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Original Research

Exercise Prescription Practices of a Group of Canadian Internal Medicine Physicians: A Cross-sectional Survey Including Barriers and Facilitators to Exercise Prescription

Alexi Kuhnow, MPT1*, Stephen Workman, MD1, 2

1Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada;

2Division of General Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada

Abstract

Background Internal Medicine (IM) physicians are in a prime role to prescribe exercise for chronic disease management. Our main objectives were to investigate the exercise prescription (EP) practices of IM physicians, and identify barriers and facilitators to EP.

Methods We emailed a confidential 16-item survey to 194 IM physicians practicing in the Central Zone of the Nova Scotia Health Authority (NSHA). The survey software Opinio was used for data collection and descriptive statistics.

Results A total of 108 IM physicians completed the survey (response rate = 55.7%). Sixty-five participants reported regular EP (60.2%). The main barriers to EP were lack of resources, time, and training. Facilitators included having patient education materials and EP pads available.

Interpretation: Although most participants reported that exercise was important for chronic disease management, about 40% did not report regularly prescribing it. Enabling facilitators and addressing barriers may improve EP practices for this group of IM physicians.

Résumé

Contexte Les internistes jouent un rôle de premier plan en matière de prescription d’exercice dans la prise en charge des maladies chroniques. Nos principaux objectifs visaient à étudier les pratiques de prescription d’exercice (PE) chez les internistes et à cerner les facteurs qui entravent ou facilitent la PE.

Méthodologie Nous avons fait parvenir par courriel à 194 internistes de la zone centrale de la Régie de la santé de la Nouvelle-Écosse un sondage confidentiel comportant 16 questions. Nous avons utilisé le logiciel de sondage Opinio pour la collecte des données et les statistiques descriptives.

Résultats Au total, il y a eu 109 répondants (taux de réponse = 56,2 %) et 108 d’entre eux ont rempli le sondage. Soixante-cinq participants ont indiqué qu’ils prescrivaient régulièrement de l’exercice (60,19 %). Les principaux obstacles à la PE sont le manque de ressources, le manque de temps et le manque de formation. Les facteurs facilitants sont l’accès à du matériel pédagogique destiné aux patients et à des ordonnanciers conçus pour la PE.

Interprétation Bien que la plupart des participants indiquent que l’exercice est important dans la prise en charge des maladies chroniques, environ 40 % d’entre eux ne le prescrivent pas régulièrement. Promouvoir les facteurs facilitants et s’attaquer aux obstacles pourraient améliorer les pratiques de PE chez ce groupe d’internistes.

Key words: chronic disease management, exercise prescription, Internal Medicine, physical activity, survey

Corresponding Author: Alexi Kuhnow: Alexi.Kuhnow@dal.ca

Submitted: 26 December 2020; Accepted: 4 March 2021; Published: 2 January 2022

Doi: http://dx.doi.org/10.22374/cjgim.v16i4.511

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

Introduction

Exercise is a key component in the prevention and management of many chronic diseases.1 Physical activity has similar benefits to mortality as pharmacotherapy for diabetes prevention, secondary prevention of coronary heart disease, and rehabilitation after stroke.2 To increase fitness and improve health-related quality of life, exercise prescription (EP) by physicians is an effective and feasible intervention.35 The number needed to treat (NNT) for one patient to perform 150 min per week of physical activity “with brief physician counselling” is 12.6 This has greater efficacy than counselling on smoking cessation, which has an NNT of 15–120.6

Despite the benefits of EP, and initiatives that promote it like Exercise is Medicine,7 many Canadian physicians do not prescribe exercise. In a recent survey of Emergency Medicine (EM) physicians, 12.4% often prescribed physical activity, while 56.1% rarely/never prescribed it.8 The main reported barrier was lack of time. In the primary care setting, rates between 20%9 and 65%10 have been reported, despite “the vast majority of Canadians not meeting recommended levels of physical activity.”11 Among Canadian Exercise is Medicine workshop attendees consisting of mostly Family Medicine (FM) physicians, 39% recommended exercise most of the time.12 Reported barriers to EP were lack of time, lack of guidance/resources for those with chronic diseases, patients not being interested in exercise, and other lifestyle changes being more important.12

