Journal of Physical Activity and Health, 2015, 12, 1336 -1343 http://dx.doi.org/10.1123/jpah.2014-0316 © 2015 Human Kinetics, Inc.
REVIEW
If Exercise is Medicine, Where is Exercise in Medicine? Review of U.S. Medical Education Curricula for Physical Activity-Related Content Bradley J. Cardinal, Eugene A. Park, MooSong Kim, and Marita K. Cardinal Background: This study provides an update on the amount and type of physical activity education occurring in medical education in the United States in 2013. It is the first study to do so since 2002. Methods: Applying content analysis methodology, we reviewed all accessible accredited doctor of medicine and doctor of osteopathic medicine institutions’ websites for physical activity education related coursework (N = 118 fully accessible; 69.41%). Results: The majority of institutions did not offer any physical activity education–related courses. When offered, they were rarely required. Courses addressing sports medicine and exercise physiology were offered more than courses in other content domains. Most courses were taught using a clinical approach. No differences were observed between MD and DO institutions, or between private and public institutions. Conclusions: More than one-half of the physicians trained in the United States in 2013 received no formal education in physical activity and may, therefore, be ill-prepared to assist their patients in a manner consistent with Healthy People 2020, the National Physical Activity Plan, or the Exercise is Medicine initiative. The Bipartisan Policy Center, American College of Sports Medicine, and the Alliance for a Healthier Generation called for a reversal of this situation on June 23, 2014. Keywords: behavioral counseling, chronic disease prevention, content analysis, history, physicians
The critical importance of medical education in North America was brought to light more than 100 years ago by Flexner.1 Visiting all 155 medical schools in the United States and Canada, Flexner characterized medical education at the time as being in a state of disarray (eg, emphasizing profit over quality, having inadequate curricula and facilities, providing insufficient training in analytical reasoning and the natural sciences). He concluded that 120 (ie, 77.4%) of the institutions were grossly inadequate in their preparation of physicians and recommended that they be closed; they were doing more harm than good. Flexner’s1 report resulted in revolutionary reforms in medical education—the curricula began to emphasize cure over prevention, it became more scientific, residency training was implemented, and specialization increased. Many of the reforms reflected the need to codify and standardize the medical curriculum for the public’s health and safety, as well as treat the common infectious diseases of the time (eg, pneumonia, influenza, tuberculosis, gastrointestinal infections). The medical profession and medicinal science improved as a result of Flexner’s work and by adopting the reductionist paradigm, which is pervasive in and characteristic of the biophysical and/or natural science disciplines. Today, however, the leading causes of death are lifestylemediated chronic diseases (eg, heart disease, cancer, noninfectious airway diseases, cerebrovascular diseases). Chronic diseases occur over time. They have a history and wholeness about them that infectious diseases may not.2 There is mounting recognition that today’s medical education—still deeply rooted in Flexner’s incisive work—requires a more holistic approach.3,4 Fifteen years after his initial report, Flexner himself expressed concern that the medical curriculum reforms of the day were already beginning to overemphasize the medicinal BJ Cardinal ([email protected]), Park, and Kim are with the School of Biological and Population Health Sciences, Oregon State University, Corvallis, OR. MK Cardinal is with the Division of Health and Exercise Science, Western Oregon University, Monmouth, OR. 1336
sciences over the humanities and the social and behavioral sciences.5 This concern continues to this day.4
Today’s Diseases, Yesterday’s Cures: Medical Education in the 21st Century One of the most important lifestyle behaviors for preventing chronic diseases is physical activity. In their review of 18 chronic diseases, Pedersen and Saltin found strong evidence that regular physical activity involvement improves the pathogenesis and symptoms specific to the diagnosis of 8 conditions: chronic heart failure, coronary heart disease, dyslipidemia, hypertension, insulin resistance, intermittent claudication, obesity, and type 2 diabetes.6 They provided further strong evidence that it improves the pathogenesis of osteoporosis and the symptoms of chronic obstructive pulmonary disease, depression, fibromyalgia, and osteoarthritis; as