Orthopedics

Feature Article 

The Role of High School Football Coverage in Resident Education

Matthew J. Salzler, MD; Geoffrey E. Stoker, MD; David J. Lunardini, MD; Christopher D. Harner, MD

Abstract

Athletic team coverage experience varies widely across orthopedic surgery residency programs in the United States. There is a paucity of literature regarding whether serving as a team physician contributes to resident education and whether it can be performed within the bounds of current work-hour restrictions. Residents consider coverage of high school football games a valuable educational experience that does not adversely affect their 80-hour work week. Sixty-one orthopedic residents who served as high school football team physicians as part of their residency curriculum completed an 11-question survey. Responses ranged from strongly agree (1) to strongly disagree (5) on a Likert scale. The majority of residents agreed that serving as a team physician was an overall valuable experience (85%), that it enhanced their orthopedic sports medicine education (89%), and that it increased their awareness of the role played by athletic trainers (97%). The majority of respondents disagreed only with the statement that serving as a team physician had negatively affected their 80-hour work week (54%), and an additional 26% neither agreed nor disagreed. The vast majority of participating orthopedic residents consider high school football team coverage a valuable experience that enhances education and can be performed within work-hour limitations. [Orthopedics. 2020;43(6):e574–e578.]

Abstract

Athletic team coverage experience varies widely across orthopedic surgery residency programs in the United States. There is a paucity of literature regarding whether serving as a team physician contributes to resident education and whether it can be performed within the bounds of current work-hour restrictions. Residents consider coverage of high school football games a valuable educational experience that does not adversely affect their 80-hour work week. Sixty-one orthopedic residents who served as high school football team physicians as part of their residency curriculum completed an 11-question survey. Responses ranged from strongly agree (1) to strongly disagree (5) on a Likert scale. The majority of residents agreed that serving as a team physician was an overall valuable experience (85%), that it enhanced their orthopedic sports medicine education (89%), and that it increased their awareness of the role played by athletic trainers (97%). The majority of respondents disagreed only with the statement that serving as a team physician had negatively affected their 80-hour work week (54%), and an additional 26% neither agreed nor disagreed. The vast majority of participating orthopedic residents consider high school football team coverage a valuable experience that enhances education and can be performed within work-hour limitations. [Orthopedics. 2020;43(6):e574–e578.]

American football is a highly popular contact sport with a high rate of injury.1,2 Reported injury rates range from 4.1 per 10,000 athlete exposures to 139 injuries in 67 high school varsity football games.1,2 Of all high school sports in the United States, football has the highest rate of concussions (6.4 per 10,000 exposures overall and 22.9 per 10,000 competition exposures), joint dislocations/separations (2.1 per 10,000 exposures), athletes requiring surgery (2.52 per 10,000 exposures), and severe injuries (6.9 per 10,000 exposures).3–7 Injury rates during competition are higher than in practice.5

Because of the high number of injuries in high school football games, these athletes could potentially benefit from sideline physician coverage. Although not well studied, current literature suggests that many high schools report a need for such coverage during competition.2,8–10 With increasing financial pressure on school districts, many high schools, particularly those in medically underserved areas, are unlikely to be able to remunerate physicians for providing coverage. Orthopedic surgery residents can potentially fill this need for high schools while simultaneously furthering their own education.

To the authors' knowledge, no study has evaluated whether orthopedic residents functioning as team physicians—in this case, for high school football teams—gain the expected educational benefits. Further, with increasing attention paid to resident work hours, it is unknown whether coverage of high school football games would cause residents to violate Accreditation Council for Graduate Medical Education (ACGME) limitations.

To evaluate these issues, the authors surveyed residents across 4 orthopedic residency programs where high school football coverage is a part of the residency curriculum. The authors' hypothesis was that, from the residents' perspective, coverage of high school football games is a valuable educational experience that does not interfere with ACGME restrictions on work hours.

Materials and Methods

Through the American Orthopaedic Association, an 11-question anonymous survey was sent to 104 post-graduate year 2 to post-graduate year 5 residents across 4 orthopedic residency programs in 2013. At each program, residents voluntarily participated in local high school football game coverage as part of their curriculum. The degree of financial compensation received as well as the actual number of hours devoted by residents varied across programs; these data were not collected. In the survey, participants were asked to what extent they agreed or disagreed with the following statements.

