











































MANUSCRIPT TYPE


CLINICIAN EXPERTISE COMMENTARY 

 

33 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018 
 

Specialization in Athletic Training: A Natural Evolution  
JJ Wetherington, MS, ATC, OTC 
St. Luke’s Sports Medicine, Boise, ID 
 

 
Key Phrases 
Emerging settings, organizational and personal outcomes, 
public health, residency, advanced practice 
 
Correspondence 
Mr. JJ Wetherington, St. Luke’s Sports Medicine, 600 Robbins 
Road Suite 401, Boise, ID 83709 
E-mail: jjwetherington@gmail.com 
Twitter: @JJ_ATC 
 
Full Citation 
Wetherington J. Specialization in athletic training: A natural 
evolution. Clin Pract Athl Train. 2018;1(1):33-36.  
https://doi.org/10.31622/2018/0001.7 

Submitted: May 4, 2018 Accepted: May 29, 2018 
 
COMMENTARY 
 
The skill set of the athletic trainer, like the skills of 
other allied health professionals, has evolved to 
match the changing demands of patient 
populations. As the skill set of the athletic trainer 
has grown, so has the settings that this skill set has 
been utilized. No longer are athletic trainers only 
recognizable in the interscholastic and 
professional sports arenas. The value of the 
athletic trainers’ skillset has resulted in the 
proliferation of the profession into settings such as 
physician practice, industrial, public safety, 
military, and research. As the practice of athletic 
training has evolved to meet these growing 
workplace demands, some individuals have 
developed specialized skills and knowledge that 
has allowed them to thrive in these emerging 
settings.  
Specialization was first recognized by Adam 
Smith and immortalized in his seminal publication 
The Wealth of Nations.1 As with the labor sector, 
specialization in medicine has characterized 
progression for nearly two decades.2 The catalyst 
for specialization in medicine can be traced to the 
publication of the, 1910 Flexner Report. After this 
report healthcare delivery, specifically medical 
education, radically changed.3 Flexner’s call for 
educational reform emphasized more 
research/evidence-based education and 
advocated for the pursuit of greater knowledge.3 
As practitioners devoted their intellectual 
endeavors to furthering their understanding about 

increasingly narrower topics, practitioners started 
to differentiate themselves into specific areas of 
expertise or focus which led them to dedicate their 
time in training to those specific areas.2 The first 
medical specialty to create its own assessment 
board was ophthalmology in 1917.2 In 1933, the 
four specialties of dermatology, obstetrics and 
gynecology, otolaryngology, and ophthalmology 
created a federation called the American Board 
of Medical Specialties (ABMS). Because of the 
emergence of these specialties, a national system 
of standards was created for recognizing 
specialists and providing information to the public. 
By 1970, there were 20 specialties. With the most 
recent addition of Genetics and Genomics in 
1991; there are currently 24 specialties 
recognized by the ABMS.4 Specialization is not 
exclusive to physicians, but also evolved in 
physical therapy, occupational therapy, and 
nursing. No matter the profession, specialization in 
medicine is driven primarily by 3 factors: 
innovation in medical science and technology, 
professional preferences, and economic 
considerations.5 
 
Education 
 
Innovation in medicine is correlated to increasing 
knowledge about a particular field.6 As 
knowledge increases, advancements in technology 
inevitably follow, which leads to more complex 
technological skills and intellectual competencies 
among practitioners.6 Increases in knowledge 
place new and major burdens on professional-
level preparation which can neither teach all the 
new information, nor quickly revise curricula to 
exclude the outdated information.6 To ensure that 
all this new knowledge is included, professional 
programs must sacrifice depth. What results is a 
generalist preparation, which often requires those 
passionate few who choose to devote their 
intellectual energies to understanding specific 
areas of this new knowledge base to seek post-
professional education to develop specialized 
expertise.    
The profession of athletic training, similar to other 
professions in medicine, has struggled to balance 

https://doi.org/10.31622/2018/0001.7


Specialization in Athletic Training: A Natural Evolution 

 

 

