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:
Has been an overall valuable experience
Has enhanced my orthopedic sports medicine education
Has helped me to improve my clinical, diagnostic, and decision-making skills
Has made me more confident in handling acute athletic injuries
Has made me feel more a part of the community
Has made me more likely to cover a high school team in the community where I will eventually practice
Has increased my interest in sports medicine as a possible career
Has increased my awareness of the roles that athletic trainers provide to sports teams
Should be continued as a part of the orthopedic residency education curriculum
Has affected my 80-hour work week
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).
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.
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.
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 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.
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.
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Relationship of the 6 Accreditation Council for Graduate Medical Education Core Competencies and the High School Football Team Physiciana
|Core Competency||Applications to High School Football Team Coverage|
|Medical Knowledge||Acute musculoskeletal pathology
Non-musculoskeletal conditions (eg, heat stroke, syncope, seizure, concussion, skin infections)
Differences between adolescent and adult athletes|
|Patient Care||Assessing whether a player can return to play
Applying Advanced Trauma Life Support principles
Sideline reductions, splinting, taping, etc|
|Interpersonal and Communication Skills||Interacting with players and coaches and reconciling their sometimes disparate goals
Relaying information to parents
Working in concert with athletic trainers and emergency medical personnel|
Functional but appropriate attire
Representing your medical center|
|Practice-Based Learning and Improvement||Ability 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 Practice||Understanding 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|