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Exercise Counseling by Primary CarePhysicians in the Era of Managed Care

Judith M.E. Walsh, MD, MPH, Daniel M. Swangard, MD, Thomas Davis, Stephen J. McPhee, MD

Background: Recommendations from the Centers for Disease Control and Prevention (CDC) and theAmerican College of Sports Medicine (ACSM) advise all adults to accumulate at least 30minutes of moderate intensity physical activity on most, if not all, days of the week, butmany U.S. adults engage in no leisure-time physical activity. Since primary care providerscan play an important role in exercise counseling and prescription, we wanted to assess theproportion of primary care physicians from four hospitals who asked about exercise habits,counseled about exercise, and prescribed exercise; and the factors that were associated

with their counseling and prescription habits.

Design: Survey of 326 internists, family practitioners, and internal medicine and family practiceresidents.

Results: One hundred seventy-five physicians completed the questionnaire (54% response rate).Two thirds of physicians reported asking more than half of their patients about exercise,43% counseled more than half of their patients about exercise, but only 14% prescribedexercise for more than half of their patients. Only 12% of physicians were familiar with thenew ACSM recommendations. Physicians aged 35 and over were more likely thanphysicians less than 35 year old to ask about (82% versus 60%), counsel about (58% versus37%), and prescribe (30% versus 8%) exercise. Family practitioners were more likely to askabout (85% versus 62%) and counsel about (59% versus 39%) exercise than internists.Physicians who felt they had adequate exercise knowledge were more likely to ask about(72% versus 49%) and counsel about (48% versus 29%) exercise than those who felt theirknowledge was inadequate. Finally, physicians who felt that they were successful inchanging behavior were more likely to ask about and counsel about exercise. The mostimportant barriers to exercise counseling were not having enough time and needing morepractice in effective counseling techniques.

Conclusion: Many primary care physicians are not asking about, counseling about, or prescribingexercise for their patients. Since primary care physicians are in the best position to provideindividualized exercise prescriptions for their patients, future research should focus ontraining physicians in effective counseling techniques that can be done as brief interven-tions.

Medical Subject Headings (MeSH): leisure activities, exercise, counseling, primary carephysicians, sports medicine (Am J Prev Med 1999;16(4):307313) 1999 American

Journal of Preventive Medicine

Introduction

Exercise is very important in disease prevention.The benefits of regular exercise include im-provements in cardiovascular fitness, body com-

position, blood lipid profile, and retention of essentialmuscle mass. A physically active lifestyle also protectsagainst the development and progression of many

chronic diseases, including coronary artery disease,diabetes mellitus, hypertension, arthritis, and depres-

sion.17 Physical inactivity is one of the most significantrisk factors for the development of coronary heartdisease (CHD),8 and individuals who exercise regularlyhave lower all-cause mortality rates.9

Despite the known benefits of exercise, about onequarter of U.S. adults engage in no leisure-time physi-cal activity.10 In the United Kingdom, the new recom-mendations by the Health Education Authority encour-age people to build up to being active 30 minutes a day,but 50% of the population is below the recommendedlevel of physical activity.11,12

From the Division of General Internal Medicine, Department ofMedicine (Walsh, Davis, McPhee), and Department of Anesthesia(Swangard), University of California, San Francisco, CA.

Address correspondence to: Judith M.E. Walsh, MD, MPH, UCSF/Mount Zion Division of General Internal Medicine 1701 Divisadero,Box 1732, San Francisco, CA 94115.

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Exercise-Related Knowledge

Three quarters of physicians felt that they had adequateknowledge to prescribe exercise to a healthy adult,although relatively few physicians (12%) were familiar

with the ACSM exercise recommendations. Most physi-cians (63%) reported feeling somewhat comfortable

with exercise counseling, with only 12.5% feeling verycomfortable.

Slightly less than two thirds (64%) of physicians feltthat exercise counseling was very important for ahealthy 35 year-old, whereas three quarters of physi-cians felt that it was important for a healthy 55 year-old,a healthy 75 year-old and any patient with coronaryartery disease.