well as provided benefits for those experiencing asthma, chronic fatigue syndrome, rheumatoid arthritis, and some forms of cancer (eg, breast, colon). Others support the value of regular physical activity involvement for improving balance, cognitive functioning, life expectancy, and overall quality of life, while concurrently decreasing dementia, falls, sarcopenia, and the overall cost of health care.7,8 The medicinal value of regular physical activity involvement is clear. It has widespread preventive, restorative, and curative powers with value superior to any other individual lifestyle intervention or treatment,9 and, in some cases, similar to available drug therapies used in preventing coronary heart disease, diabetes, rehabilitation following a stroke, and treating heart failure.10 Moreover, the value of physical activity extends beyond its functional and medicinal benefits: One of the greatest things about physical activity and play is that they make our lives go better, not just longer. It is the quality of life, the joy of being alive, the things we do with our good health that matter to us as much or more than health itself.11 (p. 6)
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However, for all of its known benefits, physical activity appears to have a rather sparse presence in the medical school curriculum. Nine English language studies have examined this topic over the past 42 years (Table 1), 4 of which were conducted in the United States,12–15 with the others occurring in Canada,16–18 the United Kingdom,19 and the United Kingdom and Ireland.20 Regardless of the country of origin or research approach employed, the take home message of these studies has been remarkably consistent:
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There is an urgent need for physical activity teaching to have dedicated time at medical schools, to equip tomorrow’s doctors with the basic knowledge, confidence and skills to promote physical activity and follow numerous clinical guidelines that support physical activity promotion.17 (p. 1025). Even in the programs that do offer coursework or experiences, instructional time is minimal ( .70 = large.33 Contingency coefficient values ≥ 0.30 were interpreted as being meaningful relationships.34
Results Of the 170 medical schools identified, the majority offered the MD degree (n = 141, 82.9%), with the balance offering the DO degree (n = 29, 17.1%). The majority of institutions were public (n = 92, 54.1%), with 76 (44.7%) being private, and 2 (1.2%) undetermined.
How Many MD and DO Schools Offer Courses Pertaining to Physical Activity? With regard to the prevalence of physical activity-related coursework, of the 118 (69.41%) institutions for which curriculum information was accessible, the largest percentage offered either no course (n = 61, 51.7%) or a single course (n = 25, 21.2%), though the range included up to 7 courses (n = 4, 3.4%).
Are the Physical Activity Courses Offered by MD and DO Schools Required or Elective? The majority of institutions did not require their students to take a single course (n = 97, 82.2%), whereas 15 (12.7%) required their students to take 1 course, 5 (4.2%) required their students to take 2 courses, and 1 ( .05, contingency coefficient = .20].
In What Format are the Courses Taught? The available coursework was most likely to be taught using a clinical approach (n = 125, 84.5%) rather than a lecture approach (n = 23, 15.5%) [χ2 (1, N = 148) = 70.30, P < .001, contingency coefficient = .57]. No online/modular coursework was found.
Does the Physical Activity Coverage in the Curricula of MD Programs Differ From That of DO Programs? MD and DO institutions were no different in terms of requiring their students to take coursework in this area [ie, 17.3% vs. 15.8%, respectively; χ2 (1, N = 117) = 0.03, P > .05, contingency coefficient = .02]. The number of courses required between MD (n = 98; mean = 0.20, SD = 0.48) and DO (n = 20; mean = 0.40, SD = 0.88) institutions did not differ [t (116) = 1.42, P > .05, d = .28].
Is There a Difference in Physical Activity Course Coverage Between Private and Public Institutions? While private and public institutions were no different in terms of requiring their students to take coursework in this area [ie, 12.5% vs. 7.3%%, respectively; χ2 (1, N = 96) = 0.03, P > .05, contingency coefficient = .12], the number of required courses at private institutions (n = 61; mean = 0.35, SD = 0.70) was higher than the number required at public institutions (n = 55; mean = 0.13, SD = 0.39) [t (114) = 1.42, P < .05, d = .39]. They also differed in delivery format, with 32.7% of private institutions delivering the content using a clinical approach, whereas 51.7% of public institutions did [χ2 (1, N = 147) = 5.57, P < .05, contingency coefficient = .19].
