The global incidence and prevalence of noncommunicable diseases (NCD) has reached pandemic proportions and remains the leading cause of death (1). Individuals with one or more NCD are at a higher risk for losing functional independence as well as increased risk for morbidity and premature mortality compared with apparently healthy individuals (2). The direct and indirect costs of managing NCD contribute to significant financial burdens on individuals and their family members as well as health care systems (3). Although the factors contributing to the development of NCD are multifactorial and complex, lifestyle barriers that limit physical activity (PA), increase sedentary time, and enable the overconsumption of foods that are energy dense (i.e., high in sodium, fat, and added sugars) are clearly associated with the development and progression of NCD (2,4). In fact, sedentary behavior and obesity have reached epidemic proportions and require immediate action to reverse this course (5,6).
In “Westernized” countries, the phenotype of low PA, high sedentary time, overconsumption of energy-dense and low nutrient foods, and excess body mass has become increasingly common (7,8). This phenotype has clearly contributed to the growing trend of individuals with multimorbidity (presence of two or more chronic conditions), which is seen in >75% of individuals ≥65 yr of age (9). Data from the Australian Longitudinal Study on Women’s Health revealed at least a twofold odds ratio of developing an additional comorbidity in the presence of an existing NCD (10). Examination of large-scale, prospective cohort data from the Emerging Risk Factors Collaboration (689,300 participants) and UK Biobank (499,808 participants) reveal increasing risks for all-cause mortality with each additional diagnosis of diabetes, stroke, or myocardial infarction. Those with all three conditions were found to have a hazard ratio of 6.9 (95% confidence interval, 5.7–8.3) for all-cause mortality, and those ≥60 yr had a 15-yr reduced life expectancy compared with apparently healthy individuals (11). Moreover, it is well known that previously referenced NCD risk factors independently contribute to the accelerated functional decline of key organ systems (i.e., renal, skeletal muscle, cardiovascular, endocrine, pulmonary, neurological, and skeletal) if left untreated or poorly managed (12–15). This consequently complicates patient care by requiring multipharmacotherapy, potentially resorting to advanced treatments for diabetes (i.e., peripheral neuropathy, wound care, and retinopathy), hemodialysis for end-stage renal disease, and/or left ventricular assist devices for patients with heart failure. However, in addition to advanced medical therapy, patients with multimorbidity that initiate and adopt comprehensive healthy living (HL) behaviors (e.g., increasing PA and reducing sedentary time, modifying dietary practices, smoking cessation, adherence to medication regimen when necessary, etc.) significantly attenuate the progression of their NCD (16). Although initiating HL medicine (HLM) (17–19) as a part of secondary prevention is crucial for improving health outcomes, an effort to reimagine the largely reactionary health care model to emphasize patient referrals to HLM experts for primary prevention services is greatly needed. Lifestyle programs for those with NCD risk factors are known to significantly reduce the incidence of metabolic disorders as well as cardiovascular and of all-cause mortality (20). It is now broadly recognized that a proactive approach to healthcare is optimal for preventing NCD risk factors from ever developing as well as managing those individuals who already have established risk factors or a confirmed diagnosis on one or more NCD; HLM is central to this proactive approach across the health spectrum (21).
