PREVENTIVE
MEDICINE
A Survey
21, 630-636
(1992)
of Physicians’ Attitudes and Practices Exercise Promotion
Related
to
HENRY N. WILLIFORD, ED.D., *,’ BETTY R. BARFIELD, M.S., R.N. ,t RAMONA B. LAZENBY, M.S., R.N.,? AND MICHELE SCHARFF OLSON, PH.D.* *Human
Performance
Laboratory
and tSchoo1 of Nursing, Auburn Montgomery, Alabama 361 I7
University
at Montgomery,
Methods. One hundred sixty-eight physicians responded to a survey to determine their attitudes and practices related to exercise and the development of exercise prescriptions. The mean age was 45.5 + 10.8 years, with the majority being male (86.7%). Results. The survey found that 48% of the physicians required an exercise history as part of their initial examination and 91% encouraged their patients to participate in regular exercise programs. Seventy percent of the physicians did not develop exercise prescriptions and only 23% were familiar with the American College of Sports Medicine guidelines related to the development of exercise prescriptions. Only a small number of physicians (3%) had ever taken a college-level course related to exercise physiology and the development of exercise programs. The majority (78%) felt that there was a definite need in medical school for a course related to the medical aspects of exercise. Conclusions. Results of this investigation indicate that while physicians support exercise for health promotion and rehabilitation, greater emphasis needs to be placed on physician involvement in promoting and/or prescribing exercise. 0 1992 Academic Prob. Inc.
INTRODUCTION
Regular physical activity may be necessary for optimal health and is associated with the prevention and control of numerous health problems. Exercise as a health promotion activity has been shown to be cost effective and produces a net economic savings, while physical fitness as a preventive measure has been shown to be related to delays in all-cause mortality (1, 2). Physicians hold a unique position in influencing patients regarding health promotion and disease prevention. Exercise is considered an important component in health promotion and is recommended by many groups, including the American College of Sports Medicine (ACSM), the National Heart, Lung, and Blood Institute, and the American Heart Association. The American College of Sports Medicine recommends physician involvement in all aspects of preventive and rehabilitative exercise programs (1) and the U.S. Preventive Services Task Force has been instrumental in developing guidelines for physical activity counseling by physicians (4). The U.S. Surgeon General’s Workshop on Health Promotion and Aging has made a research recommendation to develop guidelines for screening and baseline medical evaluations for individual patient exercise programs (5). The U.S. Department of Health and Human Services Public Health Service 1990 Health Objectives for the Nation (6) and the Healthy People 2000 National Health Promotion and Disease Prevention Objectives (7) include specific objec’ To whom reprint requests sity Drive, Auburn University
should be addressed at Human at Montgomery, Montgomery, 630
0091-7435/92
$5.00
Copyright 0 1992 by Academic Press. Inc. All rights of reproduction in any form reserved
Performance AL 36117.
Laboratory,
7300 Univer-
EXERCISE
PROMOTION
AND
PHYSICIANS
631
tives related to the role of exercise and physical fitness in disease prevention and have placed a high priority on increasing physical activity and physical fitness. One of the objectives requires direct physician involvement, suggesting that at least 50% of the primary care providers routinely assess and counsel their patients regarding the frequency, duration, type, and intensity of each patient’s physical activity practices. Several studies have shown that patients expect their physicians to promote and encourage lifestyle change (8, 9), and the Canada Fitness Survey found that approximately one-fourth of all Canadians ranked physician’s orders as a significant reason for being active (10). Physician advice and counseling are important in encouraging patients to become more physically active. The physician-patient encounter provides an excellent opportunity during which the patient can be counseled about physical activity. Before starting an exercise program, individuals often seek physician approval as well as advice regarding specific recommendations related to frequency, intensity, duration, and modes of exercise training. Also, allied health professionals often require physician approval or clearance before developing an exercise prescription for one of their clients. Because of the unique position that physicians hold in recommending and prescribing exercise, the purpose of this investigation was to determine physicians’ attitudes and practices related to the promotion of physical activity and the development of exercise prescriptions. METHODS
A questionnaire was developed by a pane1 consisting of physicians, nurses, and exercise physiologists to determine attitudes and practices of physicians and their role in exercise promotion and prescription. After the development of the questionnaire a group of health professionals reviewed the instrument to ensure clarity and reliability. Test-retest reliability scores on a sample of 50 subjects were high, ranging from 0.95 to 0.98 for each of the multiple choice questions. A list of physicians was obtained from the Board of Medical Examiners of the State of Alabama. From the list, 250 eligible physicians were randomly selected to take part in the survey. Individuals were eliminated if they did not live in the state, did not engage in direct patient care, or were in specialities in which exercise had no logical relationship. A self-addressed stamped envelope was enclosed for return purposes. One hundred sixty-eight physicians responded to the survey. yielding a 69% return rate. The mean age was 45.5 ? 10.8 years with a range of 28 to 78 years, The sample was primarily male (87%). When the age and sex of the present sample were compared with those of the entire population for the state, similar demographic data were found. Statistics from the State of Alabama Health Planning and Development Agency indicate that Alabama has approximately 6,618 full-time practicing physicians, with 85% being male. The mean age of Alabama physicians is 48.2 2 10.2 years. The sample consisted primarily of family practice and internal medicine physicians. These specialities represent 75% of the sample. RESULTS
Table 1 shows a summary of the physicians’
responses to the questions on the
632
WILLIFORD
ET
AL.