Discussion Though physicians have been called upon to counsel and support their patients in physical activity behavior acquisition and maintenance, our results suggest that over half of the physicians trained in the United States in 2013 received no formal education in the area of physical activity. As a result they may be ill-prepared to assist their patients in a manner consistent with Healthy People 2020,
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the National Physical Activity Plan, or the Exercise is Medicine initiative.28–30 They may also be inadequately prepared to assist consumers of commercially available physical activity programs, products, and services who are encouraged to consult their physician before beginning a physical activity program, use a physical activity product, or employ a physical activity service.13 Even at the institutions that do include physical activity education in their curriculum as either a requirement or an elective, the topics addressed are predominantly biophysical focused (ie, exercise physiology, sports medicine), with little attention devoted to behavioral counseling, lifestyle medicine, or preventive medicine (ie, putting scientific information into practice). Again, this seems inconsistent with the needs of patients and society. Specifically, physicians are being encouraged to lead the physical activity bandwagon in medicine and healthcare, as well as routinely counsel and support their patients in adopting and maintaining a physically active lifestyle.35 Moreover, physicians themselves are being urged to partake in physical activity for their own personal health and wellbeing, and for the benefit of others for whom they serve as physical activity role models.21 Periodic calls for more formal physical activity education in medical education have occurred over the past 42 years. During this same time the preventive, restorative, and curative powers of physical activity for health, among other humanistic and psychosocial benefits, have become increasingly clear. Physical inactivity decreases the quantity and quality of life; it is the fourth leading cause of mortality in the world,36 and it is a leading cause of morbidity.7 Some have gone so far as to refer to physical activity as medicine.35 Given this, it is remarkable that physicians receive little to no formal education in this area. Moreover, it is worth repeating the question Cummings asked some 42 years ago16: “The present situation [absence of physical activity instruction in medical schools] is such that one may well ask ‘Why consult your doctor before you exercise?’” (p. 731). There is mounting interest in addressing this situation, and, on the basis of this study, there is some evidence that progress has been made. For example, the percentage of institutions that offer coursework in physical activity education appears to be at an all-time high, at least relative to previously conducted studies (Table 2). In those studies the number of institutions offering physical activity education coursework ranged from 12.2% to 38.0%,12–15 whereas we found it to be 48.3%. We also found that 17.8% of the institutions required ≥ 1 course, whereas Garry et al reported it to be 5.9%,14 and Whitley and Nyberg reported it to be 4.4%.15 Physical activity assessment is also being recorded as a vital sign and included as part of patients’ electronic medical records in some healthcare organizations.37 Physicians and their staff can
then use this information as a form of recognition, encouragement, counseling, and/or referral. When this occurs, it is associated with positive health outcomes for the patient.38,39 An underlying premise of this systematic approach is that physicians are knowledgeable about the therapeutic value of physical activity, know the physical activity guidelines, and are able to confidently and competently discuss physical activity programming (or prescription) with their patients. This requires some degree of education, including potential contraindications and drug interactions (eg, the effects of beta blockers on heart rate response during aerobic exercise). One medical education institution that has taken this to heart is the University of South Carolina School of Medicine Greenville, which has created an “Exercise is Medicine” immersion experience for their students by identifying and incorporating key knowledge, skills, and abilities into all 4 years of their curriculum.40 At graduation their students should be able to demonstrate proficiency in physical activity and fitness assessment, exercise prescription and implementation, counseling for physical activity and behavioral strategies, and physician’s personal health (eg, role modeling). They are seeking to serve as a model institution for others and, in conjunction with Harvard University School of Medicine, hosted the first ever national Lifestyle Medicine Think Tank on September 9–10, 2013, with the aim being to explore how to get physical activity education incorporated into the nation’s medical education curricula.41 Curriculum revisions are often approached following the zero sum paradigm meaning that adding one thing will inevitably require removing something else. With that in mind, alternatives for accomplishing this should be considered (eg, integration into current courses or clinical experiences). Qualitative studies among those who have successfully achieved such changes might also be undertaken, and empirical evidence demonstrating the actual impact of such curricular changes is needed. Online learning modules, which we found no evidence of in this study, might also be developed as a means of broadly disseminating physical activity education-related content to medical education institutions. Online learning modules may also be developed for continuing education purposes, as the majority of physicians have not received any education or training in this area. Again, the impact of such work should be documented empirically and disseminated broadly. Key questions include 1) Are physicians better physicians as a result of this training? 2) Are patients who see physicians who have had such training more physically active? 3) Do patients who see physicians who have had such training have better health outcomes? and 4) If medical curriculums are already too full, could someone else do a better job fulfilling this role?35 An advantage of the methodology employed in this study is that it is not subject to response rate or self-selection biases. However,
Table 2 Inclusion of Physical Activity-Related Content in United States Medical Education, 1975–2013 Percent of institutions that offer a course
Percent of institutions that require a course
48.3
17.8
Study
Method
Sample size (response rate)
Current study (2013)
Content Analysis of Institutional Websites (MD & DO)
170 (with full data available on 69.41% of the institutions)
Garry et al13 (2002)
Administrator Survey (MD only)
102 (N/A)
12.8
5.9
Connoughton et al12 (2001)
Administrator Survey (MD only)
72 (56.25%)
23.0
–
Content Analysis of Medical Bulletins (MD only)
105 (73.6%)
38.0
4.4
Administrator Survey (MD only)
74 (73.29%)
12.2
–
Whitley and
Nyberg14
(1988)
Burke and Hultgren11 (1975)
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1342 Cardinal et al
content analysis is not without limitations. Namely, we were only able to review the manifest content of the curricula and course descriptions. Latent content or experiences may be unaccounted for. We were also unable to fully access curricular or course description information for 30.59% of the institutions.
