Introduction. Sports are the leading injury-related cause for pediatric primary care visits. Pediatric residency education guidelines suggest incorporating sports medicine (SM) education into curricula; however, research is lacking regarding effective teaching methods.
Objective. To assess reported US pediatric residency SM curricula, teaching methods, and resident evaluation of SM education.
Design/Methods. Chief residents (CRs) and third-year residents (PL3s) from 100 randomly selected US Accreditation Council for Graduate Medical Education–accredited residency programs, stratified by size and geographic location, received surveys regarding programs' SM curriculum and teaching methods and individuals' methods for learning SM.
Results. Response rates were 63% and 39% for CRs and PL3s, respectively. According to CRs, 34% of programs had no one in charge of their SM curriculum. Lecture (77%) was the primary method used for teaching SM. Hands-on teaching (37%) was used less frequently. CRs stated that 29% of programs did not include musculoskeletal examination teaching in their curriculums; 24% did not include formal teaching of concussion management, and 29% did not include reasons for medical disqualification. PL3s rated teaching of joint examinations and the preparticipation physical as the most poorly taught components of the physical examination. PL3s rated hands-on teaching and patient experience as the best methods for improving SM education. CRs reported that only 36% of programs have discussed incorporating more SM into their curriculum.
Conclusions. SM education is deficient in US pediatric residency programs. Standardized curricula should be developed with a focus on hands-on training as a means for teaching SM to pediatric residents.
Sports medicine (SM) is a growing field in pediatrics. It is estimated that 30 million children and adolescents participate in organized sports each year.1 As more children and adolescents join organized and unorganized sports, pediatricians are faced with being a primary medical resource for this active youth group. Of the >4.3 million estimated emergency department (ED) visits for sports- and recreation-related injuries in the United States,2 the 5- to 24-year-old age group comprises 68% of these visits.3 Sports are responsible for >35% of all medically attended injuries in children 5 to 17 years old4 and >20% of all ED visits in those 5 to 24 years old.3 It is estimated that childhood injuries account for >10 million primary care office visits each year (1 of every 10 visits), with sports and overexertion being the leading cause for these visits.5 In fact, >25% of adolescent injury visits are attributable to sports injury.5
Musculoskeletal injuries are the second most common reason for visits to the ED and primary care offices overall6 and rank third as reasons for adolescent medical visits, with knee pain being the most common concern.7 However, besides musculoskeletal injuries, there is also the expanding medical (nonorthopedic) component of SM. Pediatricians deal with athletes on an everyday basis, from performing preparticipation physical examinations (PPEs) to caring for athletes and active individuals with asthma, chest pain, hypertension, eating disorders, amenorrhea, and chronic disease. With this large number of sports-related visits to pediatricians, a broad knowledge base regarding SM is arguably necessary.
Musculoskeletal training has been reported as lacking in both medical school and residency programs. At 1 medical center, 82% of incoming interns who recently graduated from US medical schools failed a basic musculoskeletal medicine test.6 A review of Canadian medical schools also reveals a lack of musculoskeletal training; only 5.7% of all curriculum time is devoted to musculoskeletal medicine.8 Musculoskeletal training has been cited as deficient in both internal medicine and pediatric residency programs in the United States.9–13
The goal of this study is to assess the current components of pediatric SM training in US pediatric residency programs. The hypothesis is that SM education and training is lacking in most pediatric residency programs, especially specific teaching of the musculoskeletal examination as well as important topics such as concussion management and screening for cardiovascular disease. Specific areas to be addressed include the type and forum of SM training along with the methods that may be useful for improving and augmenting the teaching of SM.
METHODS AND MATERIALS
This cross-sectional survey was distributed to third-year pediatric residents (PL3s) and pediatric chief residents (CRs) from 100 2002–2003 US pediatric residency programs listed by the Accreditation Council for Graduate Medical Education (ACGME) (www.acgme.org). Mailings were sent between February and May 2003. This sampling represents ∼50% of US pediatric residency programs.
