Fellowship becoming 2 years

[Waterlover]

There apparently is discussion about making the sports fellowship 2 years long. Anyone have thoughts or know about that? How many years before that is implemented if so?

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[runfastnow]

From a PM&R perspective:

I cannot imagine a PM&R sports fellowship becoming two years long with the relatively strong MSK knowledge/exam skills that most (if not all) PM&R sports interested graduates have after their residency. Unless PM&R sports fellowship becomes some sort of pseudo-surgical highly procedure related fellowship in which EVERYONE is trained to pass the RMSK or equivalent US exam, AANEM EMG board exam, competent in lumbar TFESI and RF, and competent in advanced US skills such as Tenex and Sonex carpal tunnel release.

I cannot speak to those coming from IM, FM, EM, etc. but if you cannot master the exams of various joints (not even worrying about spine or EMG) and basic-to-intermediate ultrasound procedures and the medical issues somewhat specific to athletes in a year then perhaps it is a problem inherent with the fellowship program that no amount of increased time will help.

The only sports fellowship that makes sense to expand is the surgical side if they wanted to add components of competency in hip arthroscopy or cartilage/OCD repair, etc.

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I haven't heard these rumors, but would strongly oppose this expansion (if not obvious from above) as the Ivory Tower doing typical Ivory Tower things. There just isn't enough complexity in primary care sports medicine to need more than one year if you come into fellowship as at least a mediocre resident who has been interested in MSK things during your prior training.

Regardless of what specialty you do (sports, cardiology, radiology, etc.) you are not going to be a perfect physician when you leave training no matter where you do it or for how long. Academics' desire to be 'holier than thou' and keep people perpetually in training is infuriating.

 

[Freezeout]

Agreed. The only way I could see that being necessary would be if it became a requirement to come out of fellowship RMSK eligible and really wanted to expand the use of Tenex/perc tenotomy and Sonex US guided carpal tunnel releases.

 

[yeasports]

Agree with above.
There are 2 year programs in Peds; I did not apply to those.

 

[TheGreatestTrochanter]

I don't see it happening for a few reasons:
1) Most people won't want to do a two year fellowship, so there will be vastly fewer applicants.
2) Programs won't want to adapt to this, which for many would mean taking a fellow every other year if they don't have enough capacity for two fellows, or finding a way to get funding for two simultaneous fellows and finding spots for them to get a good experience.
3) Especially from PM&R you get so much MSK that the entire second year would mostly just be free labor or a lot of unnecessary supervision. This I am sure is true with FM/IR/IM fellows in a solid fellowship program. I just don't see how you can justify this. Sure you don't know everything at the end of any training program, but you should know enough to know when you don't know what is going on and to find help or learn more. As a medical community we need to be trying to minimize training years, we already may overtrain!

I do agree that if we can win the turf war on some more u/s-guided minimally invasive procedures like CTR than 2 years would be justified. We aren't there yet though, there are few programs that can offer that experience, and not many places that you could perform these due to political battles with surgeons in the institution and community.

 

[TableMD]

In a training program, with an ortho dept, there will be turf war silliness. With that said, if you can do a tenotomy/Tenex with US guidance you can certainly do carpal tunnel release.

I am not currently affiliated with an orthogroup and have started looking into the carpal tunnel release. The process to obtain the FDA mandated training seems straight forward.

From an FM perspective I went into fellowship highly motivated regarding US and MSK medicine, but still had so, so much to learn and was at an intense place. I was certainly very happy to be done after the year. I could sit for RMSK or AIUM based on diagnstics volume, but I will only do so if it means something relevant with licensing/reimbursement, and that is after one year.

I would put up with the extra year, but I am very glad to be in the real world. I think whoever came up with this idea has an ulterior motive beyond, perhaps fellow graduating numbers/jobs/or they want more free labor? Perhaps they are jealous of how peds and IM can suck fellows in for 2-3 years with their fellowships?

 

[galactus]

I agree with all of the above! I'm against 2 year fellowships.
Yes there's been talk about it, but I doubt it will happen anytime soon. It can also be a funding issue. Some programs will close because they don't have funding for a 2 year fellowship. Lengthening the fellowship to 2 years will also lead to less programs. It could make it more competitive.

Extending a fellowship can allow for more experience in the other aspects of sports: Sports cardiology, psychology/psychiatry, medicine, women's health, etc. IF, and I do mean IF, a fellowship is extended to 2 years, it would touch on other aspects of sports medicine, or add some masters of exercise science/kinesiology. 2 year programs currently do exist, and some have this model.