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Conclusion This study gives a contemporary snapshot of the quantity and type of physical activity education coursework that is occurring in medical education in the United States in 2013. The results of this study, along with others before it,12–15 suggest that the majority of physicians have not received, nor will the majority of medical students today receive, any formal education or experiences in the area of physical activity education, which is inconsistent with Healthy People 2020, the National Physical Activity Plan, and the Exercise is Medicine initiative of the American College of Sports Medicine and the American Medical Association.28–30 However, there is also modest evidence that some positive changes have occurred. For example, the amount of physical activity education available in medical schools was higher in this study than in any previous study, the example being set by the University of South Carolina School of Medicine Greenville,40 and the national Lifestyle Medicine Think Tank,41 which focused its first meeting on how to get physical activity education incorporated into the nation’s medical education curricula, support this claim. As these changes continue to unfold it will become increasingly clear what knowledge, skills, and abilities are most important for physicians to demonstrate relative to physical activity education. At present, though, there is an ongoing need to get physical activity education into the medical school curricula, which is consistent with the White Paper issued on June 23, 2014 urging for this to happen.42 Adding to this urgency is that the majority (63.7%) of U.S. adults who had seen a health care professional during the past 12 months (2011–2012) reported receiving no advice or information about exercise from them.43 Moreover, in comparison with previous studies on the subject, the rate of counseling patients for physical activity by health care professionals might actually be decreasing.43 Acknowledgments This study was funded by a DeLoach Work Scholarship granted by the University Honors College at Oregon State University.
References 1. Flexner A. Medical education in the United States and Canada: A Report to The Carnegie Foundation for the Advancement of Teaching (Bulletin No. 4). New York: The Carnegie Foundation for the Advancement of Teaching; 1910. 2. Jones DS, Podolsky SH, Greene JA. The burden of disease and the changing task of medicine. N Engl J Med. 2012;366(25):2333–2338 doi:10.1056/NEJMp1113569. PubMed 3. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355(13):1339–1344 doi:10.1056/NEJMra055445. PubMed 4. Whitehead C. Scientist or science-stuffed? Discourses science in North American medical education. Med Educ. 2013;47(1):26–32 doi:10.1111/j.1365-2923.2011.04136.x. PubMed 5. Flexner A. Medical education: a comparative study. New York, NY: MacMillan; 1925. 6. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports. 2006;16(Suppl. 1):3–63. PubMed doi:10.1111/j.1600-0838.2006.00520.x
7. Lee I-M, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229 doi:10.1016/S0140-6736(12)610319. PubMed 8. Metzl JD, Heffernan A. The exercise cure: a doctor’s all-natural, nopill prescription for better health & longer life. Emmaus, PA: Rodale; 2013. 9. Matheson GO, Klügi M, Dvorak J, et al. Responsibility of sport and exercise medicine in preventing and managing chronic disease: applying our knowledge and skill is overdue. Br J Sports Med. 2011;45(16):1272–1282 doi:10.1136/bjsports-2011-090328. PubMed 10. Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013;347:f5577 doi:10.1136/bmj.f5577. PubMed 11. Kretchmar RS. Ten more reasons for quality physical education. J Phys Educ, Recreat Dance. 2006;77(9):6–9 doi:10.1080/07303084 .2006.10597932. 12. Burke EJ, Hultgren PB. Will physicians of the future be able to prescribe exercise? J Med Educ. 1975;50(6):624–626. PubMed 13. Connaughton AV, Weiler RM, Connaughton DP. Graduating medical students’ exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001;116(3):226–234. PubMed doi:10.1016/S0033-3549(04)50038-9 14. Garry JP, Diamond JJ, Whitley TW. Physical activity curricula in medical schools. Acad Med. 2002;77(8):818–821. PubMed doi:10.1097/00001888-200208000-00011 15. Whitley JD, Nyberg K. Exercise medicine in medical education in the United States. Phys Sportsmed. 1988;16(10):93–98. 16. Cumming GR. Teaching of sports medicine in Canadian medical colleges. Can Med Assoc J. 1972;107(8):729–731. PubMed 17. Weiler R, Chew S, Coombs N, Hamer M, Stamatakis E. Physical activity education in the undergraduate curricula of all UK medical schools. Are tomorrow’s doctors equipped to follow clinical guidelines? Br J Sports Med. 2012;46(14):1024–1026 doi:10.1136/bjsports-2012-091380. PubMed 18. Wiley JP, Strother RT, Lockyer JM. Sports medicine electives: Are they available in Canadian family medicine programs? Can Fam Physician. 