Injections
• Fellows should aim for competency in the following procedures through palpation (*) and/or ultrasound (^) guidance:
• i. Subacromial bursa*^
• ii. Glenohumeral joint*^
• iii. Acromioclavicular joint*^
• iv. Sternoclavicular joint*^
• v. Biceps tendon sheath*^
• vi. Trigger points*^
• vii. Elbow joint*^
• viii. Medial epicondyle*^
• ix. Lateral epicondyle*^
• x. Olecranon bursa*^
• xi. Wrist joint (radiocarpal)*^
• xii. Carpometacarpal joint thumb*^
• xiii. Trigger finger*^
• xiv. De Quervain's tenosynovitis*^
• xv. Digital blocks*^
• xvi. Carpal tunnel*^
• xvii. Sacroiliac joint*^
• xviii. Hip joint^
• xix. Trochanteric bursa*
• xx. Ischial bursitis*^
• xxi. Pes anserine bursitis*^
• xxii. Prepatellar bursitis*^
• xxiii. Knee joint*^
• xxiv. Ankle joint (mortise)*^
• xxv. Plantar fasciitis*^
• xxvi. First metatarsal-phalangeal joint*^
• xxvii. Sinus tarsi*^
• xxviii. Peroneal/posterior tibialis tendon sheath*^
• xxix. Interphalangeal joint injections (hands & feet)*^
• xxx. Tendinopathy/tenosynovitis (all tendons/sheaths)*^
• c) Other procedures to consider for general exposure with didactics, journal articles, or clinical experiences include:
• i. Dry needling
• ii. Autologous blood injections
• iii. Platelet-rich plasma injections
• iv. Prolotherapy
• d) Electrocardiogram interpretation
• i. Currently, no universal standard for sports cardiology training exists for sports medicine physicians in the United States.
• ii. Controversy exists regarding the most suitable approach for cardiovascular screening in athletes, which mainly involves the inclusion (or not) of an electrocardiogram (ECG). Regardless, however, it is critical for sports medicine physicians to be knowledgeable of both the ECG-associated physiologic adaptations to regular exercise and the conditions associated with sudden cardiac death (SCD).
• iii. Free online training programs (http://learning.bmj.com/ECGathlete) are available to improve physician education in ECG interpretation and guide secondary testing for ECG abnormalities.
• iv. Fellows should master and demonstrate sound knowledge of contemporary ECG interpretation standards in athletes (eg, 2016 International ECG Interpretation Standards) through mentored clinical experiences, didactic sessions, and/or formal courses.
• e) Exercise Treadmill Testing
• Programs of excellence will identify ways to provide experiences in exercise treadmill testing (ETT). For fellowship programs aiming to provide exposure to ETT, performing 10 tests can help solidify objectives such as indications for testing, protocols, limitations, and process for interpretation. Those who seek to have their fellows become proficient in ETT must have their fellows perform, interpret, and document >50 tests, which is often the threshold for hospital credentialing.
• f) Exercise prescriptions
• Writing an exercise prescription is an essential skill for the sports medicine physician. All fellows should feel confident in promoting physical activity in their practice after graduation. Exercise prescriptions can be performed in a number of ways [eg, the FITT (Frequency, Intensity, Time, and Type) principle for aerobic activity]. Fellows should aim to write >25 exercise prescriptions during their fellowship year.
• g) Compartment testing
• Compartment pressure testing is a diagnostic technique that can be useful in the management of acute and chronic leg pain. Fellows should complete, interpret, and document at least 5 patient cases and be deemed competent by the program faculty.
• h) Splinting
• Splinting can be performed with a variety of off-the-shelf braces as well as with fiberglass and plaster. Fellows should be competent in immobilizing patient's injuries with the following splints:
• i. Volar wrist
• ii. Ulnar gutter
• iii. Thumb spica
• iv. Sugar tong elbow and ankle
• v. Posterior ankle
• vi. Finger—Stax/buddy tape/flexion and extension splints
• i) Casting: Fellows should be competent at immobilizing patient's injuries with the following casts:
• i. Long arm
• ii. Short arm
• iii. Thumb spica
• iv. Short leg
• j) Neuropsychological testing:
• i. Exposure in the administration of neuropsychological testing for concussion management
• ii. Interpret >10 tests
• k) Laceration repair (aim for competency if not achieved in prefellowship training)
• l) Partial or complete toenail excision (aim for competency if not achieved in prefellowship training)
• B. Medical Knowledge: Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.