For those who were on the fellowship committee seminar this weekend, they also mentioned they are looking to see if ABMS can make sports medicine into its entire own residency like in Australia, however a lot of people shut that down pretty quick lol. Two year fellowships *maybe* the future down the road, but I do not see a sports medicine residency happening

 

[runfastnow]

Great points Galactus.

The extra year gives time to touch on cardiology, exercise phys, psych, etc. I just think that AMSSM needs to take into account what patients need and demand clinically. I rarely (or have never) see patients asking for me to do a VO2max test; if I see HOCM or some other significant EKG finding then I am sending that athlete to a cardiologist; if I identify triad/REDS (which is more common) I am setting up psych and nutrition and the other things necessary. An extra year to get into these subjects more in depth will not replace a PhD in exercise phys or a cardiology fellowship or a PsyD nor do physicians have time to do all of these things for patients.

Perhaps certain academic practices allow for hours of time to be spent with each patient, but in private practice (or academic centers which track RVUs) trying to be 5 specialties all at once and trying to perform all the tests and treatments associated with the various fields is a losing and poor value proposition. In my opinion physicians should be the leader of a team and organize and let experts in specific fields be experts (VO2max, advanced HOCM testing, etc.) then synthesize all the information for the patient.

Maybe a second year option could be approved for programs who want to pursue a research/academic track for fellows if the AMSSM academics want it. The extra year to study such things has such a small/rare payoff that it would be wasting the time and resources of everyone involved.

 

[j4pac]

I decided against Sports because I went to an elite PM&R program with phenomenal US/MSK experience and was content not doing D1/pro coverage. But it was a tough decision. If it was a 2 year fellowship. LOL, would have made my decision very easy. I agree with th above, the only way that would be remotely possible is if there would be an enormous breadth of procedures that the 2nd year provides. Frankly, I don’t think that CTR is enough. There are those with 1-year training who are already delving into that realm.

 

[timisdaman]

I am against the switch to 2 years, but the argument at AMSSM was that fellows are supposed to be masters at the medical aspect of Sports Medicine, and not just the MSK part. That means EKG interpretation, sports pulmonology, etc. If you are the team physician for a college or pro team, you will need to do a lot of primary care stuff.

 

[TableMD]

I think that is reasonable as a goal. To be sold on it, it would be nice to see the gaps in pulm/cardio/etc between current fellows and the ideal of what the supplementary year of training would apply, and then match that a gap seen in practice to justify the expense. Most of us come from primary care training, and so have a fairly strong foundation in the general medicine piece. if they have concerns of areas of the field missed by new graduates Id like to take a look.

 

[runfastnow]

I am against the switch to 2 years, but the argument at AMSSM was that fellows are supposed to be masters at the medical aspect of Sports Medicine, and not just the MSK part. That means EKG interpretation, sports pulmonology, etc. If you are the team physician for a college or pro team, you will need to do a lot of primary care stuff.

I think the AMSSM is missing the point of what it means to be a team based physician. Coming from PM&R we collaborate with therapy teams, physicians, neuropsych, etc. and allow each expert to shine and then amalgamate the results into a treatment plan for the patient. As a sports physician I have no interest, time, or desire for increased risk exposure, in becoming a sports cardiologist or pulmonologst -- I can recognize the dangerous EKG patterns and know when to order echo, cardiac MRI, PFTs, etc. Plus, I'm not ablating anything in anyone's heart - my RF skills stop at medial branches.

Let the other experts do their jobs better than you (3+year fellowship only on hearts >>> a few months doing low volume sports cards as a non-cardiologist) and then synthesize it all into the best plan for the athlete.

We shouldn't refer everything to sub-specialists but the best skill a physician can have is knowing limitations and getting a second opinion. Getting some second rate training compared to specialists that already exists serves no one well.

 

[galactus]

I agree with collaboration with other specialists, especially with sports medicine patients individually. If they need to see a pulmonologist, rheum, or cardiologist I'll refer appropriately.

