Is current medical training preparing physicians to prescribe exercise to their patients?

To reduce the pandemic of chronic disease, the World Health Organization implores physicians to target physical inactivity as a key risk factor. Chronic disease causes the majority of Canadian deaths, and if physical inactivity, poor diet, and smoking were eliminated, 80% of all heart disease, stroke, and type 2 diabetes, and 40% of cancers would be prevented.[1] Physical activity is effective treatment and prevention in 25 chronic conditions.[2]

Exercise follows a dose response curve, with greater health benefits accrued by those who attain higher levels of fitness, with 50% reduced risk of all-cause mortality and cardiovascular disease death compared with those with the lowest fitness.[3] If Canadians attained the physical activity guideline level of 150 minutes of moderate to vigorous physical activity (MVPA) per week, premature deaths of Canadians would decrease 30%.[2] From a population health perspective, significantly smaller amounts of physical activity also provide substantial health benefits. Inactive patients can lower their mortality risk by 10% by simply walking 10 minutes a day.[2]

Despite the irrefutable benefits of exercise, only 17.6% of Canadians attain guideline levels of physical activity,[4] and only 15.8% of Canadian physicians provide patients with exercise prescriptions.[5] Why this disconnect? Physicians cite lack of time and remuneration as barriers to exercise prescriptions. The most common barriers, however, among medical students, residents, and clinicians are lack of knowledge, training, and competence in exercise prescriptions.

The importance of preparing physicians to counsel and prescribe exercise to patients is widely recognized outside the medical community. Education, training, and the clinical practice of writing exercise prescriptions have been identified in global strategies and national policies, including the Canadian Senate’s report, Obesity in Canada, which makes recommendations to “encourage improved training for physicians regarding diet and physical activity” and “promote the use of physician physical activity counseling, including the use of prescriptions for exercise.”[6]

UBC undergraduate medical education has started to incorporate exercise medicine into the curriculum, yet most residency training programs have not. In a recent study of 396 UBC family medicine residents, 95.6% indicated prescribing exercise will be important in their future practice, yet only 14.9% perceived their training in exercise prescriptions as adequate.[7] Furthermore, 91% of these future physicians indicated they wanted more training in exercise medicine and exercise prescribing.[7] Such training can impact behavior, with Canadian doctors reporting greater confidence discussing exercise and providing more written exercise prescriptions 3 months following a 1-day workshop.[8]

All patients are impacted by physical activity. This underscores the universal importance of doctors having foundational knowledge in exercise medicine. Physicians and trainees are currently insufficiently prepared to discuss physical activity and prescribe exercise to their patients. Addressing this deficiency at all stages of medical training is urgent, given the increasing prevalence of chronic disease and its unprecedented health and economic implications on our society. BC has an opportunity to challenge the status quo, create educational opportunities in exercise medicine, and improve the health and lives of our patients and our communities. 

A CME-accredited half-day workshop in exercise prescription is coming to Vancouver on Saturday, 28 April, at VGH. For more information and to register, visit http://casem-acmse.org/event/eimc or email eimc.ubc@gmail.com.
—Kara Solmundson, MD, CCFP (SEM), Sport Med Dip, MSc

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This article is the opinion of the Athletics and Recreation Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

References

1.    World Health Organization. Overview – Preventing chronic diseases: A vital investment. Accessed 22 February 2018. www.who.int/chp/chronic_disease_report/part1/en/index11.html.

2.    Warburton DE, Charlesworth S, Ivey A, et al. A systematic review of the evidence for Canada’s Physical Activity Guidelines for Adults. Int J Behav Nutr Phys Act 2010;7:1-220. 

3.    Blair SN, Kohl HW, Paffenbarger RJ, et al. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA 1989;262:2395-2401.

4.    Statistics Canada (2015). Table 117-0019– Distribution of the household population meeting/not meeting the Canadian physical activity guidelines, by sex and age group. Accessed 22 February 2018. www5.statcan.gc.ca/cansim/a26?lang=eng&id=1170019#F1.

5.    Petrella RJ, Lattanzio CN, Overend TJ. Physical activity counseling and prescription among Canadian primary care physicians. Arch Intern Med 2007;167:1774-1781. 

6.    Report of the Standing Senate Committee on Social Affairs, Science, and Technology. Obesity in Canada: A whole-of-society approach for a healthier Canada. March 2016. Accessed 22 February 2018. https://sencanada.ca/content/sen/committee/421/SOCI/Reports/2016-02-25_Revised_report_Obesity_in_Canada_e.pdf. 

7.    Solmundson K, Koehle M, McKenzie D. Are we adequately preparing the next generation of physicians to prescribe exercise as prevention and treatment? Residents express the desire for more training in exercise prescription. CMEJ 2016;7:e79-e96.

8.    Fowles JR, O’Brien MW, Solmundson K, et al. Exercise is medicine Canada physical activity counselling and exercise prescription training, improves counselling, prescription and referral practices among physicians across Canada. Appl Physiol Nutr Metab 2018;doi: 10.1139/apnm-2017-0763.