Of the 207 ACGME-listed pediatric residency programs, 10 programs did not meet initial criteria for participation (5 programs had no third-year pediatric positions available, and 5 programs were nonmainland-US programs); thus, random selection of the final 100 programs was made from the remaining 197 programs. Residency programs were stratified by size (small: <10 PL3s; medium: 11–20 PL3s; large: >21 PL3s) and geographic location (Northeast, South, Midwest, and West) before randomization to represent national size and geographic distributions of US pediatric residency programs. Each group then was processed through a computerized random-number generator to obtain the final sample groups.
Survey Design and Administration
Two different, short questionnaires, intended to take 5 to 10 minutes to complete, were created for CRs and PL3s. Attached to each survey was a laminated “sports medicine pearls card” designed by the principle investigator, as a “thank you” for reviewing the survey. Questions were created after review of the pertinent literature, ACGME requirements, and SM experts' opinions and observations. A pilot study of both surveys was performed by using residents from the University of Wisconsin to assess question comprehension, reliability, and completeness. These residents were not participants in the final survey. The University of Wisconsin Internal Review Board approved this project before commencing the study.
The CR survey was designed to analyze pediatric residency programs' SM curriculum and teaching methods (SM components included in the general pediatric curriculum, formal methods used for teaching SM, physicians responsible for teaching SM components, and discussed methods for improving SM education into their program). CRs were selected as the best informants regarding program curricula. All information obtained from the CR surveys, representing pediatric residency programs, is labeled “CR” in the corresponding results and tables.
The PL3 survey was intended to assess PL3 evaluation of program curricula and teaching methods along with individuals' methods for learning SM throughout residency (methods used to learn SM, educational methods that would best serve them, evaluation of general physical examination components teaching, rating of orthopedic- and medicine-based SM teaching, and physician resources for learning various components of SM). All information obtained from the PL3 surveys is designated as “PL3” in the corresponding results and tables.
Two identical questions exist on both the CR and PL3 surveys related to primary care SM (PCSM) and orthopedic SM electives available at their respective institutions. All other questions were independent of one another.
Two identical survey packets were mailed to CRs from each selected program 6 to 8 weeks apart. Programs received reminder flyers 2 to 3 weeks after the first survey mailing. CRs were asked to place surveys and reminders in the appropriate pediatric PL3 mailboxes. PL3s and CRs were asked to respond to the second survey mailing only if they had not responded to the first survey mailing. No attempt was made to pool data received from the first versus second mailing. Questions were designed to provide general conclusions regarding SM education gathered over the entire 3-year residency program and should not necessarily reflect 1 specific point in time.
All statistical analyses were performed with SAS software (version 8.2, SAS Institute Inc, Cary, NC). Comparisons between groups for the resident data were performed by using a χ2 test for categorical responses and a nonparametric Kruskal-Wallis test for continuous or ordinal responses. Comparisons between groups for the CR data were performed by using Fisher's exact test for categorical responses and nonparametric Kruskal-Wallis tests for continuous or ordinal responses. Polyserial correlations were computed to measure consistency between CR and PL3 responses. A P value of ≤.05 was selected as the level of statistical significance. All P values are 2-sided and were not adjusted for the number of parameters evaluated. As such, they should only be interpreted as exploratory.
Demographics and Distribution
Of the 100 programs surveyed, 2 were excluded from CR analysis (1 program refused to participate because of in-house internal review board difficulties at their institution, and 1 program had no CR), leaving 98 programs as the final CR sample size. CR response rates were not significantly different among different-sized programs and geographic regions. Of 98 CRs, 62 returned completed CR surveys (63% response rate).
PL3 respondents represented 84 different pediatric residency programs. Thirteen programs did not respond (CRs or PL3s), so they were excluded from PL3 analysis only under the assumption that the survey was not received or distributed by the CRs. Size distribution of these programs was 10 small, 2 medium, and 1 large, and geographic distribution was 3 Northeast, 5 South, 4 Midwest, and 1 West. Of 1125 PL3s, 434 returned completed PL3 surveys (39% response rate); 412 of the PL3 surveys were used for final PL3 analysis, because 12 were excluded for being medicine-pediatric residents, 6 were second-year pediatric residents, and 4 were received after the final deadline. PL3 response rates were equivalent across different-sized programs but differed significantly, however, across regions: Northeast (34%), South (34%), Midwest (48%), and West (44%).
