PM&R Fellowships in Sports and Musculoskeletal Medicine: Gateways to Deep Experiential Learning

During his year as a sports medicine fellow with Cleveland Clinic’s Department of Physical Medicine and Rehabilitation (PM&R), Yogen Patel, DO, worked with athletes ranging from high school students to professionals. One of his most memorable experiences came last winter, when he cared for a top college swimmer who had chest pain.

“With the help of the athletic training staff, physical therapists and physicians from multiple specialties — including sports cardiology and pulmonology — we were able to return the swimmer back to sport within two weeks,” says Dr. Patel. Soon after, the athlete won a relay event in the league championship.

Multidisciplinary to the core

Multidisciplinary collaboration to treat a variety of patients is one of the highlights of Cleveland Clinic’s sports medicine and musculoskeletal medicine fellowships. Cleveland Clinic offers three sports medicine fellowships each year, one of which is reserved for PM&R. Five years ago, Cleveland Clinic began offering one musculoskeletal medicine fellowship per year to meet increasing demands for musculoskeletal care, particularly in PM&R.

“The opportunity to work alongside other disciplines is one of various aspects of the training program that definitely sets Cleveland Clinic apart from many other programs,” says Mary Apiafi, MD, who was a PM&R sports medicine fellow in 2016-17. “Getting first-hand learning from world-renowned experts in so many fields affords trainees breadth and depth of experience. It gave me confidence going into practice as a new graduate.”

Preparing the rising number of PM&R sports med physicians

Cleveland Clinic added a PM&R sports medicine fellowship in orthopaedic sports health a decade ago. “There are a lot of avenues you can take in sports medicine, including family medicine, internal medicine, pediatrics and emergency medicine,” says sports medicine and PM&R physician Carly Day, MD. “PM&R represents a growing proportion of the physicians going into sports medicine.” Among her many roles, Dr. Day is a member of the fellowship faculty at Cleveland Clinic, a board member of the American Medical Society for Sports Medicine, a team physician with the U.S. Soccer Women’s National Team and head primary care team physician at Notre Dame College in suburban Cleveland.

During their 12-month stint, PM&R sports medicine fellows work alongside surgical and nonsurgical sports medicine physicians. They complete rotations with hand and upper extremity specialists, foot and ankle specialists, orthopaedic surgeons, radiologists and cardiologists. Fellows participate in a continuity clinic, spending a half-day each week with a sports medicine physician and another half-day with physiatrist Michael Schaefer, MD, program director of the musculoskeletal medicine fellowship.

On-field experience is also a prime focus, with fellows assigned to one local high school and college. They work in training rooms with athletes and attend all football games, as well as other sporting events. “We expect fellows to train for and be able to manage anything that happens on the sidelines, whether it’s minor or a catastrophic event,” says Dr. Day. At the beginning of the year, fellows participate in a catastrophic sports injury simulation to practice on emergencies such as spine boarding for cervical injuries and sideline defibrillator use.

In addition, the PM&R sports medicine fellow joins family practice colleagues, the musculoskeletal medicine fellow and musculoskeletal radiology fellows in robust ultrasound training. “There’s a lot of interdisciplinary fellow-to-fellow education,” observes Dr. Schaefer.

Training for nonsurgical musculoskeletal care

The musculoskeletal medicine fellowship began five years ago. “It’s a fairly distinctive fellowship that focuses on nonsurgical, orthopaedic musculoskeletal care,” says Dr. Schaefer. “It fills the gap between traditional sports medicine and traditional pain management fellowships.”

New to the program is the continuity clinic, where fellows spend a half-day with Dr. Schaefer in clinic, which benefits them and provides access to patients. The musculoskeletal fellow also has rotations in several subspecialties, including hand and upper extremities, the foot and ankle clinic, spine and spine interventions, physical therapy, occupational therapy, rheumatology and joint replacement. Fellows also observe orthopaedic surgeons in the OR.

Spending time with subspecialists is invaluable, says Dr. Schaefer. For instance, last year the musculoskeletal medicine fellow had a multidisciplinary care experience in Cleveland Clinic’s Arthritis & Musculoskeletal Center. A patient with rheumatoid arthritis who had a childhood upper extremity amputation developed carpal tunnel symptoms in her remaining hand. Protective of that hand, the patient was reluctant to have corticosteroid injections. Working together, the fellow and rheumatologist convinced the patient she could safely undergo carpal tunnel injection with ultrasound guidance. The fellow also recommended occupational therapy to reduce overuse of the hand.

Ready for life after fellowship

Sports medicine and musculoskeletal medicine fellows in PM&R work hand-in-hand with peers, attending physicians and residents, including those in Cleveland Clinic’s three-year PM&R residency program, launched in 2016 and directed by John Lee, MD. This teamwork, combined with a rigorous curriculum and hands-on experience, provides benefits that extend well beyond the fellowship.

“The depth of faculty, the intense nature of the curriculum and the opportunities afforded prepare you for life after fellowship,” says Dr. Apiafi, who now works in PM&R/sports medicine at Community Howard Regional Health in Kokomo, Indiana. “What I found most valuable about my time at Cleveland Clinic was the sense of growth after every rotation. I realize how far I’ve come.”