As for being a team based physician I would argue the opposite. I do as much as I possibly can for my athletes, but then again I come from a primary care specialty, and my practice is more primary care for my athletes and the staff. I'm essentially their PCP. For the college I cover, any incoming freshman with no PCP, the team put my name down as default. Another reason for that is that if an injury comes from the sport, the school or team insurance will cover it, but what if it's an MSK issue from a car accident, or a sick/illness related thing. School insurance/worker's comp won't cover it, so they'll have to use their medical insurance, and some insurances require a PCP on the card. I'll do MSK matters obviously, but I'll manage ADHD meds (do this for my college and pro athletes), LARCs for my female athletes, etc. Basically anything primary care/internal medicine related I'll handle, on top of any non-op ortho issues. I admit my own athletes as well. Throughout the years I've admitted anything from appendicitis to rhabdo to DKA.

I think everyone has their skill set to provide for athletes. For example I wasn't trained in any spine procedures in fellowship, so I gladly refer to my PM&R sports colleagues for that. I'm in total agreement with do what you are comfortable with and knowing your limitations and know when to refer.

TL;DR there's different ways to practice sports medicine! Making the fellowship 2 years wouldn't change how my practice is run. I'm totally fine keeping it at 1 year, and bringing our primary specialty (FM, IM, peds, PM&R, EM) expertise in the mix to take care of our sports medicine patients.

 

[lowbudget]

Don't do a 2 year unless you know for sure you want to accomplish and rise in academics and research. You need mentorship and resume building for that, and 2 years gives you time to build. Having institutional infrastructure can help you hopscotch your career.

If you just want to get out, work, see patients and make money, do 1 year. Spend your 1 year on SKILLS you will need in the real world: US, injections, physical exam, radiology interpretation, fracture/dislocation management, suturing, first assist, accurate diagnosis, independent management, (arguably exercise phys and performance). These are things that pay, that takes time to learn, and is hard to learn on your own.

Game coverage, different types of athletes, and being team physician are all optics. Don't waste your talent giving a crap about what team logo is on your chest, unless that is something you need for your self-esteem (I mean, CV). You don't need to stand outside in the rain during football season to catch a broken toe. Work 2-3 months in an urgent care, or work with a midlevel or ortho in the ER, and you'll see plenty of that. The only benefit is getting comfortable in the setting and networking. Again, optics. If your skills are on point, you can work in any setting.

 

[Synophrys]

I wish they would offer a sports medicine residency instead of a fellowship. The vast majority of SM fellowships are primary care related. However, I have not met any sports med applicants that get really fired up about OB care, or inpatient medicine. It would be great to have a Sports Med residency to build more of a collaborative environment with the surgical specialties and more procedural stuff. I would like to see a 3 year program like this -

1. Heavy ultrasound training, sideline medicine, trauma, MSK radiology, cardiology, sports psych
2. Sideline medicine, Ortho surg, Spine, Physical therapy and exercise physiology, and increase the outpatient clinic for SM
3. Heavy outpatient clinic, heavy procedural based clinic, Sideline medicine, Sports Optimization

Having a residency or a multi-year fellowship will allow for a more well rounded provider that can do more than refer to PT or inject things with ultrasound guidance. Our scope is much more inclusive of things like nutrition, performance optimization, psychology, exercise phys, radiology, rehab. However, not many fellowships do more than the basic intro to sideline trauma, ultrasound, and injections. For current fellows out there, how many of you have done muscle biopsies, compartment pressure testing, VO2 max testing, or spent time with an athlete on an alter-G?

Education should be broad and encompass as many aspects of your future scope of practice as possible. Many of these activities are not readily available for various reasons. I think it would be great to have some extra time to really reinforce certain things that typically do not get regular attention within a single year. Personally, I think we are selling ourselves short as a specialty if all we focus on is ultrasound guided procedures and referring to PT.

 

[Freezeout]

I wish they would offer a sports medicine residency instead of a fellowship. The vast majority of SM fellowships are primary care related. However, I have not met any sports med applicants that get really fired up about OB care, or inpatient medicine. It would be great to have a Sports Med residency to build more of a collaborative environment with the surgical specialties and more procedural stuff. I would like to see a 3 year program like this -

1. Heavy ultrasound training, sideline medicine, trauma, MSK radiology, cardiology, sports psych
2. Sideline medicine, Ortho surg, Spine, Physical therapy and exercise physiology, and increase the outpatient clinic for SM
3. Heavy outpatient clinic, heavy procedural based clinic, Sideline medicine, Sports Optimization

Having a residency or a multi-year fellowship will allow for a more well rounded provider that can do more than refer to PT or inject things with ultrasound guidance. Our scope is much more inclusive of things like nutrition, performance optimization, psychology, exercise phys, radiology, rehab. However, not many fellowships do more than the basic intro to sideline trauma, ultrasound, and injections. For current fellows out there, how many of you have done muscle biopsies, compartment pressure testing, VO2 max testing, or spent time with an athlete on an alter-G?