Of responding programs that had CR responses, 98% had corresponding PL3 responses. Eighty six percent of all programs surveyed (n = 84) had at least 1 PL3 response. All individual responses were represented equally in the final data analysis.
Sixty-six percent of PL3 respondents were female, and 65% were high school or college athletes. Ninety-five percent said that the amount of SM training in a residency program did not influence their residency choice, although 80% thought that they would need to know or use some aspect of SM for their future careers. Sixty-eight percent of PL3s were planning on entering a general pediatrics field (general pediatrics, adolescent medicine, or emergency medicine) after residency. Only 1% planned on pursuing a PCSM fellowship.
Pediatric SM Curricula
According to CRs, 34% of programs had no one in charge of developing their SM curriculum (Table 1).
Table 2 lists the percentage of programs that incorporated specific SM components into their general pediatrics curriculum. According to CRs, 29% of programs did not include specific musculoskeletal or joint examination teaching in their curriculum. Twenty-four percent of programs did not include formal teaching of concussion management, and 29% did not include teaching of reasons for medical disqualification in their general pediatric curricula.
Table 3 illustrates what percentage of programs, according to CRs, included specific methods for teaching SM in their general pediatrics curriculum. Lecture (77%) was the primary method used for teaching SM. The majority of programs included lectures, readings, adolescent rotations, ED rotations, and nonrequired SM rotations as methods for teaching SM. Hands-on teaching (37%) was used less frequently. Of those including SM lectures in their curriculum, the majority (54.2%) included 1 to 3 hours of lectures.
Methods for Learning SM
Most PL3s relied on ED rotations, lectures, readings, continuity clinic, adolescent rotations, and performing the PPE to learn aspects of SM (Table 4). Less than 30% of PL3s used rheumatology or orthopedic rotations to enhance their SM learning.
Thirty-one percent of CRs and 36% of PL3s stated that their pediatric residency program offered a PCSM rotation. Correlation was 0.42 (P < .0001; 95% confidence interval [CI]: 0.22–0.58) between CR and averaged PL3 responses from matching programs acknowledging that their residency offered a PCSM rotation. Correlation was 0.48 (P < .0001; 95% CI: 0.30–0.60) between CR and PL3 responses regarding no offered PCSM rotation in their residency program. Of those PL3s offered a PCSM rotation, 43% participated in a PCSM rotation (15.5% of total PL3s), and 11% planned on taking a PCSM rotation before residency completion (2.2% of total PL3s). Of PL3s not offered a PCSM rotation in their residency, 35% would be interested in taking an elective if it was offered at their institution.
Sixty-five percent of CRs and 18% of PL3s stated that their pediatric residency program offered an orthopedic SM rotation. Correlation between CR and PL3 answers regarding the existence of an orthopedic SM rotation in their program and no orthopedic SM rotation was 0.32 (P = .0032; 95% CI: 0.11–0.50) and 0 .38 (P < .0001; 95% CI: 0.18–0.55), respectively. Of those PL3s offered an orthopedic SM rotation, 33% participated in an orthopedic SM rotation (6% of total PL3s), and 12% planned on taking an orthopedic SM rotation before residency completion (1% of total PL3s).
Evaluation of Examination Skills Taught During Pediatric Residency
PL3s rated teaching of the joint examination and PPE as the most poorly taught components of the general physical examination, although comparable with the psychiatric history/examination. A scale from 0 to 5 was used, with 0 representing no teaching and 5 representing excellent teaching (Table 5).
On a scale of 1 to 5, PL3s rated overall orthopedic (joint/musculoskeletal) training as 2.5 ± 1.03 while rating medical SM training as 3.4 ± 1.03. PL3s completing a PCSM rotation during residency rated joint/orthopedic teaching better than those not taking a PCSM rotation (P < .00001; Table 6).
Improving SM Education in Pediatric Residency Programs
According to CRs, 36% of programs have discussed incorporating more SM into their curricula, with lectures and PCSM rotations being the most widely discussed methods for improving SM education.
