An interview session with Edward M. Phillips, M.D., and Brad A. Roy, Ph.D., FACSM.
Dr. Roy: Over the past decade, people have been inundated with media messages regarding the importance of living a physically active lifestyle. Unfortunately, the progress is modest, and America seems to be getting heavier and more out of shape. More recently, the role of the physician in assessing and prescribing physical activity has been identified as a key component in moving people off the couch. What are the obstacles to getting physicians to actively assess and prescribe physical activity for their patients?
Dr. Phillips: The obstacles include inadequate medical education about physical activity and exercise, limited clinical time to counsel patients on exercise, lack of reimbursement to prescribe exercise, and the physician's personal exercise regimen.
Dr. Roy: Certainly, including education regarding the science of physical activity and how to develop an appropriate exercise prescription is critical. In this regard, is there currently sufficient physician education about the importance of physical activity and how to go about developing an exercise prescription? What is available?
Dr. Phillips: Unfortunately, basic education regarding exercise is a rare offering in medical school. Only 6% of U.S. medical schools offer a core curriculum in exercise. We need to fill the educational gap through training at all levels of medical education from medical schools to residencies to Continuing Medical Education (CME) programs.
Dr. Roy: What are the opportunities for practicing physicians to learn how to prescribe physical activity?
Dr. Phillips: The recent book, ACSM's Exercise is Medicine™: A Clinician's Guide to Exercise Prescription (2), teaches health care professionals how to assess physical activity as a vital sign and prescribe exercise to various patient populations. The Harvard Medical School CME course, Active Doctors Active Patients, will focus on the science and experience of exercise. The course will be held in Boston on November 13 to 15, 2009 (www.activedoctors.org). The Institute of Lifestyle Medicine (ILM) at Spaulding Rehabilitation Hospital offers CME online programs through Harvard Medical School on exercise prescription (3). The ILM is working on writing and assessing core curriculum programs for undergraduate medical education.
Dr. Roy: I routinely present exercise data and the vital sign concept at a number of physician grand rounds and CME conferences. It seems that in every session, someone comments, "Why bother, this won't have an effect on my patients? They won't comply with the recommendation." How would you respond to such a comment?
Dr. Phillips: ACSM recently completed a survey reporting that more than 80% of patients would pursue exercise if their physician advised them to do so. Unfortunately, only 3 in 10 physicians currently address physical activity during a patient's visit. A strong clear message from a trusted authority, such as the individual's personal physician, is a powerful motivator to adopt a more physically active lifestyle.
Dr. Roy: How important are the physician's personal physical activity habits to the success of physician participation in prescribing physical activity? Isn't it important that we practice what we preach?
Dr. Phillips: Yes, studies of physician health and counseling behavior draw a clear relationship between the physician's personal health behaviors and what they counsel their patients to do. Physicians who adopt more physically active lifestyles are often vocal proponents of exercise for their patients. The Active Doctors Active Patients (1) training program will foster this transformation by providing didactic material on the science of exercise and active participation in exercise workshops to help the clinicians become regular exercisers.
Dr. Roy: Wouldn't it help if the physician were paid to prescribe exercise?
Dr. Phillips: ACSM's Exercise is Medicine™ global initiative (www.exerciseismedicine.org) understands that appropriate reimbursement will help increase clinicians' interest and compliance with the recommendations to assess physical activity as a vital sign and prescribe exercise. Additionally, Exercise is Medicine™ is working to institute a new Health Effectiveness Data and Information Set (HEDIS) measure that will grade providers on their compliance with the physical activity vital sign and providing the exercise prescription.
Dr. Roy: One of the frustrations I most often hear from physicians is time. How will physicians find the time during their busy office schedule to write an exercise prescription?
Dr. Phillips: Perhaps the best way to institute the physical activity vital sign is to assign this task to the intake staff, such as nurses or medical assistants, as they are taking vital signs. One suggestion is to ask the patient, "In the last week, how many days did you accumulate 30 minutes of moderate physical activity (such as a brisk walk)?" The possible answers range from 0 out of 7 days up to 7 out of 7 days. Patients answering 0 to 2 days of activity are considered "sedentary," 3 to 4 days of activity are "somewhat active," and 5 to 7 out of 7 days "meets recommendations." This new vital sign can be included in the electronic medical record (EMR), which is then available for the physician to review while seeing the patient.
Similarly, several tailored physical activity prescriptions can then be written by the clinician or automatically generated by the EMR for the physician to sign. This will take only 15 seconds for the physician to sign and hand the exercise prescription to the patient.
Dr. Roy: Only 15 seconds, is that really adequate? Does the physician need to spend time counseling the patient, especially those who are in the 0 to 2 "sedentary" range?
Dr. Phillips: Yes, the exercise prescription will be much more effective if it is the product of several minutes of conversation between the clinician and the patient focusing on overcoming barriers to exercise, agreeing upon short-term achievable goals (such as a 5-minute daily walk to start), utilizing available support, and exploring the patient's underlying value for pursuing exercise while being clear that filling the exercise prescription is ultimately the responsibility of the patient.