• I. Fellows must demonstrate a level of expertise in the knowledge of those areas appropriate for a subspecialist in sports medicine. Material that should be mastered includes content that is testable for the Certificate of Additional Qualification (CAQ) examination, which can be found in the CAQ Sports Medicine Examination Checklist Blueprint (www.theabfm.org/caq/sports.aspx). Core content areas include:
• a) The Role of the Team Physician
• b) Basic Science of Sports
• c) Health Prevention/Preventive Aspects of Sports Medicine
• d) Emergency Assessment and Care
• e) Diagnosis, Management, and Treatment of Sports-Related Injuries
• f) Musculoskeletal Rehabilitation
• g) Procedures
• II. Fellows may attain medical knowledge through different mechanisms such as the clinical settings, sports medicine textbooks or journal articles, didactic instruction, grand rounds, AMSSM case-studies teaching library, AMSSM Ultrasound Curriculum videos, or local/state/regional/national conference attendance.
• III. Programs should have a defined didactic curriculum that offers weekly education.
• IV. Fellows can assess their medical knowledge through the Fellowship Pretest (July/August), the in-training examination (February), and the American Board of Family Medicine Sports Medicine CAQ examination.
• V. Educational Curriculum Organization
• a) Didactics/Conferences: the program should ensure a well-rounded and complete didactic and conference curriculum that exposes the fellows to the full spectrum of Sports Medicine.
• I. The weekly didactic curriculum should be structured, well-organized, and cover a broad range of topics that mirror the blueprint for the CAQ examination in an effort to prepare the fellow for certification.
• II. Regular conferences should be a part of the organized curriculum and offer an opportunity for interprofessional education with colleagues of other disciplines such as radiologists, physical/occupational therapists, athletic trainers, orthopedic surgeons, nutritionists, psychologists, exercise physiologists, and other team members.
• III. Morbidity & Mortality (M&M) conferences are regularly scheduled peer reviews of errors that occurred during patient care.
• a. The objectives of M&M conferences are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications in a nonpunitive way.
• b. M&M conferences identify areas of improvement and systems issues (eg, outdated policies, mathematical errors, etc.), which affect patient care.
• b) Grand Rounds: Grand rounds are an important teaching tool open to a department or medical community and often involve presenting clinical cases, research, and new therapies in sports medicine.
• c) Journal club: Journal club involves the critical review of new (and possibly older, classic) sports medicine literature that may change one's clinical practice and provides fellows with a mechanism to determine the types of articles that could affect practice after graduation. The AMSSM Top 120 Articles (http://amssm.blogspot.com/p/amssm-100.html) may be a source for classic articles that could be used for journal club.
• d) Seminars/workshops: seminars and workshops are specific and focused learning times set aside for such matters as ultrasound, sideline preparedness, event planning, casting and splinting, orthotic fabrication, leadership, research, etc., based on program resources. Consideration should be made for possible collaboration with other, close-by fellowship programs with some of these learning experiences.
• e) Research: Fellows should have a ½ day per week devoted to research and other scholarly activity.
• f) Regional and national meetings: Sports medicine fellows should attend 1 local, state, or regional conference and at least 1 national sports medicine conferences that broaden the understanding of the most recent sports medicine practices.
• C. Practice-Based Learning and Improvement: Fellows must investigate and evaluate their care of patients, appraise and assimilate scientific evidence, and continuously improve patient care based on constant self-evaluation and lifelong learning principles. Fellowship programs should strive to create an environment that fosters inquiry and practice improvement.
• I. Fellows must be able to systematically analyze their clinical practice using QI methods, and implement changes with the goal of continuous practice improvement.
• II. Fellows should be able to locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems.
• a) Fellows should be encouraged to use scientific articles to support their diagnosis and management plans when precepting patients to their attending physicians.
• b) Fellows should participate in journal clubs, which occur monthly and provide education on how to critically analyze literature, with the goal of being able to independently perform these types of assessments in practice after graduation.
• III. Fellows must demonstrate the ability to incorporate formative and summative evaluation feedback into daily practice.
• a) Fellows should ask for and receive formative feedback on a monthly basis.
• b) Summative evaluations should be performed on the fellow after each rotation and reviewed with the fellow on a quarterly basis.
• c) Milestone evaluations should be performed by the Clinical Competency Committee at least every 6 months and reviewed with the fellow by faculty at least biannually.
• IV. Fellows must have access to and be able to use information technology to optimize learning.
• a) Fellowship programs must provide fellows access to a physical and electronic library.
