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Exercise is Medicine

Move It or Lose It: Summarizing Peer-reviewed Evidence for Practicing What You Preach

Bowersock, Allison H. PhD, CSCS1; Jaworski, Carrie A. MD, FACSM, FAAFP2; Pojednic, Rachele PhD, EdM3

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Current Sports Medicine Reports: August 2020 - Volume 19 - Issue 8 - p 286-289
doi: 10.1249/JSR.0000000000000735
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Abstract

Introduction

Physical activity (PA) has been regarded throughout history as a means of treating, as well as preventing, disease. From Plato to Thomas Edison, the role of PA prescribed for curative and restorative measures has been heralded as the way in which future physicians would most certainly practice and focus their efforts in patient care (1). Although the benefits of PA are widely known, the numbers of adults acting with these health habits in mind do not match up. In fact, one quarter of all U.S. adults are completely sedentary, more than half of the population does not meet the minimum daily activity recommendations and only 14% of young adults between the ages of 12 and 21 years report recent PA (2).

When the U.S. Physical Activity Guidelines were first released in 2008, Americans older than 6 years were encouraged to accrue 150 min or more of moderate or 75 min of vigorous activity per week; children, specifically, were encouraged to be active for 60 min·d−1 or more (3). In the 2018 revision to these guidelines, the aforementioned sedentary habits were kept in mind and the guidelines were broadened to emphasize simply moving more throughout the day as perhaps a more achievable goal. This revision also included an emphasis on PA promotion among preschoolers, underscored the health benefits of PA for all individuals, and made a callout to health care providers to take an active role in assessing and counseling patients on PA (4).

In response to this charge, the American College of Sports Medicine’s (ACSM) Exercise is Medicine® (EIM) global initiative has a goal of making PA assessment and promotion a standard in clinical care where connections occur between health care providers and evidence-based PA resources. The initiative proposes that PA assessment and promotion serve as the standard of care for every patient, at every visit, and as part of every treatment plan (5). By considering the proper “dose” of activity for specific clinical populations, health care professionals versed in EIM literature and training can and should use PA prescriptions as preventive medicine and as adjunctive treatment for chronic disease states. However, many providers receive little to no training on PA prescriptions and are not confident in their abilities to prescribe PA to their patients (6). In addition, evidence suggests providers’ self-efficacy in PA prescription is influenced by their personal health habits, and providers who regularly engage in PA are more likely to discuss PA with and prescribe it to their patients than those who are not physically active (7). Thus, the “practice what you preach” paradigm is inherently flawed in this instance as inactive providers are in fact not preaching PA as frequently as those who adopt these behaviors. Therefore, it is not only necessary to encourage providers to promote PA, but also just as important to assist them in finding ways to be physically active themselves.

Factors Influencing Provider Health

Research has demonstrated that physicians who share their personal health habits or intended health habits with their patients are viewed as more credible and trustworthy by those patients (8). However, medical students' and physicians' good intentions are often trumped by stressors such as negative work environments or extremely large patient panels and accompanying workloads (9). Limited research suggests that physician contentment is the deciding factor in a positive or negative patient-physician relationship (10). In addition, frustrations experienced by both the physician as well as the patient (uncertain diagnoses, long waiting periods, general poor health) can create the potential for tense interactions at the point of the office visit (11). Medical students are not immune to these and other variables that may influence behavior and overall level of contentment. For instance, in addition to excessive school-related demands on their physical time and energy, medical students often endure the emotional stress of witnessing death and dying for the first time (12). International students endure the unique challenge of acclimating to a potentially foreign environment in addition to the stressors typically associated with medical school (13). Evidence suggests that variables that contribute to life satisfaction are different from those that contribute to job satisfaction, and unfortunately, a growing body of evidence reveals that medical students and physicians often have low levels of both as compared with people in the general population with similar years of education and income (14).

The common denominator in the cases of both physicians and medical students is that job-related demands create a significant source of stress to the degree that health and health behaviors may decline as a result of these demands (15). Naturally, good health and happiness are facets of life that many people strive to achieve and maintain, but in order for medical students and physicians to effectively manage others' health, treat disease, and practice preventive medicine, it is important that the health and well-being of those providing care receive equal emphasis (16). Research has demonstrated the negative impact of poor physician health on patient health outcomes. Accumulation of stressors, as previously mentioned, has been demonstrated to lead to burnout both at the level of practicing physician, as well as during residency and in medical school (17).

