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Primary Care Sports Medicine (PCSM)

Authors

John Kiel, DO, MPH
Primary Care Sports Medicine Fellow
University of Kentucky

Andrew J. Ortega, MD
Emergency Medicine Resident
University of Illinois, College of Medicine, Peoria

Faculty Editor

Mark J. Conroy, MD, CAQ-SM
Assistant Professor of Emergency Medicine
Center for Sports Medicine
Team Physician
The Ohio State University Wexner Medical Center

Special thanks to our 1st edition writing team

Kylie Conroy, DO
Tim Snow, MD
Anna L. Waterbrook, MD, FACEP, CAQ-SM

INTRODUCTION

Description of the specialty
Sports medicine (SM) physicians provide care for injuries sustained both on and off the athletic field. Prior to the creation of this specialty, most musculoskeletal injuries were cared for by orthopedic surgeons; however, most athletic injuries are non-operative and frequently include general medical complaints as well as traumatic brain injuries. Therefore, the medical care of athletes  may exceed the knowledge and scope of any one specialist and requires a generalist approach for appropriate care. The Primary Care Sports Medicine (PCSM) subspecialty was designed to meet this need.

History of the specialty/fellowship pathway

The PCSM fellowship is available to family medicine, internal medicine, pediatrics, emergency medicine (EM), and physical medicine and rehabilitation physicians. It was certified by the American Board of Medical Specialties (ABMS) in 1992, and since 1993 a written examination for board certification has been administered by the American Board of Family Medicine. It is one of 9 ABMS accredited fellowships available to EM physicians.1

Why residents choose to follow this career path
Residents who choose this path often have an interest in athletics and caring for active people of all ages. Like others, the sports medicine fellowship expands your knowledge base in a niche of emergency medicine: diagnosing and managing musculoskeletal complaints. Completion of this fellowships offers a unique opportunity to have a diverse career in both the emergency department and the outpatient setting.

How do I know if this path is right for me?
If you have an interest in sports and athletic events, consider an elective with a sports medicine physician (ideally EM sports medicine physician or fellowship faculty if available) and/or moonlight/volunteer to cover sporting or mass participation events in your area. If you participate in such electives/events and cannot imagine your career without this patient population, then this may be the fellowship for you. 

Career options after fellowship
EM sports physicians have a variety of career paths available to them, and there are multiple ways to combine an EM and SM practice whether working in an academic or private practice. Sports medicine is a rewarding niche in emergency medicine with many opportunities for education, research, writing, publications, and participation in regional, national, and international organizations and committees. EM sports physicians have become team doctors for many sports teams at all levels of competition, including high school, collegiate, professional, and Olympic sports, as well as leaders in national sports organizations. They may also participate, organize and lead medical teams at mass participation and endurance events such as marathons.

Splitting time between departments
Emergency sports physicians often combine their clinical practice and are able to spend part of their time working in an emergency department and part of their time in a sports medicine clinic. They are able to manage non-operative musculoskeletal complaints as well as general medical conditions and minor head injuries in athletes. However, while not as common, it is possible to practice either specialty exclusively. 

Academic vs. community positions 
Both academic and community positions are available to EM sports physicians. This decision usually depends on a physician’s desire for research, educating fellows/residents, and location preferences. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are nearly 200 ACGME accredited programs nationwide, through theAmerican Board of Family Medicine, the American Board of Physical Medicine and Rehabilitation, theAmerican Board of Pediatrics, andthe American Board of Emergency Medicine. While most programs do accept EM applicants, it is recommended to check with each program individually, and it is prudent to ask if they have ever interviewed, offered a position to, or matched any EM applicants in the past. Simply, each applicants can email the respective program directors or coordinators to find out about the program application requirements. Determining which programs are truly EM friendly and have experience with EM fellows can be challenging at times.

Differences between programs
The primary difference for EM residents applying to Primary Care Sports Medicine fellowships is to differentiate if they have an EM track and/or if they have taken EM applicants in the past. It also important to find out how many, if any, EM sports faculties are available at the program. ACGME requires that fellows work a minimum of 4 hours per week in your primary specialty. However, this requirement was determined based upon the primary care, not emergency medicine, environment. Four hours per week is difficult to achieve in an EM setting and may not be ideal for the new EM graduate. Not all family medicine programs understand the needs of EM fellows and/or have systems in place to allow you to work in an emergency department. Many primary care based programs will only allow EM fellows to work in an urgent care, office-based setting. Thus, it is important to clarify the clinical setting in which you will be assigned for your continuity clinic.  It is also important to note that some programs have you work in the ED/urgent care as a resident, while others allow you to work as an independent provider. Determining the correct balance and setting will vary among EM PCSM fellows.

