What if exercise counseling came in prescription form?

Mark Twain once quipped: “Everyone talks about the weather, but nobody does anything about it.”

Is the same true of exercise? Despite a growing, multibillion dollar fitness industry, despite an increase in sales of treadmills, weights, and other home exercise equipment, despite public education campaigns like Let’s Moveeighty percent of Americans – four out of five of us–do not get the recommended amount of cardiovascular and strength training. 41 million Americans belong to gyms–less than half of those actually go to them regularly.

Doctors know that exercise benefits health in many ways, from relieving depression to preventing heart disease and cancer. And yet, our efforts at counseling patients about exercise range from absent to haphazard. In my own practice, I confess, that though I do ask people about their exercise habits when I first meet them and at their annual physicals, the conversation is often unproductive (and occasionally comical).

A couple of recent examples:

Me: Have you been exercising?
Patient: Yes, now that the weather is nice I’m walking outside.
Me: But this Boston. Soon the weather won’t be nice. What then?
Patient: I hadn’t thought about that.

Me: Have you been exercising?
Patient: Yes! I walk my dog.
Me: Great! What kind of dog do you have?
Patient: A chihuahua.

Why aren’t I doing a better job at this? Lack of time, for one thing. it’s hard to squeeze a motivational conversation about exercise into a medical visit in which so much else needs to be covered (managing diabetes and high blood pressure, immunizations, flossing …).

Also, frankly, doctors get very little training on how to counsel patients about exercise — and we may be no more likely to exercise than our patients! Also, sadly, we operate in a culture in which writing prescriptions is easier and more valued than talking.

So what if exercise counseling came in prescription form? It does.

Several studies, such as the one summarized here, have shown that when a doctor, nurse practitioner hands a patient a specific exercise recommendation–type of exercise, intensity, duration, etc.–the patient is more likely to exercise. Here is a sample of what that looks like:

What if exercise counseling came in prescription form?

A new partnership between Massachusetts General Hospital For Children and the Appalachian Mountain Club takes an especially creative approach to exercise prescription. Called Outdoor Rx, the program trained 60 health professionals in the pilot sites, Waltham and Framingham, to write prescriptions giving families special access to information and activities sponsored by the Appalachian Mountain Club.

Doctors know exercise benefits health, and we also know most of our patients aren’t exercising — and neither are most of us. Maybe we need to do more than talk about it.

Suzanne Koven is an internal medicine physician and a Boston Globe columnist.  She blogs at In Practice at Boston.com, where this article originally appeared. She is the author of Say Hello To A Better Body: Weight Loss and Fitness For Women Over 50

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  • ninguem

    Yes, but then your office would be overrun with sales reps from the exercise companies.

    The aerobics rep leaves sticky pads, the cardiofit rep brings a lunch, the crosstrainer and core strengthening reps leave pens.

  • guest

    I actually find it annoying when my PCP and GYN nag me about exercising. I am an educated medical professional, I know I need to exercise, I play squash once a week, I have a BMI of 19 and I think it’s ridiculous for my doctors to harp on my needing to exercise more. Also unhelpful. I don’t need someone to nag me. I don’t need someone to give me even more specific tasks to accomplish, exercise-wise. I need someone to come over and finish my paperwork so I can get out of the house and get to the gym.

    Just like so many things in medicine, we are all overrun with micromanagers telling us what to do in ever more specific and time-consuming ways but no one actually lending a hand to get any of it done.

    I suspect many other patients feel the same.

    • SarahJ89

      A little “how can I help you?” might go further, no?

  • Suzi Q 38

    I like the push for exercise.
    About 3 years ago, I started a good routine of about an hour of exercise every other day. I upped it to everyday, and lost 40 pounds.
    My BP was excellent, my blood sugar came down, ditto for cholesterol.

    The problem? No one knew I had spinal stenosis.
    My symptoms worsened with exercise.

    I tried swimming, but then I got fungus on my toes from the shower and my hair got thrashed from the chlorine.

    The arthritis in my right knee got worse.

    I believe in exercise. I am fighting to get back to it.

    Now I really am not allowed to do much since my cervical surgery and arthroscopic knee surgery, but I try.

    I tried pilates the other day and it was too much.

    I have been happy with Tai Chi.

    For the most part, I have tried to be careful with my food intake.

    My point is that too much of a good thing can be bad.

  • morebuzzkills

    Any way we might be able to get the exercise in pill form?

  • http://www.dpsinfo.com LaurieMann

    I actually like the idea of a “prescription sheet” on diet and exercise. I just don’t think doctors should nag about your weight too much. If you’re too far above or below normal, the doctor should talk to you briefly. If you’re utterly inactive and eat McDonald’s 3 times a day, the doctor should say something.

    • SarahJ89

      Oddly, I’ve been in both places. I was underweight most of my life until my thyroid crashed when I was in my early 30s. Since then I have gained and lost 70 pounds, regained 30 of them but kept that remaining 40 at bay for over a decade.

