Abstract
Background:
Orthopaedic surgery residents may cover athletic events, although the training provided to prepare residents for this role and oversight from attending physicians during these activities is not well understood.
Purpose:
To survey orthopaedic residents about the training provided by their residency program for on-field athletic coverage and to understand their levels of preparation for this role and confidence in treating commonly encountered on-field conditions.
Study Design:
Descriptive epidemiology study.
Methods:
An anonymous survey was emailed to residents in all American College of Graduate Medical Education–accredited, allopathic, nonmilitary orthopaedic surgery residency programs. This survey queried residents about their demographics, the opportunities their residencies require or allow for athletic coverage, their level of preparation for serving an on-field physician, and their comfort level with treating a number of on-field conditions. Likert-type scales were used to assess resident comfort level for treating 13 orthopaedic and nonorthopaedic conditions as well as their perceived level of preparedness.
Results:
Of 148 residency programs contacted, 57 programs responded (39%). Of the 57 programs responding, 51 (89.5%) allowed or required residents to cover athletic events, and 27 of 51 (52.9%) reported that training to prepare for this role was provided. Only 6 of 24 programs without training available (25%) had direct attending supervision of residents at all athletic events. Residents who answered that their residency programs mandate training prior to their participation in athletic coverage activities reported a higher level of preparation for this role than those with no training, optional training, or those who were unsure of their training requirement (P < .0001, P = .035, and P = .013, respectively). In addition, the more senior the resident was, the higher the level of confidence was in treating all orthopaedic and some nonorthopaedic conditions. Residents who had mandatory training displayed a higher comfort level in treating on-field orthopaedic and nonorthopaedic conditions than those without training.
Conclusion:
Formal training of orthopaedic residents prior to their covering athletic events can improve confidence in treating orthopaedic and nonorthopaedic conditions. Many programs do not ensure that residents are familiar with key and potentially life-saving equipment. An opportunity exists to improve resident education.
Keywords: resident training, sideline coverage, event coverage, sports medicine
Orthopaedic surgeons have the privilege of providing medical coverage for a diverse range of athletic events and are among a growing range of providers who share these responsibilities: certified athletic trainers, physical therapists, emergency medical technicians, nurses, and nonoperative physicians.18 While caring for athletes on the field, these providers may need to treat a broad array of injuries not limited to the musculoskeletal system,6–8,10,11,13,14,17 despite the fact that the education and training for each type of provider varies greatly.3,5,20,22,23,25 Many orthopaedic residency programs require residents to work as independent or assistant sideline physicians, but the training needed to effectively treat the wide variety of conditions, clinical situations, and ethical dilemmas12 encountered is not standardized. Therefore, orthopaedic surgery residents may have different levels of preparation for and confidence in their ability to fulfill the duties of this role.
The purpose of this study was to assess the prevalence of orthopaedic surgery residency programs that either mandate or allow residents to cover on-field athletic events, to quantify and qualify the training and oversight provided by these programs, and to assess orthopaedic residents’ levels of preparation and confidence in treating on-field musculoskeletal and nonmusculoskeletal conditions. Given that curricula and competency requirements in orthopaedic surgery residency programs are comprehensive in musculoskeletal pathologies,15 it was hypothesized that orthopaedic surgery residents more senior in their training will have greater confidence in assessing and treating on-field orthopaedic conditions. Moreover, we expected that residents at residency programs that provide focused training designed to prepare residents for a role as an on-field team physician would feel more prepared for this role and have more confidence in treating both orthopaedic and nonorthopaedic conditions.
Methods
A survey was created that ranged from 25 to 37 questions; the length was contingent on specific responses to questions (Appendix). This survey and the proposed study was approved by the institutional review board governing the authors’ institution. The survey queried residents about their demographics, the opportunities their residency programs require or allow for participation in athletic coverage, their confidence level with treating a number of on-field injuries or conditions, and their specific experiences with athletic coverage if their programs allowed or required it. Answers were formatted as either multiple choice or 5-point Likert-type scale responses (1 = extremely unconfident, 5 = extremely confident). The survey was tested by the authors prior to its formal release to ensure user-friendliness and anonymity.