Historically, clinical exercise physiologists (CEP) have been key stakeholders in delivering primary and secondary prevention HL interventions; they are in fact key providers of HLM (22). Although the scope of practice for CEP is broad, their primary roles center on exercise testing, prescription, and monitoring, the latter of which entails both supervised and home/community-based exercise programs, of individuals at risk for NCD or diagnosed with one or more NCD. CEP gained a prominent role in secondary prevention programs during the vast expansion of cardiac and pulmonary rehabilitation programs in the 1970s as a result of robust evidence supporting their efficacy (23–28). Bachelors or masters of science–level training in exercise-based programs were and still are widely considered sufficient to effectively practice in such settings. However, the patient phenotype commonly observed in secondary prevention programs has evolved to include a greater prevalence of obesity, greater sedentary time, poor dietary habits, advanced diabetes, chronic kidney disease requiring hemodialysis, and advanced cardiac procedures (29–31). In fact, patients with multiple comorbidities have been shown to experience a smaller degree of functional improvement in cardiac rehabilitation programs compared with patients with fewer comorbidities (32). This is important to note as it has recently been demonstrated that patients who do not respond (i.e., improve cardiorespiratory fitness) to exercise training remain at higher risk for future adverse cardiovascular events (33). Although the mediating factors contributing to this observation are not clear, a more complicated medical management may pose significant barriers to increasing and maintaining moderate to high PA levels (32). A higher level of familiarity with respective organ system pathophysiology, medical management, and clinical cognitive behavior improvement theories are necessary to promote change in patients with multiple morbidities. In this context, a precision approach to the delivery of HLM by CEP is needed moving forward. The National Research Council put forth an initial report describing the concept of precision medicine in 2011 (34), which was followed by President Obama’s Precision Medicine Initiative in 2015. Precision medicine is defined as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person” (35). The fact that this precision medicine definition includes lifestyle factors is important in the context of the current commentary and the future of the CEP profession. It is becoming increasingly recognized that the one-size-fits-all approach is not optimal for HLM. Thus, current institutional CEP training may be inadequate in preparing current and future professionals to be effective autonomous practitioners for a precision approach to care and managing clinically complex patient cases in a way that optimizes HL behaviors and improvement with prescribed interventions (e.g., exercise training significantly improving cardiorespiratory fitness). Moreover, CEP must receive adequate training to integrate into an interprofessional HLM approach, as described previously (17) and illustrated in Fig. 1. All professions illustrated in this figure have a role to play in the delivery of individualized HLM. Therefore, CEP education requires an elevation of expectations, including both didactic content and clinical training. Many licensed allied health professions (i.e., physical therapy, pharmacy, occupational therapy, disease prevention nursing, nutrition, etc.) have recognized the call to move toward professional doctoral degree programs to ensure the delivery of competent, high-quality, and effective patient care. In line with the medical field’s growing focus on the prevention and treatment of the NCD crisis, particularly through implementing high-quality HLM interventions, it is time for the CEP profession to embrace and move toward a professional doctorate degree. This article provides a roadmap for a Doctor of Clinical Exercise Physiology (DCEP) framework.
PROPOSAL FOR A DCEP MODEL
Although the need for competent, well-trained professionals is needed to deliver HLM across the health spectrum (i.e., apparently healthy to diagnosed NCD), the anticipated growth of the population with complex multimorbidities particularly highlights the need to elevate the training and skill set of CEP. Elevated training is needed to assume a more effective role in the management of all individuals by delivering high-quality, primary, and secondary prevention HLM, resulting in the long-term adoption of PA and other healthy behaviors. The proposed professional DCEP program described herein will deliver rigorous didactic, experiential training and applied clinical rotations to foster the comprehensive preparation of clinical practitioners. The core elements of a DCEP program, listed in Table 1 and described in subsequent sections, will extend beyond common coursework and preparation currently provided under master’s level graduate training.
Although current master’s CEP program across the United States offers a unique set of courses, commonalities among programs include 1) human physiology, 2) advanced exercise physiology, 3) exercise testing and prescription in healthy and various patient populations, 4) basic resting and exercise electrocardiogram interpretation, and 5) research methods and/or statistics for programs requiring completion of a thesis project. A large portion of these courses are typically completed within the first year of a program, with the second year dedicated to completing remaining coursework, a thesis research project, and/or clinical internships. For this reason, much of the didactic training in pathophysiology, pharmacology, exercise testing, prescription, and supervision of special populations (i.e., hypertension, dyslipidemia, diabetes, coronary artery disease, heart failure, pulmonary disorders, etc.) is compressed within a short window of time, thereby limiting the depth and breadth of clinical material that is addressed. Therefore, the proposed DCEP program will distribute clinical topics across multiple courses (Table 1) over 2 yr and expand the educational material delivered in each course, with the aim of increasing the expected level of competency in pathophysiology, pharmacology, clinical management, safety considerations, exercise testing/prescription, for respective NCD, and becoming well versed in the dose response modification of NCD risk factors via HLM. To compliment the clinical coursework, psychosocial behavior courses will be required to develop skill sets necessary to become effective behavioral interventionists. Becoming proficient in health coaching and cognitive behavioral practices will fortify the ability of the CEP to amalgamate theoretical exercise prescription guidelines with evidence-based strategies used to assist behavior change and adoption.
