What if coursework on blood pressure, how to measure it and what it indicated, was required in only 12% of medical schools? What if less than 5% of medical schools required students to know how to treat abnormal blood pressure? Would we accept that? Of course not! The outcome would be more patients with undiagnosed hypertension and many physicians missing a vital tool for helping patients complaining of headaches or dizziness. The downstream effect would be a rise in heart disease, stroke, and renal failure.
But we do this with another vital measure of health, one that is associated with increased risk of at least 25 chronic diseases. Physical inactivity is frequently recognized as a major public health problem. The CDC reports that over 80% of American adults fail to meet the Physical Activity Guidelines for Americans. More concerning is the fact that this statistic has only improved by 4% in the past two decades. Conversely, when people do meet the recommended amounts of exercise, they benefit from a 40% reduction in all cause mortality.
“Consult your physician before starting an exercise program” is the typical advice on nearly every piece of exercise equipment and program, giving the impression that knowledge about exercise is a standard part of being a physician. It is understandable why many Americans cite their physician as a primary source of information regarding lifestyle choices. However, few physicians counsel their patients about physical activity regularly. When physical activity is addressed, it is counseled as secondary prevention more often than primary prevention. Common barriers to counseling about physical activity include inadequate time and insufficient knowledge about the topic.
Clinical exercise physiology is a branch of physiology specifically dedicated to the understanding of how exercise works as medicine. Clinical Exercise Physiologists (CEP) hold advanced degrees and accredited certifications providing the specific knowledge and skills needed to utilize exercise as medicine safely and effectively. CEP’s are a part of the team at hospital-based weight loss clinics, cardiac and pulmonary rehabilitation programs, diabetes centers, and other clinics where providers and patients benefit from the value of this specialty in medicine. Why is their expertise missing from the standard medical curriculum?
Increased frequency in exercise counseling has been found to be related to personal exercise practices. This is true of both practicing physicians and medical students. Over 60% of US medical students adhere to the CDC physical activity recommendations. Medical students that exercise regularly are more likely to feel confident in counseling patients about physical activity and are more likely to find exercise counseling important.
A recent review of medical school curriculums found that over 50% of medical students failed to have any formal education related to physical activity. In 2015, Cardinal et al. studied the curriculums of 170 US allopathic and osteopathic medical schools. Of the institutions studied, only 21.2% had one course available to medical students and only 12.2% had a required course. The majority of these courses focused on exercise physiology or sports medicine, with only 8.1% and 4.7% educating about preventive or lifestyle medicine respectively. A pilot course on preventative medicine and nutrition at Harvard Medical School in 2004 found that participating in such a course improved medical students’ confidence on diet and exercise counseling. Furthermore, participation improved perceived dietary habits in a significant number of students.
If we want physicians to educate their patients about the benefits of exercise, we need to educate them first. How can we expect doctors to intelligently and safely prescribe physical activity to their patients if they are not given the knowledge, skills, and resources to do so?
In an effort to combat the lack of formal education related to physical activity counseling in medical school, an option enrichment elective, Fitness: The New Vital Sign?, was launched in fall of 2016 at the University of Massachusetts Medical School. Students participating in the elective were exposed to a curriculum that addressed the role of exercise in prevention and treatment of disease, common barriers to exercise counseling, how to overcome these barriers, and tools for motivational interviewing patients. Physicians from different specialties gave lectures about their field of work, clinical exercise physiologists discussed the pathophysiology behind exercise’s effect on different disease states, and patients attended to share their perspective and experiences. Students’ confidence level in counseling patients about physical activity were compared before and after participating in the course, and tracked each semester thereafter.
Students participating in the elective rated their confidence in counseling patients about physical activity at an average of 2.17 on a five-point scale, with one equaling “not at all confident” and five meaning “very confident.” After the elective, confidence increased to an average of 3.49. Notably, six months and one year after the first course launch, participants still rated their confidence at an average of 3.5 and 3.94 respectively. 82% of participants stated they feel comfortable discussing exercise with patients even when their attending physician or residents are not. After participating in the course, one student noted “I liked learning about how strong a role exercise can play in patients’ lives since we usually only hear about the effects of medications on improving outcomes. I could easily implement what I learned in the elective in my daily routine, and could witness the positive change of exercise firsthand.”
This is only preliminary data, and more data collection and analysis is to come as the course matures and evolves, but the information is striking. If we make a concerted effort to educate our medical students about physical activity and give them the tools and resources to do so, it can have a significant impact on both prevention and treatment of disease with exercise. We cannot blame uneducated doctors for not counseling their patients about physical activity, but we can do something to educate them.
- Cardinal BJ, Park EA, Kim M, Cardinal MK. If exercise is medicine, where is exercise in medicine? review of U.S. medical education curricula for physical activity-related content. Journal of physical activity & health. 2015;12(9):1336.
- Conroy MB, Delichatsios HK, Hafler JP, Rigotti, NA. Impact of a preventative medicine and nutrition curriculum for medical students. American Journal of Preventative Medicine. 2004; 27 (1): 77–80.
- Frank E, Tong E, Lobelo F, Carrera J, Duperly J. Physical activity levels and counseling practices of U.S. medical students. Medicine and science in sports and exercise. 2008;40(3):413–421.
- Garry JP, Diamond JJ, Whitley TW. Physical activity curricula in medical schools. Academic Medicine: Journal of the Association of American Medical Colleges. 2002; 77 (8): 818–820.
Marissa Mastrocola is a fourth year medical student at the University of Massachusetts Medical School. Janet Huehls is a clinical exercise physiologist at UMass Memorial Medical Center. There are no conflicts of interest.