The program coordinators of all allopathic, nonmilitary, orthopaedic residencies within the United States were emailed a link to the survey and asked to disseminate the link to residents enrolled in their programs during the 2015-2016 academic year. Within this email, residents were given instructions on how to access the survey and were ensured of their anonymity given the lack of identifiable information that would be entered on the form.
For the demographics component of the survey, residents were asked to select their residency program from a drop-down menu, as well as current year of training, future intended field of orthopaedics (fellowship-trained sports medicine, fellowship-trained other subspecialty, general practice, or undecided), previous experience with care of athletes, previous engagement in organized sports, and whether they had experienced a sports-related injury that required on-field care. These questions were included to gain an understanding of the respondent’s potential biases. Details about the opportunities for involvement in on-field athletic coverage provided by the respondent’s residency program were elicited through questions about the settings in which they may work with athletes, whether coverage is required or even allowed, what level of athletics (eg, high school, collegiate) and specific sports are covered, which year in training they are allowed to begin coverage, the presence of attending surgeons and/or athletic trainers at sporting events, and their role in handling an on-field injury. The amount and type of training prior to athletic coverage by the respondent’s program was determined by asking whether mandatory or optional training was provided, the kind of training that was provided (eg, patient simulation, lectures, preceptorship), and whether specific instruction in the use of a defibrillator or helmet/facemask removal tools was given. Finally, subjective resident confidence in the care of athletes with on-field injuries and conditions was assessed by asking about their feeling of preparedness by their residency program as well as their confidence in diagnosing and treating 13 common on-field problems (Table 1).
TABLE 1.
Confidence of Residents Treating On-Field Conditions Related to Postgraduate Yeara
| Condition | PGY-1 | PGY-2 | PGY-3 | PGY-4 | PGY-5 | P Value | |
|---|---|---|---|---|---|---|---|
| Nonorthopaedic conditions | Commotio cordis/cardiac arrest | 3.04 | 2.86 | 2.66 | 3.16 | 2.71 | .53 |
| Dehydration | 3.62 | 3.75 | 3.55 | 3.88 | 3.68 | .66 | |
| Eye injury | 2.83 | 2.86 | 2.93 | 2.95 | 2.97 | .544 | |
| Heat stroke | 3.22 | 3.27 | 3.21 | 3.35 | 3.42 | .4119 | |
| Laceration | 4.42 | 4.62 | 4.72 | 4.77 | 4.65 | .087 | |
| Superficial infections/MRSA | 3.58 | 4.05 | 4.17 | 4.19 | 4.16 | .015b | |
| Concussion/closed head injury | 3.42 | 3.43 | 3.71 | 3.84 | 3.71 | .078 | |
| Orthopaedic conditions | Ankle fracture/dislocation/sprain | 4.29 | 4.49 | 4.62 | 4.68 | 4.58 | .048b |
| Burner/stinger | 3.29 | 3.50 | 3.97 | 3.86 | 4.06 | <.001b | |
| Cervical spine injury | 3.04 | 3.51 | 3.69 | 3.84 | 3.68 | .006b | |
| Interphalangeal dislocation | 4.17 | 4.24 | 4.34 | 4.67 | 4.61 | .002b | |
| Ligamentous knee injury | 4.00 | 4.41 | 4.59 | 4.56 | 4.58 | .004b | |
| Shoulder dislocation | 4.08 | 4.54 | 4.62 | 4.69 | 4.61 | .005b |
aScores based on a Likert-type scale (1 = extremely unconfident, 5 = extremely confident). MRSA, methicillin-resistant Staphylococcus aureus; PGY, postgraduate year.
bTrend over all 5 PGYs showed positive correlations (ie, increasing confidence as postgraduate year increased).