PL3s rated hands-on teaching and patient experience as most valuable for learning SM versus all other methods (P < .00001; Table 7).
A Novel Study in SM Education
To our knowledge, this is the first SM education study that focuses on pediatric residency programs' curricula and teaching methods and compares these results with resident evaluation and suggested methods for SM learning and education. Our goal was to assess current education patterns and respond with means to possibly improve SM education and teaching. Although not the only method, residents' suggestions regarding their best learning experiences are one way to move forward in improving education. Including and responding to resident input may potentially increase enthusiasm and create a better learning environment for the learners. Our data suggest that creating a standardized SM curriculum that focuses on hands-on teaching methods and patient interactions may be a useful tool to improve SM education. As residency work hours shorten under new guidelines, effective, efficient learning opportunities need to be established to ensure comprehensive learning for pediatric residents.
The Need for SM Training in Pediatric Residency Programs
With a majority of pediatric residents continuing to enter a general pediatrics field after residency completion, SM education during residency training is crucial for learning injury care and prevention. According to survey data from annual American Board of Pediatrics General Pediatrics Examinations for first-time qualifiers, between 1996 and 2002, 68% to 71% of respondents chose general pediatrics as their entering field.14 Respondents from this study parallel this national trend.
A large percentage of PL3 respondents in this study remarked that they were former high school or collegiate athletes. Although we initially thought that this might tend to bias results, because athletes may be generally more interested in SM because of their athletic experiences and therefore seek out better education, our results do not indicate that this occurred.
Sports-related injuries account for a large percentage of primary care pediatric and ED visits. Yet, results from this study show that teaching of joint examinations and orthopedic skills is ranked poorly by residents and is not consistently included as a part of pediatric residency programs' curricula.
Along with seeing numerous initial sports injuries, both musculoskeletal and medical, general pediatricians perform a large number of well-child/PPEs every year. Preventive care visits (including screening examinations) account for 30.3% of all 0- to 15-year-old visits and 24.1% of 15- to 24-year-old visits to primary care physicians.15 Preventive care visits account for 33.9% of primary care pediatrician visits but <10% of family practitioner visits.15 General pediatricians, therefore, need to be adept at performing PPEs along with being familiar with reasons for medical disqualification. Although the majority of responding PL3s recognized the PPE as an important, resourceful, and highly used tool for learning SM, PL3s ranked teaching of the PPE as one of the most poorly taught components of the physical examination. Formal teaching of “reasons for medical disqualification” is not included in up to one third of pediatric residency programs' curricula.
Has There Been a Change Over the Past Decade in SM Education in Pediatric Residency Programs?
Little has changed regarding pediatric resident education in SM over the past decade. Despite studies showing a lack of SM education in pediatric residency programs along with the recent increased focus on community pediatrics training,16 findings from this study are similar to conclusions found in studies performed a decade ago.
A 1990 study of 10 years of graduate pediatric residents found that residency-taught orthopedics/SM skills were one of the pediatric education topics with which they felt least comfortable.9 This same group also rated orthopedics/SM as one of the top 2 areas that needed an increase in both emphasis and time during residency.9 Graduates of a pediatric primary care track (1984–1991) cited orthopedics as the top area requiring increased time in training, based on their current practice in primary care pediatrics.12 Residents have reported a lack of preparedness in both diagnosis and management skills regarding orthopedic and sports-related issues.9–12 When comparing teaching of the various components of the physical examination in this study, joint examinations and the PPE received the lowest scores, comparable with the psychiatric history/examination. There was a significant difference noted in how residents rated teaching of joint examinations compared with teaching of the lung, cardiac, abdominal, and head, eyes, ears, nose, and throat (HEENT) examinations. Almost 30% of programs did not have specific musculoskeletal examination teaching in their general pediatric curriculums.
In 1996, Stirling and Landry10 reported that 83% of pediatric residency programs devoted <6 hours to SM-related lectures, and clinical instruction was <5 hours in 43% of programs. Our study shows similar shortcomings. Although 77% of programs offer SM lectures, 88% of pediatrics programs surveyed devoted <6 hours to SM-related lectures. Only 37% of programs included hands-on teaching as part of their curricula.