TABLE 1 SUMMARY OF PHYSICIANS' RESPONSESTO QUESTIONNAIRE Question Encourage patients to exercise Obtain exercise history Normally develop exercise prescriptions Another staff member develops exercise prescriptions Receive referrals for exercise Primarily refer patients to the following for exercise prescriptions Physical therapy Other physicians Exercise physiology Nurse Familiar with ACSM guidelines Completed a college or medical school course related to exercise prescription Is there a need for an exercise related course in medical school
Yes (%)
No (%)
91 49 30 13 4
9 51 70 87 96
68 20 9 3 23
77
3 78
97 22
survey. The majority of the physicians (91%) encouraged their patients to participate in regular exercise, while 9% did not promote exercise. Less than one-half of the physicians (49%) required a review of exercise history as part of the initial examination. Approximately one-third developed exercise prescriptions for their patients, whereas 70% of the physicians reported that this was not part of their normal practice. Only 23% of the sample were familiar with the ACSM guidelines for exercise in healthy adults, and 3% had ever taken a college-level course related to exercise and the development of exercise prescriptions. However, the majority of physicians (78%) felt that there was a definite need in medical school for a course related to the medical aspects of exercise. Thirteen percent of the physicians had staff members whom they indicated developed exercise prescriptions for their patients. When asked to whom the physicians referred their patients in order to recommend an exercise program, physical therapists ranked first (68%), other physicians second (20%), exercise physiologists third (9%), and nurses fourth (3%). When asked if patients were referred to them to develop exercise programs for health promotion, 4% received referrals while 96% did not. DISCUSSION
It has been well established that exercise can have a favorable impact on an individual’s health and that physicians are highly recognized as leaders and role models in health promotion. The majority of physicians (91%) reported that they encouraged their patients to participate in regular exercise. This response indicates the physicians generally support the concept of exercise as being important in promoting good health practices and preventing disease. A similar survey of beliefs among medical students found that 95% believed that regular exercise can bring significant health benefits to the majority of people (11). The results of our survey indicated that physicians in Alabama assessed exercise history at rates (49%) similar to rates of physicians in other parts of the
EXERCISE
PROMOTION
AND
PHYSICIANS
633
country. Although limited data regarding exercise history, are available, regional surveys from Massachusetts, Maryland, and California found that an estimated 47% of primary care physicians routinely inquired about their patients’ exercise habits (5, 12, 13). One of the specific objectives of the 1990 Health Objectives for the Nation was that 50% of primary care physicians would include a careful exercise history as part of their initial examination of new patients (6). While all of our respondents were not primary care physicians, our survey indicates that the goal of 50% has not yet been accomplished. The new Objectives for the Year 2000 state: “Increase to at least 65% the proportion of primary care providers who assess and counsel their patients regarding the frequency, duration, type and intensity of each patient’s physical activity practices as part of a thorough evaluation and treatment program” (7). These new objectives go a step further and suggest that in addition to assessing health history physicians should counsel their patients regarding the specific training variables of frequency, duration, type, and intensity of physical activity practices as part of a thorough evaluation and treatment program. The development of an individual program of exercise establishing frequency, intensity, and duration of exercise is characteristically termed an exercise prescription. With respect to the Year 2000 Objectives, the physicians surveyed were well below the goal of 65% compliance for exercise history, with only 30% of the physicians normally developing exercise prescriptions. A study by Rosen et al. (14) showed a similar response rate with 30% of the surveyed physicians bringing up the topic of exercise with their patients. Iverson et al. (15) also reported that the majority of physicians did not counsel their patients regarding physical activity. Lewis et al. (16) investigated the prevalence of counseling practices of internists regarding exercise. They reported that 51% of the generalists and 43.5% of the specialists counseled their patients about exercise. The development of an exercise prescription may be perceived differently from counseling patients about exercise. This may be one reason for the differences in the response rate. Lewis et al. (16) also found that the internists who were more physically active counseled a greater percentage of patients than internists who were less active, and the internists who spent more time counseling perceived themselves to be more effective in changing patients habits. Other studies have also shown that physicians’ personal habits and attitudes toward counseling are important considerations (17, 18). Possible reasons for not counseling patients may be related to lack of confidence in counseling patients, lack of insurance reimbursements, lack of education related to the medical aspects of exercise, and lack of standard formats for assessing and prescribing exercise (11, 14, 15). It has been recommended that standardized questions regarding health history be established to further facilitate attainment of this objective (7). Mechanisms need to be in place to aid physicians in developing appropriate exercise programs for their patients. Some doctors indicated that simply telling a person to go out and walk was their idea of an exercise prescription. This was reflected in the small percentage of physicians who were familiar with the ACSM or any other guidelines for prescribing exer-