1993;39(August):1742–1744. PubMed 19. Zamani J, Vogel S, Moore A, Lucas K. Analysis of exercise content in undergraduate osteopathic education—a content analysis of UK curricula. Int J Osteopath Med. 2007;10(4):97–103 doi:10.1016/j. ijosm.2007.10.003. 20. Cullen M, McNally O, Neill SO, Macauley D. Sport and exercise medicine in undergraduate medical schools in the United Kingdom and Ireland. Br J Sports Med. 2000;34(4):244–245. PubMed doi:10.1136/ bjsm.34.4.244 21. Ángyán L. Promoting physical activity in medical education: mini-review. Acta Physiol Hung. 2004;91(2):157–166. PubMed doi:10.1556/APhysiol.91.2004.2.7 22. Kordi R, Moghadam N, Rostami M. Sports and exercise medicine in undergraduate medical curricula in developing countries: a long path ahead. Med Educ Online. 2011;16:5962 doi:10.3402/meo.v16i0.5962. PubMed 23. Rogers LQ, Bailey JE, Gutin B, et al. Teaching resident physicians to provide exercise counseling: a needs assessment. Acad Med. 2002;77(8):841–844. PubMed doi:10.1097/00001888-20020800000019 24. Holtz KA, Kokotilo KJ, Fitzgerald BE, Frank E. Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia. Can Fam Physician. 2013;59(1):e26–e32. PubMed 25. Dunlop M, Murray AD. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate curriculum. Br J Sports Med. 2013;47(11):718– 720 doi:10.1136/bjsports-2012-091891. PubMed 26. Frank E, Tong E, Lobelo F, Carrera J, Duperly J. Physical activity levels and counseling practices of US medical students. Med Sci Sports
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Exerc. 2008;40(3):413–421 doi:10.1249/MSS.0b013e31815ff399. PubMed 27. Ng V, Irwin JD. Prescriptive medicine: the importance of preparing Canadian medical students to counsel patients toward physical activity. J Phys Act Health. 2013;10(6):889–899. PubMed 28. U.S. Department of Health and Human Services. Healthy People 2020. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=33. Accessed May 31, 2014. 29. National Physical Activity Plan. (2010). Health Care. Strategy 5. Retrieved from http://www.physicalactivityplan.org/healthcare.php. Accessed May 31, 2014. 30. Lobelo F, Stoutenberg M, Hutber A. The exercise is medicine global health initiative: A 2014 update. Br J Sports Med. 2014;48(22):1627–3. PubMed 31. Association of American Medical Colleges. Member directory search result - medical school. https://members.aamc.org/eweb/DynamicPage.aspx?site=AAMC&webcode=AAMCOrgSearchResult&orgt ype=Medical%20School. Accessed May 31, 2013. 32. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–174. PubMed doi:10.2307/2529310 33. Thomas JR, Salazar W, Landers DM. What is missing p
REVIEW
If Exercise is Medicine, Where is Exercise in Medicine? Review of U.S. Medical Education Curricula for Physical Activity-Related Content Bradley J. Cardinal, Eugene A. Park, MooSong Kim, and Marita K. Cardinal Background: This study provides an update on the amount and type of physical activity education occurring in medical education in the United States in 2013. It is the first study to do so since 2002. Methods: Applying content analysis methodology, we reviewed all accessible accredited doctor of medicine and doctor of osteopathic medicine institutions’ websites for physical activity education related coursework (N = 118 fully accessible; 69.41%). Results: The majority of institutions did not offer any physical activity education–related courses. When offered, they were rarely required. Courses addressing sports medicine and exercise physiology were offered more than courses in other content domains. Most courses were taught using a clinical approach. No differences were observed between MD and DO institutions, or between private and public institutions. Conclusions: More than one-half of the physicians trained in the United States in 2013 received no formal education in physical activity and may, therefore, be ill-prepared to assist their patients in a manner consistent with Healthy People 2020, the National Physical Activity Plan, or the Exercise is Medicine initiative. The Bipartisan Policy Center, American College of Sports Medicine, and the Alliance for a Healthier Generation called for a reversal of this situation on June 23, 2014. Keywords: behavioral counseling, chronic disease prevention, content analysis, history, physicians
The critical importance of medical education in North America was brought to light more than 100 years ago by Flexner.1 Visiting all 155 medical schools in the United States and Canada, Flexner characterized medical education at the time as being in a state of disarray (eg, emphasizing profit over quality, having inadequate curricula and facilities, providing insufficient training in analytical reasoning and the natural sciences). He concluded that 120 (ie, 77.4%) of the institutions were grossly inadequate in their preparation of physicians and recommended that they be closed; they were doing more harm than good. Flexner’s1 report resulted in revolutionary reforms in medical education—the curricula began to emphasize cure over prevention, it became more scientific, residency training was implemented, and specialization increased. Many of the reforms reflected the