Lack of a Standardized SM Curriculum
One of the many reasons that SM education continues to be lacking in pediatric residency education may be that many programs do not have a formal, standardized SM curriculum. Despite both the Ambulatory Pediatric Association education guidelines,17,18 which suggest detailed structured educational goals for pertinent pediatric topics, and the current Residency Review Committee education guidelines,19 this study shows that SM curricula and standardization seem to be lacking in many programs. A recent study looking at SM education in internal medicine residency programs found this same lack of standardization.13
Improving SM Education in Pediatric Residency Programs
Although many studies have examined SM education in residency programs, few have commented on ways to improve it, which makes this study unique. Recognizing the need for general pediatricians to be able to diagnose and manage common sports problems in children and adolescents is paramount to any successful curriculum change. In this study, PL3s who took a PCSM rotation felt that their teaching of joint skills and orthopedic SM was greatly improved. A large percentage of PL3s not offered a PCSM elective were interested in taking a PCSM elective if one was available to them. This, however, is not necessarily a practical immediate solution to the problem in most pediatric programs. Although the field of pediatric SM continues to grow, only 86 US pediatricians have passed the SM Certificate of Added Qualification as of 200314 despite the large numbers of pediatricians handling sports issues every day.
Although the use of PCSM or orthopedic SM electives may enhance education, universal knowledge of the existence of these electives in pediatric programs is lacking. Response correlations between CRs and PL3s when asked if their programs offered these electives were poor, suggesting that there is not universal knowledge regarding the availability of PCSM or orthopedic SM rotations in pediatric residency programs. This lack of knowledge may contribute to the lack of SM education in pediatric residency programs.
One third of the programs surveyed in this study expressed interest in adding additional SM educational opportunities into their general pediatrics curriculum. The most popular methods discussed include adding lectures and a PCSM rotation. Although a majority of PL3s use the traditional, passive methods of lectures (82%) and reading (71%) to learn SM, hands-on teaching and patient experience were ranked as the most useful ways for them to improve their SM education. Also cited as valuable methods for learning SM were ED and adolescent medicine rotations, yet SM training in these areas has also been cited as lacking.20,21
Standardization of SM curricula is one way to provide basic education and teaching at all pediatric residency programs. Sweeny et al13 commented that internal medicine programs with a formal curriculum were 2.9 times more likely to offer any SM education experiences than those without a formal curriculum. Standardization would make sure that all residents were taught the basic components of SM necessary to practice general pediatrics, including concussion management, reasons for sports disqualifications, and musculoskeletal/joint examinations. Suggested curricula standardization by us would include formal teaching of the musculoskeletal examination including the PPE, highlighting commonly seen sports injuries. An emphasis would also be placed on the care and management of athletes with amenorrhea, asthma, cardiovascular issues, chest pain, chronic disease, concussions, eating disorders, hypertension, syncope, sports emergencies management, and teaching of reasons for medical disqualification. Knowledge of these teaching methods and opportunities needs to be universally recognized by program directors, CRs, and residents. Small-group musculoskeletal examination workshops and needs assessments have been successful SM teaching tools in previous studies.22,23 Hands-on teaching of examination skills may be a way to achieve standardization of some of the physical examination components required of physicians, although this requires additional study as well. Finally, teaching this standardized curriculum to current residents and attendings (general, adolescent, and emergency medicine pediatricians) who may lack the first-hand teaching and experience would help ensure future SM teaching in a variety of settings and specialties.
There are some limitations of this study that need to be considered when interpreting the data. The response rate for PL3s was low, although equivalent across program sizes. For this reason, no stratification of results by size or location was performed. Demographic data from this study, however, do match with national data regarding US pediatric residents, suggesting a representative sample of respondents.