Statistical Analysis
The survey was generated, and all study data were collected and measured using Research Electronic Data Capture (REDCap).9 Residency response rates were based on the total number of allopathic, nonmilitary programs contacted. The individual survey response rate was determined based on the number of residents in the programs who responded. Collective resident totals for each program over the past 5 years was determined based on National Resident Matching Program data.16
Given an anticipated variability in the responses to specific residency program–related questions, an algorithm was created to determine a unified program-wide response based on the collective answers from all residents from each program. Resident responses were compiled for each relevant question focused on residency-wide issues (eg, “Is training available to you…”), and the answer choice with the majority of responses was selected.
The linear relationships between resident confidence level and postgraduate year as well as differences between resident confidence level when considering level of training available (Tukey adjustment for multiple comparisons) were assessed using generalized linear modeling (GLIMMIX procedure) assuming a binomial distribution (SAS version 9.4; SAS Institute).
Results
Of the 148 residency programs contacted, residents from 57 programs responded, yielding a 39% program response rate. The total enrollment within these 57 residency programs during the 2015-2016 academic year was estimated at 1349, based on National Resident Matching Program data.16 With 165 resident responses, this represented a 12.2% response rate of residents who we can confirm had access to the survey.
Resident Demographics
Of the 165 respondents, 23 were in their first postgraduate year (PGY-1), and there were 37 PGY-2, 29 PGY-3, 45 PGY-4, and 31 PGY-5 residents. Approximately 28.5% of residents responded that they planned on advancing their training with a sports medicine fellowship, while 60.0% reported wanting to pursue a fellowship in a different specialty. Prior to residency, 34.5% of residents were involved in the care of athletes as either an assistant or athletic trainer. All residents personally participated in at least 1 level of athletics (recreational, high school, collegiate, minor league/semiprofessional, professional) and 50.9% participated in collegiate, minor league/semiprofessional, or professional athletics.
Program Characteristics
Aggregated resident responses for each program showed that 51 the 57 programs that responded to the survey (89.5%) allowed or required coverage of at least 1 level of athletic events. Most programs allowed coverage of high school or collegiate-level events (86.3% and 58.8%, respectively), and a few allowed coverage of minor league/semiprofessional or professional-level events (7.8% and 3.9%, respectively). On average, programs allowed their residents to begin covering sporting events during PGY-2 (mean ± SD, 2.2 ± 1.1 years).
Training and Oversight
Of the 51 programs allowing or requiring resident coverage of athletic events, residents at 27 (52.9%) programs reported that they had training to prepare for this role. The programs that provided training did so through lectures (77.8%), preceptorships (44.4%), reading lists (37.0%), patient simulation (14.8%), or videos (14.8%). No program required formal testing prior to beginning coverage. Advanced training in the use of defibrillators and helmet/facemask removal gear was provided by 19 (37.3%) and 17 (33.3%) programs, respectively. Eighteen programs (31.6%) had direct attending supervision at all events, and 22 (38.6%) had variable supervision by attending surgeons. Only 6 of 24 programs without training available (25%) had direct attending surgeon supervision of residents at all athletic events. All residents had the assistance of either an attending surgeon or a certified athletic trainer during events.
Effects of Resident Seniority on Confidence
The more senior the resident was, the higher his or her level of confidence was in treating a variety of orthopaedic and nonorthopaedic conditions (Table 1). This trend was true for all orthopaedic conditions (ankle injury, stinger, cervical spine injury, interphalangeal dislocation, knee injury, shoulder dislocation). Of the nonorthopaedic conditions (commotio cordis/cardiac arrest, dehydration, eye injury, heat stroke, laceration, superficial infection, concussion), the same trend was true only for superficial infections.
Effects of Resident Training on Preparedness and Confidence
Residents with mandatory training prior to their participation in on-field coverage reported that they felt better prepared for this role than those with no training, optional training, or those who were unsure of their training requirement (P < .0001, P = .035, and P = .013, respectively). Residents who had mandatory training displayed higher confidence levels in treating all on-field orthopaedic and nonorthopaedic conditions than those without training (Table 2), although dehydration, heat stroke, ligamentous knee injury, and shoulder dislocation were the only conditions displaying significant differences. The difference in confidence of residents who had training in the treatment of concussions compared with those who did not approached significance (P = .07).
