Premedical education

The education process in the United States starts with 13 years of publicly or privately funded study (basic education). Once a student attains a degree from this basic education (a high school diploma), they may apply to a college or university for undergraduate training. After acceptance in an undergraduate programme, the student must designate a major field of training. For the student interested in medical school, this has traditionally been biology, microbiology, chemistry, or one of the other sciences. A newer trend in the United States for those not interested in making a career in the basic sciences should they be denied a place at medical school is to designate a major in a career oriented field such as exercise physiology, microbiology, athletic training, physical therapy, or the newly forming physical therapy/athletic training (PT/ATC) programmes. The last of these is a combination of both athletic training and physical therapy, allowing the student more choices and higher salaries when choosing a job. Physical therapy has traditionally been a well paid job, but there is at present an overabundance of physical therapists in many regions of the United States. Having athletic training certification yields a superior candidate for these higher paying physical therapy positions yet still allows them access to athletes and sports teams.

Medical education

There are two camps of thought on medical training in the United States: allopathic and osteopathic medicine. Allopathic medicine is the more traditional route, employing conventional interventions for diagnosis and treatment. Its graduates are referred to as medical doctors (MDs). Osteopathic medicine is an alternative approach to medical training employing hands on manipulation of the body to assist in diagnosis and treatment of musculoskeletal and medical problems. They probably have better musculoskeletal training during medical school than their allopathic counterparts, but these differences may even out in residency. These physicians are referred to as osteopathic doctors (DOs). To apply for either of these medical schools, the candidate must have at least a four year undergraduate degree and scored high on the Medical College Admissions Test (MCAT). Typical scores are above the 80th percentile. Further criteria used to classify the large number of candidates for admission to medical school are grade point averages (individual grade point averages for science courses and courses required by the medical school are usually looked at separately), extracurricular activities, volunteer experiences (especially in the medical field), and any honours or awards. If the candidate meets the minimum acceptance criteria, they are given an interview with the faculty and staff of the medical school. At the interview, the candidate is asked questions about their desire to enter the medical field, motivations for career choices after medical school, and are assessed for their ability to communicate. Most medical schools assign numerical points to each area of the acceptance process and offer positions to the highest ranking candidates.

Once in medical school the student has specified curricula to attend. Many medical schools are adopting a problem based approach, which presents the student with a case through which they learn the areas of medicine (anatomy, physiology, pharmacology, social sciences, pathology, and others) and can apply it directly to a typical patient that they may encounter in practice.^1,2 At most medical and osteopathic schools, the student is in the classroom the first two years with only limited clinical activities. The second two years are mostly clinically oriented in the setting of the hospital or office. Most schools allow elective rotations in those areas of interest for the medical student during this period. It is here that the student interested in sports medicine can become actively involved with the care of athletes. In addition to participating in an elective rotation in sports medicine, the student can also become involved by helping at sports physicals, observing sports medicine staff during sideline coverage, participating in research, etc. Rotations in orthopaedic surgery and/or primary care will also improve their chances of acceptance into a sports medicine programme. For an additional one to two years, some medical schools offer a Doctor of Medicine/Doctor of Philosophy (MD/PhD) or a Doctor of Osteopathy/Doctor of Philosophy (DO/PhD) degree. This is highly attractive to students interested in research in the medical field and makes them ideal candidates for a sports medicine fellowship. On completion of medical or osteopathic school, students receive their medical doctorate (MD) or osteopathic doctorate (DO) and are considered a physician.

Residency training

Before being allowed to practice medicine independently as general practitioners, doctors must complete at least one year of training at a primary care residency programme (some states require a minimum of two years but this is extremely rare). Most doctors apply for and complete a residency in a designated field of medicine, either primary care or specialty training. The first year of their designated residency is termed the internship and the doctor is called an intern. Primary care residencies consist of paediatrics, internal medicine, emergency medicine, family practice, etc. Most primary care programmes are three years (internship plus two years). Many offer fellowships in areas of interests such as adolescent medicine, geriatrics, and sports medicine for an additional one to two years of training. Primary care has the advantage of a broad range of medical knowledge allowing the doctor to care for the whole patient. It has an extensive range of practice opportunities and carries the designation of primary care physician (PCP) which allows the doctor to act as a gatekeeper of medical utilisation among many insurance companies and federal agencies. Specialty residency training includes general surgery, orthopaedic surgery, ophthalmology, otolaryngology, pathology, radiology, anaesthesiology, etc. These are generally five year residencies (internship plus four years). Many of the specialty fields have subspecialties, such as cardiology, endocrinology, pulmonology, urology, vascular surgery, thoracic surgery, plastic surgery, etc, requiring another application process and an additional training period. These are the most specialised and highest paying fields in medicine in the United States. MD and DO residency programmes are sometimes separate, but there is often intermixing of doctors among these programmes.