Data regarding program curricula were gathered from the CR responses. Some may argue that residency directors may be better sources of information about curricula. However, as liaisons between administrators and residents, we felt that CRs should have a basic knowledge and understanding of the general pediatric educational opportunities and curricula at their institutions. CRs are likely to be the most accurate, timely, and knowledgeable in recognizing what opportunities their programs offer and where deficiencies occur, because they work with these issues on a daily basis.24
Finally, the validity of self-reported competencies is a debated area in the literature and a limitation that should be taken into account. Many studies support the idea that residents and medical practitioners rate their medical competencies lower than other professionals would rate them and therefore are not reliable at rating themselves.25,26 Having PL3s rate their sports and orthopedic training in comparison with other components of their training controlled some of this bias. PL3s rated musculoskeletal examination skills poorest, compared with other portions (HEENT, lung, cardiac, and abdomen) of the physical examination. Although PL3s may not be as deficient in examination skills as they may think, compared with other physical examination skills, the results show that orthopedic training continues to be lacking.
The growing sports participation rate of children and the large number of ED and primary care visits for sport-related injuries demonstrates the need for SM training for pediatricians. With recent emphasis on the importance of community-based primary care teaching, SM training and education evolves as a necessity that is required of most pediatricians regardless of what specialty they choose. There is a lack of SM training in many pediatric residency programs, and it seems that this has not improved over the past 10 to 15 years. With new residency guidelines restricting the number of resident work hours, there is not time to teach everything, so effective, efficient teaching must succeed. Standardized curricula focusing on hands-on teaching may be an effective way to improve SM education in pediatric residency programs.
This research was funded through grants from the University of Wisconsin Pediatric Research and Development Fund and the University of Wisconsin Sports Medicine Research Fund.
We thank Blaise Nemeth, MD, for his critique and suggestions regarding survey design, data interpretation, and manuscript review; and Jens Eickhoff, PhD, for statistical analysis.
- Accepted June 30, 2004.
- Address correspondence to Rebecca A. Demorest, MD, Department of Orthopaedics and Sports Medicine, Children’s National Medical Center, 111 Michigan Ave NW, Washington, DC 20010. E-mail:
No conflict of interest declared.
- ↵National Institutes of Health. Conference on Sports Injuries in Youth: Surveillance Strategies, 1991. Bethesda, MD: National Institutes of Health; 1992. NIH publication no. 93-3444
- ↵Hambridge SJ, Davidson AJ, Gonzales R. Epidemiology of pediatric injury–related primary care office visits in the United States. Pediatrics.2002;109 :559– 565
- ↵Ziv A, Boulet JR, Slap GB. Utilization of physician offices by adolescents in the United States. Pediatrics.1999;104 :35– 41
- ↵Eckler SJ, Shrier I, Lebrun CM. Review of musculoskeletal curricula in Canadian medical schools [abstract]. Clin J Sport Med.2003;13 :381
- Roberts KB, Starr S, DeWitt TG. The University of Massachusetts Medical Center office-based continuity experience: are we preparing pediatrics residents for primary care practice? Pediatrics.100(4) . Available at: www.pediatrics.org/cgi/content/full/100/4/e2
- ↵Sweeney CL, Davidson M, Melgar T, Patel D, Cucos D. The current status of sports medicine training in the United States internal medicine residency programs. Br J Sports Med.2003;37 :219– 225
- ↵American Board of Pediatrics. 2003–2004 workforce data. Available at www.abp.org/stats/wrkfrc/menu1.htm. Accessed October 7, 2004
- ↵Ambulatory Pediatric Association. Update on the APA educational guidelines revision project. Available at: www.ambpeds.org/guidelines/index.cfm. Accessed January 1, 2004
- ↵Ambulatory Pediatric Association. Proposed 2004 educational guidelines for residency training in general. Available at: www.ambpeds.org/egweb. Accessed January 1, 2004
- ↵Accreditation Council for Graduate Medical Education. Programs requirements for residency education. Available at: www.acgme.org. Accessed December 1, 2003
- ↵Emans SJ, Bravender T, Knight J, et al. Adolescent medicine training in pediatric residency programs: are we doing a good job? Pediatrics.1998;102 :588– 595
- ↵Hergenroeder AC, Chorley JN, Laufman L, Fetterhoff AC. Pediatric residents' performance of ankle and knee examination after an educational intervention. Pediatrics.2001;107(4) . Available at: www.pediatrics.org/cgi/content/full/107/4/e52
- Copyright © 2005 by the American Academy of Pediatrics