Profile of Sport and Exercise Physician trainee’s clinical practice within Australasia in 2019: a cross-sectional study

Participants and program

All Australasian College of Sport and Exercise Physician (ACSEP) trainees undertaking full-time training in training period 2 of the 2019 training year (1 August 2019−31 January 2020) were invited to participate in this study. Full-time training was classified using ACSEP’s definition of a minimum of 36 hours per week in approved clinical training environments, for 48 weeks per year. Participation required trainees to provide the researchers access to their deidentified logbook from training period 2, 2019 (n=71). Exclusion criteria were trainees undertaking part-time study, and new fellows who completed their fellowship exams in 2019.

During the ACSEP training programme, Sport and Exercise Physician trainees are required to submit a patient logbook every 6 months as a record of daily clinical encounters. The logbooks provide the raw data of Sport and Exercise Physician trainee patients. Data collected in the logbook include patient age, gender, age bracket (child 0–9, youth 10–17, adults 18–65 and older adult 65+), musculoskeletal injury zone or medical category treated and new or follow-up consultations. The logbooks do not record any data on athletes seen as part of sporting team coverage.

Data collection

Patient and public involvement

Patients and the public were not directly involved in this research. This research was solely conducted on consenting ACSEP trainees, with permission to use their patient demographic logbook, which did not contain any identifying information.

Data analysis

Data were inputted into Microsoft Excel (Microsoft Office 365 V.2020), then exported to SPSS V.28. Descriptive statistics were generated for each of the demographic and logbook items. Inferential statistics were used to explore differences and associations between demographic and clinical variables.

The patients

Data were collected for 8709 patients in the 6-month data period. Adult-aged patients were the largest patient group (78.2%, n=6808) with New Zealand trainees seeing a slightly higher percentage (75.5%, AU; 83.9%, NZ) (table 1). Patient gender breakdown showed 50.3% of patients identifying as men, 44.5% as women and 5.2% identified as neither or was not available from the logbook. There were similar numbers of new consultations (47.5%) compared with review consultations (52.1%) (figure 1).

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The most common presenting anatomical regions were knees (18.7%), ankles (17%) and the thoracic and lumbar spine (13.1%) (supplemental digital content figure 2). The percentage of knee and ankle presentations was similar between Australian and New Zealand participants (knee—17.1% and 22.1%; ankle—18.5% and 13.8%). However, there appeared to be a significantly higher percentage of thoracic and lumbar spine consultations by New Zealand participants (17.8%) compared with Australian participants (10.9%). Shoulder complaints made up 9.7% of Australian participants’ presentations but 18% of New Zealand participants’ presentation. The remaining 51% of presentations were broad and included a wide range of body regions, including hip (8.5%), thigh (4.4%), head (4%) and both wrist and elbow (3.5%).

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Of the 0–9-year age group, the most common anatomical region of complaint was the foot/ankle (13, 39.4%). For the 10–17-year age group, back (thoracic/lumbar spine) complaints (201, 17.7%) and foot/ankle complaints (195, 17.1%) were the most common, whereas for the senior age group (66 years and above) hip/groin (146, 21.0%) and knee (141, 20.34%) were the most common.

There were few medical reports reported as primary presentations to Sport and Exercise Physician trainee participants (online supplemental appendix 1).

The trainees

The ACSEP had 71 trainees in Australia and New Zealand in term 2, 2019, Fifty-four (76%) were located in Australia and 17 (24%) were located in New Zealand. Twenty trainees from years 1–5+ participated in this study with 16 training in Australia (80%) and 4 in New Zealand (20%). This represented a total of 28.2% of all the 71 trainees in Australia and New Zealand in training period 2, 2019. Most participants in this study were male trainees (14, 87%) in Australia, including a higher number of participants in years 1 and 2 of training (75%) compared with years 3 and above (see table 2).

Almost half the participants (42.1%) reported spending 4 days a week in private practice clinics; 31.6% reported working 5 days in private practice clinics and the remaining 26.3% spending only 3 days a week in private clinics. This variance was largely due to the training activities reported by Australian participants. Only Australian participants spent training time in activities other than private practice clinics or sporting team coverage. Ten Australian participants (67%) spent at least 1 day per week undertaking surgical assisting, two (13.3%) spent at least 1 day in an emergency department and one (6.7%) spent a day in general practice. Most participants in both countries spent 1 day per week with a sporting team (73.7%) with one trainee (5.3%) spending 2 days a week with a sporting team (online supplemental appendix 2).

