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OVER the past couple of decades, the evidence has accumulated that simply exercising regularly has enormous benefits for the prevention and treatment of a wide range of chronic conditions.
It’s been estimated that people who manage 150 minutes of moderate to vigorous activity per week cut their risk of major chronic disease by 25–50%. In fact, for the prevention of diabetes, treatment for heart failure, secondary prevention of coronary heart disease and stroke rehabilitation, exercise has been shown to be just as effective as conventional drug therapies at keeping patients alive and well.
Given the added advantages of exercise over drugs or surgery in terms of side effects or adverse events, the big question is why doctors don’t prescribe it more often. This evidence–practice gap is the subject of a new Perspective published in the MJA, authored by three researchers from the University of Queensland.
They identify two key barriers to prescribing exercise. One is a lack of training at undergraduate level, and the other, perhaps surprisingly, is the level of physical activity of the doctors themselves.
“We know that many medical students and doctors don’t meet the guidelines for minimum physical activity. And we also know that the best advocates for exercise are people who believe it’s important in their own lives,” explains lead author, Dr Anita Green, in an exclusive podcast for MJA InSight.
“It’s consistently been shown that the more active a clinician is, the more likely they are to think about exercise, to bring it up with the patient, and help the patient become more active.”
Dr Green, a GP by training and also the Chief Medical Officer for the upcoming Commonwealth Games on the Gold Coast, points to smoking as a good example of where doctors have been successful at lifestyle modification.
“There were extraordinarily high rates of smoking up until the mid-1960s, but now it is well under 20% of the population. That’s an area where we’ve done extremely well, but prescribing exercise is a bit more nuanced. It’s hard to do in a brief consultation, and we need to be educating undergraduates and postgraduates so they feel confident in doing this.”
Dr Tammy Hoffmann, a lecturer at Bond University and lead author of a how-to guide to prescribing exercise for chronic health conditions, agrees that training is a key issue.
“There’s a lack of awareness of the evidence for the benefits of exercise. It’s not something that the medical schools routinely teach. And then there’s the problem of knowing what you actually prescribe. Just like you wouldn’t write a prescription for a drug without saying which one, you can’t just write a prescription for exercise. You have to tailor it to a condition. It has to be the right kind of exercise for the right amount of time.”
Other than her own article, which presents specific exercises by disease type, Dr Hoffmann recommends the Royal Australian College of General Practitioners’ HANDI (Handbook of Non-Drug Interventions), a free access resource with details of non-drug treatments designed to be as easy to use as looking up a medication in a drug formulary.
Dr Hoffmann says that another barrier to prescribing exercise is a historical “drugs mindset” that many in the medical profession have.
“This is reinforced because exercise doesn’t have well funded bodies advocating for it. No one’s advertising exercise in the same way that drug companies are advertising their drugs. There are no Medicare Benefits Schedule items for exercise. The Pharmaceutical Benefits Scheme (PBS) won’t fund your gym membership. We need some rethinking in terms of reimbursement for effective non-drug interventions.”
An added problem, she says, is that it’s not easy to capture data on the extent to which doctors prescribe exercise.
“We can get the hard data for drugs through the PBS for example, but non-drug interventions are often not captured in the medical histories so we can’t be sure what’s going on.”
Professor Garry Jennings, AO, a Melbourne-based cardiologist and the Heart Foundation’s Chief Medical Advisor, says that although doctors have a key role to play in promoting and discussing exercise with their patients, the issue is ultimately much broader than that.
“There’s a whole range of things to be done, not just in medicine but in the wider community. It’s also about infrastructure, how we design our cities, and whether we do it in a way that encourages exercise and makes it enjoyable.”
Professor Jennings also makes the point that all exercise is good, even if it’s below guideline recommendations.
“Yes, it’s great if you’re doing the recommended 150 minutes per week. But it’s not for everyone, and people shouldn’t be put off if they find that too much. Any exercise is better than none at all.”
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From studies/surveys done in the US, for most primary care physicians that address physical fitness, it has been simply a statement to the patient that they should “… get more exercise.” That isn’t very actionable for most people.
One challenge is that they do not know enough about the specifics of exercise FITT (Frequency, Intensity, Time, and Type). Their schooling does’t cover it (although there is a movement to include exercise science in future curriculums)
Many are inactive themselves. That doesn’t mean that they don’t recommend exercise, but those that do exercise and know the benefits are far more likely to share that information with their patients
Another challenge is that many doctors don’t have adequate time to discuss fitness.
Sorry Phillip, as an avid exercise person, the active doctor passes on subtle cues to the patient. We lead by example, we can prescribe detailed exercises to suit the medical condition and the disability they have, we are aware of the minor injuries that “stop” newbies in their tracks and we are constantly reminding them every time we see them. Our “passion” will sway many but not all patients. We can honestly tell patient that it works.
It is true less active of us will not actively promote exercise since it lacks credibility.I know few oof us who call themselves walking risk factors
it is also true it is not brainwashed to us by drug travellers
Ofcourse reaching obesity with osteoarthitis tells us we need to act early not late
About gym membership and doctors I know and most of us would or should is we have plenty of patients who like us to certify that they have medical conditions which can benefit by exercise and of course they get some benefit from private health fund with some financial benefit
Of course we know GP management plan with team care arrangement which allows and subsidises referral to exercise physiologist or dietitian etc
Philip … why don’t you go read Dr Green’s study … the link is provided and it’s open access, after all. Instead of moaning about evidence — go read the research … sheesh
I disagree, even inactive doctors say they advise patients to walk more even if they don’t tell them to jog swim or cycle.(do you actually have any evidence of what inactive doctors tell their patients, or is this just an assertion?). Accusing doctors of not knowing something without evidence is poor journalism (and GPs seem to be on the receiving end of these kinds of assertions a lot). The problem I and my colleagues see is those who most need the exercise are overweight osteoarthritic, and may have severe emphysema or heart failure. They tend to all have reasons why they “cant exercise” meaning they wont. It tends to take a lot of time to convince some of them that even a little increase in activity will be beneficial. Fortunately we have a funded exercise physiologist to send them to. Unfortunately some of those who most need it wont go!