Exercise Counseling by Primary Care Physicians 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 the American College of Sports Medicine (ACSM) advise all adults to accumulate at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week, but many U.S. adults engage in no leisure-time physical activity. Since primary care providers can play an important role in exercise counseling and prescription, we wanted to assess the proportion 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: Results: Survey of 326 internists, family practitioners, and internal medicine and family practice residents. One hundred seventy-ve 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% prescribed exercise for more than half of their patients. Only 12% of physicians were familiar with the new ACSM recommendations. Physicians aged 35 and over were more likely than physicians less than 35 year old to ask about (82% versus 60%), counsel about (58% versus 37%), and prescribe (30% versus 8%) exercise. Family practitioners were more likely to ask about (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 their knowledge was inadequate. Finally, physicians who felt that they were successful in changing behavior were more likely to ask about and counsel about exercise. The most important barriers to exercise counseling were not having enough time and needing more practice in effective counseling techniques. Many primary care physicians are not asking about, counseling about, or prescribing exercise for their patients. Since primary care physicians are in the best position to provide individualized exercise prescriptions for their patients, future research should focus on training physicians in effective counseling techniques that can be done as brief interventions. Medical Subject Headings (MeSH): leisure activities, exercise, counseling, primary care physicians, sports medicine (Am J Prev Med 1999;16(4):307313) 1999 American Journal of Preventive Medicine

Conclusion:

Introduction
xercise is very important in disease prevention. The benets of regular exercise include improvements in cardiovascular tness, body composition, blood lipid prole, and retention of essential muscle mass. A physically active lifestyle also protects against the development and progression of many
From the Division of General Internal Medicine, Department of Medicine (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.

chronic diseases, including coronary artery disease, diabetes mellitus, hypertension, arthritis, and depression.17 Physical inactivity is one of the most signicant risk factors for the development of coronary heart disease (CHD),8 and individuals who exercise regularly have lower all-cause mortality rates.9 Despite the known benets of exercise, about one quarter of U.S. adults engage in no leisure-time physical activity.10 In the United Kingdom, the new recommendations by the Health Education Authority encourage people to build up to being active 30 minutes a day, but 50% of the population is below the recommended level of physical activity.11,12
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Recommendations by the CDC and the American College of Sports Medicine are more lenient than previous guidelines.13,14 The ACSM guidelines are directed toward the majority of adults who engage in no leisure-time activity. The guidelines advise people of all ages to accumulate at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week.15 Primary care providers can play an important role in exercise counseling and prescription. About 80% of U.S. adults will visit a physician in a one-year period.16 In Great Britain, general practitioners see 90% of their patient panel in a three-year period.12 Primary care physicians are in a unique position to counsel patients about exercise and, if appropriate, to offer an exercise prescription. Primary care physicians can prescribe exercise safely; can instruct the patient about and motivate him or her to engage in a recommended activity of appropriate duration, frequency, and intensity; and can follow up to monitor adherence and/or recommend exercise modication. The Healthy People 2000 health objective 1.12 is to increase to 50% the proportion of primary providers who regularly assess and counsel their patients about the appropriate type, frequency, duration, and intensity of exercise.17 One prior study that focused on primary care physicians and exercise counseling was done before the latest ACSM recommendations were published.18 It was also done before the managed care era, which has curtailed the time available for preventive medicine counseling. Factors currently inuencing physician exercise counseling practices may be different in light of the new ACSM recommendations and the increased time pressures of managed care. Identifying those factors that inuence exercise counseling and prescription may aid in the development of future interventions to increase exercise counseling. We hypothesized that knowledge of current exercise recommendations, having effective counseling skills, and having time available to counsel would be associated with asking about, counseling about, and prescribing exercise. This study was designed to assess what percentage of primary care physicians ask about, counsel about, and prescribe regular exercise, and which factors are associated with these habits.

