Exercise is Medicine - Why isn't it being prescribed more regularly
Book Reviews, May 13, 2016
This is not a book review as much as a commentary on an article published in Current Sports Medicine Reports written by Dr Thomas M. Best entitled Exercise - The Medicine We Should All Prescribe.
I just had a chance to read American College of Sports Medicine’s latest issue of Current Sports Medicine Reports. An article by Thomas M. Best, MD, PhD., Exercise – The Medicine We Should All Prescribe (1) drew my interest, and, since it was in the Invited Commentary section of the publication, I figured I would give it a go.
The first thing I think that needs to be pointed out about the article is that Dr. BEST is recommending exercise as a prescription – I find this to be logical. The Best doctors in my opinion would prescribe exercise to their patients as exercise is not only medicine, as ACSM has trademarked in 2007, we know it to be the very best medicine for treating and resolving major chronic disease.
Dr. Best makes some excellent points in this article, outlining that physicians need to promote exercise, physical activity must be a vital sign examined by physician routinely, and there is a need to have more education about exercise and its potential for health promotion in medical schools. He also addresses that there are serious challenges facing physicians trying to prescribe exercise to their patients including: limited results when primary care based interventions have been examined, issues with long-term adherence to exercise, and that many patients aren’t given the correct explanation of health information needed to make an informed decision or aren’t ready to process this information. Lastly, he implies that this is a CRITICAL issue facing our nation’s health care.
To all of this I would say, first this is more critical than Dr. Best implies. I say this because our nation’s health care is not only our system of patient health, it is the health of our nation. Based on current trends, we are a sick nation. Health is a valuable commodity and we are lacking in this commodity as a nation.
How do we properly address this issue? Dr. Best’s suggestions of physicians, routinely, Identifying Physical Activity (PA) as a vital sign is a good first step, but it MUST go further. PA is a simple measure of “lack of being sedentary”. I have seen many patients in cardiac rehabilitation that can report being physically active, but under further examination, there is a serious lack of physical fitness in these same individuals. Being physically active is better than being sedentary, but being fit is the primary goal of activity. Not achieving fitness with your activity is an empty achievement, as discussed in the landmark paper, published in JAMA, by Steven Blair in 1989 (2).
Currently, physicians are not trained to prescribe exercise and, with other healthcare shortages, do not have the time necessary to spend with patients to correctly prescribe it. Proper prescription requires monitoring of individual response to exercise, which is critical for proper, safe, care, not only in the initial prescription of exercise, but in its progression. As mentioned, long term adherence is also an issue with exercise. Boredom can also be an issue if exercise prescription does not evolve with the patient’s capacities and goals.
As to long term adherence and adoption of exercise, physicians play a key role. It is critical that physicians REGULARLY discuss individual exercise prescription and fitness with patients in the same sense that any medication prescription is discussed in clinical visits. Isn’t that what we are saying? Exercise is Medicine™!
Lastly, to address this issue, physicians need safe and effective resources to use with patients. This starts with committing to regularly discussing Exercise as Medicine in clinic and addressing each patient’s need in their current state. This means identifying their state of readiness, which allows for individualization of care.
This leads me to the processing the health information, many patients are in a phase of readiness which is called Pre-contemplation. This phase of readiness is considered “un-informed” regarding the risks of their lifestyle and intervention options. Many patients may seem ambivalent to a physician’s request to address their lack of PA. This is not a lack of respect for the physicians’ advice, but a lack of understanding as to why it is being advised. This can effectively be addressed through education or counseling on the subject. This takes someone with at least some training and experience in behavior modification and the TIME to deliver the counseling. Then, and only then, might a patient move into what is termed the contemplation phase of readiness or maybe into the preparation phase of readiness. Once someone is preparing to become physically active, then it is important to have safe and effective alternatives to refer to.
So, while I love the message Dr. Best is sending, ultimately to accomplish the task, a few items are needed:
1. Physicians committed to regularly discuss the medicine called exercise in their clinical visits
2. We must identify readiness of the patient to adopt regular PA and determine the appropriate treatment, whether it is health coaching or exercise itself.
3. Treat the patient with “Awareness Raising” counseling or exercise.
The way I see it is: there is a missing piece in this puzzle. While I can spell out the steps 1, 2, 3, the person that is appropriate and fully capable to delivering these services in clinic is NOT in clinic. These individuals have moved on to either a different role in the health care system or they are working in another industry all together. It is the “Exercise Physiologist” trained in health coaching that can help physicians and the health care system achieve this critical goal.
If you would like to see this model in action, you should check out Restore Medical Fitness©.
Best, T.M. (2016) Exercise — the medicine we should all prescribe: Current sports medicine reports. Available at: http://journals.lww.com/acsm-csmr/Citation/2016/05000/Exercise___The_Medicine_We_Should_All_Prescribe.7.aspx?sessionEnd=true (Accessed: 13 May 2016).
Blair, S.N., Kohl, H.W., Paffenbarger, R.S., Clark, D.G., Cooper, K.H. and Gibbons, L.W. (1989) ‘Physical fitness and all-cause mortality’, JAMA, 262(17), pp. 2395–2401. doi: 10.1001/jama.1989.03430170057028.
Exercise is Medicine™ is trademarked by the American College of Sports Medicine