34 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

and evolve educational system to meet the 
growing knowledge base in our field.  Athletic 
training education and accreditation of athletic 
training programs progressed from being 
controlled by the member organization of the 
National Athletic Trainers’ Association (NATA) to 
being independently run by the Commission on 
Accreditation of Athletic Training Education 
(CAATE). Along with structural changes, the way 
that education was delivered has radically 
changed over that period.7 Athletic training 
evolved from an internship driven-model to a 
curriculum-driven model. Most recently, the CAATE 
announced that by 2022 professional programs 
must transition to the master’s level. The 
educational elevation has inspired an expansion 
in the breadth of the practice of athletic training. 
Expanding education is truly the only way to 
widen scope and demonstrate in a practice 
analysis that this new knowledge base includes the 
responsibilities required of the profession. A 
worry of some surrounding the change in 
professional degree requirements is that the 
education for athletic training is becoming too 
watered down and athletic trainers are lacking 
depth in their entry-level knowledge base. This is 
a common worry amongst the athletic training 
community and is also a concern for other medical 
professions. For example, this was also a fear of 
general practitioners, as their knowledge base 
has widened considerably since its creation. As 
more and more athletic trainers advance their 
practice into new and narrower fields, the 
knowledge base that athletic trainers are 
expected to know is reaching a critical mass. This 
increase in knowledge base is placing an 
increased burden on athletic training educators to 
teach all the new knowledge without sacrificing 
depth. As educators spend the majority of their 
time in the classroom with students teaching the 
expanding scope of practice, there is even less 
time for them to clinically practice and evolve their 
own skills. The lack of time for educators makes it 
even more difficult for them to teach and provide 
meaningful experience-based mentorship for their 
students. This tipping point has happened in other 
professions and resulted in the creation of 
formalized specialist training to further clinical 
skill sets.  
 
Along with the athletic training educational 
requirements changing, so is the practice of 

athletic training. Athletic trainers are not only 
increasing their knowledge base and clinical 
practice skill set, they have expanded their 
footprint into settings outside of the interscholastic 
and professional sports arenas. This expansion of 
practice into new arenas has required athletic 
trainers to deepen their current skill set, as well as 
develop new skills. These new skills are not 
transferrable to all athletic training practice. 
Residencies organically developed to meet the 
need for athletic trainers to deepen their current 
skills, and learn new skills to help them thrive. The 
residency model is well known in medicine and is 
intended to build upon the generalist education 
that all receive. The CAATE, recognizing the 
growing trend in specialized training, developed 
standards for residency programs to ensure that 
students were receiving advanced preparation 
through a planned program of clinical and 
didactic education in specialized content areas. 
The CAATE has initially recognized eight specialty 
areas: prevention & wellness, urgent & emergent 
care, primary care, orthopedics, rehabilitation, 
behavioral health, pediatrics, and performance 
enhancement.7 The CAATE has acknowledged that 
this list is not all encompassing, and has laid out 
steps to propose new specialties areas as they 
arise. These are all great steps for our the 
profession that will continue to help the profession 
advance.  
 
Specializations may narrow even further, or occur 
when specialties are combined to develop 
subspecialties (e.g., pediatric neurology).6 As 
subspecialties develop, so will the need for 
training through fellowships training. The 
fellowship is seen in medicine, and is intended to 
deepen a practitioner’s focus on a specific topic 
to the level of content expert. Athletic training has 
not reached this point yet, but it is not too far off 
in the future. Similar to physicians, athletic trainers 
are starting to subspecialize by patient 
population or body part. In orthopedics alone 
there are athletic trainers who have 
subspecialized their practice to pediatrics, 
trauma, total joint and adult reconstruction, foot 
and ankle, spine, hand, and/or upper extremity. 
These ground breaking athletic trainers will be the 
ones to foster the growth of fellowship training in 
the field of athletic training.  
Professional Practice 



Specialization in Athletic Training: A Natural Evolution 

 

 

35 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

 
Specialization is an organic evolution of medical 
practice, but specialized practitioners cannot 
reach their full potential without support and 
backing from the profession. As the few innovative 
professionals devise and test these advanced 
skills, the profession must perfect who should be 
utilizing these skills.6 Not all of these advanced 
skills can be performed by all practitioners, and 
in these cases specialization is often needed to 
support these particular practices.6 The idea of 
specialization is not always meet with resounding 
support. Athletic training is no different than other 
medical professionals who have worried about 
fragmentation of their profession and the loss or 
under valuing of the generalist skillset.2 Physicians 
had these same concerns, and specialization was 
seen as a benefit for the generalist practice, as it 
allowed for the strengthening, focusing, and 
reinvestment of the generalist practice and 
education.  
Another concern of specialization is the 
misrepresentation of unqualified practitioners.2 
The creation of board certification of specialty 
status was seen as an ingenious way for 
professions to control the concerns of 
specialization. In response to the growth of 
optometry as a separate discipline, the American 
Medical Association, and the American 
Ophthalmological Society created an 
independent board of specialists. This board was 
tasked with creating standards that would 
recognize physicians whose knowledge and skills 
demonstrated expertise in identifying and 
treating disorders of the eye.2 Physicians created 
the AMBS as an independent board to maintain 
the standards for physician certification.4 
Proposals for new specialties initially come from 
professional societies and are exhaustively vetted 
by the board.2  The profession of athletic training 
should follow this blueprint by creating an 
independent board of specialties who does not 
seek to create specialties, but instead focus on the 
maintenance of quality for the specialty 
certification. The creation of the specialty 
certification should come from the specialty 
practice societies who can properly recognize the 
specific patient populations, the highly focused 
knowledge required to treat such patients, and 
the skills that need to be obtained beyond that of 
the generalist practice for that specialty field of 
practice. In addition, these specialty societies 