Apart from the typical clinical course load offered in master’s level graduate programs, few, if any, graduate programs integrate coursework that formally prepares students to be well versed in insurance-based practices, clinic management, and program marketing. Often these skills are acquired during on-the-job training or through years of experience, thereby limiting productivity and placing burdens on clinic workflow. Therefore, special emphasis will be placed on offering courses that prepare students to be fluent in the policies and procedures of the healthcare system, become effective program managers, and understand strategies to promote services within and outside the hospital system. Receiving formal education on these topics at a professional doctoral level will create the foundation necessary to successfully manage and ensure the financial stability and independence of clinical services offering HL interventions. In addition, managerial courses will place special emphasis on strategies to strengthen patient care through the development of interprofessional teams as illustrated in Fig. 1 (i.e., physical therapists, occupational therapists, nurses, registered dietitians, etc.). This objective falls in line with the growing recognition and call for health care providers to move toward interprofessional care models to appropriately manage complex patient cases by capitalizing on the respective profession’s area of expertise (36,37), thus creating an environment that facilitates the delivery of individualized and optimally effective clinical services.
To reinforce the didactic component, practical, clinical experiences will be strategically offered throughout the 3-yr program to coincide with relevant course work. Students in the first year of the program will complete a 1-yr rotation in primary prevention programs with responsibilities that span the following: 1) conducting preexercise participation health screenings; 2) exercise testing, interpretation, and programming; and 3) applying health coaching techniques to help individuals reach self-identified and appropriate goals according to their individual health status. Experiences gained throughout the first year will serve as the foundation to expand clinical skill sets in the second year, which will afford students the opportunity to shadow and gain experience in secondary prevention programs such as worksite and school-based health and wellness programs, phase II and phase III cardiac rehabilitation, pulmonary rehabilitation, cancer rehabilitation, and bariatric weight loss programs. In the third year, students will take on more significant roles in the aforementioned secondary prevention programs by performing clinical tasks expected of an entry-level CEP (i.e., cardiopulmonary exercise testing, patient medical history review and interpretation, HL programming, and behavioral interventions) while under the supervision of trained professionals. These experiences will align nicely with didactic coursework taken during the third year, which will familiarize students to health insurance practices, professional conduct, and managerial practices within the health care system. The collective experiences gained through the didactic and practical components of the proposed program will effectively contribute to a deeper appreciation and mastery of relevant medical terminologies, disorders, interventions, pharmacology, cardiovascular assessment, and behavior modification interventions.
Preparation for Certification Exams
The attainment of a clinical certification exemplifies one’s competency in a realm of clinical practice. Numerous certifications exist among the established health specialties that CEP are qualified to receive. In many cases, acquiring certifications relevant to a particular field makes a candidate more marketable. Therefore, the proposed DCEP program will provide the necessary education and opportunities for students to qualify for various certifications. Certifications of note include 1) the American College of Sports Medicine (ACSM) Certified Clinical Exercise Physiologist; 2) the ACSM/American Cancer Society Certified Cancer Exercise Trainer; 3) the ACSM National Center on Health, Physical Activity and Disability Certified Inclusive Fitness Trainer; 4) Diabetes Educator; 5) Phlebotomist; and 6) Advanced Cardiac Life Support. However, obtaining one or more of these certifications will not be expected and will not preclude individuals from successfully completing the DCEP program.
NEXT STEPS AND FUTURE DIRECTIONS
The DCEP program outlined in this commentary represents an initial model intended to promote discussion among key stakeholders in the professional preparation of DCEP. The collective professional and academic experiences of the author group were applied to design the proposed didactic and practical components of the program, with the objective of augmenting critical areas of training to prepare DCEP to deliver individualized HLM across the health spectrum, from those who are apparently healthy to patients with complicated multimorbidity. As this, to our knowledge, is the first article proposing a DCEP educational model, the author group welcomes constructive feedback from students, practitioners, educators, and organizations representing CEP. The goal is to garner broad support for the DCEP among key stakeholders and ultimately implement an accredited DCEP model in the United States, providing high-quality academic and experiential training for developing the next generation of DCEP.