• b) Ideally, fellows would have online access to journals such as the American Journal of Sports Medicine, British Journal of Sports Medicine, Clinical Journal of Sports Medicine, Sports Health: A Multi-Disciplinary Approach, and Current Sports Medicine Reports.
• V. Scholarly Activity
• a) Scholarly Activity Development: The ability to complete scholarly activity within 1 year is often challenging. Thus, directors and fellows may consider project planning before entry into the fellowship year and possibly manuscript completion after graduation. Additionally, directors are encouraged to send their fellows to classes or courses on research design and methods. An example would be the AMSSM Fellows Research and Leadership Conference held each July where fellows can refine project ideas. To meet AMSSM or ACSM deadlines for abstract submission, fellows will need to plan appropriately, brainstorm project design, obtain institutional review board approval, perform the project, analyze data, and write an abstract.
• b) Faculty Scholarly Activity: Faculty are encouraged to work with fellows to complete scholarly activity. Faculty who develop an area of expertise are likely to understand knowledge gaps that can be addressed by future projects. An accumulation of publications can assist a faculty member in obtaining promotion from assistant to associate professor and from associate to full professor. Case reports/presentations, grant funding, journal reviews, conference planning, and committee work at an institutional/regional/national level are other ways to perform scholarly activity and work toward promotion.
• c) Quality Improvement Projects: Fellows should complete at least one QI project during their fellowship year. Quality improvement projects can address a variety of areas within sports medicine and are aimed at improving daily practice.
• d) Case Reports: The fellowship program should expose the fellow to a high volume of cases to improve proficiency in musculoskeletal and nonmusculoskeletal sports medicine. Fellows should ideally aim to submit at least 1 case during the fellowship year, which can be presented at a national meeting. Ideally, these cases would be published in a peer-reviewed journal.
• e) Publications: Fellows should aim to publish at least one peer-reviewed (eg, original research, review articles, etc.) publication that results from work performed during the fellowship year.
• f) Presentations: Presentations provided at various levels (eg, local, regional, or national) may also count toward scholarly activity.
• g) Book Chapters: Fellows may aim to complete at least one book chapter during their fellowship year.
• h) Committees: Fellows can join one local/regional/national sports medicine committee to provide service to the broad discipline of sports medicine.
• VI. Fellow Evaluation
• a) Philosophy: Fellows should be evaluated regularly throughout their fellowship experience. The format should parallel the goals and objectives for each area within the curriculum.
• b) Metrics: Fellows should have evaluations that address the following (when appropriate) in all curricular areas: knowledge, skills, attitudes, and behaviors.
• c) 360-Degree Perspective: Fellows should be evaluated from a 360-degree perspective, including staff, patients, residents/students, attending physicians, athletic training staff, and any other members of the multidisciplinary team. Evaluations should consider measurements in comprehension and quality of patient care.
• d) Dashboards: Data from a population health management system or electronic health records should be used to create a dashboard for fellows to understand the quality, volume, and characteristics of a fellows' patient panel.
• e) Professionalism: The program should ensure that the fellow appropriately understands and adheres to the values and principles of sports medicine, as well as, the philosophy of the program. The program should develop and provide a professionalism agreement that is signed by the fellow at the beginning of the year.
• f) ACGME Competencies: The program should ensure that the fellow is taught and assessed using the ACGME milestones and core competencies.
• g) Interpersonal Skills: Observational data assessing the fellow's interaction with patients can be obtained through direct observation, or videos should be provided so that fellows can improve their performance. Feedback should be provided in a timely manner to allow for early and continued improvement in performance. A multidisciplinary assessment can be provided with the assistance of a specialist in behavioral science. These behavioral science-related curricula and competencies should be weighted consistently with other curricular entities.
• h) Burnout: The fellowship year can be quite rigorous and demanding. The impact of professional development on a fellow's personal life should be periodically assessed. A healthy balance between personal life and professional endeavors should be encouraged.
• i) In-Training Assessment: The AMSSM Pretest (offered in July/August) and the AMSSM In-training examination (offered in February) are standardized objective measures of evaluation that can assist the program in designing an individualized educational plan (IEP). Data from these examinations can also be used to evaluate the program's overall curriculum.
• j) Advising: An IEP should be developed for each fellow and revisited on a regular basis. Each fellow must have an identified advisor (ie, program director, associate program direction, or core faculty) and meetings should occur quarterly to review data from evaluations, previous rotations, and upcoming experiences. Meetings should also provide a basis to discuss career planning.
• k) Practice Management: Fellows should be assessed for their competence to code and bill, and for practice management principles. Assessments can occur through intermittent chart audits or other management of health systems mechanisms.