Education should be broad and encompass as many aspects of your future scope of practice as possible. Many of these activities are not readily available for various reasons. I think it would be great to have some extra time to really reinforce certain things that typically do not get regular attention within a single year. Personally, I think we are selling ourselves short as a specialty if all we focus on is ultrasound guided procedures and referring to PT.

I agree that having the ability to do/focus on these things would be great, but the problem I’d see with it is job market when you’re done. Primarily sports/MSK jobs can already be kinda limited in terms of availability. One thing I wish I’d gotten more of was concussions outside of sports/in adults. It seems like a real need but also seems like it could be a paperwork nightmare.

 

[Synophrys]

The job market is not as limited as you think. Many people narrow their approach to the job market due to their perception of what they think the market is. For example searching for a "sports medicine" job does not bring back many results. I encourage our fellows to consider the concept of what it is we do and then find jobs that allow for that to be practiced. If you want to do MSK medicine and treat acute injury, there are a handful of ways to approach it -

1. Occupational Medicine - almost exclusively MSK injury in the setting of work comp
2. Ortho Group - pretty self explanatory
3. Sports Medicine Commercial Clinic - Likely associated with a large group practice, but private practice is always an option as well
4. Private Practice - Reach out to some Chiropractors or PT guys and see if they are willing to rent you space in their office to build both practices
5. Academic Medicine - Limited number of spots but very attainable if you are willing to move around the country
6. College health center - More active primary care population so you avoid much of the chronic disease management in exchange for mood disorders and std's
7. Event Management or exclusive team physicians - As the field grows, I imagine a consulting gig will build.
8. Urgent Care / ER - fast tracks in ER typically focus on MSK and minor procedures. A good way to enjoy shift work.
9. Primary Care - " Over 40 million Americans have musculoskeletal disorders.1 Musculoskeletal complaints account for 10% to 15% of all visits to primary care physicians, and 70% of all new musculoskeletal injuries are treated by primary care physicians " check out the article here -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492313/

The market is changing, and with it so must we. Besides, our job market will likely never be as bad as pathology has it...

 

[deleted997790]

Looks like this is really happening...

 

[Waterlover]

Looks like this is really happening...

Do you have a source, and starting when?

 

[TheGreatestTrochanter]

I hear there is still a lot of pushback from this from several programs. I wouldn't bet this would happen anytime soon.

 

[deleted997790]

The program directors in here can answer these questions better. Word on the streets is that AMSSM isn’t making this an option or a vote...

 

[Waterlover]

The program directors in here can answer these questions better. Word on the streets is that AMSSM isn’t making this an option or a vote...

Hmm, but what year would this start, if so? Like 2021, 2022, 2023? etc.

 

[Waterlover]

I hear there is still a lot of pushback from this from several programs. I wouldn't bet this would happen anytime soon.

I hope you're right lolol

 

[deleted997790]

Hmm, but what year would this start, if so? Like 2021, 2022, 2023? etc.

I’m honestly not sure. I’m receiving trickling information from people who know program directors. I’ve heard there’s been phone calls, documentation submissions, etc.

 

[door_to_balloon_knot]

Looking at fellowship myself and I think it’s a terrible idea. When in doubt of WHY something is happening, bet that it’s money related. How many new programs have opened up recently in the last few years? I’m willing to bet that the decision to make the training longer is several fold and not all in the trainees’ best interest:

1. Cheap labor for any extra year and able to generate more RVU’s for the program/ hospital. Any program’s number of fellows will be doubled which means more days covered for clinics and patients seen. Purely a money grab.

2. More Gate-keeping to keep the labor market skewed towards demand although this may not necessarily be a bad thing. 1 year of additional training? No big deal. Another 2 where you are now out 2 years worth of attending salary? Now that is enough to make anyone pause. To put in perspective that’s is $400k+ lost in lifetime earning potential. Are those 2 years going to allow you to command a high enough salary to overcome this deficit in addition to the interest your loans will continue to compound away like a ticking time bomb? Willing to guess that will be difficult to do.

