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Sports Medicine Moves Toward Specialty Status

A New Subspecialty for Orthopedic Surgery

Few topics in sports medicine generate as much passion as the word "specialty." The term "specialty" doesn't just raise issues about professional standing—it also strikes at the heart of economic compensation, practice turf, and patient perceptions.

The topic has risen to the forefront of discussions in sports medicine circles recently in response to the American Board of Medical Specialties' (ABMS) March 2003 approval of an orthopedic sports medicine subspecialty. The American Orthopaedic Society for Sports Medicine (AOSSM) applied for orthopedic sports medicine subspecialty certificate in 2002 and received the support of all ABMS primary specialty boards.

The ABMS approval means there are now two sports medicine subspecialties. The primary care sports medicine subspecialty was approved in 1989; its subspecialty certificate is administered by four different specialty boards: family medicine, internal medicine, pediatrics, and emergency medicine.

Currently, there is no sports medicine subspecialty for physiatrists, though plans are underway to allow physiatrists to sit for the primary care sports medicine subspecialty exam or to pursue their own subspecialty certification, says Michael Fredericson, MD, associate professor in the division of physical medicine and rehabilitation at Stanford University School of Medicine in Stanford, California. He says that physiatry residency programs have dramatically changed over the past decade, with most residents now spending a majority of their time training in outpatient musculoskeletal medicine clinics and many residents choosing to pursue fellowship training in sports medicine.

Christopher D. Harner, MD, an orthopedic surgeon and medical director of the Center for Sports Medicine at the University of Pittsburgh, was involved in drafting the AOSSM's subspecialty application. Currently a 30-member task force of experts has been appointed to develop the examination in collaboration with the American Board of Orthopaedic Surgery (ABOS) and the National Board of Medical Examiners. The test is projected to have 180 questions and be based on orthopedic sports medicine fellowship curriculum. Harner says editing and validating the test will take about 2 years, and he estimated that the first exam will be offered in the fall of 2006. The certification test for orthopedic sports medicine will be administered by the ABOS. Those who haven't trained in an orthopedic sports medicine fellowship but meet other guidelines will be allowed to take the test during the initial 5-year period. After that, all applicants must have completed training from an accredited sports medicine fellowship program.

Why an Orthopedic Subspecialty?

Mark R. Hutchinson, MD, director of Sports Medicine Services and attending orthopedic surgeon in the Department of Orthopaedics at the University of Illinois at Chicago, says subspecialty issues have been debated for years within the American Academy of Orthopaedic Surgery (AAOS) and the AOSSM. He says that the AAOS has historically resisted any additional subspecialties within orthopedics. (Hand surgery is the only other ABMS-approved orthopedic subspecialty.) "They've argued that when orthopedic surgeons have completed residency and are board certified, they have documented their ability to perform the entire range of orthopedic procedures, including many of those commonly recognized as being sports medicine—for example, arthroscopy and ligament reconstruction," Hutchinson says.

The AOSSM has had mixed feelings about an orthopedic sports medicine subspecialty, Hutchinson says. "On one side, they were respecting the opinion of their orthopedic colleagues while knowing that, in reality, our athletes would often be best served by surgeons who focus on these procedures and have received a certificate to document their added qualification," he says.

Sports medicine is the largest area of specialty training in orthopedics, according to the AOSSM. AAOS census data reveal that 44% of practicing orthopedists claim a special interest in sports medicine. There are 95 orthopedic sports medicine fellowship programs, of which 55 are accredited by the Accreditation Council for Graduate Medical Education. (For comparison, according to listings on the AMSSM Web site, there are approximately 90 primary care sports medicine fellowships. Most are listed as accredited; 3 are not and 5 are pending. There are at least 5 sports medicine fellowships targeted to physiatrists.)

Harner says that the major motivations behind the orthopedic sports medicine subspecialty were twofold: to have the same subspecialty certificate opportunities as their primary care colleagues and to boost standards for orthopedic sports medicine fellowship programs. "It has been made very clear by the leadership of the AOSSM that this will serve as an educational standard and not a practice standard," he says.

Skepticism Among Some Surgeons

Harner and Hutchinson say some orthopedic surgeons oppose the new subspecialty because some feel that training is adequate, while others worry that the new subspecialty sets a new practice standard that possibly exposes them to greater liability risk. Harner says that some orthopedic surgeons are concerned that the new subspecialty will isolate sports medicine from the rest of orthopedics. "But in our discussions with various leaders in the subspecialty of hand surgery, this has not been the case," he says.

Harner notes: "We recognize that general orthopedists—and other specialists—are qualified to care for athletes, but we believe that those who undergo special fellowship training in orthopedic sports medicine need to demonstrate that they have achieved a certain depth and breadth of sports medicine knowledge."