need to codify and standardize the medical curriculum for the public’s health and safety, as well as treat the common infectious diseases of the time (eg, pneumonia, influenza, tuberculosis, gastrointestinal infections). The medical profession and medicinal science improved as a result of Flexner’s work and by adopting the reductionist paradigm, which is pervasive in and characteristic of the biophysical and/or natural science disciplines. Today, however, the leading causes of death are lifestylemediated chronic diseases (eg, heart disease, cancer, noninfectious airway diseases, cerebrovascular diseases). Chronic diseases occur over time. They have a history and wholeness about them that infectious diseases may not.2 There is mounting recognition that today’s medical education—still deeply rooted in Flexner’s incisive work—requires a more holistic approach.3,4 Fifteen years after his initial report, Flexner himself expressed concern that the medical curriculum reforms of the day were already beginning to overemphasize the medicinal BJ Cardinal ([email protected]), Park, and Kim are with the School of Biological and Population Health Sciences, Oregon State University, Corvallis, OR. MK Cardinal is with the Division of Health and Exercise Science, Western Oregon University, Monmouth, OR. 1336
sciences over the humanities and the social and behavioral sciences.5 This concern continues to this day.4
Today’s Diseases, Yesterday’s Cures: Medical Education in the 21st Century One of the most important lifestyle behaviors for preventing chronic diseases is physical activity. In their review of 18 chronic diseases, Pedersen and Saltin found strong evidence that regular physical activity involvement improves the pathogenesis and symptoms specific to the diagnosis of 8 conditions: chronic heart failure, coronary heart disease, dyslipidemia, hypertension, insulin resistance, intermittent claudication, obesity, and type 2 diabetes.6 They provided further strong evidence that it improves the pathogenesis of osteoporosis and the symptoms of chronic obstructive pulmonary disease, depression, fibromyalgia, and osteoarthritis; as well as provided benefits for those experiencing asthma, chronic fatigue syndrome, rheumatoid arthritis, and some forms of cancer (eg, breast, colon). Others support the value of regular physical activity involvement for improving balance, cognitive functioning, life expectancy, and overall quality of life, while concurrently decreasing dementia, falls, sarcopenia, and the overall cost of health care.7,8 The medicinal value of regular physical activity involvement is clear. It has widespread preventive, restorative, and curative powers with value superior to any other individual lifestyle intervention or treatment,9 and, in some cases, similar to available drug therapies used in preventing coronary heart disease, diabetes, rehabilitation following a stroke, and treating heart failure.10 Moreover, the value of physical activity extends beyond its functional and medicinal benefits: One of the greatest things about physical activity and play is that they make our lives go better, not just longer. It is the quality of life, the joy of being alive, the things we do with our good health that matter to us as much or more than health itself.11 (p. 6)
Medical Education Curricula Review 1337
However, for all of its known benefits, physical activity appears to have a rather sparse presence in the medical school curriculum. Nine English language studies have examined this topic over the past 42 years (Table 1), 4 of which were conducted in the United States,12–15 with the others occurring in Canada,16–18 the United Kingdom,19 and the United Kingdom and Ireland.20 Regardless of the country of origin or research approach employed, the take home message of these studies has been remarkably consistent:
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There is an urgent need for physical activity teaching to have dedicated time at medical schools, to equip tomorrow’s doctors with the basic knowledge, confidence and skills to promote physical activity and follow numerous clinical guidelines that support physical activity promotion.17 (p. 1025). Even in the programs that do offer coursework or experiences, instructional time is minimal ( .70 = large.33 Contingency coefficient values ≥ 0.30 were interpreted as being meaningful relationships.34
Results Of the 170 medical schools identified, the majority offered the MD degree (n = 141, 82.9%), with the balance offering the DO degree (n = 29, 17.1%). The majority of institutions were public (n = 92, 54.1%), with 76 (44.7%) being private, and 2 (1.2%) undetermined.
How Many MD and DO Schools Offer Courses Pertaining to Physical Activity? With regard to the prevalence of physical activity-related coursework, of the 118 (69.41%) institutions for which curriculum information was accessible, the largest percentage offered either no course (n = 61, 51.7%) or a single course (n = 25, 21.2%), though the range included up to 7 courses (n = 4, 3.4%).