county hospital, and one a for-prot private institution. All general internists and family practitioners at the hospitals were included. Each physician received a copy of the questionnaire as well as a cover letter explaining the purpose of the study. The study was approved by the Committee on Human Research of the University of California, San Francisco. The 38-item written questionnaire was modeled on a similar questionnaire previously developed by Sherman and Hershman.18 We used several questions from the original questionnaire and added new questions related to the ACSM recommendations and the time constraints of managed care. The questionnaire included questions about physician demographic factors (age, gender), personal health habits, including personal exercise habits, resting heart rate, and exercise knowledge. Physicians were specically asked whether or not they were familiar with the exercise recommendations of the ACSM. Resting pulse rate was used as an indicator of personal tness. Physicians were asked what percentage (0%25%, 25%50%, 50%75%, 75%) of their patients they typically asked about exercise, counseled about exercise, and prescribed exercise. Physicians were asked about their perceived success in counseling about behavior change, as well as the factors that they perceived as barriers to exercise counseling. Physicians were asked to review a list of potential barriers to exercise counseling and were asked to indicate those that they thought were signicant and to rank them from most to least important. Perceived success was rated on a four-point scale, which ranged from not successful to very successful. Perceived importance of exercise was graded on a vepoint Likert scale, which ranged from not important to moderately important to extremely important. Physician type (internal medicine versus family practice, resident versus attending) was assessed by the specialty under which the physician was listed in the hospital listing or the residency program in which he/she was enrolled. Data analysis. The main outcome variables were asking about, counseling about, and prescribing exercise to more than 50% of patients. The independent variables included physician demographics and personal health habits, exercise knowledge, exercise behavior, and perceived success in counseling. We compared physicians who asked, counseled, and prescribed exercise to more than 50% of their patients with those who did not. Chi-square tests were used for all univariate analyses. For each independent variable that achieved signicance in the univariate model, we performed multiple stratied analyses to control for the confounding effect of the other independent variables. Statistical signicance was set at p 0.05 for all analyses.

Methods
We surveyed 326 primary care general internists, family practitioners, and residents in internal medicine and family practice in San Francisco. Physicians were identied through administrative lists at four hospitals, all of which were afliated with the University of California, San Francisco. Four types of urban hospitals were chosen. One was an academic medical center, one a community-based university-owned hospital, one a
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Table 1. Demographic characteristics of physicians responding to survey (N 175) Characteristic Age (mean, years) Female (n 78) Male (n 97) Resting heart rate (mean, bpm) Smokes cigarettes Excersises regularly No. times a week exercises (n 107) Length of session (n 109) Practice Type Internal Medicine Family Practice Mean or % 34 32 35 67 4.6% 65% 3.6 49.3 min 81% 19% S.D. 7.25 5.5 8.2 10.6 1.5 21.8 min

Demographic Characteristics
Physician characteristics are described in Table 1. About 45% of the respondents were female. Overall, respondents were relatively young, with an average age of 32 for female and an average age of 35 for male respondents. The majority of respondents were internists (n 141: 81%). About two thirds of the respondents were in residency training and one third were practicing physicians.

Respondents Exercise-Related Behaviors

Two thirds of respondents reported exercising regularly. Those who exercised did so an average of 3.6 times per week for approximately 50 minutes per session. The average pulse rate for all respondents was 67 (SD 10.6). More physicians who reported exercising regularly had a resting pulse rate 65 than those who did not report exercising regularly (65.1% versus 21.0%: p 0.001).

Results
Completed questionnaires were received from 175 physicians (54% response rate). Response rate was similar in internists and family practitioners (54% versus 48%).

Table 2. Respondents exercise inquiries, counseling, and prescriptions (N 175) Characteristic Asking 50% of patients about exercise Counseling 50% of patients about exercise Prescribing 50% of patients exercise Have adequate knowledge to prescribe exercise to healthy adult Familiar with ACSM recommendations Level of comfort with exercise counseling Very comfortable Somewhat comfortable Somewhat uncomfortable Very uncomfortable Rates exercise as very important for: a healthy 35-year-old a healthy 55-year-old a healthy 75-year-old a patient with CAD Time spent counseling patient 02 min 25 min 6 or more min Among all respondents: Routinely counsel about type of exercise Routinely counsel about strenuousness of exercise Routinely counsel about duration of exercise Routinely counsel about frequency of exercise Recommendation for healthy adult to obtain maximum aerobic benet: No. times per week (mean) Length of session (minutes) Heart rate as % of maximal predicted Heart rate (MPHR) Would refer to exercise specialist if available Perceived success in changing patients health related behaviors Very successful Successful Somewhat successful Not successful
*Denominators vary due to missing data

n 116 75 25 130 21 38 111 24 2 112 130 128 136 68 95 11 165 121 157 163

% 66% 43% 14% 74% 12% 21.7% 63.4% 13.7% 1.1% 64% 74% 73% 78% 39.1% 54.6% 6.3% 94.3% 69.1% 89.7% 93.1% 3.86 30 min 76%