On an individual level, poor physician health or feelings of frustration and burnout have been associated with poor patient care and even patient death, as well as patient noncompliance, medical prescription errors, reduced patient counseling care and time, failure to recommend preventive screening, and dissatisfied patients (18). Plus, the stressors introduced in medical school are the same if not multiplied later in life, with additional life events that may increase demands on personal time and subsequent struggles to maintain balance between work and family or social time (19). On a broader scale, poor physician health can negatively affect the medical office and even the medical organization at which the physician serves. Acutely, poor health and stress may contribute to an increase in absenteeism, but even more alarming, research has demonstrated that these behaviors lead to increased job turnover, early retirement, and increased spending at the organizational level for the rehiring process (20). Therefore, researchers strongly recommend the “increased awareness of the importance of physician well-being” for “increased job satisfaction and overall well-being, and reduced likelihood of … stress and burnout” (18).

Personal and Clinical Practice PA Implementation

Personal practice

Research suggests residents and physicians are more likely to discuss PA with patients if they are familiar with those practices as a result of their own lifestyle behaviors (8). Frank, et al. (6,8), whose body of work applies to physician practices and medical students not only in the United States but also in Canada and South America, revealed a direct link between physicians’ personal health behaviors and counseling behaviors in the clinical setting. More recently, a survey of sports medicine physicians revealed similar results suggesting that providers who are active themselves are more likely to council on PA and specifically provide counseling on what they know (21).

Several studies endorse the importance of social support, not only for healthy lifestyle behaviors but also for health in general. Results from the national survey of Norwegian physicians revealed a significant relationship between social support and life satisfaction, both in actual support through a spouse or friend and perceived support (22). These findings align with a growing body of evidence, suggesting that the critical nature of social support for medical students and physicians should, therefore, be accentuated in medical school and physicians’ places of work. A compelling survey of medical school deans and medical students revealed a common opinion among the deans surveyed that promoting healthy lifestyle behaviors among students is important and should be emphasized by the respective institutions (23). As commonly understood that knowledge does not automatically translate into actions, the deans also reported acknowledgment that emphasis on these factors could and should be improved upon to facilitate role modeling by medical students.

Providers must “walk the talk.” A growing body of literature indicates that physicians who are active are much more likely to counsel their patients on exercise and PA (5,21,24). Physician counseling on PA and exercise has been shown to directly affect the behavior of their patients by increasing the minutes of PA (25–27) as well as demonstrate improvements in clinical markers (28,29).

However, not all physicians recommend PA to their patients. Only 32% of adults have reported speaking to their physician about PA (29), and documentation of physician counseling on PA occurs in less than half of the patient records (30). Moreover, documentation is highly erratic with the frequency of exercise inputs in primary care records varying from as low as 0.4% of patients to as high as 87.8%, most often in records of patients with identified chronic conditions (30). This is despite the fact that the United States Preventive Services Task Force suggests evidence regarding the benefits of providing PA counseling to patients with cardiovascular disease risk factors, obesity, and abnormal glucose levels (31) and calls for PA assessment and promotion be the standard of care for every patient, at every visit, and as part of every treatment plan (8).

Over the past two decades, physicians have given many reasons why they do not counsel on exercise, including confidence, education, and lack of reimbursement and time (21,32). However, there are now several studies to indicate that one of the primary reasons physicians do speak to their patients about PA is their own activity levels (21,33,34). Recent data suggest that a higher personal practice of PA was associated with more minutes counseling patients about exercise and PA (33). Interestingly, physicians also were more likely to advise patients to participate in activities with which they were most familiar, often recommending walking, aerobic activity, strength training, and cycling (21). While it is admirable that active physicians are recommending activity to their patients, also it is alarming that they rely on personal experience rather than evidence-based guidelines. This is perhaps due in part to the lack of adequate education in PA in medical schools as more than half of the medical students in the United States do not receive formal training in PA (35).

Yet, despite this lack of formal training, it is promising that physicians and medical students do have a higher likelihood of being physically active than the general U.S. population (24). What is more, the providers who “walk the talk” are perceived as more credible providers than those who are inactive or less active than their peers (8). This is key as patients also are more likely to improve clinical outcome markers when their physician is active (36). And, although patient outcomes are critical metrics, it should be noted that physicians who display healthier behaviors like exercise also demonstrate key indicators of personal and professional well-being (34,37,38).