Internal Medicine (IM) physicians are in a prime role to prescribe exercise to their patients as they regularly provide comprehensive care for people with chronic diseases. Many of these diseases have been shown to benefit from physical activity, including chronic obstructive pulmonary disease,13 hypertension,14 stroke,15 heart disease,16 cancer,17 diabetes,18 and Alzheimer’s disease.19 In the United States, rates of EP vary for IM physicians. For instance, one study found that 48% of Internists counselled more than 60% of their patients on the benefits of exercise,20 while another reported that 33% of General Internists provided counselling on exercise to at least 75% of their patients.21

Exercise prescription is paramount to fulfill the mission set out by the Canadian Society of Internal Medicine to “provide expert medical care for adults with complex multi-system diseases… [and] to promote the health and well-being of Canadian patients.”22 Although IM physicians are in a pivotal position to provide EP to individuals with chronic diseases, to our knowledge their EP practices have not been investigated in Canada. Our main objectives were to determine the EP practices of a group of Canadian IM physicians, as well as barriers and facilitators to EP. Secondary objectives were to determine their confidence with EP, personal exercise habits, and beliefs about EP.

Methods

Participants

To select participants, the purposive sampling method was used. We generated a list of all IM subspecialties as reported by the Nova Scotia Health Authority (NSHA) Department of Medicine, as given in Table 1. We also used the Royal College of Physicians and Surgeons of Nova Scotia (CPSNS) website’s Physician Search function. We selected each subspecialty of IM, as well as Internal Medicine itself for the search. We limited the search to the Central Zone of the NSHA for feasibility. This generated a list of all physicians currently registered to practice in any IM subspecialty in the Central Zone of the NSHA (n = 194). Participants were excluded if they did not complete the survey. There were no other exclusion criteria because our list consisted of physicians who met our inclusion criteria. These were: having an attending position, being registered to practice with the CPSNS, and working in any IM specialty in the Central Zone.

Table 1. Demographics of participants

Number (%)
Age
<30 0 (0)
30–39 27 (24.8)
40–49 26 (23.9)
50–60 33 (30.3)
>60 19 (17.4)
Prefer not to answer 3 (2.8)
Gender
Female 43 (39.5)
Male 63 (57.8)
Other 0 (0)
Prefer not to answer 2 (1.8)
Medical specialty
Cardiology 18 (16.5)
Critical care 4 (3.7)
Clinical allergy and immunology 2 (1.8)
Dermatology 3 (2.8)
Endocrine and metabolism 5 (4.6)
Gastroenterology 6 (5.5)
General internal medicine 10 (9.2)
Geriatric medicine 11 (10.1)
Hematology 8 (7.3)
Infectious diseases 4 (3.7)
Medical oncology 10 (9.2)
Nephrology 4 (3.7)
Palliative medicine 2 (1.8)
Physical medicine and rehabilitation 7 (6.4)
Respiratory medicine 7 (6.4)
Rheumatology 6 (5.5)
Other 1 (0.9)
Practice setting
Academic health sciences centre 86 (78.9)
Ambulatory clinic 14 (12.8)
Community hospital 5 (4.6)
Other 3 (2.8)
Years practicing medicine
<5 17 (15.6)
5–9 21 (19.3)
10–20 19 (17.4)
>20 51 (46.8)

Survey

We developed our survey using the guide by Burns et al.23 for self-administered surveys of clinicians. We generated items through a literature review which resulted in 5 domains: demographics, EP practices, exercise habits and barriers to exercising, beliefs and attitudes towards EP, and barriers and facilitators to EP. Following this, we reduced items to eliminate redundancies but maintained questions in the 5 domains. We designed our survey to be quick to complete so as to promote more participation.