TABLE 2.
Average Confidence of Residents in Treating On-Field Conditionsa
| Condition | No Training | Mandatory Training | P Value | |
|---|---|---|---|---|
| Nonorthopaedic conditions | Commotio cordis/cardiac arrest | 2.82 | 3.11 | .53 |
| Dehydration | 3.44 | 4.13 | .004b | |
| Eye injury | 2.65 | 3.05 | .24 | |
| Heat stroke | 3.00 | 3.55 | .046b | |
| Laceration | 4.58 | 4.74 | .58 | |
| Superficial infections/MRSA | 3.96 | 4.16 | .69 | |
| Concussion/closed head injury | 3.48 | 3.97 | .07 | |
| Orthopaedic conditions | Ankle fracture/dislocation/sprain | 4.48 | 4.74 | .21 |
| Burner/stinger | 3.73 | 4.08 | .26 | |
| Cervical spine injury | 3.62 | 3.76 | .90 | |
| Interphalangeal dislocation | 4.32 | 4.61 | .24 | |
| Ligamentous knee injury | 4.31 | 4.74 | .021b | |
| Shoulder dislocation | 4.35 | 4.82 | .008b |
aOptional training excluded. Scores based on a Likert-type scale (1 = extremely unconfident, 5 = extremely confident). MRSA, methicillin-resistant Staphylococcus aureus.
bStatistical significance (P ≤ .05).
Discussion
On-field coverage of athletic events brings with it a multitude of challenges, especially when considering the breadth of injuries, conditions, and clinical situations faced by a treating provider. Although many different types of care providers may treat athletes on the field, this study shows that orthopaedic residents during their PGY-2 year, on average, are often given the opportunity to independently cover a variety of levels of sporting events during residency and that preinvolvement training is lacking. Resident confidence in treating orthopaedic conditions on the field was shown to be higher in the more senior residents. We also found that, compared with residents in programs with no training, those in programs with preinvolvement training had significantly greater confidence in treating nonorthopaedic conditions such as heat stroke and dehydration, a nearly significantly greater confidence in treating concussions, and a greater feeling of preparedness for the role of on-field physician. Although not statistically significant, confidence in treating every other nonorthopaedic condition was higher in the residents whose programs provided training.
In all American College of Graduate Medical Education–accredited residency programs, the treatment of patients by residents, especially when done without direct supervision, requires a previous demonstration of competency.1 Competency is achieved after appropriate training through lectures, supervised clinical experiences, or other means. In our cohort of orthopaedic residency programs, about half (52.8%) provided any form of preinvolvement training prior to allowing or requiring coverage of athletic events, and only 25.0% of programs that did not provide training had direct physician oversight of residents. Perhaps even more important, training on the use of a defibrillator—a potentially life-saving device—outside of basic life support training was strikingly low (37.3%). These concerning data suggest that while the process of educating orthopaedic residents for this role has long been left to the discretion of individual residency programs, an opportunity exists to develop a standardized curriculum that may increase resident confidence and potentially improve the care of athletes.
The results of this survey demonstrate that orthopaedic resident confidence in treating nonorthopaedic conditions is, on average, lower than the confidence in treating orthopaedic conditions and that confidence did not grow in treating almost all nonorthopaedic conditions over 5 years of residency. However, we did see that training may improve resident confidence, as confidence either significantly improved or trended toward improvement for those with training in many nonorthopaedic conditions. These findings are important, as physicians from other specialties, certified athletic trainers, physical therapists, emergency medical technicians, and nurses who care for athletes on the field may have more training, greater confidence, and therefore a potentially greater ability in treating these conditions. However, it is well known that physicians in nonorthopaedic specialties such as pediatrics,4 internal medicine,23 and family medicine2 have limited training and lower confidence in treating sports medicine–related and musculoskeletal conditions. This may be prohibitive for effective on-field athletic care, as up to 73% of physician evaluations of collegiate-level athletes involved musculoskeletal injuries.21 Regardless of the specialty of the individual serving as an on-field physician, he or she must “have a working knowledge of trauma, musculoskeletal injury, and medical conditions affecting the athlete.”24
This study represents the experiences of an appropriate sample of residents from a broad range of residency programs. Residents were almost equally distributed among PGY level, and the percentage of residents who completed the survey who were interested in pursuing a fellowship in sports medicine was similar to the overall percentage of all orthopaedic residents participating in the San Francisco Match for an Orthopedic Sports Medicine Fellowship (28.5% and 28.2%, respectively).19 Residency programs were broadly distributed in terms of geography, size, academic focus, and athletic affiliations.
