Sports medicine (SM), a subspecialty established by the American Board of Family Medicine (ABFM) in 1993, has grown immensely over the past decade with the certification of over 2200 SM physicians (SMPs).1,2 Correspondingly, the number of fellowship programs has grown to 143 over this time.3 The increased demand for SMPs may be because they are providing an important level of secondary care, which includes the treatment of musculoskeletal conditions, as well as nonmusculoskeletal conditions, that may affect athletes and those who exercise.4 Currently, SM certification is available through the American Board of Medical Specialties to physicians with certification in an eligible primary specialty (family medicine, physical medicine and rehabilitation, emergency medicine, internal medicine, or pediatrics) and who complete an Accreditation Council for Graduate Medical Education–accredited SM fellowship. In family medicine, SMPs earn a Certificate of Added Qualification (CAQ) instead of a subspecialty certificate like physicians in other primary specialties.
The practice patterns of SMPs has not been studied for over 10 years. A survey published in 2008 examined scope of practice, career satisfaction, and self-perceived skills of family physicians with a CAQ in SM [sports medicine family physicians (SM-FPs)]. This study found that SM-FPs tended to be young, male, satisfied with their careers, and faculty members in teaching settings. In addition, an inverse relationship existed between confidence in managing general medical problems and the percentage of musculoskeletal complaints managed.1 Another study, also published in 2008, examined specific attributes of a career in SM, including academic and team affiliations. This study demonstrated that clinical duties represented the largest proportion of the SM-FPs' schedules and that most SM-FPs performed routine athletic event coverage.5 In addition, a study published in 2001 examined gender differences within SM and found that men SM-FPs were generally older, more likely to be married, and were more likely to cover training rooms and sporting events than women SM-FPs.6 Finally, in 2015, most SM-FPs were reported to spend 50% of their time or less practicing SM, although from 2005 to 2015, the number of SM-FPs observed to be spending 50% or more of their time practicing SM increased significantly.7
Given the growth and changes in composition of SMPs over the past decade and the changes within the health care system, an updated analysis of the practice patterns of SMPs is needed. For example, in 2008, 80% of SMPs were trained in family medicine,1 which declined in 2018, to 62%; with physical medicine and rehabilitation-trained physicians the next largest group at 19%.2 In addition, as of 2008, the SMP population was comprised of 16.2% women which was an increase from 10% in 1998;1 it is unknown whether this increase has continued. In practice setting, as of 2001, more than 40% of SM-FPs described their practices as a private group practice;6 yet as of 2016, physicians were shown to be trending away from owning their own practice8 and it is not known whether this trend applies to SMPs. The distribution of SMPs between urban and rural practice settings is also unknown. Given these changes and lack of new information about the SM field within the past decade, examination of practice patterns of current SMPs is long overdue. Our objective was to describe the demographics, time spent practicing SM, scope of practice, team physician status, and practice setting of SM-FPs and compare them to other family physicians without a CAQ.
We used data from the 2017 and 2018 ABFM Family Medicine Certification (“primary”) and SM CAQ examination registration practice demographic questionnaires from physicians seeking to continue their certification. These questionnaires are a mandatory component of examination registration and are completed 3 to 4 months before the examination date.9 The primary examination questionnaire asked about involvement in continuity care, practice ownership and organization, scope of practice, and faculty status. The SM questionnaire asked about percent effort devoted to SM; time in clinical care, research, teaching, and administration; and team physician and fellowship faculty status.
To create our analytic samples, we accessed ABFM administrative databases and determined CAQ status. We excluded family physicians with other CAQs to compare SM-FP diplomates to non-CAQ family physicians. Because of small sample sizes in some categories, we collapsed responses on practice organization into larger categories; Federally Qualified Health Center or Look-Alike; Rural Health Clinic (federally qualified); Indian Health Service; Government clinic, non-federal; Federal; Workplace clinic; and Other are in the “Other” category. We grouped percent time in SM into bands of 0% to 20%, 21% to 40%, 41% to 60%, 61% to 80%, and 81% to 100% for analysis. We created a variable representing the sum of number of different levels of teams a SM-FP covered.
We conducted descriptive statistics and then tested for differences between the SM-FPs and non-CAQ family physicians on data from the primary examination registration data using χ2 and t-tests. Data from the SM examination registration are presented alongside the primary data, but were not formally tested for significance against the primary cohorts. Given prior literature on gender differences in level of team supervision,6 we conducted bivariate statistics by gender for time in SM and supervision. Given the high number of comparisons, we report Bonferroni corrected P-values for significance. SAS Version 9.4 (Cary, NC) was used for all analyses.
The American Academy of Family Physicians Institutional Review Board approved this study.