In a press release announcement of the new orthopedic surgery subspecialty, Peter J. Fowler, MD, president of the AOSSM and medical director of the University of Western Ontario Fowler Kennedy Sport Medicine Clinic in London, Ontario, said that orthopedic surgeons who have a special interest in sports medicine but do not pursue fellowship training will still benefit from ongoing growth stimulated by formal postgraduate education.

Hutchinson says he will likely take the certification exam the next time he needs to recertify. "I do not feel it can hurt, and, ultimately, I believe I will be in better position to teach my residents and open doors for them into the future," he says, adding that he does not think the new certificate will significantly change his current knowledge base.

Reactions From the Primary Care Side

The new orthopedic sports medicine subspecialty certificate influences the broader sports medicine playing field. In the past few years, there have been discussions within primary care sports medicine to drop the primary care designator. Geoffrey E. Moore, MD, an internist in Taberg, New York, says, "Primary care is a nice foundation, but sports medicine goes far enough beyond primary care that I think the concept of primary care sports medicine hurts development in being recognized as a specialty." Now, with the addition of an orthopedic sports medicine subspecialty, there's widespread concern, as evidenced by recent intense discussions on the AMSSM listserv, that nonsurgical sports medicine will be pushed toward the more limiting primary care designator.

Some in primary care see the new orthopedic sports medicine subspecialty as a benefit for the wider sports medicine community. Erik Adams, MD, PhD, a sports medicine physician at the Midwest Institute of Sports Medicine in Middleton, Wisconsin, says, "What the public needs to know is that sports medicine is a medical specialty in its own right, and if our orthopedic colleagues help accomplish this, all the better."

Christopher Madden, MD, a family practice physician in Longmont, Colorado, says that subspecialty titles are important for many reasons, but especially for negotiations with insurance companies. There are still great disparities in insurance reimbursement for sports medicine services, not only between medical specialties, but among geographic regions, and among different insurance companies in the same region. "Generally, we need to do what is best for sports medicine as a profession, and I feel this is to support our orthopedic colleagues," Madden says. "I'm not convinced that the new orthopedic subspecialty designation will create more problems than already exist."

Orthopedic and primary care groups have generally supported each other's subspecialty efforts. Despite the fact that in many sports medicine settings, orthopedists and primary care physicians collaborate smoothly, the new subspecialty may renew some debate over practice turf and what it means to be a team physician. John M. McShane, MD, director of the sports medicine fellowship program in the Department of Family Medicine at Thomas Jefferson University in Philadelphia, says primary care physicians provide the greatest breadth of service and meet the greatest demands in everyday sports medicine.

Hutchinson, in his role as an orthopedic surgeon, sees the divisions somewhat differently. He believes that musculoskeletal injuries are best cared for by an orthopedist and that issues such as sports-related asthma, cardiac clearance, and supplement use are best addressed by primary care specialists. "It is my opinion that athletes are best taken care of by a team approach of specialists who know what they know and don't know and are willing to defer to the most knowledgeable member of the team," he says, adding, "I would hope that this new certificate would assist in allowing that relationship to occur."

Renewed Specialty Discussion

Reaction to the new orthopedic sports medicine subspecialty seems to be renewing a push among primary care sports medicine physicians for an officially recognized sports medicine specialty. For sports medicine in the United States to advance to specialty status, Moore says that nonsurgical sports medicine needs to improve its own body of science. "American sports medicine physician-scientists are vanishing because the US community of sports medicine has focused intently on being team physicians," he says. To generate more research, fellowship programs need to incorporate more sports science, Moore says, adding, "Graduates of family medicine sports medicine fellowships are not well equipped to compete for NIH [National Institutes of Health] funding because they don't have a sufficient track record of research, and their departments do not have sufficient stature on campus to carry a lot of weight." Moore predicts that unless sports science training for fellows improves, US sports medicine physicians will fall behind their international peers.

According to several sources, sports medicine has achieved specialty status in Finland and New Zealand. Specialty applications have been forwarded to medical specialty boards in the United Kingdom and in Australia. Constance M. Lebrun, MD, director of primary care sports medicine at the University of Western Ontario Fowler Kennedy Sport Medicine Clinic in London, Ontario, says a committee of Canadian Academy of Sports Medicine is currently evaluating the possibility of pursuing specialty or subspecialty status.

Lisa Schnirring

Field Notes

Bush Addresses Drugs in Sport

In his State of the Union address on January 20, President George W. Bush urged professional sports to set a better example for children by eliminating the use of anabolic steroids and other performance-enhancing drugs. He called on "team owners, union representatives, coaches, and players to take the lead, to send the right signal, to get tough, and to get rid of steroids now." He said that parents, schools, and government must work together to help children make decisions that will "affect their health and character for the rest of their lives."

