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.
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I love this, great read.
Great article to draw attention to this important issue. My colleagues and I have been prescribing exercise since we graduated residency (2002). We have had it in our patient contracts. Most importantly throughout the different places I have worked, my patients have always seen me exercising so when I prescribe it, they know I am also taking my own advise. The best way to lead is by example! Maybe we should not just teach med students/residents to prescribe exercise, but to make it part of the Doctor’s day. It would also help with our high rates of stress and burnout and likely improve job satisfaction.
It’s up to all of us to share the health and wellness benefits of exercise. Our Nordic Walkers love bragging to their Doctor’s about the changes getting active has made in their lives!
Yours in health
I agree physicians should be talking about exercise more when they are dealing with their patients who have chronic health issues.Let’s not forget the most qualified exercise specialist-the movement specialists,that is Registered physiotherapists!Some are covered by OHIP.Many individuals have extended benefits that they are not using as well.We are not just injury recovery specialists or post surgical rehabilitation professionals.We are exercise specialists who can analyse a person’s body and their needs.Let’s get the doctors referring more to a Registered physiotherapist if the exercise talk comes up.If it doesn’t just know that someone can see a Registered physiotherapist without a referral anytime!
Ginger Peters Registered Physiotherapist,Owner,Ginger’s Physiotherapy Place, London Ontario
Great thoughts in this article! Perhaps some of your student colleagues might be interested in our Learn To Run Program we offer in partnership with the Hart House! Great read!
From – The Runner’s Academy
Great perspective, but there are options out there. One great option would be to find a good Physiotherapist in the community and refer appropriate patients. There are coverage options through Community Physiotherapy Clinics (OHIP-funded), which cover an episode of care for eligible populations (https://www.ontario.ca/page/physiotherapy-clinics-ohip-funded). Those of working age generally have extended health benefits that they can utilize for this purpose. There are also group exercise and falls prevention programs for seniors, covered under OHIP (https://www.ontario.ca/page/exercise-and-falls-prevention-programs).
As a former Kinesiologist and Exercise Physiologist I am thrilled to read your article. As Doc Mike Evans 23.5 hours has cleverly demonstrated, exercise can have tremendous benefit. Exercise Prescription however is more complicated than simply encouraging a patient to go out and walk – in parallel I’m certain Dietitians will agree that simply encouraging people to “eat better” has limited impact. Motivational interviewing techniques and engaging the patient in the plan of action are critical. Coupling that with the specifics of chronic disease or risk thereof with other factors including past activity history, medications, social economic status/supports, and personal life priorities do make this complicated. Ontario regulated the profession of Kinesiologists to recognize their specific expertise in this area – I know there are ample qualified Kinesiologists in the province who would be more than happy to work alongside physicians to support their patients (the challenge of course is funding those RKINs to do this work).
Great article Arjun. I could not agree more with this perspective. Advocacy for exrecise as a form of treatment is exactly what pushed me towards persuing a career in medicing. Best of luck with the rest of your studies.
Interesting article with some very good points. I can see the importance of physical activities and diets being part of the medical school curriculum as it has a significant impact on health and wellbeings of individuals. One thing I do disagree is “Family doctors in Ontario cannot bill for physical activity counselling – and should be able to.”. The counselling should be part of the package as a whole when counselling on whichever disease states the patient has. Let’s say the patient is obesed, physical activity should definitely be counselled, or if the patient has hypertension and it has been shown that non-pharmacological strategies such as exercise can decrease their blood pressure to reduce the pharmacological burden on the patient. Monetary incentives should not be the motivation for physicians to do what is part of their job and the moral responsibility to provide the best care to their patients. However, I do ageee a better use of that funding may be on coverage of dietitians and personal trainers for patients that require the service and cannot afford.
Courses in exercise, diet and nutrition should be absolutely mandatory in medical school. These are critical areas that, addressed and implemented by patients, could have a significant and positive impact on their physical and mental health. Excellent article!
Great article Arjun. Having worked clinically within a FHT for 3 years the lack of buy in by physicians that exercise was important to their patients health was very discouraging and one of the factors that drove me back into academia. Glad to see that there is discussion about the importance of physical activity and healthy eating in the medical curriculum now and hope to see that the next generation of doctors are better prepared to address this issue in practice.
Fantastic perspective and great read!