• l) Final Graduate Summary: Each program must provide a final evaluation for each fellow. This summary must attest to the fellow's ability to practice independently, competently, and autonomously. The summary document should include an assessment of the fellow's abilities to practice in settings such as the office, training room, and sideline, as well as, proficiency in procedures (listed in Procedural Training in Sports Medicine Fellowship Programs). Additionally, the program should provide the graduating fellow with supporting information to document their skills, which could assist in credentialing at their future institution. The program should follow up with graduates to assess the privileges granted based on documentation from both the graduating fellow and the program.
• D. Interpersonal Skills and Communication: The fellow must demonstrate skills that are effective in the exchange of information and collaboration with patients, their families, and health professionals.
• I. It is critical for fellows to effectively educate patients, members of patients' families, medical students, residents, coaches, athletes, other professionals, and other health care professionals (including nurses and allied health personnel) regarding issues related to sports and exercise. Educational materials, such as AMSSM Sports Medicine Today (http://www.sportsmedtoday.com) can be an effective point of care tool to assist in the education of patients, coaches, families, and other interprofessional team members.
• II. Work effectively as a member or leader of a health care team or other professional group.
• a) Fellowship programs should provide didactic sessions on how to effectively manage teams.
• b) At least 10 hours of education per year should be devoted to leadership training and principles.
• III. Maintain comprehensive, timely, and legible medical records
• a) At least 10 chart audits should be performed each quarter by the program to assess the fellows' ability to communicate effectively in the EMR.
• b) Feedback from chart audits should be provided in a timely manner so that fellows can incorporate any needed changes.
• IV. Teamwork
• a) Fellows must be receiving training in an environment that maximizes teamwork among the many caregivers that makes up the sports medicine team.
• b) Fellows must be observed and evaluated and given appropriate timely feedback regarding their communication and leadership skills within the framework of the sports medicine team. This is a critical component of sports medicine systems-based practice education and must be a key component of the regular evaluations and goal-setting meetings held by the Program faculty.
• E. Professionalism: Fellows must demonstrate commitment toward executing professional responsibilities and adherence to ethical principles. In truth, many arenas within fellowship training are lumped into the category of professionalism without concrete examples or process. Ideally, program directors, faculty, and fellows should have a discussion that provides structure and mutual understanding regarding professional standards. The standards should be captured in a Professionalism Contract that is signed by the fellows and addresses commitments to self, patients, colleagues, staff, students/residents, fellowship program, the sports medicine discipline, and society. Included in the contract should also be core principles of excellence, duty, integrity, respect, accountability, and altruism.
• Professionalism and personal responsibility are hallmarks of fellowship training and are often where remediation is needed in fellowships more than in areas such as medical knowledge or patient care. Professional societies, third party payers, and hospitals all require proof of professional conduct as part of the licensing procedure. Fellowships must make the expected behaviors known to fellows upon entry into the program.
• I. Transitions of Care: Transitions of care have become a more important source of medical errors as the number of transitions has grown with the implementation of duty hour requirements. To ensure patient safety, programs must require excellence in these transitions even if fellows are not taking hospital call or providing care for hospitalized patients. Programs should educate fellows on expected handoff methods and policies and monitor and document direct observation of competency in this communication between team members. There are several templates available such as the I-PASS (Illness Severity, Patient Summary, Action List, Situation Awareness and Contingency Planning, and Synthesis by Receiver) system.
• II. Programs should provide fellows with clear expectations of call duties for clinic patients and athletic team athlete coverage to ensure continuity of care with the fewest transitions while meeting all fellow duty hour requirements and fellow wellness expectations.
• III. Programs should ensure a back-up system with proper supervision available at all times for fellow clinic time and sports coverage to ensure patient safety. These schedules should be made available to all members of the heath care team.
• IV. Alertness Management/Fatigue Mitigation: Upon entry to the program, fellowships should share the program policies for education on the signs of fatigue/sleep deprivation, alertness management/fatigue mitigation protocols, and plans for ensuring patient safety and continuity of care in the event the fellow may be unable to perform his/her duties.
• V. Supervision of Fellows and Clinical Progression
• a) Fellows must advance through the 4 stages of supervision throughout the course of their fellowship program receiving progressively increased authority and responsibility as skills and knowledge allow.
• i. Direct Supervision
• ii. Indirect Supervision with Direct Supervision Immediately Available
• iii. Indirect Supervision with Direct Supervision Available
• iv. Oversight
• b) Fellows should gradually perform an increasing role in resident and student supervision and educational responsibility in recognition of their progress toward independence. These levels of supervision should be clearly delineated in the schedules and curriculum.