634
WILLIFORD
ET AL.
cise. The development of an exercise prescription for an individual who has serious health problems and is taking a variety of medications can be quite extensive (3). In 1989, a report regarding the use of physical activity counseling for healthy adults as a primary preventive intervention was developed by the U.S. Preventive Services Task Force (4). This report represented an important major National policy orientation regarding the physician’s role in prescribing exercise for prevention of coronary heart disease, hypertension, non-insulin-dependent diabetes, osteoporosis, obesity, and mental health problems. In the report specific guidelines were established with respect to physical activity counseling. The established guidelines are important since they represent a practical, easy-to-follow technique for counseling patients. The present questionnaire revealed that only 3% of the physicians had taken a college-level course related to the development of exercise prescriptions. Sixtythree percent of the medical students surveyed in the United Kingdom reported that they received too little teaching about the medical aspects of exercise and another 37% felt they were unduly ignorant of the medical aspects of exercise (11). From the present data it appears that medical schools have placed little emphasis on training physicians to prescribe exercise. Seventy-eight percent of the respondents from our survey expressed the need for a course related to the medical aspects of exercise, Physicians may feel uncomfortable in developing exercise prescriptions because of lack of training. It has been suggested that physicians need to increase their efforts and develop their skills in counseling. Lewis et al. (16) suggested that it might be advantageous to encourage positive health habits and counseling skills in the first year of medical school. In terms of referrals to other health professionals for developing exercise programs, physical therapy was the group that received the greatest number of referrals, with physicians referring fewer patients to other physicians and exercise physiologists. It appears that physicians have better access to physical therapists and are more familiar with this occupation with regard to developing exercise programs. A possible reason for physician referral to the physical therapist is that state licensure provides for quality control assurance. Exercise physiology is relatively young as a profession, with a fairly small number of exercise physiologists working in health care facilities. This may be the one reason for the limited number of referrals to this group. The ACSM has developed several certification programs for exercise physiologists and other exercise-related personnel. These certification programs may also increase the quality control measures. A small percentage of the physicians referred patients to nurses. More and more nurses are currently involved in health promotion and are working in exercise-related areas, However, nurses, like physicians, are generally not formally trained in developing exercise prescriptions. If there is an increase in the promotion of exercise by physicians, one would expect greater involvement from a variety of health care professionals to aid the physicians in prescribing appropriate exercise. There are a variety of professional and educational organizations that offer postgraduate medical courses and provide reference materials to physicians. The
EXERCISE
PROMOTION
AND PHYSICIANS
635
American College of Sports Medicine is the largest sports medicine organization in the world, with nearly 12,000 members involved in science, medicine, education, and sports (19). One of its primary missions is to disseminate research and information about the benefits and effects of exercise. In 1978 the ACSM published guidelines related to the quality and quantity of exercise for healthy adults (20) and in 1990the ACSM revised the guidelines related to frequency, intensity, duration, and modes of exercise (21). Twenty-three percent of the physicians were familiar with the ACSM guidelines. The ACSM is attempting to attract a greater number of physicians and to disseminate materials related to proper exercise programs. The ACSM has also established a Healthy People 2000 Committee to promote the public health objectives within its membership. Educational materials have been made available to physicians and other health care providers to promote the Healthy People 2000 Objectives. The President’s Council on Physical Fitness and Sport is another organization that is attempting to encourage the role of physician involvement related to exercise. In conjunction with private industry, they have developed an exercise plan that will be distributed and handled by primary care physicians, internists, and orthopedic surgeons. CONCLUSION