Are the Physical Activity Courses Offered by MD and DO Schools Required or Elective? The majority of institutions did not require their students to take a single course (n = 97, 82.2%), whereas 15 (12.7%) required their students to take 1 course, 5 (4.2%) required their students to take 2 courses, and 1 ( .05, contingency coefficient = .20].
In What Format are the Courses Taught? The available coursework was most likely to be taught using a clinical approach (n = 125, 84.5%) rather than a lecture approach (n = 23, 15.5%) [χ2 (1, N = 148) = 70.30, P < .001, contingency coefficient = .57]. No online/modular coursework was found.
Does the Physical Activity Coverage in the Curricula of MD Programs Differ From That of DO Programs? MD and DO institutions were no different in terms of requiring their students to take coursework in this area [ie, 17.3% vs. 15.8%, respectively; χ2 (1, N = 117) = 0.03, P > .05, contingency coefficient = .02]. The number of courses required between MD (n = 98; mean = 0.20, SD = 0.48) and DO (n = 20; mean = 0.40, SD = 0.88) institutions did not differ [t (116) = 1.42, P > .05, d = .28].
Is There a Difference in Physical Activity Course Coverage Between Private and Public Institutions? While private and public institutions were no different in terms of requiring their students to take coursework in this area [ie, 12.5% vs. 7.3%%, respectively; χ2 (1, N = 96) = 0.03, P > .05, contingency coefficient = .12], the number of required courses at private institutions (n = 61; mean = 0.35, SD = 0.70) was higher than the number required at public institutions (n = 55; mean = 0.13, SD = 0.39) [t (114) = 1.42, P < .05, d = .39]. They also differed in delivery format, with 32.7% of private institutions delivering the content using a clinical approach, whereas 51.7% of public institutions did [χ2 (1, N = 147) = 5.57, P < .05, contingency coefficient = .19].
Discussion Though physicians have been called upon to counsel and support their patients in physical activity behavior acquisition and maintenance, our results suggest that over half of the physicians trained in the United States in 2013 received no formal education in the area of physical activity. As a result they may be ill-prepared to assist their patients in a manner consistent with Healthy People 2020,
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the National Physical Activity Plan, or the Exercise is Medicine initiative.28–30 They may also be inadequately prepared to assist consumers of commercially available physical activity programs, products, and services who are encouraged to consult their physician before beginning a physical activity program, use a physical activity product, or employ a physical activity service.13 Even at the institutions that do include physical activity education in their curriculum as either a requirement or an elective, the topics addressed are predominantly biophysical focused (ie, exercise physiology, sports medicine), with little attention devoted to behavioral counseling, lifestyle medicine, or preventive medicine (ie, putting scientific information into practice). Again, this seems inconsistent with the needs of patients and society. Specifically, physicians are being encouraged to lead the physical activity bandwagon in medicine and healthcare, as well as routinely counsel and support their patients in adopting and maintaining a physically active lifestyle.35 Moreover, physicians themselves are being urged to partake in physical activity for their own personal health and wellbeing, and for the benefit of others for whom they serve as physical activity role models.21 Periodic calls for more formal physical activity education in medical education have occurred over the past 42 years. During this same time the preventive, restorative, and curative powers of physical activity for health, among other humanistic and psychosocial benefits, have become increasingly clear. Physical inactivity decreases the quantity and quality of life; it is the fourth leading cause of mortality in the world,36 and it is a leading cause of morbidity.7 Some have gone so far as to refer to physical activity as medicine.35 Given this, it is remarkable that physicians receive little to no formal education in this area. Moreover, it is worth repeating the question Cummings asked some 42 years ago16: “The present situation [absence of physical activity instruction in medical schools] is such that one may well ask ‘Why consult your doctor before you exercise?’” (p. 731). There is mounting interest in addressing this situation, and, on the basis of this study, there is some evidence that progress has been made. For example, the percentage of institutions that offer coursework in physical activity education appears to be at an all-time high, at least relative to previously conducted studies (Table 2). In those studies the number of institutions offering physical activity education coursework ranged from 12.2% to 38.0%,12–15 whereas we found it to be 48.3%. We also found that 17.8% of the institutions required ≥ 1 course, whereas Garry et al reported it to be 5.9%,14 and Whitley and Nyberg reported it to be 4.4%.15 Physical activity assessment is also being recorded as a vital sign and included as part of patients’ electronic medical records in some healthcare organizations.37 Physicians and their staff can