3. As a side-note to putting the brakes on the number of applicants, just take a quick look in the EM, pathology, and rad-onc subforms to see the ramifications of supply overcoming demand. May be the old guard of program directors and current attending want to make sure that their position/ compensation/ $ per RVU is still justified by making sure there isn’t a wave of fresh fellows every year willing to work for worse conditions and pay just to find a job.

 

[deleted997790]

Looking at fellowship myself and I think it’s a terrible idea. When in doubt of WHY something is happening, bet that it’s money related. How many new programs have opened up recently in the last few years? I’m willing to bet that the decision to make the training longer is several fold and not all in the trainees’ best interest:

1. Cheap labor for any extra year and able to generate more RVU’s for the program/ hospital. Any program’s number of fellows will be doubled which means more days covered for clinics and patients seen. Purely a money grab.

2. More Gate-keeping to keep the labor market skewed towards demand although this may not necessarily be a bad thing. 1 year of additional training? No big deal. Another 2 where you are now out 2 years worth of attending salary? Now that is enough to make anyone pause. To put in perspective that’s is $400k+ lost in lifetime earning potential. Are those 2 years going to allow you to command a high enough salary to overcome this deficit in addition to the interest your loans will continue to compound away like a ticking time bomb? Willing to guess that will be difficult to do.

3. As a side-note to putting the brakes on the number of applicants, just take a quick look in the EM, pathology, and rad-onc subforms to see the ramifications of supply overcoming demand. May be the old guard of program directors and current attending want to make sure that their position/ compensation/ $ per RVU is still justified by making sure there isn’t a wave of fresh fellows every year willing to work for worse conditions and pay just to find a job.

So all of this is true. @galactus can probably confirm, as there was a memo that went out to all the program directors from what I’m being told from the AMSSM. Part of what is supposed to be accomplished here is less fellows per year, a much more competitive fellowship and official recognition as specialists. They also want sports med docs to be considered first to be head team physicians (Bc of the ability to manage ALL medical conditions vs just orthopedic emergencies).

there was apparently a lot more in that memo, including a possibility of a three year fellowship? Again I don’t have access to that memo. This is all from a previous fellow who was discussing with another fellow who was discussing with his program director lol

apparently, the 2 year fellowship is supposed to include a structured curriculum with mandatory months of training in cardiopulmonary testing, ultrasound, etc etc.

until someone can confirm that thisis true, it may just be hearsay?

 

[TableMD]

Part of what is supposed to be accomplished here is less fellows per year, a much more competitive fellowship and official recognition as specialists. They also want sports med docs to be considered first to be head team physicians

less fellows/more competitive
- if that is the goal, then perhaps decrease the number of fellowships? That would make it more competitive and there would be less fellows

official recognition as specialists
- from who? Will the desired entity(ies) be impressed by the extra year?

Head Team physicians
- will an extra year get this accomplished at program/team of interest that otherwise would not want us if we were only trained for 1 year?

I certainly favor expanding educational opportunity and expanding one’s practice and set of skills in a systematic and organized fashion, I just have a sense that there isn’t appropriate consideration with this plan.Obviously I could be wrong

 

[door_to_balloon_knot]

less fellows/more competitive
- if that is the goal, then perhaps decrease the number of fellowships? That would make it more competitive and there would be less fellows

official recognition as specialists
- from who? Will the desired entity(ies) be impressed by the extra year?

Head Team physicians
- will an extra year get this accomplished at program/team of interest that otherwise would not want us if we were only trained for 1 year?

The ship has sailed for decreasing fellowships as hospitals once get a taste of physician level care and reimbursement while paying less than an RN will be impossible to let go.

Official recognition from CMS so that they can bill at a $/ RVU similar to Ortho versus FM I bet

Head team physicians are all about connections. 1 or 2 years of training I’m sure they can give less than a rat’s a$$.

 

[deleted997790]

less fellows/more competitive
- if that is the goal, then perhaps decrease the number of fellowships? That would make it more competitive and there would be less fellows

official recognition as specialists
- from who? Will the desired entity(ies) be impressed by the extra year?

Head Team physicians
- will an extra year get this accomplished at program/team of interest that otherwise would not want us if we were only trained for 1 year?