In summary, there is increasing concern related to the role that physicians play in screening and counseling patients related to the benefits of exercise. A number of organizations are promoting exercise as a preventive measure and are encouraging physicians and other health care providers to become more involved in the process. Physicians in Alabama tend to assessand counsel their patients regarding exercise at rates similar to those found in other parts of the country. If the Healthy People 2000 National Health Promotion and Disease Prevention Objectives are to be accomplished, greater emphasis regarding physician involvement and health promotion is needed. REFERENCES 1. Hatziandreu EI, Kaplan JP, Weinstein MC, Caspersen CJ, Warner KE. A cost-effective analysis of exercise as a health promotion activity. Am J Pub/it Health 1988; 78:1417-1421. 2. Blair SN, Kohl HW, Paffenbarger RS, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality: A prospective study of men and women. JAMA 1989; 262:2395-2401. 3. American College of Sports Medicine. Guidelines For Graded Exercise Testing And Exercise Prescription. 3rd ed. Philadelphia: Lea & Febiger, 1986. 4. Harris SS, Caspersen CJ, Gordon HD, Estes EH. Physical activity counseling for healthy adults as a primary prevention intervention in the clinical setting: Report for the U.S. Preventive Services Task Force. JAMA 1989; 261:359&3598. 5. Abdellah FG, Moore SR (Eds.). Surgeon General’s Workshop on Health Promotion and Agingproceedings. Washington, DC: Office of the Surgeon General, U.S. Public Health Service, 1988. 6. Department of Health and Human Services. Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC: U.S. Govt. Printing Office, Fall 1990. 7. U.S. Department of Health and Human Services. Promoting Health/Preventing Disease. Year 2000 Health Objectives for the Nation. Washington, DC, Winter 1990. 8. David AK, Boldt JE. A study of preventive health attitudes and behaviors in a family practice setting. J Fam Pracz 1980; 11:77-84.
WILLIFORD
636
ET AL.
9. Hyatt JD. Perception of the family physician by patients and family physicians. .J Fum Pratt 1980; 10:295-300. 10. Gilmore A. Canada fitness surveys finds fitness means health. Can Med Assoc J 1983; 129:181183. 1 I. Young A, Gray JA, Ennis JR. Exercise medicine: The knowledge and beliefs of final-year medical students in the United Kingdom. Med Educ 1983; 17:36%373. 12. Valente CM, Sobal J, Muncie HL, Levine DM, Antlity AM. Health promotion: Physicians’ beliefs attitudes and practices. Am J Prev Med 1986. 13. Wechsler H, Levine S, Idelson RK, Rohman M, Taylor JO. The physician’s role in health promotion a survey of primary care practitioners. N Eng J Med 1983; 308:97-100. 14. Rosen MA, Lodgsdon DM, Demak MM. Prevention and health promotion in primary care: Baseline results on physicians from the INSURE project on lifecycle preventive health services. Prev Med 1984; 13535548. 15. Iverson DC, Fielding JE, Crow RS, Christenson GM. The promotion of physical activity in the United States population: The status of programs in medical, worksite, community and school settings. Pub& He&h Rep 1985; 100:212-224. 16. Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern Med 1991; 11454-58. 17. Wells KB, Lewis CE, Leake B, Ware JE. Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA 1984; 252:284&2848. 18. Wyshak G, Lamb GA, Lawrence RS, Curran WJ. A profile of health-promoting behaviors of physicians and lawyers. N Engl J Med 1980; 303:104-107. 19. American College of Sports Medicine, 1990-1991 Membership Directory. Indianapolis, IN: American College of Sports Medicine, 1990. 20. American College of Sports Medicine. Position statement on the recommended quantity and quality of exercise for developing and maintaining fitness in healthy adults. Med Sci Sports Exercise 1978; lO:vii-x. 21. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in health adults. Med Sci Sports Exercise 1990; 22:265-274. Received Revised Accepted
October 14, 1991 March 9, 1992 Mnrch 9, 1992
MEDICINE
A Survey
21, 630-636
(1992)
of Physicians’ Attitudes and Practices Exercise Promotion
Related
to
HENRY N. WILLIFORD, ED.D., *,’ BETTY R. BARFIELD, M.S., R.N. ,t RAMONA B. LAZENBY, M.S., R.N.,? AND MICHELE SCHARFF OLSON, PH.D.* *Human
Performance
Laboratory
and tSchoo1 of Nursing, Auburn Montgomery, Alabama 361 I7
University
at Montgomery,
Methods. One hundred sixty-eight physicians responded to a survey to determine their attitudes and practices related to exercise and the development of exercise prescriptions. The mean age was 45.5 + 10.8 years, with the majority being male (86.7%). Results. The survey found that 48% of the physicians required an exercise history as part of their initial examination and 91% encouraged their patients to participate in regular exercise programs. Seventy percent of the physicians did not develop exercise prescriptions and only 23% were familiar with the American College of Sports Medicine guidelines related to the development of exercise prescriptions. Only a small number of physicians (3%) had ever taken a college-level course related to exercise physiology and the development of exercise programs. The majority (78%) felt that there was a definite need in medical school for a course related to the medical aspects of exercise. Conclusions. Results of this investigation indicate that while physicians support exercise for health promotion and rehabilitation, greater emphasis needs to be placed on physician involvement in promoting and/or prescribing exercise. 0 1992 Academic Prob. Inc.