then use this information as a form of recognition, encouragement, counseling, and/or referral. When this occurs, it is associated with positive health outcomes for the patient.38,39 An underlying premise of this systematic approach is that physicians are knowledgeable about the therapeutic value of physical activity, know the physical activity guidelines, and are able to confidently and competently discuss physical activity programming (or prescription) with their patients. This requires some degree of education, including potential contraindications and drug interactions (eg, the effects of beta blockers on heart rate response during aerobic exercise). One medical education institution that has taken this to heart is the University of South Carolina School of Medicine Greenville, which has created an “Exercise is Medicine” immersion experience for their students by identifying and incorporating key knowledge, skills, and abilities into all 4 years of their curriculum.40 At graduation their students should be able to demonstrate proficiency in physical activity and fitness assessment, exercise prescription and implementation, counseling for physical activity and behavioral strategies, and physician’s personal health (eg, role modeling). They are seeking to serve as a model institution for others and, in conjunction with Harvard University School of Medicine, hosted the first ever national Lifestyle Medicine Think Tank on September 9–10, 2013, with the aim being to explore how to get physical activity education incorporated into the nation’s medical education curricula.41 Curriculum revisions are often approached following the zero sum paradigm meaning that adding one thing will inevitably require removing something else. With that in mind, alternatives for accomplishing this should be considered (eg, integration into current courses or clinical experiences). Qualitative studies among those who have successfully achieved such changes might also be undertaken, and empirical evidence demonstrating the actual impact of such curricular changes is needed. Online learning modules, which we found no evidence of in this study, might also be developed as a means of broadly disseminating physical activity education-related content to medical education institutions. Online learning modules may also be developed for continuing education purposes, as the majority of physicians have not received any education or training in this area. Again, the impact of such work should be documented empirically and disseminated broadly. Key questions include 1) Are physicians better physicians as a result of this training? 2) Are patients who see physicians who have had such training more physically active? 3) Do patients who see physicians who have had such training have better health outcomes? and 4) If medical curriculums are already too full, could someone else do a better job fulfilling this role?35 An advantage of the methodology employed in this study is that it is not subject to response rate or self-selection biases. However,
Table 2 Inclusion of Physical Activity-Related Content in United States Medical Education, 1975–2013 Percent of institutions that offer a course
Percent of institutions that require a course
48.3
17.8
Study
Method
Sample size (response rate)
Current study (2013)
Content Analysis of Institutional Websites (MD & DO)
170 (with full data available on 69.41% of the institutions)
Garry et al13 (2002)
Administrator Survey (MD only)
102 (N/A)
12.8
5.9
Connoughton et al12 (2001)
Administrator Survey (MD only)
72 (56.25%)
23.0
–
Content Analysis of Medical Bulletins (MD only)
105 (73.6%)
38.0
4.4
Administrator Survey (MD only)
74 (73.29%)
12.2
–
Whitley and
Nyberg14
(1988)
Burke and Hultgren11 (1975)
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1342 Cardinal et al
content analysis is not without limitations. Namely, we were only able to review the manifest content of the curricula and course descriptions. Latent content or experiences may be unaccounted for. We were also unable to fully access curricular or course description information for 30.59% of the institutions.
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Conclusion This study gives a contemporary snapshot of the quantity and type of physical activity education coursework that is occurring in medical education in the United States in 2013. The results of this study, along with others before it,12–15 suggest that the majority of physicians have not received, nor will the majority of medical students today receive, any formal education or experiences in the area of physical activity education, which is inconsistent with Healthy People 2020, the National Physical Activity Plan, and the Exercise is Medicine initiative of the American College of Sports Medicine and the American Medical Association.28–30 However, there is also modest evidence that some positive changes have occurred. For example, the amount of physical activity education available in medical schools was higher in this study than in any previous study, the example being set by the University of South Carolina School of Medicine Greenville,40 and the national Lifestyle Medicine Think Tank,41 which focused its first meeting on how to get physical activity education incorporated into the nation’s medical education curricula, support this claim. As these changes continue to unfold it will become increasingly clear what knowledge, skills, and abilities are most important for physicians to demonstrate relative to physical activity education. At present, though, there is an ongoing need to get physical activity education into the medical school curricula, which is consistent with the White Paper issued on June 23, 2014 urging for this to happen.42 Adding to this urgency is that the majority (63.7%) of U.S. adults who had seen a health care professional during the past 12 months (2011–2012) reported receiving no advice or information about exercise from them.43 Moreover, in comparison with previous studies on the subject, the rate of counseling patients for physical activity by health care professionals might actually be decreasing.43 Acknowledgments This study was funded by a DeLoach Work Scholarship granted by the University Honors College at Oregon State University.
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