should determine the qualifications required to sit 
for the certification examination.  
Specialization does not end with satisfactory 
performance on a single examination. 
Practitioners need to remain competent throughout 
their careers. The practice of athletic training has 
evolved significantly in a short amount of time, 
and for some athletic trainers this is within the life 
of their whole career. It has been demonstrated 
that skills decay and innovation happens, so once 
a specialty certification is obtained it needs to be 
maintained.2 Recertification requirements are just 
as vital to the success of the specialty development 
as initial certification.2   
 
Economic Considerations 
 
In the age of healthcare delivery changes and 
quality movement, consumers are demanding 
more from health care. Consumers as well as 
healthcare organizations are demanding more 
transparency and higher standards to ensure their 
providers have the knowledge and skills required 
for positive patient outcomes.2 Board certifications 
of specialty training is one of the frequent criteria 
used to ensure competence.2 When the public 
identifies an area of need or an aspirational goal 
develops, new areas of specialization tend to 
arise.6 Initially these new fields usually have a 
great shortage of professionals who have both the 
interest and the specific expertise to address to 
these problems.6 As known from the law of supply 
and demand, as the supply decreases the demand 
and cost of the product goes up. Even without 
specialty certification, the economic benefit of 
specialty skill set has already being seen. 
Research has demonstrated that athletic trainers 
who report performing seven or more specialized 
skills indicated that they earn significantly higher 
yearly salaries than those who did not.8 However, 
a proliferation of specialties without adequate 
reasoning may confuse the public and healthcare 
organizations, thus minimizing the positive impact 
of the profession. The value of specialty 
certification should be undeniable, but most 
people do not understand what criteria that 
certification represents, or fully appreciate that 
different kinds of organizations can offer 
certificates that represent varying degrees of 
rigor and clinical relevance.  
 



Specialization in Athletic Training: A Natural Evolution 

 

 

36 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

Conclusions 
 
Specialization should be difficult to obtain and just 
as hard to maintain. It is not meant to degrade or 
diminish the work of the generalist practitioner. It 
is, in fact, the recognition that within a generalist 
discipline it is becoming increasingly difficult to 
keep up with the depth of knowledge needed for 
this type of practice, especially when including 
technical, clinical, and managerial skills. The 
intended goal of specialization is to promote and 
foster the growth of the profession. Specialization 
is not something to be feared. It is something that 
should be embraced and cultivated. If properly 
done it can be a huge step forward in the 
evolution of athletic training. If poorly managed it 
could mean even more stagnation as the 
profession is presented with the changing 
landscape of healthcare delivery.  
 
REFERENCES 
 
1. Smith A. Inquiry into the Nature and Causes of 

the Wealth of Nations. London: W. Strahan 
and T. Cadell; 1776. 

2. Cassel CK, Reuben DB. Specialization, 
subspecialization, and subsubspecialization 
in internal medicine. New Engl J Med. 
2011;364(12):1169-1173. 
https://doi.org/10.1056/NEJMsb1012647 

3. Flexner A. Medical Education in the United 
States and Canada: A Report to the Carnegie 
Foundation for the Advancement of Teaching. 
Bulletin no.4. New York: Carnegie 
Foundation for the Advancement of 
Teaching, 1910.  

4. ABMS History of Improving Quality Care. 
American Board of Medical Specialties Web 
site. http://www.abms.org/about-
abms/history/. Accessed April 16, 2018. 

5. Detsky AS, Gauthier SR, Fuchs VR. 
Specialization in medicine: How much is 
appropriate. J Am Med Assoc. 
2012;307(5):463-464. 
https://doi.org/10.1001/jama.2012.44 

6. Peplau H. Specialization in professional 
nursing. Clin Nurse Spec. 2003;17(1):3-9. 
https://doi.org/10.1097/00002800-
200301000-00002 

7. Residency Programs. Commission on 
Accreditation of Athletic Training Education 

Web site. https://caate.net/residency-
programs/. Accessed April 16, 2018. 

8. Hassell J, Wetherington J, Kitano J, Scharer 
K, Paturzo M. The roles and responsibilities 
of athletic trainers working the physician 
practice. Poster session presented at: Big Sky 
Athletic Training Sports Medicine 
Conference; 2018; Big Sky, Montana.  

 

 

https://doi.org/10.1056/NEJMsb1012647
https://doi.org/10.1001/jama.2012.44
https://doi.org/10.1097/00002800-200301000-00002
https://doi.org/10.1097/00002800-200301000-00002

	COMMENTARY