The average number of patients seen in clinic per week by participants was 20, with some variation across year levels (this was calculated on the 26-week training period, whereby 2 weeks annual leave within the 26-week term was assumed) (table 3). New Zealand trainees3 accumulated 2750 patient consults (31.5%), whereas Australian trainees13 had 5959 patient consults (68.5%) (table 4).

The trainees

The overall response rate for this study was 28.1%, close to reported rates of 35% for medical specialty surveys,14 and similar across both countries. The sample size did not allow for subanalysis.

There appeared to be jurisdictional differences in the data—New Zealand trainees spent their training time exclusively in primary-care clinics or with sporting teams. This is reflected in the total number of patient consults per country, where Australian trainees made up 80% of respondents to the study, they only consisted of 68.5% of total patient consults (5959). This is compared with New Zealand trainees who comprised only 20% of respondents, however consisted of 31.5% of total patient consults (2750) (table 4). One-third of Australian trainees reported spending at least 1 day in a week in other clinical activities including surgical assisting, general practice and emergency medicine. This difference is likely related to the funding models of the training programmes in the respective countries. New Zealand trainees are paid a contract salary via the Accident Compensation Commission or via their clinic. They receive a yearly salary and are not reimbursed for specific patient encounters, while the majority of Australian colleagues work as subcontractors within their clinic and were paid on a fee-for-service basis with their income dependent on the number of patients consulted (the exception to this being a limited number of regional funded positions and sporting institute placements). (The only exception is Australian trainees on rural health workforce grants who were paid a salary by the government (the logbook data did not capture whether trainees were part of this scheme).) In addition, the limited government rebates for consultations with Australian Sport and Exercise Physicians trainees (typically $38AUD for initial consults and $21AUD for review consults) lead to high out-of-pocket costs for patients. This has two potential ramifications for Australian trainees. First, it may limit patient ability to have repeat consultations, which as a result may affect the trainee’s patient load and exposure. This may account for trainees work in non-sport and exercise medicine areas such as surgical assisting to sustain their income. This could potentially explain the higher percentage of patient consults (31%) by New Zealand trainees as a proportion of total New Zealand participants (20%). The reasons for participating in other clinical activities as part of training require additional research. Whether these additional activites places Australian or New Zealand trainees at an advantage/disadvantage requires further investigation. Potentially, having continued experience in orthopaedic assisting may be useful for a Sport and Exercise Physician. It is unclear, however, whether this is outweighed by the increased face to face patient exposure in clinics, and financial stability that New Zealand trainees may receive.

The reported number of patients seen may also have an impact on training experience. Data from the logbooks suggest Australasian Sport and Exercise Physician trainees only consulted with 16–20 patients per week in their in-clinic caseload. Hours supervised by an ACSEP supervisor is the main training requirement set out by the college, not patient numbers. (First year trainees are required to work in a Sport and Exercise Medicine (SEM) clinic supervised by a specialist SEP for 20 hours a week, which averages out to only 0.8 SEM patients per hour. In second year, the SEP trainee must spend 14 hours in SEM clinic, and in 3+ they must spend at least 8 hours in SEM clinic.) However, the fee-for-service nature of Australian trainees may pose an issue. A trainee can meet the mandated supervised training hours and consult with few patients leading them to seek clinical opportunities to supplement their income. The fee issue highlighted above raises significant questions about the viability of the current funding model in Australia and whether this impacts the quality of training remains an open question.

As stated by Gamage et al, Sport and Exercise Physician consultations are long, with the average initial consult being 40 min duration. While this study did not record consultation length, it can be surmised that trainees like SEP Physicians are also conducting long consults. In Australia, the government rebates patients receive for such consult is only $38AUD. This is significantly less than the equivalent GP Registrar rebates for the same-length consult of $117.40AUD. Similarly, a review consult of between 20 and 30 min is rebated only $21, whereas the equivalent length GP registrar consult constitutes a $79.70AUD rebate. While this study did not examine consultation fees for trainees, fees for service are considerably higher than the government rebates, with a considerable difference between Sport and Exercise trainees and GP trainee rebates, leading to high out of pocket fees for patients.

