Mar 9, 2016
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Amy Hollingworth

As the athletic training profession works to boost its profile, a key player could be residencies. The one at the New Hampshire Musculoskeletal Institute combines mentoring, hands-on experience, and research.

This article appeared in the March 2016 issue of Training and Conditioning.

Armed with a bachelor’s degree and BOC certification, many young athletic training professionals will look to their futures and wonder: what’s next? Some will decide to head straight into entry-level work, while others will pursue an advanced degree. However, another opportunity that should be on their radar is entering an athletic training residency.

Consider this: In the 2012 document, “Future Directions in Athletic Training Education,” the NATA Executive Committee for Education advised the Board of Directors to “encourage the development of residencies, specializations, and specialty certifications to provide career advancement and skill development specifically related to athletic training clinical practice.” The Executive Committee believed residencies could push the profession in a more specialized direction, thereby providing athletic trainers with more expertise and redefining their career paths. Residencies could also serve as attractive alternatives to entry-level work.

So what are athletic training residencies and what do they accomplish? The Commission on Accreditation of Athletic Training Education (CAATE) says the purpose of residencies is “to provide advanced preparation of athletic training practitioners through a planned program of clinical and didactic education in specialized content areas.” They typically last a year and must fulfill six “core competencies” set by the CAATE, including patient-centered care, interdisciplinary collaboration, evidence-based practice, quality improvement, health care informatics, and professionalism.

The New Hampshire Musculoskeletal Institute (NHMI), located in Manchester, N.H., runs the oldest athletic training residency in the country. Originally founded in 1993 as a fellowship, our Integrated Clinical Sports Medicine Residency (ICSMR) became the first CAATE-accredited residency in 2013 and today is still one of only two in the country.

Over more than 20 years, we have seen the impact residencies can have on the profession. By providing a unique blend of didactic instruction, interdisciplinary interaction, and clinical autonomy, residencies develop more knowledgeable and well-rounded athletic trainers.

NUTS AND BOLTS

NHMI is made up of professional development and clinical arms. We provide symposia, workshops, and courses to medical professionals in the area to advance their knowledge in sports medicine. And through our Safe Sports Network, a sports medicine outreach and education initiative, we are able to provide athletic training care for local athletes. With didactic and clinical components, the ICSMR gels with both of these objectives.

The goal of the ICSMR is to give athletic trainers an educational experience that will serve as the foundation for their future practice. To achieve this, residents observe and work with numerous health care professionals throughout the program.

The foundation of the ICSMR is our clinical rotations. Athletic trainers in the field deal with much more than musculoskeletal injuries, so our residents develop a knowledge base in many areas of medicine. In this way, our specialty is analogous to that of primary care physicians. With that in mind, the rotations build skills that help our athletic trainers master clinical evaluation and diagnosis.

I serve as the residency program director. The residency has approximately 20 preceptors, who educate the residents in clinical practice. Most preceptors are medical professionals within the community, and they volunteer their time to teach in our program.

Up until 2000, we only accepted one resident annually. However, we had so many strong candidates that we explored the possibility of adding another. We reached out to our existing preceptors and approached other area clinicians to see if they would be willing to give their time to educate a second resident. The response was overwhelmingly positive, so we were able to expand.

The typical ICSMR candidate has achieved considerable academic success and wants to make an impact on the profession. They are intrinsically motivated, reliable, responsible, adaptable, and independent learners filled with intense curiosity. The most successful residents exhibit a passion for learning and possess strong critical thinking and leadership skills.

Our program generally receives 30 to 40 applications each year, and they’ve come from many states and three different countries. Applicants must be BOC certified and licensed to practice in New Hampshire by the start of the residency year. Most have completed only undergraduate work, but we’ve had several with master’s degrees, as well. A valid driver’s license, car, and proof of car insurance are also necessary.