Higher levels of PA and physician health are an association that starts in medical school. Medical students with higher levels of leisure time PA demonstrate increased quality of life (39), decreased stress (40), and overall well-being (41). By contrast, lack of exercise, along with unmet mental health needs, stress, and emotional exhaustion, has been demonstrated to be predictors of medical student depression in both the United States and internationally (42). Beyond medical school, increased PA and provider health is a trend that carries through all levels of the medical profession with residents stating that among many other wellness activities, only exercise served to reduce burnout and mental health problems (37). And in practicing emergency care physicians, exercise has been shown to be a protective factor against burnout, including emotional exhaustion and depersonalization (38).

Clinical practice

Once successful at adopting one's personal PA plan, research, as that outlined above, shows that a physician is more likely to apply this knowledge in their daily clinical practice (21,24,34,37). However, despite even the best of intentions, busy clinicians still struggle to include PA discussions in their patient visits mainly due to limits on time. It is likely improbable that a physician will have sufficient time to fully counsel a patient on PA and exercise prescriptions, even with a good base of knowledge on the topic. Despite this, it is still feasible for a physician to acknowledge a patient's need to exercise or congratulate their already established efforts while simultaneously connecting them to community partners who can provide more extensive counseling and support.

To this end, it is imperative that providers think creatively in an effort to develop such methods to ensure that patients are both made aware of the provider's philosophy that PA is a cornerstone in their care as well as are provided with the means to be successful in doing so. Several concepts that can be utilized by physicians to assist with this include the implementation of a PA vital sign (PAVS) in their practice and utilization of health care team members to do the counseling and partnerships with local community partners.

One of the most successful methods of ensuring that providers start PA discussions with their patients is through the use of a PAVS. Championed by both Kaiser Permanente and Intermountain Healthcare over the last decade, both systems have provided invaluable research on the implementation of a PAVS, as well as methods to engage providers and market to patients (43). Through the use of two to three simple questions at the time of a patient intake, the PAVS allows for a quick assessment of where a patient is in their PA journey. Once the PAVS is calculated, the provider can opt to address the information either briefly or more extensively, depending on what the time allows. Either way, using the PAVS “starts the conversation” between provider and patient and solidifies the importance of PA in their care.

Options for busy providers in terms of enlisting help in PA counseling includes using one of their own team members, such as a nurse educator, athletic trainer, or physician assistant versus having an established referral system in place. In one’s own office, much success has been found through the use of a written exercise or PA prescription. The act of writing out a plan has shown a greater effect on increasing PA in patients versus just providing verbal instruction (25,44). An easy and well-known method that providers can instruct their staff on using is the FITT prescription which is short for “frequency, intensity, time, and type.” By engaging the patient in a discussion on their interests and barriers as it relates to exercise, one can easily develop a FITT prescription that matches their patient's current level of PA and interests. It also promotes patient “buy-in” as they have helped in shaping their own prescription (45).

In addition to the FITT prescription, providers can streamline PA promotion by having premade handouts on topics, such as how to start an exercise program with various chronic medical conditions, lists of free community resources, such as walking tracks and low-cost group fitness opportunities, downloadable exercise programs and fitness phone apps, as well as reputable fitness professionals in the community. The EIM web site (www.exerciseismedicine.org) has a wealth of resources that can support health care providers in developing these concepts. By taking these extra steps, it will become even more apparent to the patient that the provider believes in the importance of PA in their care.

In situations where one’s clinical practices do not allow for team members to be the lead on PA promotion, as well as when physicians wish to provide a more robust support network for their patients, creating partnerships with fitness professionals in one’s community is paramount. Using EIM-credentialed fitness professionals is a way to ensure that one’s patient will be properly advised and supervised. Physicians should see these relationships as extensions of the office visit and create mechanisms to allow for communication between these providers and the physician's office. In doing such, the patient will once again witness the belief that the physician has in the role of PA within their care. This will only serve to enhance the patient's experience and success with implementing and maintaining their PA plan.

Conclusion

Clearly, the importance of having physicians believe in PA as a pathway to better health is of utmost importance in successful PA promotion. There are two key areas to focus on concerning future physician personal practices and patient care regarding PA. First, we must increase physician education on the benefits of exercise for themselves and their patients. Second, we need to encourage physicians to “walk the talk” and practice PA behaviors that will help them serve as role models for patients while alleviating uncontrollable professional stressors. Employers also must acknowledge the importance of facilitating environments in which providers are supported and encouraged to engage in PA in their personal lives as evidence has demonstrated such habits do positively influence attitudes, behaviors, and counseling habits in clinical settings.

The authors declare no conflict of interest and do not have any financial disclosures.

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