Our sample included 299 SM-FPs for the SM examination and 458 SM-FPs and 15815 family physicians in the ABFM primary exam data. Sports medicine family physicians are generally younger than non-CAQ family physicians with 64.9% of SM-FPs being 49 years or less (Table 1). Sports medicine family physicians are predominantly men (78.2%), graduates of US medical schools (91.5%), and faculty members (54.4%). Almost one-third (31.3%) of SM-FPs are fellowship faculty members. There are no differences in medical training (MD or DO) between SM-FPs and family physicians without a CAQ (P = 1.0000). Sports medicine family physicians are more likely to work in medium-sized (6-20 providers, 37.9% vs 31.1%, P = <0.0001) or large (more than 20 providers, 33.6% vs 23.0%, P = <0.0001) practices, academic health center/faculty practices (18.3% vs 6.5%, P = <0.0001), and multiple specialty (not only primary care) practices (43.7% vs 21.0%, P = <0.0001) when compared with non-CAQ family physicians. Finally, SM-FPs are more likely to work at a site located in an urban setting when compared with family physicians without a CAQ (92.8 vs 83.7%, P = <0.0001).
More than half (57.7%) of SM-FPs report spending 60% of their time or less practicing SM, whereas 30.9% report spending 81% to 100% (Table 2). There are no differences by gender in time spent practicing SM (P = 1.0000). In addition, 66.7% of SM-FP report being a team physician. Among the SM-FPs who are team physicians, adolescent team (73.2%) coverage is the most common response. Overall, men SM-FPs are more likely to be team physicians than women SM-FPs (71.3% vs 45.3%, P = 0.0108); however, there is not a statistically significant difference between genders at any specific level of supervision (P = 1.0000). Almost all (95.8%) of the women SM-FPs within the team physician group report supervising 3 or fewer levels (professional, collegiate, etc) of athletes, whereas 19% of men SM-FPs within the team physician group report supervising 4 or more levels of athletes.
More than half (58.4%) of SM-FPs spend 81% to 100% of their SM time providing direct patient care, whereas the vast majority spend 0% to 20% of their SM time teaching (87.3%), doing research (98.6%), or administration (93.1%) (Table 3). In addition, the vast majority of SM-FPs spend 0% to 20% of their time performing field supervision of athletes (92.1%), emergency assessment and care (94.5%), exercise as treatment (92.4%), management of medical problems in the athlete (79.4%), or rehabilitation of ill and injured athletes (93.1%). Almost half (49.5%) of SM-FPs spend 41% to 80% of their time providing diagnosis, treatment, management, and disposition of common sports injuries and illness. Sports medicine family physicians are less likely to practice pediatric outpatient care (55.1% vs 65.1%, P = 0.0206) and end of life care (17.7% vs 29.9%, P = 0.0003) than family physicians without a CAQ (Table 4). However, SM-FPs are more likely to practice integrative medicine (10.6% vs 5.0%, P = 0.0009) and perform casting (68.0% vs 23.0%, P = <0.0001), joint aspiration and injection (89.0% vs 57.6%, P = <0.0001), and musculoskeletal ultrasound (45.0% vs 2.6%, P = <0.0001). Finally, there is not a statistically significant difference in scope of practice for providing prenatal care, newborn hospital care, pediatric hospital care, intensive/critical care, behavioral health care, baby delivery, and adult hospital care between SM-FPs and family physicians without a CAQ.
Our large and contemporary study of SM-FPs found that the percentage of time devoted to practicing SM is in line with earlier trends,7 because the majority spend 60% of their time or less practicing SM, indicating significant practice time in their primary specialty. This suggests that SM-FPs likely maintain their family medicine skills while having the ability to provide specialist level care to patients with sports injuries and illnesses. In doing so, most SM-FPs continue to fill an important role within primary care by treating musculoskeletal and nonmusculoskeletal conditions in people of all ages and all activity levels through maintenance of their primary specialty skills.4
Even within their time practicing SM, SM-FPs seem to be fulfilling primary care needs with the majority providing direct patient care in the form of diagnosis, treatment, management, and disposition of common sports injuries and illnesses to a variety of patients, not just athletes, which is an intention of SM fellowship training. This supports previous findings,1 because SM-FPs may be reducing the demand on orthopedic surgeons by treating these common sports injuries of athletes and nonathletes, especially when considering that up to 90% of common nonsurgical musculoskeletal complaints are believed to be manageable in the primary care setting.10 Sports medicine family physicians are able to use their additional SM training to treat sports injuries more confidently than family physicians without a CAQ, potentially resulting in fewer referrals to orthopedic surgeons. This contention is supported by prior findings as the referral rate from the SM clinic to orthopedics clinic was shown to be only 2.4%.11 Sports medicine family physicians could be filling the consultant role themselves by receiving referrals from other non-SM clinicians.1
In the current study, almost one-third of SM-FPs spend 81% to 100% (8-10 half days a week) of their time practicing SM, which confirms prior findings7 that show more SM-FPs are spending most of their time practicing SM. Perhaps more career opportunities are presenting themselves as the subspecialty grows, where SM-FPs are able to spend a greater percentage of their time practicing SM, such as working in an orthopedic clinic. Although the data do not allow direct comparison of primary certification to SM CAQ examination data, the SM-FPs included in the primary cohort are far more likely (47% vs 21%) to work in multispecialty (nonprimary care exclusive) practice settings. This supports the hypothesis that there is a strong presence of SM-FPs in orthopedic clinics. These career opportunities do not seem to include becoming a team physician however, because 89.3% of SM-FPs were team physicians in 2008,1 whereas only 66.7% of SM-FPs are team physicians in this current study. It is possible that the team physician positions are saturated, and the rate of growth of new team physician positions may not match the rate of new SMPs certified. Finally, the similar distribution of men and women within the percentage of time spent practicing SM categories could indicate that women are receiving similar opportunities to practice SM as men.