Exercise Asking, Counseling,and Prescribing Behaviors

Physicians asking, counseling, and prescribing behav-iors are described in Table 2. Two thirds (66%) ofphysicians reported asking more than half of theirpatients about exercise, 43% counseled more than halfof their patients about exercise, but only 14% pre-scribed exercise for more than half of their patients.

Among physicians who counseled patients aboutexercise, over half of them spent 25 minutes doing so.The vast majority of these physicians counseled patientsregarding the type (94.3%), duration (89.7%), andfrequency (93.1%) of exercise, although somewhatfewer counseled regarding the strenuousness (69.1%)of the exercise. About 70% of all physicians said that

they would refer patients to an exercise specialist if sucha person were available to provide counseling.

Respondents recommendations to the averagehealthy adult were to exercise about 4 times per weekfor 30 minutes, achieving a heart rate of 76% ofmaximal predicted heart rate in order to obtain maxi-mum aerobic benefit.

Very few physicians felt successful in changing pa-tients health-related behaviors. No physicians felt verysuccessful, and only 31.8% felt successful. The ma-

jority of respondents felt only somewhat successful(53.5%) or not successful (14.7%).

Factors Associated With Asking About,Counseling About, and Prescribing Exercise

Asking about exercise. Several factors were associatedwith asking50% of patients about exercise. Physicians

older than aged 35 were more likely to ask patientsabout exercise than those aged 35 and younger (82%

versus 60%: p 0.005). A greater proportion of familypractitioners (85%) than internists (60%) asked pa-tients about exercise (p .009). Attending physicians

were more likely to ask about exercise than residents(83% versus 59%: p 0.002). Physicians who said theyhad adequate knowledge about exercise were morelikely to ask than those who did not (72.3% versus48.9%: p .004), and physicians who felt they weremoderately or somewhat successful in changingpatients behavior were more likely to ask than those

Table 3. Predictors of respondents exercise inquiries, counseling, and prescribing practices

Predictor

Asking>50%of patientsn (%) p

Counseling>50%of patientsn (%) p

Prescribing for>50% of patientsn (%) p

Age:35 75 (60) 46 (36.8) 10 (8)35 41 (82) .005 29 (58.0) .01 15 (30) .0002

Pulse rate:65 60 (71.4) 43 (51.2) 13 (52)65 52 (60.5) .132 31 (36.1) .05 12 (48) .77

MD Type:Internal Medicine 85 (60) 54 (38) 18 (13)Family Practice 29 (85) .009 20 (59) .04 6 (18) .49

MD Type:Attending 44 (83) 33 (62) 14 (26)Resident 70 (59) .002 41 (34) .001 10 (8) .002

Exercise knowledge:Adequate 94 (72.3) .004 62 (47.6) .03 24 (18.5) .007Not adequate 22 (48.9) 13 (28.9) 1 (2.22)

Perceived success inchanging behavior:Moderate 38 (70.4) 25 (46.3) 8 (14.8)Somewhat 68 (74.7) 42 (46.2) 17 (18.7)None 7 (28) .001 5 (20.0) .05 0 .07

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who felt not successful (70.4% versus 74.7% versus28%: p 0.001).

Counseling about exercise. Factors associated withcounseling 50% of patients about exercise includedage 35 (58% versus 37%: p 0.01), physician pulserate 65 (51% versus 36%; p 0.05), adequate knowl-edge about exercise (47.6% versus 28.9%: p 0.03),

and perceived success in changing behavior (moderate-ly successful, 46.3%; somewhat successful, 46.2%; versusnot successful, 20%: p 0.05). Physicians who werefamiliar with the recommendations of the ACSM weresomewhat more likely to engage in regular exercisecounseling (61.9% versus 40.2%: p 0.06). Familypractitioners did more counseling than did internists(59% versus 38%: p 0.04), and attending physiciansdid more counseling than did residents (62% versus34%; p 0.001).