Gary I. Wadler, MD, a doping expert and associate professor of clinical medicine at New York University School of Medicine in Manhasset, New York, says Bush's comments echo a growing public outrage over drugs in sport. "Now it is time for national introspection about the role sports plays in our society as well as coming to grips with the whole issue of how performance-enhancing drug use is undermining the essence of what competitive athletics is supposed to be all about," he says. "Performance-enhancing drugs are increasingly undermining and eroding the foundations of sport in our country, and those committed to fair play and the public health are saying 'Enough is enough.'"

Numerous media reports, including the high-profile deaths of athletes such as Minnesota Viking Korey Stringer and Baltimore Oriole Steve Bechler, have focused needed attention on safety issues for ergogenic drugs. The 2004 Athens Summer Olympic Games will be using better drug screening procedures to detect banned substances, including modified anabolic steroids, such as tetrahydrogestrinone (THG). Nutritional supplements (eg, creatine and ephedra) as well as drugs, have come under increasing scrutiny.

Patricia D. Mees

FDA Bans Ephedrine-Containing Supplements

The US Food and Drug Administration (FDA) announced on December 30, 2003, a ban on the sale of products containing ephedrine, stating that these products pose an unreasonable health risk. Manufacturers of ephedrine-containing supplements were notified by certified mail of the intent, and the final rule will become effective 60 days after publication to allow time for Congressional review.

The FDA's action was spurred by the deaths of collegiate and professional athletes within the past 3 years. Several of the deaths have prompted lawsuits by spouses and relatives of the athletes who died after using these products.

In a press release issued on the same day, the American College of Sports Medicine (ACSM) hailed the action and maintains the belief that ephedrine's dangers far outweighed the benefits. ACSM president William O. Roberts, MD, a family practice physician in St Paul, says in a press release that "[the news] means an overdue step is being taken toward protecting our nation's athletes and others who, unfortunately, use this dangerous substance for weight loss or to enhance performance," he says. "Tragically, this move comes too late for some, but perhaps we will finally see an end to the promotion and use of this potentially dangerous supplement." This action follows the prohibitions of ephedrine-containing products by the National Football League and minor league baseball last year and the growing concern about unsupervised use of supplements by younger patients.

The ban has engendered some controversy, and the spokespersons for the supplement industry have stated that ephedrine, when used properly, can aid short-term weight loss. Many physicians disagree, saying that while studies have shown that ephedrine combined with caffeine promotes weight loss, side effects, including hypertension and cardiovascular consequences, warrant the ban. Physicians concede that no other over-the-counter supplement for weight loss has yet proven as effective as ephedrine, but no human studies of long-term effects have been done, and comparable effects can be obtained with prescription drugs for weight loss that are safer.

Paul W. Mamula, PhD

Staggering Costs of Obesity

Medical expenditures for obesity-related care in the United States reached $75 billion in 2003, according to a study published in the January issue of Obesity Research. US taxpayers will absorb half these costs through Medicare and Medicaid.

Obesity-related 2003 Medicare costs were $1.7 billion in California alone. Obesity prevalence among Medicaid recipients ranges from 21% in Rhode Island to 44% in Indiana, according to data from the Centers for Disease Control and Prevention (CDC).

Julie Gerberding, CDC director says, "The long-term effects of obesity on our nation's health and on our economy should not be underestimated."

The impact of obesity on society takes other tolls, as well. A study published in the January issue of the Journal of Occupational and Environmental Medicine found that obese employees reported more difficulty getting along with coworkers and severely obese workers missed significantly more days of work.

Patricia D. Mees

Walking Holds the Line on Obesity

Overweight adults who are not dieting should exercise to prevent further weight gain, according to a study published in the January issue of Archives of Internal Medicine. In the study, overweight adults who exercised about 30 minutes a day (activity equal to brisk walking) avoided gaining additional weight.

The study, conducted by researchers at Duke University, involved 120 overweight or mildly obese patients between the ages of 40 and 65 who had an average body mass index (BMI) of 29.7 kg/m2 (patients with BMIs between 25 and 29.9 are considered overweight; those with a BMI of 30 or more are considered obese). Patients were instructed not to diet during the 8-month study. Patients who did not exercise gained about 2.5 lb, but 73% of those who took brisk walks for 11 miles a week, or roughly 30 minutes a day, maintained their weight or even lost a few pounds.

This study produced two important findings. First, the research confirms that exercise programs done without reduction of calories are relatively ineffective ways of losing weight. The study also demonstrates that even small amounts of exercise help stave off weight gain.

Paul W. Mamula, PhD