INTRODUCTION
Regular physical activity may be necessary for optimal health and is associated with the prevention and control of numerous health problems. Exercise as a health promotion activity has been shown to be cost effective and produces a net economic savings, while physical fitness as a preventive measure has been shown to be related to delays in all-cause mortality (1, 2). Physicians hold a unique position in influencing patients regarding health promotion and disease prevention. Exercise is considered an important component in health promotion and is recommended by many groups, including the American College of Sports Medicine (ACSM), the National Heart, Lung, and Blood Institute, and the American Heart Association. The American College of Sports Medicine recommends physician involvement in all aspects of preventive and rehabilitative exercise programs (1) and the U.S. Preventive Services Task Force has been instrumental in developing guidelines for physical activity counseling by physicians (4). The U.S. Surgeon General’s Workshop on Health Promotion and Aging has made a research recommendation to develop guidelines for screening and baseline medical evaluations for individual patient exercise programs (5). The U.S. Department of Health and Human Services Public Health Service 1990 Health Objectives for the Nation (6) and the Healthy People 2000 National Health Promotion and Disease Prevention Objectives (7) include specific objec’ To whom reprint requests sity Drive, Auburn University
should be addressed at Human at Montgomery, Montgomery, 630
0091-7435/92
$5.00
Copyright 0 1992 by Academic Press. Inc. All rights of reproduction in any form reserved
Performance AL 36117.
Laboratory,
7300 Univer-
EXERCISE
PROMOTION
AND
PHYSICIANS
631
tives related to the role of exercise and physical fitness in disease prevention and have placed a high priority on increasing physical activity and physical fitness. One of the objectives requires direct physician involvement, suggesting that at least 50% of the primary care providers routinely assess and counsel their patients regarding the frequency, duration, type, and intensity of each patient’s physical activity practices. Several studies have shown that patients expect their physicians to promote and encourage lifestyle change (8, 9), and the Canada Fitness Survey found that approximately one-fourth of all Canadians ranked physician’s orders as a significant reason for being active (10). Physician advice and counseling are important in encouraging patients to become more physically active. The physician-patient encounter provides an excellent opportunity during which the patient can be counseled about physical activity. Before starting an exercise program, individuals often seek physician approval as well as advice regarding specific recommendations related to frequency, intensity, duration, and modes of exercise training. Also, allied health professionals often require physician approval or clearance before developing an exercise prescription for one of their clients. Because of the unique position that physicians hold in recommending and prescribing exercise, the purpose of this investigation was to determine physicians’ attitudes and practices related to the promotion of physical activity and the development of exercise prescriptions. METHODS
A questionnaire was developed by a pane1 consisting of physicians, nurses, and exercise physiologists to determine attitudes and practices of physicians and their role in exercise promotion and prescription. After the development of the questionnaire a group of health professionals reviewed the instrument to ensure clarity and reliability. Test-retest reliability scores on a sample of 50 subjects were high, ranging from 0.95 to 0.98 for each of the multiple choice questions. A list of physicians was obtained from the Board of Medical Examiners of the State of Alabama. From the list, 250 eligible physicians were randomly selected to take part in the survey. Individuals were eliminated if they did not live in the state, did not engage in direct patient care, or were in specialities in which exercise had no logical relationship. A self-addressed stamped envelope was enclosed for return purposes. One hundred sixty-eight physicians responded to the survey. yielding a 69% return rate. The mean age was 45.5 ? 10.8 years with a range of 28 to 78 years, The sample was primarily male (87%). When the age and sex of the present sample were compared with those of the entire population for the state, similar demographic data were found. Statistics from the State of Alabama Health Planning and Development Agency indicate that Alabama has approximately 6,618 full-time practicing physicians, with 85% being male. The mean age of Alabama physicians is 48.2 2 10.2 years. The sample consisted primarily of family practice and internal medicine physicians. These specialities represent 75% of the sample. RESULTS
Table 1 shows a summary of the physicians’
responses to the questions on the
632
WILLIFORD
ET
AL.