The questions were formatted to be similar to other Canadian studies.8,10,24 We presented EP practices as a 5-item scale so that participants could select whether they never/rarely/sometimes/often/always prescribe exercise. Responses of sometimes/often/always were grouped as “did regularly prescribe exercise.” We defined EP in the survey as any verbal or written prescription that may include the type, frequency, intensity, and duration of exercise. Participants could also select which types of exercise they prescribed.

Similarly, we asked participants how many minutes per week they participated in various activities which included resistance training, walking, biking, aerobics, swimming and “other,” which was an open-ended option. We added the total minutes of each activity per participant to arrive at their weekly amount of physical activity. We chose to include this in our survey because previous studies have found that physicians who exercise are more likely to prescribe it to their patients.8,10

In an attempt to assess confidence in EP, we asked participants to rate their agreement with the statement, “I am confident prescribing exercise to my patients” on a 6-item scale from strongly agree to strongly disagree. We reported that participants were confident with EP if they selected either strongly agree/agree.

Barriers and facilitators were provided in a multiple-choice format, where we asked participants to select all that applied to them. The barriers and facilitators used as multiple-choice options were generated by a review of previous studies that asked physicians to identify barriers and facilitators to EP.8,12,25

The final confidential 16-item survey was populated into the survey software Opinio in order to provide it online. Opinio also provided descriptive statistics.

Invites to participants were sent by email in July 2019. Two reminder emails, one in August and one in September 2019, were sent to increase response rates. Participants provided written informed consent before being able to access the online survey. This study was approved by the NSHA Research Ethics Board (File 1024518).

Results

Survey response

Of the 194 IM physicians who were invited to participate, 108 completed the survey (response rate = 55.7%).

Demographics

Table 1 has full demographics for participants. Approximately, one-third of participants were 50–60 years old, and about 60% were male. The IM specialties represented the most were Cardiology, Geriatric Medicine, Medical Oncology, and General Internal Medicine. Overall, the respondents were representative of their subspecialties.

Exercise Prescription Practices

Sixty-five participants reported regular EP (60.2%). The percentage of participants who reported sometimes, often, or always providing EP were 27.5%, 28.4%, and 3.7%, respectively. Eighteen percent reported that they never provide EP, and 21.1% reported rarely providing EP. The type of exercise that was prescribed most frequently was walking (21.4%), followed by home exercises (11.1%), swimming/aquafit (11.1%), and strength training (10.6%). Please see Table 2 for more information on EP practices.

Table 2. Main survey results by percentage of participants who selected the response

Percentage (%)
EP practices
Never provide EP 18.4
Rarely provide EP 21.1
Sometimes provide EP 27.5
Often provide EP 28.4
Always provide EP 3.7
Regularly provide EP 60.2
Types of exercise prescribed
Walking 21.4
Home exercises 11.1
Swimming/Aquafit 11.1
Strength training 10.6
Had any formal training in EP 29.4
Personally exercise > 150 min/week 60.2
Barriers to performing exercise
Lack of time 30.2
Other activities take priority 20.4
Fatigue/Too tired 18.1
Lack of routine 11.7
Agree that “Exercise is an Effective Treatment Option” 88.1
Agree that “Exercise Increases Health Span” 95.4
Confident with EP 54.1

EP = exercise prescription.

Approximately 30% of participants reported having any formal training in EP.

Personal exercise habits

Sixty-five participants reported that they exercise more than 150 min per week (60.2%) on their own. The most commonly identified barrier to exercising was the lack of time (30.2%). This was followed by other activities taking priority (20.4%), fatigue/being too tired (18.1%) and lack of routine (11.7%). We gave the option to write in additional barriers but no participants chose this option.