Upon gaining broad stakeholder input and support and optimizing the proposed DCEP model, a national accreditation mechanism through a professional organization will be needed. A rigorous accreditation process ensures that the education delivered to students is comparable across DCEP programs. Once a DCEP educational model and accreditation process is established, universities with the infrastructure, faculty, and commitment to establishing programs will have to be identified. Ideally, universities interested in pursuing this program should have strong ties with medical facilities committed to education and have secondary prevention programs (i.e., cardiac, pulmonary, cancer rehabilitation, and bariatric weight loss programs) that are prepared to incorporate students into their daily operations to fulfill the practical component of the DCEP program.
Although the primary aim of developing a DCEP program is to elevate the professional training students receive so that they are prepared to be highly effective practitioners, opportunities to collect data to support professional licensure for the CEP would be a reasonable long-term goal. Currently, CEP are unlicensed clinical professionals in the United States that are unable to independently bill for services they provide. Although there are many reasons why acquiring licensure has been unsuccessful, prominent limiting factors include the following: 1) a lack of standardized training across programs, 2) no requirement for program accreditation, and 3) the community’s limited understanding of the CEP scope of practice. In many ways, the rationale for pursuing a DCEP model overlaps with the path physical therapists took toward creating their professional doctorate over 20 yr ago. In addition to holding high standards for future doctorate level trainees, a primary rationale for pursuing the doctorate physical therapy model was to become recognized as a true clinical profession, capable of autonomous practice and direct access (38). Through widespread agreement and a united effort by professionals, academics, and the American Physical Therapy Association, the doctorate model was successfully implemented, which ultimately contributed to the advancement of the physical therapy profession. The path to licensure for the CEP is certainly not clearly defined; however, creating accredited professional doctoral programs that elevate the level of CEP training may facilitate efforts to seek licensure at both state and federal levels. Efforts to develop a mechanism to bill for the services provided by a licensed DCEP are also necessary and would require data establishing the efficacy of DCEP-led primary and secondary HLM interventions on reducing the incidence of NCD, healthcare costs, and morbidity and mortality through the respective programs. Being granted the ability to bill for primary and secondary prevention services by health insurance providers would have a transformative effect on standard patient care. In addition to being able to offer primary prevention services in existing programs (i.e., cardiovascular and pulmonary rehabilitation facilities), licensed DCEP could develop and operate independent health facilities dedicated to implementing HLM services. This approach would allow such programming to become more readily available to patients, particularly in rural areas, without having to be restricted to hospital-based practices. The authors are the first to acknowledge that the acceptance and implementation of our vision for the DCEP model in the United States will take time to gain widespread acceptance among key stakeholders. Given the current landscape of health care and the NCD crisis that is upon us, we feel it is of the utmost importance to begin this dialogue now.
Of note, Australia has implemented an accreditation and billing model for exercise physiologists, citing this profession’s important role in NCD prevention and treatment (22,39). This landmark legislative move grants accredited exercise physiologists eligibility for a Medicare Provider number, giving them the ability to provide primary and secondary preventative exercise physiology services with a general practitioners referral (40). The integration of accredited exercise physiologists into the clinical management of patients through this referral system has contributed to enhanced patient care by slowing progression of chronic disease and by reducing the incidence of acute exacerbations requiring hospitalization (41). Since being granted eligibility for Medicare Provider numbers in 2006, the widespread adoption of exercise physiologist provided services has occurred, with 80,000 referrals recorded in 2010 and 620,000 services provided in 2013 (42). Coupled with the efficacy of services and adoption by the medical community, this mechanism of interdisciplinary care in Australia has great potential to address the burgeoning incidence and prevalence of NCD. As such, Australia may serve as a valuable model for the DCEP model we are proposing in the United States. Facing the growing societal and health consequences of poorly managed NCD, highly trained DCEP will be a fundamental step in transforming primary and secondary preventative healthcare through the effective use of HLM.
With the continuing global rise of NCD and concomitant increased prevalence of complicated multimorbidity in patients attending secondary prevention programs, it has become increasingly necessary to ensure that clinical practitioners deliver high-quality HLM in a safe and optimally effective manner. The development of DCEP programs will provide the high-quality training needed to prepare students to meet this challenge and play a significant role in curbing the individual, societal, and economic impact experienced through insufficiently managed unhealthy lifestyle behaviors.
The views of this article do not constitute endorsement by the American College of Sports Medicine.
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