There are limitations to this study. First, although perception of confidence and preparedness may be a reasonable surrogate for actual performance,2 this subjective variable is not a direct assessment of how effective residents are at treating on-field conditions. Second, while our distribution of residents and residency programs was reasonable, our low response rate may be a source of bias. This survey did not parse out the topics of training that were provided; had this been done, a better understanding into the effectiveness of specific forms and topics of training may have been determined. Finally, the number of study participants who reported that they previously participated in collegiate, minor league, or professional athletics was 50.9%, and the number of participants who reported prior experience as a trainer was also high at 34.5%. While little reference exists to compare either of these to an expected range, these numbers are fairly high and may represent a bias toward increased experience and confidence among study participants. Training was reported as mandatory by residents in 10 programs (17.5%) and optional in 17 (29.8%).
Of the respondents in this study, 28.5% reported that they intended to pursue a fellowship in orthopaedic sports medicine. While it is difficult to differentiate between United States–based and foreign graduates participating in the sports medicine fellowship application process, data from the 2010 through 2015 matches are available and show a range from 212 to 260 applicants in recent years, which is in keeping with the numbers reported in this survey.16,19
While the study findings support the view that the curricula of orthopaedic surgery residencies increases confidence in treating orthopaedic conditions, they also suggest that increased training in nonorthopaedic conditions correlates with greater confidence in treating such conditions. A need exists for more structured training in nonorthopaedic, sports medicine–related conditions in orthopaedic surgery residency to give orthopaedic residents the tools needed to care for athletes on the field.
Conclusion
Formal training of orthopaedic residents prior to their covering athletic events can improve confidence in treating orthopaedic and nonorthopaedic conditions. Many programs do not ensure residents are familiar with key and potentially life-saving equipment. This study highlights an opportunity to improve resident education.
Appendix
Orthopaedic Team Coverage Survey
Please complete the survey below.
All answers will be blinded to the researchers.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: J.D.H. is currently under a consultant contract with DePuy-Synthes to provide educational content for orthopedic surgery residents. DePuy-Synthes has in no way influenced the topic or content of this paper, and this paper has in no way influenced the topic or content of any material provided to DePuy-Synthes.
Ethical approval for this study was waived by the Research Protection Office at Rhode Island Hospital.
References
- 1. American College of Graduate Medical Education. Common Program Requirements. https://www.acgme.org/Portals/0/PDFs/Common_Program_Requirements_07012011[2].pdf. Published 2011. Accessed August 8, 2016.