Beliefs/Attitudes towards EP

Most participants (88.1%) selected that they strongly agree/agree with the statement, “Exercise is an effective treatment option for my patients.” Almost all participants (95.4%) selected that they strongly agree/agree with the statement, “Exercise increases healthspan (the period in one’s life that they are healthy).” More than half of participants (54.1%) selected that they strongly agree/agree with the statement, “I am confident prescribing exercise to my patients.”

Barriers and facilitators to EP

Lack of resources like patient education materials was the most commonly selected barrier to EP (14.3%). Other common barriers were that patients’ conditions prohibit exercise (13.3%), lack of time (12.6%), lack of adequate training/education in EP (10.9%), and lack of patient interest (8.8%). Participants had the option of writing in a barrier that we did not list, but no participant chose this option. Figure 1 demonstrates the barriers to EP selected by participants.

Figure 1. Barriers to Participants Prescribing Excercise to Patients

Figure 2 demonstrates facilitators to EP. The most commonly selected facilitator was to have patient education materials available (15%), closely followed by having EP pads available (14.6%). Other facilitators were patients being interested in exercising (12.1%), more community resources for patients (10%), more time for EP (8.4%), and training about EP (7.3%). Participants could write in other facilitators but none did.

Figure 2. Facilitators to Participants Prescribing Exercise to Patients

Discussion

To our knowledge, this is the first Canadian study to survey IM physicians about their EP practices. Sixty percent of IM physicians reported regular EP, which is on the high end of rates reported in other studies.8,10,12 This could be because we included participants who selected that they sometimes prescribe EP in our definition of regular EP. Almost 55% of participants rated themselves as confident with EP, similar to rates described in Canadian studies of FM physicians.12,25 It could be that the remaining participants did not rate themselves as confident because only 30% reported having any formal training in EP. Inadequate training was identified in our survey as a barrier to EP.

The main barriers to EP were lack of resources like patient education materials, patients’ conditions prohibiting exercise, and lack of time and training. Facilitators of EP were having patient education materials and EP pads available, patients being interested in exercising, more community resources for patients, and having more time for EP. Barriers identified in our study were similar to those reported in other Canadian studies. In a 2017 survey of Exercise is Medicine attendees, most physicians reported lack of time, patients not interested in exercise, and lack of guidance/resources for those with chronic diseases as barriers to EP.25 Similar barriers of lack of time, necessary skills/tools, and reimbursement were identified in an earlier study of FM physicians.26

Since EP is an effective and feasible management strategy for a myriad of chronic conditions, interventions aimed at improving EP rates among IM physicians would provide benefits to many patients. Future studies are needed to determine effective strategies to improve EP for IM physicians. These strategies could focus on three areas we identified in our study: increasing confidence with EP, encouraging physicians to exercise, and addressing barriers and facilitators to EP.

“Exercise is Medicine” workshops have proven to be effective at increasing rates of EP.12,25 Encouraging IM physicians to attend these workshops may improve their EP through education and improved confidence.

Physicians who exercise are more likely to provide EP to their patients.8,10 Workplace interventions could address the barrier of lack of time to exercise and may increase physical activity levels.27 Additionally, providing pedometers to physicians could increase exercise adherence.28

Other Canadian studies have recommended that medical schools should both encourage students to exercise and provide education about exercise counselling in order to improve confidence and rates of EP in their future careers.29,30

Finally, addressing barriers and facilitators may improve EP among IM physicians. For instance, EP pads are already being provided to physicians in British Columbia and New Brunswick.31 Figure 3 provides a sample EP pad to facilitate EP. Another facilitator identified in our study was to have more community resources available for patients. A strategy to address this facilitator could be to provide more education to physicians about available community resources and how patients can access them. Finally, lack of patient interest was identified as a barrier to EP. In 2018, the SPOTLIGHT project assessed interest in physical activity in over 5000 adults.32 The study concluded that assessing an individual’s goals and interest in physical activity may help increase physical activity levels. This is congruent with the principles of motivational interviewing, which has been shown to improve exercise adherence.33