118 0 54 91 25

70.7% 0% 31.8% 53.5% 14.7%

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Table 3. Predictors of respondents exercise inquiries, counseling, and prescribing practices Asking >50% of patients n (%) 75 (60) 41 (82) 60 (71.4) 52 (60.5) 85 (60) 29 (85) 44 (83) 70 (59) 94 (72.3) 22 (48.9) 38 (70.4) 68 (74.7) 7 (28) Counseling >50% of patients n (%) 46 (36.8) 29 (58.0) 43 (51.2) 31 (36.1) 54 (38) 20 (59) 33 (62) 41 (34) 62 (47.6) 13 (28.9) 25 (46.3) 42 (46.2) 5 (20.0) Prescribing for >50% of patients n (%) 10 (8) 15 (30) 13 (52) 12 (48) 18 (13) 6 (18) 14 (26) 10 (8) 24 (18.5) 1 (2.22) 8 (14.8) 17 (18.7) 0

Predictor Age: 35 35 Pulse rate: 65 65 MD Type: Internal Medicine Family Practice MD Type: Attending Resident Exercise knowledge: Adequate Not adequate Perceived success in changing behavior: Moderate Somewhat None

.005 .132 .009 .002 .004

.01 .05 .04 .001 .03

.0002 .77 .49 .002 .007

.001

.05

.07

Exercise-Related Knowledge
Three quarters of physicians felt that they had adequate knowledge to prescribe exercise to a healthy adult, although relatively few physicians (12%) were familiar with the ACSM exercise recommendations. Most physicians (63%) reported feeling somewhat comfortable with exercise counseling, with only 12.5% feeling very comfortable. Slightly less than two thirds (64%) of physicians felt that exercise counseling was very important for a healthy 35 year-old, whereas three quarters of physicians felt that it was important for a healthy 55 year-old, a healthy 75 year-old and any patient with coronary artery disease.

they would refer patients to an exercise specialist if such a person were available to provide counseling. Respondents recommendations to the average healthy adult were to exercise about 4 times per week for 30 minutes, achieving a heart rate of 76% of maximal predicted heart rate in order to obtain maximum aerobic benet. Very few physicians felt successful in changing patients health-related behaviors. No physicians felt very successful, and only 31.8% felt successful. The majority of respondents felt only somewhat successful (53.5%) or not successful (14.7%).

Exercise Asking, Counseling, and Prescribing Behaviors

Physicians asking, counseling, and prescribing behaviors are described in Table 2. Two thirds (66%) 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% prescribed exercise for more than half of their patients. Among physicians who counseled patients about exercise, over half of them spent 25 minutes doing so. The vast majority of these physicians counseled patients regarding the type (94.3%), duration (89.7%), and frequency (93.1%) of exercise, although somewhat fewer counseled regarding the strenuousness (69.1%) of the exercise. About 70% of all physicians said that
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Factors Associated With Asking About, Counseling About, and Prescribing Exercise
Asking about exercise. Several factors were associated with asking 50% of patients about exercise. Physicians older than aged 35 were more likely to ask patients about exercise than those aged 35 and younger (82% versus 60%: p 0.005). A greater proportion of family practitioners (85%) than internists (60%) asked patients about exercise (p .009). Attending physicians were more likely to ask about exercise than residents (83% versus 59%: p 0.002). Physicians who said they had adequate knowledge about exercise were more likely to ask than those who did not (72.3% versus 48.9%: p .004), and physicians who felt they were moderately or somewhat successful in changing patients behavior were more likely to ask than those