The patients

Logbook data revealed most Sport & Exercise Medicine patients treated in the timeframe were adults from 18 to 65 years. This is a broad age category collected through the logbook options for selecting patient age and unfortunately does not allow for further breakdown into subgroups or discussion. (This finding has led to a recommendation to ACSEP to refine the age categories in the logbook to better capture this data in the future.) More granular data were available for the child, adolescent and older adult populations. Foot and ankle injuries were the most common injuries seen in children and adolescents. This is consistent with what has been observed in Australasia, with patient’s younger than 18-year old’s being the most likely age group to injure their ankles.13 Older adults presented most with hip and knee complaints. Hips and knees are two of the joints most commonly impacted by osteoarthritis, so this is a likely explanation for this finding.15 Over 20% of the patients seen by participants were under the age of 18 years (13.5%) or in the older age-group (8%). Both age groups have unique age-specific pathology ranging from developmental in the paediatric population to systemic, lifestyle-related and degenerative in the older population. What is not clear from the current data is the diagnosis of the complaints affecting these body regions. This data would be helpful for future work to understand why these populations are seeking care from a Sport and Exercise Physician trainee.

The proportion of younger age group patients seen by trainees is relatively proportionate with the Australian population.16 As highlighted by Freed, Spike,17 training programmes need to include specific content related to paediatric care to ensure future specialists are equipped to manage this population. The proportion of older adults seen by trainees was less than what is seen in general practice,17 however higher than may have been assumed with nearly 1 in 10 patients seen by Sport and Exercise Physician trainees being 65 or older. It may be helpful to assess whether this is proportionately reflected in the curriculum, including things such as mandatory coverage of masters sporting events. The skills Sport and Exercise Physicians have developed in athlete management is largely an integrative wellness model as opposed to a reductive ‘disease’ model, and, therefore, Sport and Exercise Physicians can play an important role in the broader healthcare setting in chronic disease prevention.18 19 This may influence current referral habits from both GPs, other specialists and allied health practitioners. Broader distribution of these figures may lead to a larger number of referrals to Sport and Exercise Physicians not only for paediatric or older adults but also for non-sporting-related musculoskeletal conditions. The range of age-groups represented challenges potential perceptions in the community that Sport and Exercise Physicians treat young elite athletes and suggests that the specialty is providing a broad role in the general community with conditions not isolated to sport.18

There were slight regional differences observed in conditions treated. New Zealand trainees also saw almost double the number of shoulder injuries than Australian trainees. While this may be due to the small sample size, another explanation may be the different sports played in each country. Lower limb injuries including hamstring strain and ACL injuries are the most common injuries in professional Australian Football (a sport not played in New Zealand), with shoulder injuries being the third most common injury.20 There is conflicting data on shoulder injury prevalence in professional rugby league and rugby union, with shoulder injuries being reported as the most common injury zone representing 28% of all injuries21 with other studies showing their prevalence at 9.3% behind lower limb injuries at 57.1% in Australian professional Super rugby players.22 This observed difference may be partly due to different playing surfaces with a hotter and drier climate in Australia, which has been associated with higher rates of ACL injuries.23

Consultations by participants with patients were approximately a 1.1:1 return/new patient consultation ratio and this ratio increased for New Zealand trainees to 1.3:1. This observation suggests that trainees are likely following up patients for a single subsequent consultation only. Whether this reflects the low complexity or more acute presentations require additional investigation.

Limitations

The primary limitation of the current study is the data available for extraction from trainee logbooks. Australasian Sport and Exercise Physician trainee logbooks were designed for an educational purpose rather than an evaluative one. Subsequently, there are gaps in the data, which could provide greater clarity around patient presentations. The retrospective nature of the current work means that only data included in the logbooks could be drawn on. The small sample size, notably from New Zealand trainees and the spread of trainees, involved was another limitation and may lead to only limited conclusions to be drawn from the data. Reasons for non-participation in this study are likely to include logistical issues with signing, printing and returning consent forms. Unfortunately, participants were required to manually fill out consent forms, and return them to the researchers, which is likely to have led to many trainees not prioritising the study. However, the demographics of the group suggest that this is a representative sample of both the Australian and New Zealand trainees. The strengths of this study are that it is the first comprehensive review of the work patterns of Sport and Exercise Physician trainees in Australasia.