Prescribing exercise. The only three factors signifi-

cantly associated with prescribing exercise to 50% ofpatients were aged 35 (30% versus 8%; p 0.0002),exercise knowledge (18.5% versus 2.2%: p 0.007),and attending (versus resident) physician status (26%

versus 8%: p .002). Perceived success in changingpatients behavior was of borderline statistical signifi-cance (moderately successful 14.8%; somewhat success-ful 18.7%; not successful 0%; p 0.07).

Factors not associated with asking, counseling, orprescribing exercise included physicians gender, pulserate, smoking habits, personal exercise habits, familiar-ity with ACSM recommendations, and comfort with

exercise counseling.For all variables found to be significantly associated

in univariate analyses, stratified analyses were per-formed to eliminate the effects of other confounding

variables. Each factor remained independently associ-ated even after correcting for confounders.

Barriers to Exercise Counseling

Several factors were described by physicians as barriersto exercise counseling. These barriers in rank orderincluded not having enough time, needing practice in

effective counseling techniques, belief that counselingpatients will not lead to behavior change, being unsureabout exercise knowledge, thinking that patients arenot interested, and feeling that time is better utilizedcounseling about other lifestyle changes (Table 4).

Although respondents were asked whether lack ofreimbursement for counseling was a barrier, no respon-dent stated that it was. Other barriers asked about butnot frequently cited included not being convinced thatexercise is beneficial and being concerned that coun-seling about lifestyle changes would be oversteppingones boundaries.

Discussion

This study, done in the managed care era, assessedphysicians rates of exercise counseling and factors that

were associated with asking about, counseling about,

and prescribing exercise. The results of our studyconfirm the results of a previous study, which showedthat about half of physicians do not counsel theirpatients about exercise.18 In our study, two thirds ofrespondents asked about exercise, less than half coun-seled about exercise, and relatively few prescribedexercise.

Several factors were associated with asking about,counseling about, and prescribing exercise. These in-cluded aged 35, being an attending physician, havingadequate exercise knowledge, being a family practitio-ner, and perceived success in exercise counseling.

Older physicians ask, counsel, and prescribe morethan younger physicians. Sherman and colleagues alsofound that older physicians were more likely to provideexercise counseling.18 In our study, although attendingphysicians were on average slightly older than residents,the age effect persisted even when correcting for at-tending versus resident status.

Attending physicians are asking and counseling pa-tients about exercise more frequently than are resi-dents. In addition, being an attending physician wasone of only three factors predictive of prescribingexercise to patients. Residents may be doing less exer-cise counseling because they feel the need to focusmore on active medical problems. Alternatively, per-haps residents are not provided enough preventivemedicine education. Prior studies have shown that resi-dents feel inadequately trained in disease prevention.19

Family practitioners are asking about and counselingabout exercise more frequently than are internists. Thismay reflect differences in trainingperhaps familypractitioners are better trained in exercise counselingthan are internists. It is also possible that family practi-tioners are caring for healthier patients than are inter-nists and that family practitioners thus have more timefor preventive medicine counseling.

Table 4. Barriers cited by respondents to exercisecounseling (N 175)

Barrier Number %

Not enough time 71 40.6I need more practice with effective

counseling skills21 12

Counseling will not lead to behaviorchange

18 10.3

Unsure of knowledge 13 7.4Patients are not interested 13 7.4Time better utilized counseling about

other lifestyle changes12 6.9

*Barriers have been rank ordered from highest to lowest by thenumber of individuals who ranked a barrier as #1

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Physicians who felt more successful in exercise coun-seling were also more likely to ask and counsel, andsomewhat more likely to prescribe exercise. This find-ing is similar to that reported by Sherman and coau-thors who found that physicians who did not feel thatcounseling was important were least likely to counsel.18

Lewis and coauthors, in a survey of members of theAmerican College of Physicians, also found that per-

ceived effectiveness of counseling was associated withthe intensity with which the physician counsels aboutexercise.20

In this study, respondents cited several barriers toexercise counseling. Insufficient time was the mostimportant barrier, which was also found by Orleans andSherman in two prior studies.18,21 In our study, themajority of physicians who did counsel patients aboutexercise reported spending 25 minutes doing so. Inthe context of all the other activities that must beperformed in a short time period, the additional timefor exercise counseling may seem like too much. In this

current era of increasing time pressures under man-aged care, we must focus our efforts on maximizing theuse of the time available for exercise counseling, andon teaching physicians how to do brief, effective inter-

ventions, or perhaps on training ancillary staff in exer-cise counseling techniques.