Length of time required to complete fellowship 
These are primarily 1-year fellowships, with a very few number of programs supporting a 2-year fellowship. Typically, a second year of fellowship would be primarily devoted to research endeavors.

Skills acquired during fellowship 

  • Advancement in the ability to diagnose, evaluate, and manage musculoskeletal injuries, as well as other sports-related injuries (i.e., concussions, exertional heat illness, etc.).
  • Increased experience in musculoskeletal ultrasound, both diagnostic and procedural.
  • Procedural ultrasound skills focused on joint injections, calcium deposit aspiration, arthrocentesis, and soft tissue injection.
  • Procedures including joint aspirations and injections, splinting/casting, endurance testing, compartment testing, some possible fluoro-guided procedures.
  • Training in the ability to follow up acute injuries and manage chronic disease of athletes with continued studying of exercise physiology and athletic injuries. 

Typical rotations/curriculum 
Example of rotations include rehab clinic, sports medicine clinic, covering of sports events including games, meets and mass events, orthopedic rotations, etc. All fellowships include a certain percentage of time working shifts in the emergency department. You will additionally have scheduled didactic time.

Board certification afterwards?
Yes, a written exam is administered through the American Board of Family Medicine. 

Average salary during fellowship 
Fellows are typically paid at the PGY4 level (or PGY5 if completing a 4-year residency) according to the GME contract of their academic institution. There is some variability based upon whether you function as a resident or attending during your emergency department shifts.

PREPARING TO APPLY

How competitive is the fellowship application process?
According to 2018 NRMP match statistics for Sports Medicine, 181 out of 188 programs filled (92.9%); and 283 out of 292 positions filled (96.9%). One program withdrew from the match. There were 386 applicants with rank and 283 of them matched (75.7%).

Requirements to apply
While there are no formal requirements for application, aside from being board certified or board eligible in your respective specialty, there is a fellowship preparation track that is recommended by the AMSSM:

  • Elective in sports medicine
  • 1 year of longitudinal team physician experience with local high school team
  • Medical coverage in 1 mass participation event
  • Presentation during at least 2 sports medicine conferences
  • Presentations of 1 journal club article related to sports medicine
  • Scholarly project in sports medicine
  • Attendance for at least 1 sports medicine conference

Research requirements 
Most programs require participation in a research project during fellowship, typically under the direction of faculty, but the requirements and structure varies from program to program. Thus, completing research during residency would be highly beneficial on your application.

Suggested elective rotations to take during residency (and how to excel during these elective rotations)

  • Orthopedics: Show interest in the non-operative management of MSK injuries. Practice your procedural, splinting and casting skills.
  • Sports Medicine Rotation: Reach out to mentor/ sports medicine physician and let them know you plan to pursue a career in Sports Medicine.
  • Ultrasound: Show interest in the ultrasound skills that pertain specifically to SM. Practice and improve joint injections and aspirations using ultrasound.

Should I complete an away rotation?
If your home institution does not offer a sports medicine elective, and/or you are interested in a particular program/region, then an away rotation should be completed. If there is the opportunity to complete a sports medicine elective at your home institution, it is highly recommended that you participate in this.

What can I do to stand out from the crowd?
Applicants should complete at least 1 sports medicine rotation. While SM fellowship directors realize you are busy as a resident, it is important to get some exposure to Sports Medicine, not only to show your interest and dedication, but to ensure it is the correct career path for you. Similar to EM programs, it is possible to rotate at programs of interest in order to become familiar with the program and their leadership. Consider a resident research project/QI in sports medicine. Experience in sporting event coverage is common in applicants. Presentations/publications in SM are important to show academic interest in the field. Additionally, membership in national organizations (i.e. AMSSM or AOSSM) is recommended.

Should I join a hospital committee?
This is not necessary; however, participation in other venues in the healthcare landscape outside of your residency program can help strengthen your application.

Publications other than research
Publications such as blog posts, magazine articles, case reports, etc., in sports medicine-relevant topics can help to strengthen your CV.

How many recommendations should I get? Who should write these recommendations?
Traditionally 3 letters of recommendation are preferred. One recommendation should be from your program director. Another letter of recommendation should be written by a sports medicine physician with whom you have worked. Additionally, letters can be written by EM faculty and/or other sports physicians who know you well. Ideally, one letter of recommendation is written by a fellowship director; however, programs do recognize that this is not always possible.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship? 
Yes, applicants can still be competitive after working as an attending. It is important that you continue to show evidence of interest/experience/dedication to sports medicine.

