Let Us Carry on Doing Nothing? Humbug!
The importance of physical activity as a vital sign and key determinant for health, public health, quality of life, and even happiness has been acknowledged by numerous global, national, and international medical organizations (5,7–10,19,24,28). However recent studies suggest health care professionals are not being taught why and how to effectively assess, prescribe, and promote regular physical activity to their patients (6,25). It is therefore hardly surprising that health care professionals are not prescribing and promoting physical activity (1,27). This ambivalence by caregivers bears similarities to a sedentary patient, where both are metaphorically doing nothing. Neither is considering the numerous wider consequences and cost to health, happiness, society, and resources. Both would benefit greatly from contemplating their responsibilities and assessing the personal and wider pros and cons of continuing to do nothing. This may help start a (transtheoretical and contemplative) process of behavior change (18).
Responsibility takes many forms and includes collective, social, duty, human, ethical, moral, cultural, legal, professional, educational, corporate, and media, to name a few. Responsibility is not conceptually to apportion “blame,” and it is critical to recognize that current physical activity failings are institutional (top down and bottom up) and span many more sectors than health care alone.
Given the overwhelming evidence to support the promotion of regular physical activity for improved individual and societal health and happiness, it is logical that recent calls to action have centered on the “movement-centric” sports medicine community (13,23). In the United Kingdom, where sport and exercise medicine (SEM) has become a recognized medical specialty in its own right, the role and duties of an SEM specialist, including physical activity promotion, education, and exercise medicine, have been defined (11,19). The development of SEM in the United Kingdom has provided a platform to highlight the importance of sport and exercise for both health and public health, with calls for improved education and skill development for future doctors on physical activity science and physical activity promotion using behavior change techniques (12,14,19). In the United States, physical activity promotion is a required curricular element in family medicine residency training and in sports medicine fellowship training. However the quantity and quality of that training are highly variable between institutions and are definitely not a focus of most training programs. This approach may lead to a perception of low importance to trainees and could, in part, explain inadequate physical activity knowledge and skills found in practitioners.
However, there is a wider basic need to motivate all health care professionals to promote regular physical activity and not just physicians or sports medicine physicians. For more than 2,500 years, since Hippocrates, we have known that “walking is man’s best medicine” (2) and physical activity is key to health (both physical and mental). If care giving is centered on providing what is necessary for the health, welfare, maintenance, and protection of our patients, then physical activity promotion is the responsibility of all professional health care givers.
The health care community should prioritize the implementation of physical activity promotion initiatives, given an ever-growing evidence base and current expert public health guidance. Applying behavior change theory centered on motivation (4), we can attempt to understand the reasons why clinicians are apathetic when it comes to the concept of physical activity promotion during doctor-patient consultations. In the United States and United Kingdom, doctors are not following national guidelines promoting physical activity to their patients (1,27). There are many reasons for this personal and collective neglect, but consideration of medical malpractice is pertinent. In the United Kingdom, the promotion of physical activity as a management recommendation is fundamental to 39 separate clinical condition medical guidelines, which carry a duty of care with medicolegal responsibilities (26). To not follow these guidelines and therefore ignore physical activity promotion is arguably risky. Will there ever be a malpractice case where a physician is brought to account for not following guideline physical activity promotion leading to avoidable ill health and suffering caused by the patient’s inactivity? Perhaps more importantly, physical activity promotion provides patients with higher quality care. In the United States, physical activity promotion is a quality of care measure (Healthcare Effectiveness Data and Information Set (HEDIS) measure) for older adults and for children and adolescents. Reimbursement from Medicare is tied to achieving certain quality of care benchmarks. Therefore not addressing physical activity assessment and counseling results in lower reimbursement from Medicare. These are compelling reasons for health care systems and providers to move more quickly through the stages of change and install system changes necessary for effective physical activity promotion to take place.
Health care professionals may ask what physical activity promotion has got to do with them if physical activity is an individual lifestyle choice and therefore not the responsibility of the health care sector to address and resolve. They may say they have more important things to do. Low cardiorespiratory fitness kills more Americans than smoking, diabetes, and obesity combined (3), so how is it possible that we accept responsibility for other damaging lifestyle choices such as tobacco, unhealthy dietary practices, alcohol, and drug use but ignore physical inactivity? Those responsible for health care budgets and cost-effectiveness understand the importance of physical activity and the value to be found in delivery of physical activity promotion to reduce the growing financial burden and drain on resources of physical inactivity on the health care sector (10,17,20). In these austere times, this is even more poignant and relevant.
How to Prescribe and Promote Physical Activity in Primary and Specialist Care
Primary care advice on physical activity is a pillar of the World Health Organization’s global physical activity plan (2010) (29). This includes practice nurses, pharmacists, as well as primary care providers (family medicine physicians, general practitioners in the United Kingdom, general internal medicine, and pediatrics) who can, both clinically and cost-effectively, accurately assess and offer advice and brief interventions on physical activity. In the United Kingdom, the Department of Health views these interventions as “exceptional value for money” (17). Physical activity promotion is simple to deliver in health care settings.