Figure 3. Sample Exercise Prescription Pad

Limitations

Although the response rate was 55.7%, the number of participants in our study was small at 108 which limits the generalizability of the results. Validated items were not used in our survey so as to reduce its length and improve response rates. There are two limitations that may account for the high frequency of EP compared to other studies: sampling bias, since physicians who prescribe exercise regularly may have been more likely to participate, and our definition of regular EP which included sometimes/often/always providing EP, rather than just often/always. Lastly, we chose to use the term “exercise” in our survey, but the term “physical activity” may have been more inclusive.

Conclusions

This group of IM physicians had a high rate of EP at 60%, although 40% did not report regular EP. About half of the participants were confident with EP, and 60% reported personally exercising more than 150 min per week. Barriers to providing EP included lack of resources, time, and training. Main facilitators were having patient education materials and EP pads available. Interventions that (i) encourage exercise performance, (ii) improve confidence with EP, and (iii) address these barriers and facilitators may help improve EP practices for this group of IM physicians, but large-scale studies are needed.

Acknowledgments

The authors would like to acknowledge the support of the Dalhousie Medical Research Foundation’s Department of Medicine University Internal Medicine Research Foundation Studentship.

REFERENCES

1. Hoffman TC, Maher CG, Briffa T, et al. Prescribing exercise interventions for patients with chronic conditions. CMAJ. 2016;188(7):510–18. 10.1503/cmaj.150684

2. Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: Metaepidemiological study. Br J Sports Med. 2013;49(21):1414–22. 10.1136/bjsports-2015-f5577rep

3. Bullard T, Ji M, An R, et al. A systematic review and meta-analysis of adherence to physical activity interventions among three chronic conditions: Cancer, cardiovascular disease, and diabetes. BMC Public Health. 2019;19(1):636. 10.1186/s12889-019-6877-z

4. Grandes G, Sanchez A, Sanchez-Pinilla RO, et al. Effectiveness of physical activity advice and prescription by physicians in routine primary care. Arch Intern Med. 2009;169(7):694–701. 10.1001/archinternmed.2009.23

5. Petrella RJ, Koval JJ, Cunningham DA, et al. Can primary care doctors prescribe exercise to improve fitness? The Step Test EP (STEP) project. Am J Prev Med. 2003;24(4):316–22. 10.1016/S0749-3797(03)00022-9

6. Thornton JS, Frémont P, Khan K, et al. Physical activity prescription: A critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: A position statement by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med. 2016;5:1109–14. 10.1136/bjsports-2016-096291

7. Sallis RE. Exercise is medicine and physicians need to prescribe it! Br J Sports Med. 2009;43:3–4. 10.1136/bjsm.2008.054825

8. Soegtrop R, Douglas-Vail M, Bechamp T, et al. Physical activity prescription by Canadian Emergency Medicine Physicians. Appl Physiol Nutr Metab. 2018;43:861–4. 10.1139/apnm-2017-0616

9. Baillot A, Baillargeon JP, Paré A, et al. Physical activity assessment and counseling in Quebec family medicine groups. Can Fam Physician. 2018;64(5):e234–41. PMid: 29760272

10. Frank E, Segura C, Shen H, et al. Predictors of Canadian physicians’ prevention counseling practices. Can J Public Health. 2010;101(5):390–5. 10.1007/BF03404859

11. Taylor GW. Health status of Canadians 2016: A report of the Chief Public Health Officer. Ottawa: Public Health Agency of Canada (PHAC); 2016. p. 1–68.