Serving as a team physician during residency:

  1. Has been an overall valuable experience

  2. Has enhanced my orthopedic sports medicine education

  3. Has helped me to improve my clinical, diagnostic, and decision-making skills

  4. Has made me more confident in handling acute athletic injuries

  5. Has made me feel more a part of the community

  6. Has made me more likely to cover a high school team in the community where I will eventually practice

  7. Has increased my interest in sports medicine as a possible career

  8. Has increased my awareness of the roles that athletic trainers provide to sports teams

  9. Should be continued as a part of the orthopedic residency education curriculum

  10. Has affected my 80-hour work week

  11. I have been fairly compensated for serving as a high school team physician

Responses were provided based on a 5-point Likert scale with the following answer options: strongly agree (1), agree (2), neither agree nor disagree (3), disagree (4), and strongly disagree (5). Mean response values with a 95% confidence interval (CI) were calculated. A mean value of less than 3.0 suggests overall agreement with the statement, whereas a value greater than 3.0 suggests overall disagreement. The percent of residents who agreed (Likert score 1 and 2), disagreed (Likert score 4 and 5), and remained neutral (Likert score 3) with each statement was also calculated. Survey results were compiled in and evaluated with Excel (Microsoft, Redmond, Washington).

Results

Sixty-one (59%) of 104 residents completed the survey. The extent of agreement with each survey statement is depicted in Figure 1 as a percentage and in Figure 2 as a mean with 95% CI. Residents most strongly agreed that serving as a team physician during residency increased their awareness of the roles of athletic trainers (mean, 1.49; 95% CI, 1.34–1.64; 97% agreement), that it had been an overall valuable experience (mean, 1.75; 95% CI, 1.54–1.97; 85% agreement), and that it had enhanced their sports medicine education (mean, 1.74; 95% CI, 1.54–1.94; 89% agreement). The only survey statement with which the residents disagreed was that serving as a team physician had affected their 80-hour work week (mean, 3.44; 95% CI, 3.19–3.69; 54% disagreement). An additional 26% neither agreed nor disagreed with this statement.

Agreement by percentage. The percentage of residents who agreed (Likert score 1 and 2), disagreed (Likert score 4 and 5), and remained neutral (Likert score 3) with each statement.

Figure 1:

Agreement by percentage. The percentage of residents who agreed (Likert score 1 and 2), disagreed (Likert score 4 and 5), and remained neutral (Likert score 3) with each statement.

Agreement per Likert scale. Mean values with 95% confidence interval bars. A mean value of less than 3.0 suggests overall agreement with the statement, whereas a value greater than 3.0 suggests overall disagreement.

Figure 2:

Agreement per Likert scale. Mean values with 95% confidence interval bars. A mean value of less than 3.0 suggests overall agreement with the statement, whereas a value greater than 3.0 suggests overall disagreement.

Discussion

The results of this study suggest that residents consider serving as high school football team physicians to be a valuable experience that enhances their knowledge of sports medicine. It also suggests that it improves their overall clinical development, including their diagnostic and decision-making skills.

In addition to providing acute educational benefits, serving as a team physician may have other long-lasting effects. Residents reported feeling as if they were a more active part of the local community. They also felt that, due to their coverage experience as residents, they were now more likely to pursue similar opportunities in the future. This may help alleviate the widespread need for sideline coverage of high school football games, improve overall care of high school athletes, and help orthopedic surgeons continue to play an active role in their communities. Although there is no longitudinal component to this study to corroborate these hopes, the results are certainly promising in this regard.

Despite how beneficial coverage of high school sports appears, time spent on this activity counts toward overall resident duty hours. In 2003 and 2011, the ACGME enacted new work-hour restrictions without a consequent change in the length of orthopedic residency. Thus, programs have been forced to improve the efficiency of education to provide the same resident experience with less available time. Although controversy has surrounded these restrictions, residency programs are required to comply.11–13 This study, which was performed after the 2011 work-hour restrictions went into effect, suggests that serving as a team physician does not affect compliance with the 80-hour work week. Further, in terms of improving efficiency in education, we believe that serving as a team physician addresses all 6 ACGME Core Competencies: Medical Knowledge, Patient Care, Interpersonal and Communication Skills, Professionalism, Practice-Based Learning and Improvement, and Systems-Based Practice (Table 1). In addition, to maximize these benefits, the senior author (C.D.H.) recommends that residents should remain with a particular team for as many games or seasons as possible. It is difficult to gain an adolescent patient's trust as a young physician, and longitudinal coverage of the same group of athletes would help residents learn to build trust and facilitate optimal patient care. This continuity would also foster long-term relationships with coaches, athletic trainers, and communities as a whole.