I certainly favor expanding educational opportunity and expanding one’s practice and set of skills in a systematic and organized fashion, I just have a sense that there isn’t appropriate consideration with this plan.Obviously I could be wrong

the whole idea is ludicrous. Increasing the fellowship to two years will decrease the # of fellowships because of funding. If they implement a criteria of what has to be done during the fellowship (regenerative medicine, cardiopulmonary testing, etc), that will close down an additional # of fellowships (especially the smaller non D1 schools).

recognition as specialists from the CMS

head team physicians: apparently an extra year of doing the same thing again and again makes you more competitive? I agree with @door_to_balloon_knot...it’s all about connections.

the entire idea of a 2 year fellowships seems to be a waste...I heard in the document, they were pretty clear about there being too many sports med docs. Sounds like someone at the AMSSM is catching feelings.

 

[Reboa]

I thought cms payments per rvu are the same across specialties. I’ve asked this question before here and people said that.

 

[deleted997790]

I thought cms payments per rvu are the same across specialties. I’ve asked this question before here and people said that.

It’s consultation fees. Certain insurance companies pay consultation fees but I don’t see how this matters either. I don’t get the point of specialty recognition other than saying “I’m a specialist”, which most people already consider sports med doctors...

however, this article (http://www.medpac.gov/docs/default-...ciancompensationreport_cvr_contractor_sec.pdf) says “For individual specialties, family medicine physicians earn a median of $50.37 per work RVU. Three specialties (pediatrics, nephrology, and ophthalmology) have median compensation per RVU that is lower than the median among family medicine physicians.” (2019)

 

[runfastnow]

I still cannot understand the logic behind this.

After a PM&R residency and sports medicine fellowship I was 100% prepared to be a competent sports medicine physician. An additional year of fellowship would not have made me a sports cardiologist or allow me to run an exercise lab.

 

[JBM16BYU]

I agree with the above sentiments that say that if PM&R sports medicine fellowships are to become 2 years, (or frankly any sports fellowship that routinely takes PM&R) I would hope that each would offer (1) fluoroscopy training for interventional spine (at least lumbar) procedures, (2) enough EMGs to become boarded by ABEM, (3) enough MSK US experience to obtain RMSK (or something similar), (4) advanced ultrasound procedural training, such as carpal tunnel releases, trigger finger releases, Tenex, tenotomies, etc. Essentially creating a non-operative "interventional orthopedist" or "interventional physiatrist" or "interventional sports physician," at least from a PM&R standpoint. While sports cardiology might be interesting and you might pick up tidbits, I'd be most likely referring them to cardiology anyways since they spend years on solely the heart. The same goes for sports allergy, sports pulmonology, sports dermatology, etc. There are bread and butter things I think we could all feel comfortable managing, at least acutely on the sidelines if needed, but I'm not a pulmonologist who has mastered treating asthmatics, just as an example.

 

[door_to_balloon_knot]

It’s consultation fees. Certain insurance companies pay consultation fees but I don’t see how this matters either. I don’t get the point of specialty recognition other than saying “I’m a specialist”, which most people already consider sports med doctors...

however, this article (http://www.medpac.gov/docs/default-...ciancompensationreport_cvr_contractor_sec.pdf) says “For individual specialties, family medicine physicians earn a median of $50.37 per work RVU. Three specialties (pediatrics, nephrology, and ophthalmology) have median compensation per RVU that is lower than the median among family medicine physicians.” (2019)

Consultation fees have higher RVU amounts compared to the standard E/M -203/-204/-205. That could play a factor. Too lazy to look into it but I think it’s like another 0.5 wRVU higher despite doing the same amount of work.

 

[door_to_balloon_knot]

As an aside, the whole specialty fk’d themselves when FM programs got greedy during the tenure of the last ABFM president who was a big fan of sports med. As a result, before the president departed, he basically rush approved a huge amount of programs. Now the same PD’s that applied to have opened these programs are complaining there may be too many Sports med docs?

Well no sht.

 

[deleted997790]

I agree with the above sentiments that say that if PM&R sports medicine fellowships are to become 2 years, (or frankly any sports fellowship that routinely takes PM&R) I would hope that each would offer (1) fluoroscopy training for interventional spine (at least lumbar) procedures, (2) enough EMGs to become boarded by ABEM, (3) enough MSK US experience to obtain RMSK (or something similar), (4) advanced ultrasound procedural training, such as carpal tunnel releases, trigger finger releases, Tenex, tenotomies, etc. Essentially creating a non-operative "interventional orthopedist" or "interventional physiatrist" or "interventional sports physician," at least from a PM&R standpoint. While sports cardiology might be interesting and you might pick up tidbits, I'd be most likely referring them to cardiology anyways since they spend years on solely the heart. The same goes for sports allergy, sports pulmonology, sports dermatology, etc. There are bread and butter things I think we could all feel comfortable managing, at least acutely on the sidelines if needed, but I'm not a pulmonologist who has mastered treating asthmatics, just as an example.

