Sports Medicine for Emergency Medicine Physicians, Too Few to Maintain the Fellowship in Emergency Medicine

Abstract

Sports medicine (SM) is a clinical subspecialty concerned with the diagnosis and treatment of injuries and illnesses sustained both in and out of the athletic arena. Historically, orthopedic surgeons provided the bulk of care for the athlete. Since the majority of issues with athletes are nonoperative musculoskeletal injuries, traumatic brain injuries, or general medical conditions, primary care providers have developed an important role in SM. The primary care sports medicine (PCSM) physician has become increasingly popular with amateur and professional teams, as growth of sports participation has created medical demands that far exceed the ability of a single medical specialty to provide care.1 Orthopedic surgery practices have also realized the benefits of utilizing PCSM physicians to assist in patient care. The PCSM fellowship started in 1992 when the American Board of Emergency Medicine, the American Board of Pediatrics, the American Board of Family Practice, and the American Board of Internal Medicine made an application to the American Board of Medical Specialties (ABMS) to offer subspecialty certification in SM and received approval. Family medicine (FM) is the administering board and has offered written exams since 1993. Today, SM is 1 of only 6 fellowships recognized by the ABMS for emergency medicine (EM) physicians. SM should be appealing to emergency physicians, as patients with acute athletic injuries present to the emergency department on a fairly routine basis. Although there is no reliable sports injury tracking system, recent reports estimate over 4 million emergency department visits occur annually for injuries related to participation in sports and recreation.2 One could imagine that the demand for sports medicine fellowships would be high. The reality is that there is minimal participation in SM among EM clinicians, and in general there is very little participation in PCSM among any specialty other than FM. The sparse participation is not due to a lack of training opportunities. The majority (62%) of the 97 PCSM fellowship programs allow EM residents to apply. However, only 6 (6.2%) of these fellowships are run by EM, while 83 (85%) are run by FM departments. Currently, 0.5% (n = 101) of all board-certified EM attending physicians and 2.3% (n = 1,486) of all board-certified FM attending physicians are PCSM board certified.3 In our recent survey of 2008 to 2009 EM residency program directors with 89% (116/130) response rate, we found that 51% of program directors reported no SM practitioners.3 Seven percent of departments have 4 or more fellowship-trained attending physicians, while 66% of programs have no one who is fellowship-trained working in their department. In comparison, a mean 1.7 (95% confidence interval: 0.2–3.2) residents per program surveyed were reported to be interested in a career in SM. However, during the last 10 years, 60 EM residents in total have completed a PCSM fellowship following EM residency training. This number is surprisingly small and is inconsistent with the reported interest. There is no readily apparent answer as to why EM residents fail to pursue SM fellowships. Given the lack of prior penetration by EM physicians into SM, current residents with potential interest in SM have EM mentors to look to for guidance, teaching, and exposure to the field. While there are many SM fellowship positions available to EM residents, most of these fellowships are run by FM departments and, thus, may not appeal as much to EM applicants. In order to make a significant presence in SM, we must continue to encourage our residents to do SM electives, be involved in sports coverage, and apply to fellowships. For these opportunities to present themselves, programs must continue to hire fellowship graduates in order to mentor residents and train fellows of their own. If more EM based SM fellowships become available, there will be more EM mentors in the field and more EM resident exposure to SM. This would, in turn, likely lead to more resident participation in fellowship training. A letter to the editor in Academic Emergency Medicine in 20034 discussed the EM ultrasound fellowship and said that these fellowships are needed to advance the field and to provide EM physicians the expertise in ultrasound. Similarly, SM fellowship training is also needed in the field of EM to advance research and to develop EM leaders within the subspecialty. Without this type of growth, SM will continue to be dominated by FM, and EM will never gain a presence in a subspecialty that seems to best suit the EM physician.