• VI. Programs should directly observe and document the fellow's skills upon entrance into the program in all of the core competencies. This can be through simulation, Observed Structured Clinical Examination (OSCE), pre-In-Training Examination testing, or with direct patient care.
• VII. The milestones should be filled out as a self-evaluation for the fellow upon entrance into the program and within the first 2 weeks by the faculty. This sets a baseline for an IEP that can be developed with specific learning objectives mutually agreed upon by the Program Director and fellow and eventually modified solely by the fellow identifying specific learning goals as the fellowship progresses.
• VIII. Programs must have appropriately credentialed and privileged attending physicians available for fellow supervision and evaluation at all times, and this schedule should be available for all health care providers and patients informed of these respective roles at all times.
• IX. The program director, associate program director, and advisor (if different from program director or associate program director) should meet with fellows on a regular basis and at least every 3 months to discuss evaluations, milestone progress, progress toward individual goals, and specific learning needs to revise IEPs.
• X. Programs must develop policies detailing the guidelines for circumstances and events in which fellows must communicate with appropriate supervising faculty members. These policies should be given to and discussed with fellows upon entrance into the program.
• XI. Clinical responsibilities and progression toward independence should be based on the collective evaluation of the faculty as discussed at regular interval meetings of the Fellowship Clinical Competency Committee.
• XII. Fellow Duty Hours: Duty hour requirements have been established with the goal of improving patient safety and improving fellow wellness and preparedness to learn. Fellows should be fit for duty and prepared to provide quality care, and this must be balanced with the fact that upon graduation from the program, fellows must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods of time.
• XIII. Programs should have a policy regarding duty hours, and this policy should be presented to and discussed with the fellow upon entrance into the program. The policy should specifically address: the 80-hour work week, a minimum of 1 day free of duty every week (when averaged over 4 weeks), a maximum of 24 hours of continuous duty, no additional clinical responsibilities after 24 hours of continuous in-house duty, effective transitions of care taking no more than an additional 4 hours of time, 8 hours free of duty between scheduled duty periods, no more than 6 consecutive nights of night float, in-house call no more frequently than every-third-night, and at-home call must count toward the 80-hour maximum weekly hour limit when called into the hospital.
• XIV. Programs must have a moonlighting policy, and this policy should be given to and discussed with fellows upon entrance into the program. Moonlighting must not interfere with the ability of the fellow to achieve the goals and objectives of the educational program. Moonlighting time must be counted toward the 80-hour work week limitation.
• XV. Programs should have a policy regarding when fellows can break duty hours, and this policy should be given to and discussed with fellows upon entrance into the program. In unusual circumstances, fellows, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient or return to the hospital with less than the expected 8-hours free of duty. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient (such as a spinal cord-injured athlete), academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. These instances must be documented and reviewed with the Program Director after each occurrence.
• F. System-Based Practice: Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.
• I. Fellows must be able to work effectively and coordinate care in various athlete health care delivery settings and systems, which include the following:
• a) Primary care sports medicine clinic
• b) Orthopedic clinic
• c) Student health clinic
• d) Training room (eg, high school, college)
• e) Sideline/event coverage (eg, football game, mass participation event)
• II. Fellows should also be able to advocate for quality patient care and incorporate considerations of cost awareness and risk benefit analysis in clinical medicine.
• a) Fellows should receive instruction in sports medicine billing and coding during management of health systems curriculum.
• b) At least 10 hours of time per year should be devoted to sports medicine management of health systems curriculum.
• III. Fellows should be able to work in interprofessional teams to enhance athlete safety and improve quality of care.
• a) Fellows should receive 360 degree evaluations from sports medicine staff, including office staff, athletic trainers, coaches, patients, faculty, etc., at least twice per year to evaluate the fellows' ability to work collaboratively in teams.
• b) Fellows should aim to take at least one sideline emergency preparedness course during fellowship year to maximize the ability to work effectively in teams in an emergency setting.
• IV. Participate in identifying system errors and in implementing potential systems solutions.
• a) Fellows should complete at least 1 QI project during their fellowship year to assist in identifying possible system errors and implementing solutions.
• b) Fellows should aim to participate in one committee within the program, clinic, school, or institution that is designed to identify errors within the athlete health care system.

ACKNOWLEDGMENTS

The authors thank Jonathan Finnoff, DO, Andrew Gregory, MD, Kimberly G. Harmon, MD, and Stephen Paul, MD, for their thorough review, edits, and comments of this document.