      In all that time I have been dutifully weighed every time I see the doctor (which is as infrequently as possible). Not *once* in all that time has anyone commented upon my weight. Not when I was dangerously overweight, not when I lost 70 pounds, not when I regained more than is healthy, not when I’ve kept off most of the initial disastrous gain. Not once. Why on earth do they bother to weigh me at all? It’s like it’s a meaningless reflex activity no one bothers to think about.

      My husband sees his doctor once a year for a physical (another meaningless ritual, but it does mean they touch base which is good but could be done in a ten-minute conversation). When he came back this time I asked him “Have you gained or lost this year?” He didn’t know because they weighed him and it was never referred to again in the visit.

      I would actually love it if a PCP or two could tell me what on earth is going on here? Why do you waste everyone’s time weighing them when the information appears to be of no interest to anyone but me? My weight loss and maintenance have been strictly self motivated. Which is a good thing. I would have been out of luck had I been invested in an “Atta girl” from my doc when I lost that 70 pounds. No one noticed and yes, that was discouraging.

      • http://www.dpsinfo.com LaurieMann

        I think your doctor may be on the other extreme – not saying anything about weight. I think that, too, is a mistake. I remember being shocked in the ’90s when I nurse asked me if I minded being weighed. I said, “Of course not.” I’ve recently noticed they no longer ask that.

  • ErnieG

    While I believe exercise and diet are important for health, I am not so sure physicians should delve into the specifics of each, other than advising them specific things to avoid for their specific disease states. For example, an individual with knee OA probably should not run, an individual with CHF or CKD needs to avoid salt intake, and individual with severe CAD should probably go to cardiac rehab first to formulate an adequate exercise program, etc.
    Remember, we are disease managers, not health advisors, and our training is nowhere near what others can provide about diet and exercise. We can refer them to sources, both free and paid, as well as online and “brick and mortar” such as the Y, etc, and maybe we need to write a script telling them to seek such resources. Yes, we have a role it advising patients to optimize their health, but there are too many variables to write a dose and sig, other than get at least 30min of exercise daily and stand rather then sit.

    • guest

      Amen. I like to tell my patients specific facts about exercise they may not have heard, that might motivate them, such as ” Studies suggest that vigorous aerobic exercise for 30 minutes a few times a week has a measurable effect on mood.” Recent information about the metabolic effects of prolonged sitting is also interesting and useful for them to know.

      It’s my job to provide them with information that may help them make better choices.

      It’s not my job to micromanage their personal lives.

  • SarahJ89

    I’ve always found it amazing that my insurance is willing to pay tons of money for inpatient hospitalization but nothing to help me stay the course on the exercise that prevents so many medical problems.

    • Jess

      “What would help enormously would be to have a $10 an hour walking companion”

      Get a dog! They cost less than $10/day and they WILL NOT let you miss a walk!
      ;-)

      • SarahJ89

        I have two dogs and yes, they DO get me out. But when I’m really not feeling well I don’t stay out as long as I should. A human helps put things over the top.

        I also keep poultry, partly for the eggs and meat, partly for the free fertilizer. And partly because it’s the sort of thing that gets you outdoors for as much or as little time as you like. But it does get you out and regularly so–twice a day, without fail. Plus, hauling water and grain is a little like weight lifting.

        Seriously, when I broke my arm my orthopod didn’t bother to send me to PT because “you’ll do that yourself, I can tell.” He was right. When I had a bucket to pick up (they weigh 20 pounds when full of water) I used the healing arm, not my usual dominant arm. And it worked very well, was cheaper and integrated into my daily life.

      • Anne-Marie

        Anyone who volunteers at an animal shelter will attest to the down side of glibly telling everyone they should get a dog…

        • SarahJ89

          Agreed. It’s not like getting a toaster oven.

  • CME4PT

    Physical Therapists are exercise specialists who know how to prescribe exercise for patients with complicated medical issues. MDs can simply write a prescription for physical therapy and then move on to your next patient. Unlike your visit, my visit with a patient lasts anywhere from 30 minutes to an hour and I might see the patient 2-3 times per week initially. I have time to have those discussions. I can monitor how a patient is doing, make changes to their exercise plan when needed and be a resource for the patient. Unfortunately, most insurance companies won’t cover PT for exercise prescription for obesity. However, if the patient also has back pain, knee OA or spinal stenosis (or a variety of other neurological or orthopedic conditions), we’re fine. Get to know the PTs you refer to and they will be able to read between the lines to give your patients what they need.

    • Jess

      The physical therapist my mother’s PCP referred her to after a hip replacement was a godsend. Between the surgeon’s skill in doing her hip replacement and the PT’s skill in getting her up and moving like she hadn’t moved in probably a decade, it’s not just that Mom’s new hip is great but that she’s also a lot fitter and healthier now than she had been for quite a while. In hindsight, it’s a shame she had to wait till a medical event (hip replacement) before she was referred to a PT. She could have been much healthier years ago.

  • Jess

    And yet the obesity epidemic in Mexico is just as bad as it is here.

    So much for that idea.

  • STEPHEN

    If I were a physician and wanted to recommend exercise, I think that a simple form of basic yoga would be a good starting point for those patients that have been not active enough. The benefits of yoga and simple meditation are too numerous to list here, so…
    thoughts?