Sports medicine fellowships

Several of the primary care specialties offer fellowships in sports medicine for an additional one to two years of training. There is an additional application process involved. Again, separate allopathic and osteopathic fellowships do exist but there is often intermingling of doctors among the programmes. Acceptance in a sports medicine fellowship is generally based on previous sports medicine experience, extracurricular activities, electives, and career desires. It is generally very beneficial if the applicant has done an elective rotation with the programme. Most programmes are accredited by a national board (American Board of Medical Specialties or the American Osteopathic Association) but overseen by its smaller member boards.³ Accreditation of a sports medicine programme requires the programme to have a minimum number of hours preserved to maintain the fellow's primary care training, a minimum number of hours of supervised sports medicine clinics with qualified personnel, have access to a broad range of specialists, as well as have exposure to numerous types of athletes. Specific learning objectives with respect to the athlete must also be met. These cover areas such as anatomy, physiology, biomechanics, pharmacology, nutrition, psychology, preventive care, conditioning and training, and management of injuries and illnesses. By graduating from an accredited programme, the resident is eligible for board certification in sports medicine (Certificate of Added Qualification) as overseen by its member board. Board certification is required at present for specialist reimbursement from most insurance companies⁴ and is favoured in teaching positions at accredited programmes. In the days of educated patients, board certified doctors will be actively sought out and those without certification will be rare (or very broke).

There are primary care programmes at present that are based in orthopaedic groups and are essentially designed to expand the groups sports coverage and reduce their office responsibilities by having a fellow for a very modest cost. Because they are not typically accredited programmes, these fellowships are ideal for the primary care resident whose career interests entail familiarity with sports injuries in their primary care practice, acquiring a position at an orthopaedic practice, or covering a few local sports teams.

There are also fellowships in sports medicine designed for the resident trained in orthopaedic surgery. They generally teach the surgical approach to sports medicine and do not stress the numerous other areas of athletic care. The fellows are not board eligible in sports medicine when their fellowship is complete. This means essentially that insurance companies reimburse them at the same rate for their surgeries as their colleagues without fellowship training. They do not have an accrediting body, which means there are no curriculum requirements or standards for supervision. Completion of a fellowship at a well known programme, however, can significantly improve a candidate's prospects at a desirable surgical sports medicine position allowing them to care for young healthy patients with few surgical complications and who are highly motivated to rehabilitate. It may rarely even involve team coverage as a head team doctor with a major sports team.

Practice positions

The PCSM fellow who is interested in maintaining qualifications in primary care and who would like to care for elite athletes will find job opportunities somewhat limited. Most job openings with this description are in academic fields, mostly residency programmes and fellowship programmes. A moderate number of positions are available in university student health clinics with promises of team coverage at the university and may include some sports medicine injury clinics. These are generally lower paying positions, have no call or inpatient requirements, and are not thought of by some to use the full training potential of the primary care doctor. There is an overabundance of positions for PCSM doctors in family practice settings, especially large groups, where their expertise is used to reduce the number of referrals to orthopaedic surgeons, curtail the number of unnecessary surgeries, and generate savings for the practice and insurance groups. The PCSM doctor may be able to charge as a specialist with some insurance companies under certain circumstances and still maintain their primary care status.⁴ Some orthopaedic surgery groups are very interested in hiring PCSM doctors to manage their non-surgical patients, perform presurgical clearances, expand team coverage, and sometimes to act as inpatient consultants. These are generally high paying jobs, but most do not use their primary care training enough to maintain their board certification and risk losing their PCP status.

It is hoped that the preceding information will be instructional to those not familiar with our policies and practices in the United States and may help some students interested in sports medicine make educated and directed decisions. The road to becoming a doctor of sports medicine can be a long one (table 1), but for those interested in this field it can be a very fulfilling and lifelong career.