Honestly, I’m family medicine and I’m not against a two year fellowship. That being said, PM&R has a huge advantage when it comes to msk medicine and I can NOT see any reason why someone who was trained in PM&R should do 2 years. I had zero MSK ultrasound training in residency and my msk anatomy and physical exam was meh...

 

[Reboa]

So is the average sports med doc able to bill as a specialist?

 

[door_to_balloon_knot]

Honestly, I’m family medicine and I’m not against a two year fellowship. That being said, PM&R has a huge advantage when it comes to msk medicine and I can NOT see any reason why someone who was trained in PM&R should do 2 years. I had zero MSK ultrasound training in residency and my msk anatomy and physical exam was meh...

Did you not have any elective rotations with ortho, PMR, PCSM? If you had zero MSK ultrasound along with lackluster anatomy understanding as well as exam skills, I think that’s more on you than the program. My program was heavily into OB (which seems to be the “cool” thing these days) but I had more than ample opportunities to learn and understand the above to the point where I (without bragging) was at a level beyond my attendings simply because they have no interest in them.

Edit: more so, the loss of $460k+ versus $230k+ is an equally if not more important issue.

 

[deleted997790]

Did you not have any elective rotations with ortho, PMR, PCSM? If you had zero MSK ultrasound along with lackluster anatomy understanding as well as exam skills, I think that’s more on you than the program. My program was heavily into OB (which seems to be the “cool” thing these days) but I had more than ample opportunities to learn and understand the above to the point where I (without bragging) was at a level beyond my attendings simply because they have no interest in them.

This was definitely on me. We had orthopedics, a home based sports medicine fellowship, etc. But, most non orthopedic/pm&r residents don’t know how to do a good physical exam and most don’t remember msk anatomy. This wasn’t just a “me” thing. Residents are too focused on HTN, diabetes, heart failure or whatever their respective field requires them to know. I occasionally teach residents physical exams and review anatomy, and this is a pretty consistent finding. Orthopedic surgeons agree with this.

Knowing that I was going to go into sports medicine, I should have put more effort into learning and reviewing before my fellowship...but, oh well. That was years ago. My program was a division 1 program and niether of the two sports medicine (family medicine) attendings were proficient with ultrasound. This became a tedious task without proper training - online courses, in person courses, books, etc.

There are still programs where the attendings are not proficient or comfortable with diagnostic ultrasound. A more structured curriculum isn’t a bad idea - 2 years? maybe not necessary.

 

[deleted87716]

So is the average sports med doc able to bill as a specialist?

There's no such thing as "billing as a specialist," unless you're talking about consult codes, which are increasingly becoming unreimbursed. We all bill the same E&M codes for office visits. As a sports medicine specialist, you'll likely be doing a lot more procedures than traditional FM (e.g., joint injections under US guidance, casting, splinting, interpretation of imaging, etc.), so you should be able to bill more for these. You can also get paid for serving as a team physician, but that's been severely curtailed by the 'Rona.

 

[TableMD]

 

[galactus]

There's no such thing as "billing as a specialist," unless you're talking about consult codes, which are increasingly becoming unreimbursed. We all bill the same E&M codes for office visits. As a sports medicine specialist, you'll likely be doing a lot more procedures than traditional FM (e.g., joint injections under US guidance, casting, splinting, interpretation of imaging, etc.), so you should be able to bill more for these. You can also get paid for serving as a team physician, but that's been severely curtailed by the 'Rona.