TABLE 1 SUMMARY OF PHYSICIANS' RESPONSESTO QUESTIONNAIRE Question Encourage patients to exercise Obtain exercise history Normally develop exercise prescriptions Another staff member develops exercise prescriptions Receive referrals for exercise Primarily refer patients to the following for exercise prescriptions Physical therapy Other physicians Exercise physiology Nurse Familiar with ACSM guidelines Completed a college or medical school course related to exercise prescription Is there a need for an exercise related course in medical school
Yes (%)
No (%)
91 49 30 13 4
9 51 70 87 96
68 20 9 3 23
77
3 78
97 22
survey. The majority of the physicians (91%) encouraged their patients to participate in regular exercise, while 9% did not promote exercise. Less than one-half of the physicians (49%) required a review of exercise history as part of the initial examination. Approximately one-third developed exercise prescriptions for their patients, whereas 70% of the physicians reported that this was not part of their normal practice. Only 23% of the sample were familiar with the ACSM guidelines for exercise in healthy adults, and 3% had ever taken a college-level course related to exercise and the development of exercise prescriptions. However, the majority of physicians (78%) felt that there was a definite need in medical school for a course related to the medical aspects of exercise. Thirteen percent of the physicians had staff members whom they indicated developed exercise prescriptions for their patients. When asked to whom the physicians referred their patients in order to recommend an exercise program, physical therapists ranked first (68%), other physicians second (20%), exercise physiologists third (9%), and nurses fourth (3%). When asked if patients were referred to them to develop exercise programs for health promotion, 4% received referrals while 96% did not. DISCUSSION
It has been well established that exercise can have a favorable impact on an individual’s health and that physicians are highly recognized as leaders and role models in health promotion. The majority of physicians (91%) reported that they encouraged their patients to participate in regular exercise. This response indicates the physicians generally support the concept of exercise as being important in promoting good health practices and preventing disease. A similar survey of beliefs among medical students found that 95% believed that regular exercise can bring significant health benefits to the majority of people (11). The results of our survey indicated that physicians in Alabama assessed exercise history at rates (49%) similar to rates of physicians in other parts of the
EXERCISE
PROMOTION
AND
PHYSICIANS
633
country. Although limited data regarding exercise history, are available, regional surveys from Massachusetts, Maryland, and California found that an estimated 47% of primary care physicians routinely inquired about their patients’ exercise habits (5, 12, 13). One of the specific objectives of the 1990 Health Objectives for the Nation was that 50% of primary care physicians would include a careful exercise history as part of their initial examination of new patients (6). While all of our respondents were not primary care physicians, our survey indicates that the goal of 50% has not yet been accomplished. The new Objectives for the Year 2000 state: “Increase to at least 65% the proportion of primary care providers who assess and counsel their patients regarding the frequency, duration, type and intensity of each patient’s physical activity practices as part of a thorough evaluation and treatment program” (7). These new objectives go a step further and suggest that in addition to assessing health history physicians should counsel their patients regarding the specific training variables of frequency, duration, type, and intensity of physical activity practices as part of a thorough evaluation and treatment program. The development of an individual program of exercise establishing frequency, intensity, and duration of exercise is characteristically termed an exercise prescription. With respect to the Year 2000 Objectives, the physicians surveyed were well below the goal of 65% compliance for exercise history, with only 30% of the physicians normally developing exercise prescriptions. A study by Rosen et al. (14) showed a similar response rate with 30% of the surveyed physicians bringing up the topic of exercise with their patients. Iverson et al. (15) also reported that the majority of physicians did not counsel their patients regarding physical activity. Lewis et al. (16) investigated the prevalence of counseling practices of internists regarding exercise. They reported that 51% of the generalists and 43.5% of the specialists counseled their patients about exercise. The development of an exercise prescription may be perceived differently from counseling patients about exercise. This may be one reason for the differences in the response rate. Lewis et al. (16) also found that the internists