Our data show that over the last 10 years, more women are in SM, but the ratio of men to women is still very unbalanced, especially when considering that women made up 58% of family medicine residents in 2013 to 2014.12 The reason that women are not drawn to the SM field at the same rate as men is unknown; however, in a previous study, 24% of women SM-FPs felt that their gender had a negative effect on their career as opposed to 1% of men SM-FP.6 In addition, women are not only underrepresented in the SM field, but they are also less likely to become a team physician. There could be an intimidation factor present for women considering entering the SM career field, because the sports world has traditionally been male predominant. However, given the recent growth of women's sports, with women making up 42.8% of high school athletes13 and 44% of NCAA athletes14 as of 2018, women should be encouraged to enter SM, as patient preference for a physician of the same gender has been established for visits occurring in nonemergent/“routine” settings and visits involving “sensitive issues,” both of which are likely in SM.15
We found few differences in primary care scope of practice between SM-FP and non-CAQ family physicians, indicating that SM-FPs retain broad knowledge and skill. This supports the concept that SM-FPs can provide comprehensive primary care while still providing specialist level treatment of SM conditions. Furthermore, it is not surprising given that the cohort of SMPs analyzed are family medicine-trained, that some of them are able to maintain their prenatal, newborn, and pediatric treatment skills, with a small portion of SM-FPs reporting baby delivery to be in their scope of practice. As for procedural care, not surprisingly SM-FPs practice musculoskeletal procedures significantly more than a family physician without a CAQ. Sports medicine family physicians are most likely trained to be competent in such procedures during their SM fellowship and therefore perform these procedures more often than a typical family physician, because they have more confidence and opportunity to do so. Finally, there is not a significant difference between SM-FPs and family physicians without a CAQ in practice of chronic pain management. This suggests that SM-FPs develop or maintain this skill in their practices and may be better trained to treat chronic pain related to musculoskeletal conditions because of their additional training in SM. Sports medicine family physicians could be using integrative medicine as a chronic pain management strategy, because SM-FPs are shown to practice integrative medicine significantly more than family physicians without a CAQ.
Sports medicine family physicians are predominately located in urban settings and in larger practice settings that house multispecialty teams of physicians. The concentration in urban areas is likely because of an increased need for SM-FPs in urban areas as individuals living in urban and suburban areas exercise more in general than individuals living in rural areas.16 In addition, athletes in suburban high schools are more likely to exhibit sport participation patterns that are associated with increased risk of overuse injury than athletes in rural high schools.17 These exercise patterns among both athletes and active individuals living in urban areas may lead to a higher frequency of sports injuries and illnesses, contributing to an increased demand for SM-FPs in urban compared with rural settings, therefore leading to more employment opportunities for SM-FPs in urban settings. SM programs may need to tailor their programs to the needs of rural populations if a high number of their graduates are practicing in rural settings.
Several limitations in this study deserve mentioning. First, the results represent only those physicians seeking to continue their ABFM or SM CAQ certification in 2017 and 2018. Although past work has shown the ABFM primary examination cohorts are generally representative year-to-year9 the representativeness of the SM examination cohorts each year is unknown. Similarly, our SM-certified group is only family physicians and may not be representative of the entire SMP population. However, family physicians are 62% of all SMPs so the results apply to most SMPs.2 Our sample is roughly 10% of all certified SM-FPs which may be considered a small sample but, the 100% response rate to the questionnaires increases representativeness. Finally, our data are self-reported and may be subject to recall, immediacy, or social desirability biases.
Because the state of the SM field had not been reported on in over 10 years, a contemporary study of the practice patterns of SMPs, particularly SM-FPs was much needed. Overall, SM-FPs are young, men, graduates of US medical schools, and are likely to be members of faculty at teaching centers. The generally young age of SM-FPs could be a reflection of the age of the subspecialty itself, because the first SM fellowship was not accredited through the Accreditation Council for Graduate Medical Education until 1996. Most SM-FPs spend 60% of their time or less practicing SM, whereas an increasing number are exclusively or almost exclusively practicing SM, with about two-thirds serving as team physicians. In addition, SM-FPs tend to practice in large settings with practitioners of various specialties and are likely to practice at an urban site. The scope of practice of SM-FPs seems to be slightly narrower than that of family physicians without a CAQ; however, the overall similarity in scope of practice could indicate that SM-FPs are still practicing their primary specialty for a significant percentage of their time. During the time that they are practicing SM, SM-FPs are providing direct patient care, treating common nonsurgical musculoskeletal complaints, and potentially decreasing the number of referrals to orthopedic surgeons. Finally, the current gender composition of SM-FPs is not representative of the current gender composition of family medicine residencies; future studies should examine the motivation and barriers for women pursuing SM training and careers.
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