Relationship of the 6 Accreditation Council for Graduate Medical Education Core Competencies and the High School Football Team Physiciana

Table 1:

Relationship of the 6 Accreditation Council for Graduate Medical Education Core Competencies and the High School Football Team Physician

Although residents agreed that their role as team physician was educational, at the senior author's institution, the residents were also financially compensated by their medical center for coverage. Overall, the residents in the survey agreed (2.51) that they were fairly compensated for coverage; however, because the surveyed programs differ in this regard, we cannot comment on the amount of compensation, if any, those residents consider fair. Although compensating residents for coverage can be costly to an institution, it has the potential to augment clinical revenue through increased patient visits, surgical volume, durable medical equipment sales, and imaging. It has been shown that certified athletic trainers can increase patient volume and revenue generation more than a medical assistant.14 Although this study does not address cost-effectiveness, it is possible and even likely that residents working as team physicians would have a similar effect as athletic trainers. Even if not cost-effective, residents' responses to survey items 1 to 4 suggest that this is a positive learning experience. Most importantly, resident involvement as high school team physicians serves to improve the relationship between a medical center and its community, especially when carried out longitudinally over a number of years.

There were potential limitations in the study design. One potential limitation was the relatively low number of participants and response rate. The former was mitigated somewhat by a high rate of responder agreement on the majority of the questions, but the latter may have increased the risk of participation bias. A second potential limitation was the heterogeneity in the structures of the 4 residency programs included within this study. For example, depending on the program, the number of games covered per resident ranged from approximately 4 to 12; on the lower end, there were programs whose residents shared team physician responsibilities by alternating games, and on the higher end, there were some residents whose teams had extended post-season play. However, because of the varied football coverage structures within these programs and the relative agreement within the survey responses, the heterogeneity may make the results more generalizable. The details of what constitutes fair financial compensation and medicolegal concerns, another potential barrier to resident coverage,15 were not elaborated on in this survey. Although malpractice insurers differ, at the senior author's institution, the residents are covered for malpractice as the athletic coverage is considered part of their curriculum. Data that may more objectively reflect educational benefit (ie, In-Training Examination scores) were also not considered.

Regarding this study's strengths, high school football is extremely popular in the United States, and its players are prone to a variety of injuries. Orthopedic resident coverage of high school football teams is common, but to the authors' knowledge, this study is the first to describe residents' appraisal of this coverage as an educational experience. The increasingly important issue of work hours was addressed, and several training programs were included to improve generalizability. Moreover, the authors believe the foundations of this Likert-style survey can be used as a model for resident evaluation of any training activity. As such, there are numerous potential applications. Program directors may use permutations of the survey to assess the value of, for example, bioskills training modules, cadaver laboratories, or any clinical rotation in general. Surveys like this are easy to build, administer, and analyze and can provide meaningful feedback.

Looking forward, although this study demonstrates that residents consider high school football coverage a valuable experience, there is still room for improvement. At the senior author's institution, there are multiple lectures prior to the season that are designed to enhance the experience and education of the residents. These lectures cover a broad range of subjects from medical topics (eg, heat illness/stroke, seizures, viral flu, rashes, lacerations, concussions, myocardial infarctions, and cerebrovascular accidents) and orthopedic issues (eg, sideline management of sprains, dislocations, fractures, spinal injuries, helmet management) to practical and logistical issues (eg, interactions with athletic trainers, emergency medical personnel, coaches). The authors are constantly updating this portion of their curriculum, and this may be one method to improve on the resident experience as a team physician.

Conclusion

Orthopedic residents consider serving as a team physician a valuable experience that enhances their overall clinical development as well as their sports medicine education without interfering with 80-hour work week compliance.