This. I practice more sports medicine than family now, but I'm under the taxonomy of family medicine, so in regards to billing it's all the same. Do I do more procedures than my FM partners? Of course. I usually my ultrasound daily and that adds to the billing as well.
In regards to being a team physician, the vast majority of us aren't paid for those roles, as it's the hospital system that's the sponsor of the team. We get paid when they see us as an office visit. The game coverage, travel, and all the swag is just a bonus

 

[Kissmyabjj]

I would have been down for this

I agree with the above sentiments that say that if PM&R sports medicine fellowships are to become 2 years, (or frankly any sports fellowship that routinely takes PM&R) I would hope that each would offer (1) fluoroscopy training for interventional spine (at least lumbar) procedures, (2) enough EMGs to become boarded by ABEM, (3) enough MSK US experience to obtain RMSK (or something similar), (4) advanced ultrasound procedural training, such as carpal tunnel releases, trigger finger releases, Tenex, tenotomies, etc. Essentially creating a non-operative "interventional orthopedist" or "interventional physiatrist" or "interventional sports physician," at least from a PM&R standpoint. While sports cardiology might be interesting and you might pick up tidbits, I'd be most likely referring them to cardiology anyways since they spend years on solely the heart. The same goes for sports allergy, sports pulmonology, sports dermatology, etc. There are bread and butter things I think we could all feel comfortable managing, at least acutely on the sidelines if needed, but I'm not a pulmonologist who has mastered treating asthmatics, just as an example.

 

[TheGreatestTrochanter]

I agree with the above sentiments that say that if PM&R sports medicine fellowships are to become 2 years, (or frankly any sports fellowship that routinely takes PM&R) I would hope that each would offer (1) fluoroscopy training for interventional spine (at least lumbar) procedures, (2) enough EMGs to become boarded by ABEM, (3) enough MSK US experience to obtain RMSK (or something similar), (4) advanced ultrasound procedural training, such as carpal tunnel releases, trigger finger releases, Tenex, tenotomies, etc. Essentially creating a non-operative "interventional orthopedist" or "interventional physiatrist" or "interventional sports physician," at least from a PM&R standpoint. While sports cardiology might be interesting and you might pick up tidbits, I'd be most likely referring them to cardiology anyways since they spend years on solely the heart. The same goes for sports allergy, sports pulmonology, sports dermatology, etc. There are bread and butter things I think we could all feel comfortable managing, at least acutely on the sidelines if needed, but I'm not a pulmonologist who has mastered treating asthmatics, just as an example.

Love that idea, though there are a good number of PM&R programs that can do 1, 2 and 3 already within a year, but only a small number of academic centers that do 4 due to turf wards with ortho (at least with CTR and trigger finger releases). A lot would have to change for this to happen.

 

[deleted997790]

Love that idea, though there are a good number of PM&R programs that can do 1, 2 and 3 already within a year, but only a small number of academic centers that do 4 due to turf wards with ortho (at least with CTR and trigger finger releases). A lot would have to change for this to happen.

Isn't that so frustrating? Our program didn’t teach us ultrasound guided carpal tunnel releases (“sonex”) Bc ortho intervened and blocked the hospital from allowing PCSM docs from learning/performing/teaching these...

 

[Lurts]

Do you all have any advice about learning some of these more advanced techniques post-fellowship?

 

[door_to_balloon_knot]

Do you all have any advice about learning some of these more advanced techniques post-fellowship?

Not sure what you mean by advanced but Malanga’s book on ultrasound guided procedures is a great reference for some things you may or may not have done.

 

[Lurts]

Primarily things like Sonex, Tenex, nerve hydrodissections, etc, but thank you, I will definitely check out that book!

 

[deleted997790]

Primarily things like Sonex, Tenex, nerve hydrodissections, etc, but thank you, I will definitely check out that book!

Our program taught us tenex and hydrodissections. After learning how to comfortably guide needles under ultrasound, these procedures are very easy to learn. Seriously, the hardest thing to learn is sonoanatomy, diagnostic ultrasound (this is a requisite to all the above procedures) and how to guide needles under ultrasound. If u can do these things comfortably, the above mentioned procedures can all be learned in one month or less

 

[TheGreatestTrochanter]

Primarily things like Sonex, Tenex, nerve hydrodissections, etc, but thank you, I will definitely check out that book!

The actual needle work for those is not incredibly challenging. As was mentioned, we will run into trouble if we turn into proceduralists only without knowing your anatomy stone cold. You need to know what nerves, vessels, tendons run where so you don't get into trouble damaging structures inadvertently. Especially something like Sonex, if you can't tell me in great detail the distal median nerve with its cutaneous and recurrent motor branches, its variable locations for branching off, and be able to identify this on ultrasound before the procedure, you should not be doing this procedure. Sonex makes it safer than just using a cutting needle, but a solid understanding of anatomy and sonoanatomy is a requisite. I think honestly during fellowship just getting that down, and knowing when they are appropriate to be done should be the focus.