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who felt not successful (70.4% versus 74.7% versus 28%: p 0.001). Counseling about exercise. Factors associated with counseling 50% of patients about exercise included age 35 (58% versus 37%: p 0.01), physician pulse rate 65 (51% versus 36%; p 0.05), adequate knowledge about exercise (47.6% versus 28.9%: p 0.03), and perceived success in changing behavior (moderately successful, 46.3%; somewhat successful, 46.2%; versus not successful, 20%: p 0.05). Physicians who were familiar with the recommendations of the ACSM were somewhat more likely to engage in regular exercise counseling (61.9% versus 40.2%: p 0.06). Family practitioners did more counseling than did internists (59% versus 38%: p 0.04), and attending physicians did more counseling than did residents (62% versus 34%; p 0.001). Prescribing exercise. The only three factors signicantly associated with prescribing exercise to 50% of patients 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 changing patients behavior was of borderline statistical signicance (moderately successful 14.8%; somewhat successful 18.7%; not successful 0%; p 0.07). Factors not associated with asking, counseling, or prescribing exercise included physicians gender, pulse rate, smoking habits, personal exercise habits, familiarity with ACSM recommendations, and comfort with exercise counseling. For all variables found to be signicantly associated in univariate analyses, stratied analyses were performed to eliminate the effects of other confounding variables. Each factor remained independently associated even after correcting for confounders.

Table 4. Barriers cited by respondents to exercise counseling (N 175) Barrier Not enough time I need more practice with effective counseling skills Counseling will not lead to behavior change Unsure of knowledge Patients are not interested Time better utilized counseling about other lifestyle changes Number 71 21 18 13 13 12 % 40.6 12 10.3 7.4 7.4 6.9

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

Discussion
This study, done in the managed care era, assessed physicians rates of exercise counseling and factors that were associated with asking about, counseling about, and prescribing exercise. The results of our study conrm the results of a previous study, which showed that about half of physicians do not counsel their patients about exercise.18 In our study, two thirds of respondents asked about exercise, less than half counseled about exercise, and relatively few prescribed exercise. Several factors were associated with asking about, counseling about, and prescribing exercise. These included aged 35, being an attending physician, having adequate exercise knowledge, being a family practitioner, and perceived success in exercise counseling. Older physicians ask, counsel, and prescribe more than younger physicians. Sherman and colleagues also found that older physicians were more likely to provide exercise counseling.18 In our study, although attending physicians were on average slightly older than residents, the age effect persisted even when correcting for attending versus resident status. Attending physicians are asking and counseling patients about exercise more frequently than are residents. In addition, being an attending physician was one of only three factors predictive of prescribing exercise to patients. Residents may be doing less exercise counseling because they feel the need to focus more on active medical problems. Alternatively, perhaps residents are not provided enough preventive medicine education. Prior studies have shown that residents feel inadequately trained in disease prevention.19 Family practitioners are asking about and counseling about exercise more frequently than are internists. This may reect differences in trainingperhaps family practitioners are better trained in exercise counseling than are internists. It is also possible that family practitioners are caring for healthier patients than are internists and that family practitioners thus have more time for preventive medicine counseling.
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Barriers to Exercise Counseling

Several factors were described by physicians as barriers to exercise counseling. These barriers in rank order included not having enough time, needing practice in effective counseling techniques, belief that counseling patients will not lead to behavior change, being unsure about exercise knowledge, thinking that patients are not interested, and feeling that time is better utilized counseling about other lifestyle changes (Table 4). Although respondents were asked whether lack of reimbursement for counseling was a barrier, no respondent stated that it was. Other barriers asked about but not frequently cited included not being convinced that exercise is benecial and being concerned that counseling about lifestyle changes would be overstepping ones boundaries.