Since the ICSMR is part of a nonprofit organization funded by donations, residents do not pay any tuition. They are offered housing in a small Manchester apartment with all basic utilities, and we provide a monthly stipend and health insurance. Upon completion of the ICSMR, they receive 20 continuing education credits for evidence-based practice.

Most of our alumni have gone on to work full time in the health care field as athletic trainers, physician assistants, and physicians. Several have completed or are currently pursuing advanced degrees.

COVERING ALL DISCIPLINES

The ICSMR requires more than 50 hours of committed time per week. Those hours are split between didactic instruction and clinical work.

Residents have two 90-minute didactic learning sessions with me each week. Our curriculum is designed to improve their ability to make differential diagnoses using an interactive approach. Some of the specific didactic activities we do together include:

Problem-based learning: This type of instruction uses clinical cases and role-playing to develop and improve the residents’ ability to diagnose based on the signs, symptoms, and history presented by the injured athlete.

Grand rounds: Residents report on interesting cases they see either in rotations or during their clinical work. They share the demographic and medical history of the patient, identify anything unusual about the injury, and detail medical management of the condition.

Practice briefs presentations: With my guidance, residents select a general medical condition and perform a literature review to identify its most important aspects. They then disseminate this information to athletic trainers within our NHMI network, who use it to improve their clinical practice.

Journal club: This is a group of NHMI clinicians who meet regularly to critically evaluate recent articles in the academic literature. An article is selected before we meet, and the residents and preceptors read and prepare a review of it to share with the other members of the group.

Our didactic program also includes 28 one-to-two week clinical rotations that typically run from 8 a.m. to 12 p.m., Monday through Friday. Each occurs in conjunction with a preceptor who is a specialist within his or her discipline.

Most of the rotations are accompanied by three web-based lessons. These highlight the educational requirements, salaries, and professional work settings for each specialty. Basic anatomy review and information about specific conditions are included, as well as elements of evidence-based practice.

Although much of athletic training is musculoskeletal, our general medical focus means that residents are exposed to numerous non-orthopedic settings, as well. Residents actually spend more than half of their time in non-orthopedic rotations, including primary care and general medical, emergency care, cardiac surgery, neurology, neurosurgery, ophthalmology, dermatology, and complementary alternative medicine. In each environment, they observe the preceptors during office hours and occasionally on hospital rounds.

On the orthopedic side, residents spend a week or two with six different orthopedic surgeons and two orthopedic physician assistants. The reason for this variety is so they can witness many different styles for providing care and performing a history. Each surgeon or physician assistant has their own way of interacting with patients, and residents can utilize bits from each one to develop their own approach.

The final didactic element of the ICSMR is a yearlong research project. Past residents’ investigations have looked into topics such as joint hypermobility, hamstring stretching, and emergency management of football equipment.

These projects include everything from literature review through question/methods development, institutional review board approval, data collection and interpretation, abstract and manuscript submission, and abstract presentation. We added this component to the residency to form athletic trainers who are capable of critically assessing research as consumers.

For the ICSMR’s clinical component, residents spend every afternoon working directly with athletes. They serve as athletic trainers at a local high school and cover the free drop-in injury clinic run by the NHMI Safe Sports Network.

In the high school setting, the residents are the only athletic trainers on campus, so they are able to practice autonomously. I stop in occasionally to observe and support them, but they are in charge.

Our partnership with the local high school has been very successful. The residents, although inexperienced, are very knowledgeable and possess strong critical thinking skills. Coupled with the continued learning they receive during our didactic sessions, they are able to provide a high level of care.

WORTHWHILE ENDEAVOR

Despite the NATA’s support for the continued growth of athletic training residencies, some still question their worth. One of the most frequent questions I’m asked is: “What can a residency provide that an athletic trainer can’t get from an entry-level position or graduate degree program?”