Many physicians cited lack of exercise knowledge as abarrier to exercise counseling. Physicians who felt theyhad adequate exercise knowledge were more likely toask, counsel, and prescribe exercise to patients. Unfor-tunately, only 12% of physicians were familiar with the

ACSM recommendations and although the majority ofphysicians felt that regular exercise was important for a55 year-old, a 75 year-old and a patient with coronaryartery disease, fewer physicians felt that exercise wasimportant for a healthy 35 year-old. Efforts to improveexercise knowledge must occur at all levels of medicaltraining including medical school, residency, and post-graduate education.

Another important barrier was the need for effectivecounseling skills. Orleans and Sherman both alsofound the need for effective counseling skills to be animportant barrier.18,21 Physicians can be trained incounseling, and brief physician intervention has beenshown to improve smoking cessation rates.22 Futureinterventions should be directed toward improvingcounseling skills and increasing the frequency of exer-cise counseling among physicians.

Patients want to receive physical activity counselingfrom their primary care physicians.23,24 Exercise coun-seling would appear to be a very cost-effective preven-tive intervention, yet it does require some time andeffort. The goal of a future intervention should be tokeep the time and effort it requires from the primaryphysician to a minimum, while making optimal use ofthe physicians power to motivate.8 We must teachphysicians about current exercise recommendations,

and train physicians in behavioral counseling so thatthey will realize that their counseling is effective.

Training programs for exercise counseling in pri-mary care do exist. Investigators at Group HealthCooperative in Puget Sound have designed and piloteda clinical tool designed to make fitness testing andcomprehensive exercise counseling practical in routineprimary care. In this program, the physician assesses

the patients current exercise habits and physical fitnesscompared to norms for the patients age and gender.The program also provides comprehensive written ex-ercise counseling and individualized advice about activ-ity and fitness based on the patients current exercisehabits.8

In the Physician-based Assessment and Counselingfor Exercise (PACE) project, primary care providers

were trained to counsel patients regarding adoptionand maintenance of physical activity. The majority oftrained providers reported being able to perform thephysical activity counseling within 15 minutes, and felt

that the study protocols improved their ability to coun-sel patients regarding physical activity. In an uncon-trolled field trial of PACE, patients reported physicalactivity increased after counseling, but the programremains to be tested in a clinical trial.25

One multiple risk factor reduction trial, the Indus-trywide Network for Social, Urban and Rural Efforts(INSURE) project, found that continuing medical ed-ucation seminars combined with physician remindersand reimbursement for preventive counseling was asso-ciated with a modest increase in the number of patients

who start exercising.26

In the Activity Counseling Trial (ACT), primary carephysicians are being trained to integrate 34 minutesof initial advice on physical activity into a routine visit.The impact of this advice plus behavioral counselingprovided by a health educator on patients physicalactivity levels will be assessed for a two-year period.27

Further evaluation of these programs will lead to thedevelopment of improved exercise counseling strate-gies that can be used by primary care physicians.

The results of our study should be interpreted withcaution for several reasons. Our respondents were allfrom the San Francisco Bay Area of California, which

may not be representative of the rest of the UnitedStates. However, two prior studies that addressed exer-cise counselingwere both done in Massachusetts,18,28 sothatthe results of our study in another geographic settingare valuable. Second, our response rate was 54%, andsince respondents are probably more likely to provideexercise counseling, we may have overestimated thetrue frequency of counseling. However, our responserate is similar to the rate (61%) seen in a previousstudy.18 Third, the small sample size may have limitedthe power of the study, particularly with respect to factorsassociated with exercise prescription, since so few provid-

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