Physicians who felt more successful in exercise counseling were also more likely to ask and counsel, and somewhat more likely to prescribe exercise. This nding is similar to that reported by Sherman and coauthors who found that physicians who did not feel that counseling was important were least likely to counsel.18 Lewis and coauthors, in a survey of members of the American College of Physicians, also found that perceived effectiveness of counseling was associated with the intensity with which the physician counsels about exercise.20 In this study, respondents cited several barriers to exercise counseling. Insufcient time was the most important barrier, which was also found by Orleans and Sherman in two prior studies.18,21 In our study, the majority of physicians who did counsel patients about exercise reported spending 25 minutes doing so. In the context of all the other activities that must be performed in a short time period, the additional time for exercise counseling may seem like too much. In this current era of increasing time pressures under managed care, we must focus our efforts on maximizing the use of the time available for exercise counseling, and on teaching physicians how to do brief, effective interventions, or perhaps on training ancillary staff in exercise counseling techniques. Many physicians cited lack of exercise knowledge as a barrier to exercise counseling. Physicians who felt they had adequate exercise knowledge were more likely to ask, counsel, and prescribe exercise to patients. Unfortunately, only 12% of physicians were familiar with the ACSM recommendations and although the majority of physicians felt that regular exercise was important for a 55 year-old, a 75 year-old and a patient with coronary artery disease, fewer physicians felt that exercise was important for a healthy 35 year-old. Efforts to improve exercise knowledge must occur at all levels of medical training including medical school, residency, and postgraduate education. Another important barrier was the need for effective counseling skills. Orleans and Sherman both also found the need for effective counseling skills to be an important barrier.18,21 Physicians can be trained in counseling, and brief physician intervention has been shown to improve smoking cessation rates.22 Future interventions should be directed toward improving counseling skills and increasing the frequency of exercise counseling among physicians. Patients want to receive physical activity counseling from their primary care physicians.23,24 Exercise counseling would appear to be a very cost-effective preventive intervention, yet it does require some time and effort. The goal of a future intervention should be to keep the time and effort it requires from the primary physician to a minimum, while making optimal use of the physicians power to motivate.8 We must teach physicians about current exercise recommendations,
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and train physicians in behavioral counseling so that they will realize that their counseling is effective. Training programs for exercise counseling in primary care do exist. Investigators at Group Health Cooperative in Puget Sound have designed and piloted a clinical tool designed to make tness testing and comprehensive exercise counseling practical in routine primary care. In this program, the physician assesses the patients current exercise habits and physical tness compared to norms for the patients age and gender. The program also provides comprehensive written exercise counseling and individualized advice about activity and tness based on the patients current exercise habits.8 In the Physician-based Assessment and Counseling for Exercise (PACE) project, primary care providers were trained to counsel patients regarding adoption and maintenance of physical activity. The majority of trained providers reported being able to perform the physical activity counseling within 15 minutes, and felt that the study protocols improved their ability to counsel patients regarding physical activity. In an uncontrolled eld trial of PACE, patients reported physical activity increased after counseling, but the program remains to be tested in a clinical trial.25 One multiple risk factor reduction trial, the Industrywide Network for Social, Urban and Rural Efforts (INSURE) project, found that continuing medical education seminars combined with physician reminders and reimbursement for preventive counseling was associated with a modest increase in the number of patients who start exercising.26 In the Activity Counseling Trial (ACT), primary care physicians are being trained to integrate 3 4 minutes of initial advice on physical activity into a routine visit. The impact of this advice plus behavioral counseling provided by a health educator on patients physical activity levels will be assessed for a two-year period.27 Further evaluation of these programs will lead to the development of improved exercise counseling strategies that can be used by primary care physicians. The results of our study should be interpreted with caution for several reasons. Our respondents were all from the San Francisco Bay Area of California, which may not be representative of the rest of the United States. However, two prior studies that addressed exercise counseling were both done in Massachusetts,18,28 so that the results of our study in another geographic setting are valuable. Second, our response rate was 54%, and since respondents are probably more likely to provide exercise counseling, we may have overestimated the true frequency of counseling. However, our response rate is similar to the rate (61%) seen in a previous study.18 Third, the small sample size may have limited the power of the study, particularly with respect to factors associated with exercise prescription, since so few provid-

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ers prescribed exercise. Finally, physicians reports of their own behavior may not always be accurate.29 We must continue to work on overcoming the barriers to exercise counseling to achieve the Healthy People 2000 health objective of increasing the proportion of primary providers who regularly assess and counsel their patients about the appropriate type, frequency, duration, and intensity of physical activity.17 Primary care physicians are probably in the best position to individualize exercise prescriptions for their patients, given patients medical conditions and interests, yet few of them felt competent in counseling. Further research and educational efforts should focus on improving physician training in exercise counseling at all levels. Since so few physicians were aware of the current physical activity recommendations, improving physician knowledge must be a priority. Given that physicians in our study said that they would refer to exercise counseling specialists, physicians themselves could be trained to become the exercise counseling experts. Other directions for future research include continued physician training in counseling techniques, such as motivational interviewing, 30,31 the impact of written exercise prescriptions, and the effect of computerized reminders to perform physical activity counseling. Finally, training non-physicians in physical activity counseling deserves research attention as another modality to increase patients physical activity levels.

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