If exercise is medicine, why don’t doctors talk to their patients about it?
Doctors are taught to talk to ask patients about sensitive topics. We practice asking our patients about their sex lives. We ask patients to share if they are feeling suicidal. We frequently talk about the colour and consistency of bowel movements.
It’s time for us to also start talking to patients about changing their exercise habits.
There is evidence that exercise has a role in therapy for over 20 chronic diseases, including depression, multiple sclerosis, and hypertension. And brief advice in primary care seems to be effective in increasing how much people exercise.
Yet physicians rarely counsel their patients about exercise. In 2015, the Canadian Medical Association encouraged physicians to rectify this and prescribe exercise to patients. At the same time, the report recognized that medical students and residents reported insufficient competency in this area upon graduation.
Time and competency are some of the top cited reasons why physicians do not counsel patients on exercise. Jane Thornton, an MD and advocate of exercise as medicine, pushed to resolve this through better training for medical students, and attendees at the 2016 annual CMA meeting subsequently passed a motion to support physical activity counselling training in medical school.
This is a step in the right direction, but it still needs to be emphasized by schools as an important aspect of the physician-patient relationship. Exercise counselling and motivational interviewing need to be taught and prioritized in clinical environments, not just in lectures. This will provide students with expertise in how to broach this subject with patients, as well as reinforce the value that our policies and educators place on exercise advocacy.
I am the last cohort of an older curriculum at our school that doesn’t include diet and exercise as discrete lectures. However, some of my fellow students, who are currently being taught about the importance of exercise, seem resistant to the idea. They expressed concern to me with the “wasted lecture time” on diet and exercise. They already knew exercise was beneficial, so why spend time on that?
I have empathy for these students. They’re stressed by the many demands of medical school. And I feel that they’re reflecting the broader values within health care. Our system prioritizes diagnosis and treatment. Family doctors in Ontario cannot bill for physical activity counselling – and should be able to.
We cover hospital bills and doctors’ appointments, but healthcare workers who specialize in diet and exercise – including kinesiologists, dietitians and personal trainers – are rarely covered by public health plans, except in specific circumstances or certain family health teams.
Barriers to communication also exist. Physicians are biased against overweight patients, for example, as physicians are more pessimistic about patient’s capabilities to lose weight than patients are about themselves. In these cases, physicians who believed patients were able to facilitate better conversations.
There is also a stigma that overweight or inactive physicians face. Evidence shows that doctors are less likely to advocate for exercise when they themselves are inactive. Additionally, physicians who are overweight or obese are less confident in addressing physical activity with patients. This is also reflected within medical students, and improving physical activity habits in medical students could theoretically increase rates of exercise counselling as physicians based on current trends. Finally, a systematic review confirmed that overweight physicians provided less generalized health advice than colleagues who were normal weight.
Because of this, the CMA recommended exercise initiatives within doctors and students to increase our own activity levels. However, equally as important is actually learning how to counsel our patients in clinical settings and discussing our own personal reservations about broaching this subject. Learning to talk the talk may help us walk the walk, and vice-versa.
We definitely need to learn how to prescribe exercise, but this will only be useful if we can overcome our internal barriers and health-care’s devaluation of preventative care. It’s time to get comfortable talking to patients about exercise.
Arjun Sithamparapillai is a second year medical student at the University of Toronto who works as a personal trainer and has a passion for exercise advocacy and public health.