Dr. Roy: How do the patients "fill" their prescription once they leave the office? Where do they go? Are there tools available to help the patient fulfill the prescription? How do we help the patient transition to home or a facility?
Dr. Phillips: Filling the exercise prescription is individualized to the patient. In many cases, a pedometer and an exercise log are sufficient to get the patient up to the recommended 30 minutes of moderate daily physical activity. Community resources including safe available walking paths help to achieve this prescription. Social support through exercise groups or walking clubs (often in a local shopping mall in the morning before the stores open) provide a community and a safe environment that is available even in bad weather.
Fulfilling the recommendations to perform resistance exercise at least twice per week can be accomplished at home but more often is helped by health/fitness professionals who can instruct the individual on proper weight lifting technique, address safety concerns, and help tailor an appropriate progression of increased resistance. This may be more easily achieved in a health or fitness club.
Dr. Roy: Are physicians comfortable referring patients to health/fitness clubs?
Dr. Phillips: No, health clubs are not yet perceived to be part of the continuum of clinical care.
Dr. Roy: What would convince them to do so; how does a health club become part of the continuum of care?
Dr. Phillips: The health club industry is moving onto a basic certification process being developed through NSF (National Sanitation Foundation, a third party accrediting agency) with participation from all sectors of the health and fitness industry. The Medical Fitness Association has recently published Standards and Guidelines for Medical Fitness Center Facilities (4). Additionally, they have rolled out their Medical Fitness Facility Certification. This is an external survey that addresses the processes, personnel, emergency procedures, and outcome/performance measures of a medical fitness facility.
A fully certified medical fitness facility has medical oversight including medical and professional personnel on site such as nurses, physical therapists, certified exercise physiologists, and in some cases, physicians, who are well versed in emergency procedures. These facilities are positioned to accept physician referrals for all patients including those with chronic health conditions such as heart disease, hypertension, diabetes, and arthritis.
Dr. Roy: What qualities will a physician look for in an exercise professional when referring a patient to that professional?
Dr. Phillips: A physician referring his/her patients to an exercise professional will feel more confident if the individual has qualifications such as appropriate educational training and a professional certification that has been accredited by the National Commission for Certifying Agencies.
Dr. Roy: One of the hot topics in health care today is "pay for performance." If a physician is going to be paid based on patient outcomes and a facility can demonstrate success in producing such outcomes (e.g., lowering A1C levels, reducing hospital readmits, etc), won't this make them more likely to refer? It seems like there could be a strong partnership that would enhance the patient experience.
Dr. Phillips: Fitness facilities that are able to demonstrate positive health outcomes such as normalized blood pressures and reduced hemoglobin A1C levels should become natural allies for physicians who will be paid for helping patients achieve these measurable health outcomes.
Dr. Roy: What feedback do physicians want? How would this tie back into pay for performance?
Dr. Phillips: Completing the feedback loop and providing physicians with simple regular communication on the progress of the patient through the exercise program is critical. This may include a summary of their attendance and participation, progression through the cardiovascular and resistance exercises, and measures of their fitness, such as a 6-minute walk test or similar functional measures.
Dr. Roy: These are certainly exciting times, and as we move down the road of health care reform, physical activity must be a large part of our primary and secondary preventative strategies. What other suggestions do you have for the health and fitness professionals who want to partner with physicians and other allied health professionals to better utilize exercise therapy?
Dr. Phillips: A simple low-cost option is to join the Exercise is Medicine™ global initiative by signing on at the Web site www.exerciseismedicine.org. The Web site is developing a means of locating fitness professionals available and near to the referring clinician. Other options for engaging directly with local physicians may include offering hands on exercise experience at the health club or studio. To continue to gain credibility within the medical community, health and fitness professionals need to acquire appropriate certification to adhere to rigorous professional standards and to demonstrate the efficacy of their interventions (such as outcome studies for health club participants). Another option would be to reach out to physicians through educational programs at your club or at the local hospital.
CONDENSED VERSION AND BOTTOM LINE
The importance of every person living a physically active lifestyle is well documented. Unfortunately, few Americans participate in the recommended amount of physical activity to achieve health benefits. Physicians are a key link to motivating people to become more physically active. This interview discusses the role of the physician in physical activity counseling, what steps are being taken to support physician participation, and how health and fitness professionals can complement physician efforts.
1. Active Doctors Active Patients
. Harvard Medical School Department of Continuing Education, November 13-15, 2009, Boston, MA. Available from: www.activedoctors.org
2. Jonas S, Phillips EM. ACSM's Exercise Is MedicineTM: A Clinician's Guide to Exercise Prescription
. Philadelphia (PA): Wolters Kluwer, Lippincott Williams & Wilkins; 2009.
3. Lifestyle Medicine for Exercise Prescription
. Harvard Medical School CME Online Program. Available from: www.harvardlifestylemedicine.org
4. Medical Fitness Association. Standards and Guidelines for Medical Fitness Center Facilities
. Roy BA, editor. Monterey (CA): Healthy Learning; 2009.