who were more physically active counseled a greater percentage of patients than internists who were less active, and the internists who spent more time counseling perceived themselves to be more effective in changing patients habits. Other studies have also shown that physicians’ personal habits and attitudes toward counseling are important considerations (17, 18). Possible reasons for not counseling patients may be related to lack of confidence in counseling patients, lack of insurance reimbursements, lack of education related to the medical aspects of exercise, and lack of standard formats for assessing and prescribing exercise (11, 14, 15). It has been recommended that standardized questions regarding health history be established to further facilitate attainment of this objective (7). Mechanisms need to be in place to aid physicians in developing appropriate exercise programs for their patients. Some doctors indicated that simply telling a person to go out and walk was their idea of an exercise prescription. This was reflected in the small percentage of physicians who were familiar with the ACSM or any other guidelines for prescribing exer-
634
WILLIFORD
ET AL.
cise. The development of an exercise prescription for an individual who has serious health problems and is taking a variety of medications can be quite extensive (3). In 1989, a report regarding the use of physical activity counseling for healthy adults as a primary preventive intervention was developed by the U.S. Preventive Services Task Force (4). This report represented an important major National policy orientation regarding the physician’s role in prescribing exercise for prevention of coronary heart disease, hypertension, non-insulin-dependent diabetes, osteoporosis, obesity, and mental health problems. In the report specific guidelines were established with respect to physical activity counseling. The established guidelines are important since they represent a practical, easy-to-follow technique for counseling patients. The present questionnaire revealed that only 3% of the physicians had taken a college-level course related to the development of exercise prescriptions. Sixtythree percent of the medical students surveyed in the United Kingdom reported that they received too little teaching about the medical aspects of exercise and another 37% felt they were unduly ignorant of the medical aspects of exercise (11). From the present data it appears that medical schools have placed little emphasis on training physicians to prescribe exercise. Seventy-eight percent of the respondents from our survey expressed the need for a course related to the medical aspects of exercise, Physicians may feel uncomfortable in developing exercise prescriptions because of lack of training. It has been suggested that physicians need to increase their efforts and develop their skills in counseling. Lewis et al. (16) suggested that it might be advantageous to encourage positive health habits and counseling skills in the first year of medical school. In terms of referrals to other health professionals for developing exercise programs, physical therapy was the group that received the greatest number of referrals, with physicians referring fewer patients to other physicians and exercise physiologists. It appears that physicians have better access to physical therapists and are more familiar with this occupation with regard to developing exercise programs. A possible reason for physician referral to the physical therapist is that state licensure provides for quality control assurance. Exercise physiology is relatively young as a profession, with a fairly small number of exercise physiologists working in health care facilities. This may be the one reason for the limited number of referrals to this group. The ACSM has developed several certification programs for exercise physiologists and other exercise-related personnel. These certification programs may also increase the quality control measures. A small percentage of the physicians referred patients to nurses. More and more nurses are currently involved in health promotion and are working in exercise-related areas, However, nurses, like physicians, are generally not formally trained in developing exercise prescriptions. If there is an increase in the promotion of exercise by physicians, one would expect greater involvement from a variety of health care professionals to aid the physicians in prescribing appropriate exercise. There are a variety of professional and educational organizations that offer postgraduate medical courses and provide reference materials to physicians. The
EXERCISE
PROMOTION
AND PHYSICIANS
635