12. Fowles JR, O’Brien MW, Solmundson K, et al. Exercise is Medicine Canada physical activity counselling and EP training improves counselling, prescription, and referral practices among physicians across Canada. Appl Physiol Nutr Metab. 2018;43:535–9. 10.1139/apnm-2017-0763

13. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease—2008 update—Highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A. 10.1155/2008/420268

14. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75(6):1334–57. 10.1161/HYPERTENSIONAHA.120.15026

15. Wein T, Lindsay MP, Côté R, et al. Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017. Int J Stroke. 2017;13(4):420–43. 10.1177/1747493017743062

16. Mancini GB, Gosselin G, Chow B, et al. Canadian Cardiovascular Society Guidelines for the diagnosis and management of stable ischemic heart disease. Can J Cardiol. 2014;30:837–49. 10.1016/j.cjca.2014.05.013

17. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. Can Cancer J Clin. 2012;62:242–74. 10.3322/caac.21142

18. Sigal RJ, Armstrong MJ, Bacon SL, et al. Physical activity and diabetes. Diabetes Canada Clinical Practice Guidelines Expert Committee. Can J Diabetes. 2018;42(Suppl 1):S54–63. 10.1016/j.jcjd.2017.10.008

19. Groot C, Hooghiemstra AM, Raijmakers PG, et al. The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials. Ageing Res Rev. 2015;25:13–23. 10.1016/j.arr.2015.11.005

20. Abramson S, Stein J, Schaufele M, et al. Personal exercise habits and counseling practices of primary care physicians: A national survey. Clin J Sport Med. 2000;10:40–8. 10.1097/00042752-200001000-00008

21. Sherman SE, Hershman WY. Exercise counseling: How do general internists do? J Gen Intern Med. 1993;8:243–8. 10.1007/BF02600089

22. The Canadian Society of Internal Medicine. About CSIM [Internet]. Ottawa; 2020. Available from: www.csim.ca/about. Accessed on Dec 20, 2020.

23. Burns KE, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179(3):245–52. 10.1503/cmaj.080372

24. Petrella RJ, Lattanzio CN, Overend TJ. Physical activity counseling and prescription among Canadian primary care physicians. Arch Intern Med. 2007;167(16):1774–81. 10.1001/archinte.167.16.1774

25. O’Brien NW, Shields CA, Oh PI, et al. Health care provider confidence and EP practices of Exercise is Medicine Canada workshop attendees. Appl Physiol Nutr Metab. 2017;42(4):384–90. 10.1139/apnm-2016-0413

26. Petrella RJ, Wright D. An office-based instrument for exercise counseling and prescription in primary care. The Step Test EP (STEP). Arch Fam Med. 2000;9(4):339–44. 10.1001/archfami.9.4.339

27. Malik SH, Blake H, Suggs LS. A systematic review of workplace health promotion interventions for increasing physical activity. Br J Health Psychol. 2014;19(1):149–90. 10.1111/bjhp.12052

28. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: A systematic review. JAMA. 2007;298(19):2296–304. 10.1001/jama.298.19.2296

29. Holtz KA, Kokotilo KJ, Fitzgerald BE, et al. Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia. Can Fam Physician. 2013;59(1):e26–32. PMid: 23341676

30. McFadden T, Fortier M, Sweet SN, et al. Canadian medical students’ perceived motivation, confidence and frequency recommending physical activity. Prev Med Rep. 2019;15:100898. 10.1016/j.pmedr.2019. 100898

31. Owens B. Exercise prescription endorsed. CMAJ. 2014;186(13): e478. 10.1503/cmaj.109-4846

32. Carraça EV, Mackenback JD, Lakerveld J, et al. Lack of interest in physical activity—Individual and environmental attributes in adults across Europe: The SPOTLIGHT project. Prev Med. 2018;111:41–8. 10.1016/j.ypmed.2018.02.021

33. Stonerock GL, Blumenthal JA. Role of counseling to promote adherence in healthy lifestyle medicine: Strategies to improve exercise adherence and enhance physical activity. Prog Cardiovasc Dis. 2016;59(5):455–62. 10.1016/j.pcad.2016.09.003