References

  1. Badgeley MA, McIlvain NM, Yard EE, Fields SK, Comstock RD. Epidemiology of 10,000 high school football injuries: patterns of injury by position played. J Phys Act Health. 2013;10(2):160–169. doi:10.1123/jpah.10.2.160 [CrossRef] PMID:22821941
  2. Hoffman MD, Lyman KA. Medical needs at high school football games in Milwaukee. J Orthop Sports Phys Ther. 1988;10(5):167–171. doi:10.2519/jospt.1988.10.5.167 [CrossRef] PMID:18796961
  3. Kerr ZY, Collins CL, Pommering TL, Fields SK, Comstock RD. Dislocation/separation injuries among US high school athletes in 9 selected sports: 2005–2009. Clin J Sport Med. 2011;21(2):101–108. doi:10.1097/JSM.0b013e31820bd1b6 [CrossRef] PMID:21358499
  4. Rechel JA, Collins CL, Comstock RD. Epidemiology of injuries requiring surgery among high school athletes in the United States, 2005 to 2010. J Trauma. 2011;71(4):982–989. doi:10.1097/TA.0b013e318230e716 [CrossRef] PMID:21986739
  5. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005–2007. Am J Sports Med. 2009;37(9):1798–1805. doi:10.1177/0363546509333015 [CrossRef] PMID:19531659
  6. Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National high school athlete concussion rates from 2005–2006 to 2011–2012. Am J Sports Med. 2014;42(7):1710–1715. doi:10.1177/0363546514530091 [CrossRef] PMID:24739186
  7. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755. doi:10.1177/0363546511435626 [CrossRef] PMID:22287642
  8. Rutherford DS, Niedfeldt MW, Young CC. Medical coverage of high school football in Wisconsin in 1997. Clin J Sport Med. 1999;9(4):209–215. doi:10.1097/00042752-199910000-00005 [CrossRef] PMID:10593215
  9. Vangsness CT Jr, Hunt T, Uram M, Kerlan RK. Survey of health care coverage of high school football in southern California. Am J Sports Med. 1994;22(5):719–722. doi:10.1177/036354659402200524 [CrossRef] PMID:7810800
  10. Aukerman DF, Aukerman MM, Browning D. Medical coverage of high school athletics in North Carolina. South Med J. 2006;99(2):132–136. doi:10.1097/01.smj.0000199749.22741.5e [CrossRef] PMID:16509550
  11. Levine WN, Spang RC III, . ACGME Duty hour requirements: perceptions and impact on resident training and patient care. J Am Acad Orthop Surg. 2014;22(9):535–544. doi:10.5435/JAAOS-22-09-535 [CrossRef] PMID:25157035
  12. Fitzgibbons SC, Chen J, Jagsi R, Weinstein D. Long-term follow-up on the educational impact of ACGME duty hour limits: a pre-post survey study. Ann Surg. 2012;256(6):1108–1112. doi:10.1097/SLA.0b013e31825ffb33 [CrossRef] PMID:23069864
  13. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am. 2011;93(23):e1421–e1429. doi:10.2106/JBJS.K.00700 [CrossRef] PMID:22159864
  14. Pecha FQ, Xerogeanes JW, Karas SG, Himes ME, Mines BA. Comparison of the effect of medical assistants versus certified athletic trainers on patient volumes and revenue generation in a sports medicine practice. Sports Health. 2013;5(4):337–339. doi:10.1177/1941738112472659 [CrossRef] PMID:24459550
  15. Pearsall AW IV, Kovaleski JE, Madanagopal SG. Medicolegal issues affecting sports medicine practitioners. Clin Orthop Relat Res. 2005;(433):50–57. doi:10.1097/01.blo.0000159896.64076.72 [CrossRef] PMID:15805936

Relationship of the 6 Accreditation Council for Graduate Medical Education Core Competencies and the High School Football Team Physiciana

Core CompetencyApplications to High School Football Team Coverage
Medical KnowledgeAcute musculoskeletal pathology Non-musculoskeletal conditions (eg, heat stroke, syncope, seizure, concussion, skin infections) Differences between adolescent and adult athletes
Patient CareAssessing whether a player can return to play Applying Advanced Trauma Life Support principles Sideline reductions, splinting, taping, etc
Interpersonal and Communication SkillsInteracting with players and coaches and reconciling their sometimes disparate goals Relaying information to parents Working in concert with athletic trainers and emergency medical personnel
ProfessionalismPunctuality Functional but appropriate attire Representing your medical center
Practice-Based Learning and ImprovementAbility to monitor player progress and injury natural history over the course of a season Ability to learn from mistakes with subsequent games Feedback can be gained from attending physicians when players are referred to home institution clinic
Systems-Based PracticeUnderstanding what kind of pre-hospital treatment may be provided by athletic trainers and/or emergency medical personnel Deciding to refer to pediatric vs adult emergency departments Communicating with receiving hospital personnel Understanding the high school sports environment as a whole and its importance to communities
Authors

The authors are from the Department of Orthopaedic Surgery (MJS, GES), Tufts Medical Center, Boston, Massachusetts; the University of Vermont Medical Center (DJL), South Burlington, Vermont; and the University of Texas at Houston (CDH), Houston, Texas.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Matthew J. Salzler, MD, Department of Orthopaedic Surgery, Tufts Medical Center, 800 Washington St #306, Boston, MA 02111 ( MSalzler@tuftsmedicalcenter.org).

Received: May 20, 2019
Accepted: October 24, 2019
Posted Online: September 03, 2020

10.3928/01477447-20200827-08

Sign up to receive

Journal E-contents