American College of Sports Medicine is the largest sports medicine organization in the world, with nearly 12,000 members involved in science, medicine, education, and sports (19). One of its primary missions is to disseminate research and information about the benefits and effects of exercise. In 1978 the ACSM published guidelines related to the quality and quantity of exercise for healthy adults (20) and in 1990the ACSM revised the guidelines related to frequency, intensity, duration, and modes of exercise (21). Twenty-three percent of the physicians were familiar with the ACSM guidelines. The ACSM is attempting to attract a greater number of physicians and to disseminate materials related to proper exercise programs. The ACSM has also established a Healthy People 2000 Committee to promote the public health objectives within its membership. Educational materials have been made available to physicians and other health care providers to promote the Healthy People 2000 Objectives. The President’s Council on Physical Fitness and Sport is another organization that is attempting to encourage the role of physician involvement related to exercise. In conjunction with private industry, they have developed an exercise plan that will be distributed and handled by primary care physicians, internists, and orthopedic surgeons. CONCLUSION
In summary, there is increasing concern related to the role that physicians play in screening and counseling patients related to the benefits of exercise. A number of organizations are promoting exercise as a preventive measure and are encouraging physicians and other health care providers to become more involved in the process. Physicians in Alabama tend to assessand counsel their patients regarding exercise at rates similar to those found in other parts of the country. If the Healthy People 2000 National Health Promotion and Disease Prevention Objectives are to be accomplished, greater emphasis regarding physician involvement and health promotion is needed. REFERENCES 1. Hatziandreu EI, Kaplan JP, Weinstein MC, Caspersen CJ, Warner KE. A cost-effective analysis of exercise as a health promotion activity. Am J Pub/it Health 1988; 78:1417-1421. 2. Blair SN, Kohl HW, Paffenbarger RS, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality: A prospective study of men and women. JAMA 1989; 262:2395-2401. 3. American College of Sports Medicine. Guidelines For Graded Exercise Testing And Exercise Prescription. 3rd ed. Philadelphia: Lea & Febiger, 1986. 4. Harris SS, Caspersen CJ, Gordon HD, Estes EH. Physical activity counseling for healthy adults as a primary prevention intervention in the clinical setting: Report for the U.S. Preventive Services Task Force. JAMA 1989; 261:359&3598. 5. Abdellah FG, Moore SR (Eds.). Surgeon General’s Workshop on Health Promotion and Agingproceedings. Washington, DC: Office of the Surgeon General, U.S. Public Health Service, 1988. 6. Department of Health and Human Services. Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC: U.S. Govt. Printing Office, Fall 1990. 7. U.S. Department of Health and Human Services. Promoting Health/Preventing Disease. Year 2000 Health Objectives for the Nation. Washington, DC, Winter 1990. 8. David AK, Boldt JE. A study of preventive health attitudes and behaviors in a family practice setting. J Fam Pracz 1980; 11:77-84.
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9. Hyatt JD. Perception of the family physician by patients and family physicians. .J Fum Pratt 1980; 10:295-300. 10. Gilmore A. Canada fitness surveys finds fitness means health. Can Med Assoc J 1983; 129:181183. 1 I. Young A, Gray JA, Ennis JR. Exercise medicine: The knowledge and beliefs of final-year medical students in the United Kingdom. Med Educ 1983; 17:36%373. 12. Valente CM, Sobal J, Muncie HL, Levine DM, Antlity AM. Health promotion: Physicians’ beliefs attitudes and practices. Am J Prev Med 1986. 13. Wechsler H, Levine S, Idelson RK, Rohman M, Taylor JO. The physician’s role in health promotion a survey of primary care practitioners. N Eng J Med 1983; 308:97-100. 14. Rosen MA, Lodgsdon DM, Demak MM. Prevention and health promotion in primary care: Baseline results on physicians from the INSURE project on lifecycle preventive health services. Prev Med 1984; 13535548. 15. Iverson DC, Fielding JE, Crow RS, Christenson GM. The promotion of physical activity in the United States population: The status of programs in medical, worksite, community and school settings. Pub& He&h Rep 1985; 100:212-224. 16. Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern Med 1991; 11454-58. 17. Wells KB, Lewis CE, Leake B, Ware JE. Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA 1984; 252:284&2848. 18. Wyshak G, Lamb GA, Lawrence RS, Curran WJ. A profile of health-promoting behaviors of physicians and lawyers. N Engl J Med 1980; 303:104-107. 19. American College of Sports Medicine, 1990-1991 Membership Directory. Indianapolis, IN: American College of Sports Medicine, 1990. 20. American College of Sports Medicine. Position statement on the recommended quantity and quality of exercise for developing and maintaining fitness in healthy adults. Med Sci Sports Exercise 1978; lO:vii-x. 21. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in health adults. Med Sci Sports Exercise 1990; 22:265-274. Received Revised Accepted
October 14, 1991 March 9, 1992 Mnrch 9, 1992