The Exercise Is Medicine® initiative (www.exerciseismedicine.org) suggests asking two exercise vital sign questions (21), so that a patient’s weekly activity can be compared with the recommended guideline. Health care professionals should use these questions in every consultation, and physicians should be reimbursed for exercise history taking and physical activity promotion.
The “6As” can be used to guide counseling — assess, advise, agree, assist, arrange, and assess again. Accountability of both doctor and patient also could be a worthy seventh “A,” ensuring that medical records demonstrate the intervention, allow for outcome evaluation, and trigger follow-up reminders at future consultations. A written “green” prescription, making up exercise and lifestyle goals, is an important element signaling that exercise is indeed medicine, with a dose and frequency (15,22). The effectiveness of physical activity interventions in specialist (in the UK “secondary”) care settings is less well known, but equally appropriate, given that numerous referrals to secondary care are for chronic diseases caused by physical inactivity, which can be treated with physical activity.
Noncommunicable chronic diseases kill more people worldwide than anything else (28). It is unacceptable that physical inactivity is the fourth leading preventable global killer, and physical inactivity accounts for approximately 5.3 million deaths per year (16). Yet physician understanding of the importance of physical inactivity as a cause of disease, use of physical activity prescription in the prevention, management and treatment of disease, and the skills required to deliver effective physical activity promotion are neglected hugely in medical education in the United States and United Kingdom (6,25). Health care education boards and examination boards may have the greatest responsibility to ensure that tomorrow’s health care professionals are best prepared to assess and prescribe exercise in accordance with health guidelines. There is an urgent need for education on physical activity to be embedded within undergraduate medical education, as well as postgraduate curricula, continuous professional development, and workforce development. The importance of physical activity education for physician assistants, nurse practitioners, physical therapists, and nurses is equally critical. Health care needs to have a “collective voice” that consistently promotes physical activity, preventing one caregiver’s advice being undermined by someone else involved in patient care.
In accord with Benjamin Franklin, “an ounce of prevention is worth a pound of cure.” Health care systems have a responsibility to change to a preventive approach, recognizing that prevention is better than cure. This will increase life expectancy and quality, decrease health inequalities, and produce tangible financial savings. Current approaches that spend on treatment rather than prevention will continue to produce unnecessary morbidity and mortality and an unsustainable economic burden for our children.
It is essential to recognize that the promotion of physical activity within the health care sector is just one of the seven key investments that will work to increase physical activity (7,8). No one investment will work without a comprehensive approach and multiple concurrent strategies (7,8). Furthermore a health care professional using a brief intervention or exercise prescription will need local infrastructure and services to ensure they can guide their patient to suitable and fun opportunities for physical activity.
Global advocacy for physical activity described seven areas of investment that work for physical activity (7,8). These “best buys” are as follows:
- “Whole-of-school” programs providing physical activity for every school child
- Transport policies and systems that prioritize walking, cycling, and public transport
- Urban design regulations and infrastructure that provides for equitable and safe access for recreational physical activity, and recreational and transport-related walking and cycling across the life course
- Physical activity and noncommunicable disease prevention integrated into health care delivery
- Public education, including mass media to raise awareness and change social norms on physical activity, and the risks of physical inactivity
- Community-wide programs involving multiple settings and sectors and that mobilize and integrate community engagement and resources to promote physical activity
- Sports systems and programs that promote “sport for all” and encourage participation across the lifespan
Over the last few thousand years, the forbears of medicine, Galen, Hippocrates, and Maimonides, all have reported the important positive impact of physical activity on health and well-being. Physical inactivity’s propensity to cause preventable morbidity and mortality has been under-recognized grossly by both the public and by health care professionals, as modern medicine has evolved indulging powerful capitalist pharmaceutical and industry conflicts of interest.
If health care professionals are serious about doing the best for every patient every patient visit, which is the purpose of care giving, then we must be skilled in assessing physical activity levels as well as providing appropriate advice and able to guide patients through options and to activity. We have a professional duty and responsibility to know and deliver best treatments as well as keep ourselves up to date with and strive for current best practice. Either we are serious about doing the best for our patients or we are not.
Physical activity is central to health and doing nothing is not a responsible option for our patients or health care professionals. Perhaps even more important is the need for all health care professionals to embrace physical activity and strive for medical and care giving systems change, at government, organizational, educational, and medical leadership levels. Continued apathy towards physical activity promotion will forfeit increases in life expectancy, better health outcomes and quality of life but also will consign our health care systems to a dark economic future that is largely avoidable.
The authors declare no conflicts of interest and do not have any financial disclosures.
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