- 2. Amoako AO, Amoako AB, Pujalte GG. Family medicine residents’ perceived level of comfort in treating common sports injuries across residency programs in the United States. Open Access J Sports Med. 2015;6:81–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Boggild M, Tator CH. Concussion knowledge among medical students and neurology/neurosurgery residents. Can J Neurol Sci. 2012;39:361–368. [DOI] [PubMed] [Google Scholar]
- 4. Demorest RA, Bernhardt DT, Best TM, Landry GL. Pediatric residency education: is sports medicine getting its fair share? Pediatrics. 2005;115:28–33. [DOI] [PubMed] [Google Scholar]
- 5. Emans SJ, Bravender T, Knight J, et al. Adolescent medicine training in pediatric residency programs: are we doing a good job? Pediatrics. 1998;102(3 pt 1):588–595. [DOI] [PubMed] [Google Scholar]
- 6. Fitch RW, Cox CL, Hannah GA, Diamond AB, Gregory AJ, Wilson KM. Sideline emergencies: an evidence-based approach. J Surg Orthop Adv. 2011;20:83–101. [PubMed] [Google Scholar]
- 7. Gardiner JR, Madaleno JA, Johnson DL. Sideline management of acute knee injuries. Orthopedics. 2004;27:1250–1254. [DOI] [PubMed] [Google Scholar]
- 8. Harmon KG, Drezner JA. Update on sideline and event preparation for management of sudden cardiac arrest in athletes. Curr Sports Med Rep. 2007;6:170–176. [PubMed] [Google Scholar]
- 9. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Hodge DK, Safran MR. Sideline management of common dislocations. Curr Sports Med Rep. 2002;1:149–155. [DOI] [PubMed] [Google Scholar]
- 11. Hutchinson M, Tansey J. Sideline management of fractures. Curr Sports Med Rep. 2003;2:125–135. [DOI] [PubMed] [Google Scholar]
- 12. Krajca-Radcliffe J, Cummings NM. Sideline ethical dilemmas. J Bone Joint Surg Am. 2014;96:e132. [DOI] [PubMed] [Google Scholar]
- 13. Krutsch W, Voss A, Gerling S, Grechenig S, Nerlich M, Angele P. First aid on field management in youth football. Arch Orthop Trauma Surg. 2014;134:1301–1309. [DOI] [PubMed] [Google Scholar]
- 14. Loeb PE, Mirabello SC, Andrews JR. The hand: field evaluation and treatment. Clin Sports Med. 1992;11:27–37. [PubMed] [Google Scholar]
- 15. Matzkin E, Smith EL, Freccero D, Richardson AB. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am. 2005;87:310–314. [DOI] [PubMed] [Google Scholar]
- 16. National Resident Matching Program. NRMP Program Results 2012-2016 Main Residency Match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Program-Results-2012-2016.pdf. Published 2015. Accessed July 5, 2016.
- 17. Putukian M, Raftery M, Guskiewicz K, et al. Onfield assessment of concussion in the adult athlete. Br J Sports Med. 2013;47:285–288. [DOI] [PubMed] [Google Scholar]
- 18. Salzman GA, Burke RV, Muller VM, Spurrier RG, Zaslow TL, Upperman JS. Assessing medical care availability for student athletes of a large urban high school district. J Pediatr Surg. 2015;50:1192–1195. [DOI] [PubMed] [Google Scholar]
- 19. San Francisco Match. Residency and Fellowship Match. Orthopedic Sports Medicine Fellowship. https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=11&typ=1&name=OrthopedicSportsMedicine#. Accessed August 8, 2016.
- 20. Smith D. Are all physical therapists qualified to provide sideline coverage of athletic events? Int J Sports Phys Ther. 2012;7:120–123. [PMC free article] [PubMed] [Google Scholar]
- 21. Steiner ME, Quigley DB, Wang F, Balint CR, Boland AL. Team physicians in college athletics. Am J Sports Med. 2005;33:1545–1551. [DOI] [PubMed] [Google Scholar]
- 22. Stirling JM, Landry GL. Sports medicine training during pediatric residency. Arch Pediatr Adolesc Med. 1996;150:211–215. [DOI] [PubMed] [Google Scholar]
- 23. Sweeney CL, Davidson M, Melgar T, Patel D, Cucos D. The current status of sports medicine training in United States internal medicine residency programmes. Br J Sports Med. 2003;37:219–225. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Team physician consensus statement. Am J Sports Med. 2000;28:440–441. [DOI] [PubMed] [Google Scholar]
- 25. Waterbrook AL, Pritchard TG, Lane AD, et al. Development of a novel sports medicine rotation for emergency medicine residents. Adv Med Educ Pract. 2016;7:249–255. [DOI] [PMC free article] [PubMed] [Google Scholar]