What if I am a DO applicant? 
The process is the same for DO or MD applicants who have completed an ACGME accredited residency program and are board certified or board eligible in emergency medicine. For programs that do not participate in ERAS/NRMP, please contact each specifically regarding this question.

What if I am an international applicant?
Not all programs accept international applicants; please refer to individual program websites.

APPLICATION PROCESS

How many applications should I submit?
There is a wide range of recommendations, with about 10-15 the average number recommended. 

How do I pick the right program for me?
A program should have the right fit and feel for you. The program should offer broad exposure to many levels and types of sports. Other considerations include geographic location, family, and how future career goals align with individual program strengths/emphasis. It is strongly recommended to attend a program with a Emergency Medicine-Sports Medicine dual boarded physician on faculty or a program that has at least previously had an EM-SM fellow.

Common mistakes during the application process
Applying too late is the most common mistake. Most programs have a deadline of Oct. 1 to submit completed applications and a December deadline for rank list submission. However, many programs begin offering interviews on a rolling basis as soon as they receive applications, and may have all their interview slots filled before Oct. 1. Another common mistake is not getting a letter of recommendation from a sports medicine physician.

Application deadlines
On July 15 programs can begin reviewing applications. It is recommended to have your application submitted by this date to allow you the best chance at obtaining an interview. Application deadlines vary based upon individual programs. Certification of the rank list is usually due mid-December and the match is in early January. Please refer to ERAS/AAMC website as well as individual program websites for deadlines. 

Tips for writing your personal statement.
Highlight important goals/achievements and how this has shaped you and how it relates to becoming a SM physician. Most important, be authentic. Tell your story in a way that is uniquely you, and let your personality shine through. 

Is this a match process? 
Most programs participate in ERAS-NRMP.

What happens if I don’t obtain a fellowship position?
Scramble. There may be at-large positions available after the match. An applicant can re-apply the following year, but it is recommended they meet with their SM faculty mentor to analyze what may have gone wrong and improve their application as necessary. In 2018, there were 9 unfilled programs and 9 unfilled positions.

INTERVIEW PROCESS

How do I stand out from the crowd?
Be on time. Be familiar with the program you are interviewing with. Ask thoughtful questions. Do not be afraid to be enthusiastic. 

What types of questions are typically asked?
Questions may include: Why do you think sports medicine is right for you? What are your experiences in sports medicine? How do you envision incorporating your fellowship training into your future career? 

How many interviews should I go on?
This varies depending on strength of application, but approximately 10 interviews are recommended.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Madden, Christopher et al. Netter’s Sports Medicine. Philadelphia, PA: Saunders; 2009.
  • Waterbrook A. Sports Medicine for Emergency Physicians: A Practical Handbook. Cambridge; 2016.
  • Harrast et al. Sports Medicine, Second Edition: Study Guide and Review for Boards. Demos Medical; 2016.

Important skills to practice while in residency to prepare for fellowship
It is important to spend the time in residency learning your primary specialty well, as many people choose to practice both after fellowship. It is also recommended to spend time in sports medicine clinics and on the sideline of sporting events. No one expects you to be an expert in sports medicine prior to starting your fellowship, but rather have just some familiarity with practice and principles. Incorporating SM into your EM residency journal clubs, lectures, and presentations will allow you to stay up-to-date on not only the latest EM topics on both fields.

Tips on how to succeed as a fellow
Start early: Contact current fellows and program director to get advanced advice. Review anatomy and physiology prior to start of fellowship.

Show up early to events, introduce yourself to event staff and athletic trainers as appropriate, and review emergency action plans for events. While it is important to show interest and enthusiasm, it is also important to pay attention to team dynamics: medical care of athletes is a team sport where everyone plays an important role.

Be prepared for journal clubs, lectures, etc.

CONCLUSION

Additional resources

Journals

  • American Journal of Sports Medicine
  • Clinical Journal of Sports Medicine
  • Sports Health

Podcasts

National organizations

Conferences
AMSSM and ACSM both hold annual conferences that are worth attending. If you are attending ACEP or SAEM, make sure to attend the sports medicine section/interest group meetings. EMRA now has a sports medicine division and is actively recruiting members.

How to find a mentor
Ideally, find an Emergency Medicine-Sports Medicine dual-boarded physician, but many areas do not have one. In that case, connect with other SM physicians; many are very open and helpful to residents from any specialty. They may also be able to get you connected with other EM SMdual-boarded physicians either locally, regionally, or nationally. There are several mentor matching services that can be found through EMRA, ACEP Sports Medicine Section, and the AMSSM. The EM-SM fellowship network is small, and physicians are very welcoming and encouraging of interest, as this is a very rewarding EM subspecialty.