Sports medicine: the primary care perspective.

Annotation: Dr. Jim Puffer has impeccable credentials to discuss the evolution of sports medicine as a primary care specialty. A founding member of the Primary Care Sports Medicine Fellowships and head USA Team Physician for the 24th Olympiad, Dr. Puffer's leadership in Sports Medicine is legend. As the aggregate musculoskeletal expertise and surgical triage abilities of the primary care sports medicine physician sharpen, the responsibilities of those physicians broaden. Increasingly important is the sports medicine team's interaction--both personal and professional--related to individual athletes. Equally important is the specific and growing collaboration between primary care sports medicine and orthopaedic sports medicine in the greater sports medicine world.

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Primary care physicians have a long and rich tradition of providing medical care to athletes of all ages. The spectrum of this care has been broad and has included, for example, such routine tasks as completing a preparticipation examination for a young, aspiring athlete; counseling a middle-aged patient with multiple risk factors for coronary artery disease on how to safely begin an exercise program; and caring for countless numbers of high school athletes on the field in small communities across America on any given Friday evening during the football season. The great majority of primary care physicians have had no formal training in delivering these services. Some may have had limited exposure to these types of experiences during their training, but until recently, the great majority of physicians acquired these skills "on the job".

Twenty years ago, it became increasingly apparent to leaders within the nascent field of primary care sports medicine that a need for formal, educationally valid training experiences existed. As a result, in the mid 1980s, the first three formal sports medicine fellowship programs for primary care physicians were created at the Cleveland Clinic, Michigan State University, and the University of California at Los Angeles (UCLA). These pioneering programs provided a structured curriculum in sports medicine, a supportive environment in which to learn the basic elements of conducting high quality clinical research and the opportunity to provide supervised care to athletes under the direction of well-respected mentors in primary care sports medicine. All three programs shared an important common element: they were aligned with supportive orthopaedists who were specializing in sports medicine and who saw the natural synergism created when well-trained primary care physicians were paired with orthopaedists to provide care to athletes.

The popularity of these programs was overwhelming, and very shortly after their establishment, additional fellowship programs were created across the country. At the same time, a small group of leaders in the field approached the American Board of Family Practice (ABFP) to investigate the possibility of certifying physicians who had completed fellowship training in sports medicine. Under the leadership of Nicholas J. Pisacano, MD, the Executive Director of the ABFP, and with the critical assistance of Donald Kettlekamp, MD, then-executive director of the American Board of Orthopaedic Surgery, application was made to the American Board of Medical Specialties (ABMS) for a Certificate of Added Qualification in Sports Medicine. Very quickly, the ABFP was joined by the American Board of Internal Medicine, the American Board of Pediatrics, and the American Board of Emergency Medicine in seeking approval for certification in this emerging field. The ABMS finally approved the joint applications of these four boards in 1991. The first group of primary care physicians was certified in 1993. Formal accreditation of the first 32 fellowship programs to apply for such status by the Accreditation Council for Graduate Medical Education (ACGME) occurred shortly thereafter.

At the present time, over eighty accredited fellowship programs exist in primary care sports medicine, and approximately 1,600 physicians hold Certificates of Added Qualification in Sports Medicine. This has created a critical mass of experts in the discipline. More importantly, it has provided an essential resource for primary care residency training programs, which have long had a need to enhance their training in the area of musculoskeletal medicine. Many sports medicine fellowship-trained, board certified primary care physicians have accepted teaching positions in these programs, and have upgraded the training of residents in the recognition and management of common musculoskeletal problems.

As the discipline of primary care sports medicine has matured, so has the recognition that specialty trained physicians in this discipline are an essential component of the health care team that takes care of athletes in both institutional and community settings. Today, most National Collegiate Athletic Association (NCAA) Division I institutions have a primary care physician as part of their sports medicine staff, and in many instances, primary care physicians serve as the head physician for teams at these institutions. The additional skills that these physicians have brought to these settings have enhanced the breadth of care afforded these athletes and has added immeasurably to the quality of care delivered. Accordingly, for the past fifteen years, this expertise has been recognized by the NCAA, which has endeavored to include primary care physicians on its major committee that establishes organizational policy on the health, medical welfare, and safety of student athletes, the Committee on Competitive Safeguards and Medical Aspects of Sports.

Perhaps the most important outcome of formalizing training in sports medicine has been the development of superb clinician-researchers who are just now maturing into seasoned investigators. Most notably, these bright and talented physicians have furthered our understanding of the female athlete triad, the risk factors for sports-specific injuries, and the mechanisms which influence alterations in the athlete's heart in response to vigorous training. They have conducted randomized, controlled clinical trials investigating the utility of management strategies for many common injuries. Centers of excellence in primary care sports medicine research have developed at many institutions, and the faculties at these institutions continue to conduct cutting-edge research, while training the next generation of primary care sports medicine clinician-researchers.

Primary care sports medicine has come a long way since it was formalized twenty years ago. It has established itself as a unique discipline within the major primary care specialties, and formal fellowship training has resulted in the development of seasoned clinicians who have championed the importance of musculoskeletal medicine and sports medicine within primary care residency training programs. They have elevated the care of recreational and competitive athletes by embracing a delivery model which is comprehensive and continuous in nature, and which nicely complements the expertise which their colleagues in orthopaedic sports medicine bring to this endeavor. They have become the natural partners of sports orthopaedists in delivering care in a variety of settings, including both academic and private practice arrangements. Most importantly, well-trained young investigators are creating new knowledge which will guarantee the vitality and robust nature of the discipline.

It is difficult to envision where primary care sports medicine will be at the end of the next twenty years. It is probably safe to say that the care that is delivered by physicians who have been appropriately trained and certified will be driven by the evidence that has been developed from the research of their predecessors and the dramatic advances in technology that will further refine the ability to diagnose and manage the unique maladies suffered by athletes. Of paramount importance in any future paradigm of care, however, will be the uniquely synergistic relationship that primary care sports medicine physicians continue to share with their orthopaedic counterparts. This model will continue to clearly demonstrate its ability to deliver the highest quality of care to athletes in the most cost-effective manner as we move further into the next century.

The only difference between me and a madman is that I'm not mad.
--Salvador Dali

Accepted May 21, 2004.

James C. Puffer, MD

From the American Board of Family Practice, Lexington, KY.

Reprint requests to James C. Puffer, MD, Executive Director, American Board of Family Practice, Inc., 2228 Young Drive, Lexington, KY 40505-4294. Email: [e-mail]