The biggest difference between residencies and other post-undergrad options is the high degree of hands-on experience available in programs like ours. In testimonial after testimonial, past ICSMR participants have noted that actually seeing how specialists manage conditions advanced their skills immeasurably. It’s one thing to read about cardiac issues during coursework, but only in a residency will athletic trainers have the chance to observe an open-heart surgery.

Being exposed to many evaluations of the same injury helps solidify residents’ diagnostic skills, as well. For instance, an athletic trainer in an entry-level position at a high school may see one or two ACL tears in a year. Yet, with our orthopedic rotations, residents are exposed to numerous ACL tears, helping to improve their recognition and diagnosis of these injuries in the future.

In terms of how they differ from traditional graduate programs, residencies tend to include less classroom time and more autonomous clinical experience. Our residency in particular exposes the young athletic trainer to multiple aspects of medicine beyond the traditional musculoskeletal setting.

We do this through our non-orthopedic rotations. Some are not directly related to athletic trainers’ daily tasks, but they are included because of the liaison aspect of the profession. Although athletic trainers in the field will never administer or interpret diagnostic imaging, our residents spend a week in the radiology department at a local hospital. The knowledge gained will come in handy when they have to explain contrast MRIs to injured athletes.

Similarly, our rotations in the primary care setting help residents become more familiar with the surrounding network of physicians, including knowing when and where to refer patients. And residents observe in chiropractic and acupuncture clinics to learn about alternative therapies that are available to athletes.

Finally, residencies allow more opportunities to work with other medical professionals. The interdisciplinary interaction in the traditional academic setting is usually limited to a team physician, while the athletic trainer in an entry-level position is often the only health care provider in his or her facility. Residencies are frequently structured around clinical settings, so participants come into contact with various medical professionals on a daily basis.

EXPANDING THE IDEA

While official residencies are structured programs, all athletic trainers can incorporate certain elements of their curriculum. To start, adopt a mindset of life-long learning. Actively reflecting on a daily basis and pulling out the important nuggets from every situation can help you grow personally and professionally.

For instance, host journal clubs with colleagues to keep up with current literature and best practices within the profession. In addition, searching for, creating, and sharing your own problem-based learning cases with your staff can help hone everyone’s history, physical exam, and differential diagnostic skills.

Going forward, residencies will have a strong place in the future of athletic training. As the educational priorities shift and the profession becomes more specialized, the need for the real-world experience provided in a residency will only increase.

OFFICIAL BUSINESS

The Commission on Accreditation of Athletic Training Education (CAATE) started issuing accreditations for athletic training residencies in 2013. Since then, only two in the country have been accredited-the Integrated Clinical Sports Medicine Residency (ICSMR) at the New Hampshire Musculoskeletal Institute (NHMI) and a program at Texas Health Ben Hogan Sports Medicine. However, many other residencies are in the process of growing our ranks.

Getting accredited is a peer review process designed to ensure quality and accountability. There are three main steps. First, you must submit a self-evaluation and self-study report of your program to the CAATE. Next, the CAATE review committee will conduct a site visit and then make their recommendation to the CAATE, which has the final say regarding accreditation. Once you are accredited, you must regularly evaluate and report your growth to the CAATE in order to remain in good standing.

At the NHMI, we pursued accreditation for the ICSMR as soon as it became available. It took about a year to go from beginning our self-study to having our site visit. Our accreditation came a few months after that.

It was an easy decision to pursue accreditation. Several instances over the years had shown us that our residency was not perceived as representing a true educational experience. We were being painted with the same brush as many “internship” programs that were really just a substitute for cheap labor. Considering the thought and effort that has always gone into our curriculum, having external affirmation of our residency was important to us.


Amy Hollingworth, ATC, LAT, RN, is Director of the Integrated Clinical Sports Medicine Residency and coordinates the Safe Sports Network at the New Hampshire Musculoskeletal Institute. She served on the New Hampshire Athletic Trainers Governing Board from 2007 to 2013. She can be reached at: [email protected].


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