In 2009, Dr. Richard Sallis wrote in a British Journal of Sports Medicine editorial, “The healthcare systems must begin to think of exercise as a medication that should be prescribed to patients. There should be a merging of the fitness industry with the healthcare industry, so that patients can be better helped to find an appropriate fitness regimen.“ While more interaction may be occurring since Dr. Sallis’s editorial, the effort is still tedious, and takes time, creativity, and perseverance.
But should it be that way?
Fitness professionals work with clients with a wide range of medical issues. As a personal trainer, it is important to effectively network and position yourself with the medical community to help provide your clients with the best service possible. Below are some of the ways you can move toward that important professional goal.
Developing Professionally through Continuing Education
Education should always be at the forefront of your professional development. Developing technical skills to expand your scope of practice as a PT, whether through degree or certification programs, is critical to making inroads with the medical community.
With the complexity of medical conditions that fitness professionals will encounter, a college degree with appropriate coursework will always increase credibility. As alluded to earlier, some universities are beginning to “house” both programs of exercise science and health science in the same schools/departments. They combine entry-level classes for fitness and medical degree candidates to create interactivity as they begin their formal education, such as anatomy and physiology. A couple of examples include Missouri State University’s College of Health and Human Services and Slippery Rock University of Pennsylvania’s College of Health, Environment and Science.
Obtaining a certification is usually required for employment at most fitness clubs/studios, etc. In the US, the National Commission on Certification Agencies is the gatekeeper for the fitness professional and its criteria must be met in order to be recognized as an accredited certification agency. The list changes from time to time. Quite often, this list is utilized as a factor in hiring practices (Williamson, 2010), though health and fitness clubs all have their own employment practices and views on preferred certifications. One other medically-related option comes from the American Academy of Health, Fitness, and Rehabilitation Professionals (AAHFRP), which offers a medical fitness certification for Medical Exercise Specialist. Michael Jones, PhD, PT, and president of AAHFRP, indicates that more than 9,000 students have become certified across six continents (Africa, Australia, Europe, Asia, and North and South America).
Developing Professionally through Collaborative Referrals
Barriers to Referrals
In 2011, Dr. Sallis stated, “I have found that referrals to fitness professional can be extremely helpful. I am often frustrated that fitness experts are not readily available to my patients. To that end, we need to better link the fitness industry with the healthcare industry. Why do these groups operate so separately? When I have a patient who desperately needs to engage in regular physical activity to improve their health, why can’t I refer them to a fitness professional trained to get and keep people active?”
This scarcity of qualified fitness professionals may not be a problem everywhere, but it is clear that some patients would rather receive direct advice from the medical provider than from a fitness professional. Several years ago ACSM found that nearly two-thirds of patients (65%) would be more interested in exercising to stay healthy if advised by their doctor and given additional resources. However, only four out of 10 physicians (41%) talk to their patients about the importance of exercise, and don’t always offer suggestions on the best ways to be physically active (Jones and Phillips, 2009).
A study was conducted in the United Kingdom to investigate the exercise referral process. Seventy-one general practitioners and practice nurses participated in the study. The study found that barriers to patient referral included lack of time, lack of feedback regarding patients referred, medical – legal responsibility, a feeling that patients may not take exercise advice given and the belief that physical activity promotion is not a priority during routine consultations. The results call for a closer partnership involving training for promoting physical activity in general practice and to receive more feedback regarding patient benefits, and perceived barriers for health professionals when referring patients to exercise referrals (Graham et al., 2005).
A Hong Kong pilot study was conducted collaborating efforts between medical practitioners and physiotherapists. While a small study, the eight participants ranging from age 19-36 had a body mass index (BMI) of over 28 kg/m2 and participated in an eight-week individualized exercise
program. The participants were led jointly by doctors and physiotherapists and demonstrated improved cardiopulmonary fitness, cholesterol profile, and muscle strength and flexibility. They also expressed greater confidence in achieving a positive outcome (Jones, A. et al., 2009).
As stated by Sallis (2011), “There is a long way to go to develop a healthcare system that supports getting patients more active. As the burden of chronic disease associated with inactivity is growing at a staggering rate, healthcare providers can no longer ignore the growing evidence connecting physical inactivity and poor health. Clinicians have a duty to assess the exercise habits of every patient and make sure the patient understands the health risks associated with inactivity. We should also explore practical ways to help patients overcome barriers to carrying out an exercise prescription, such as referrals to fitness professionals. I have found that patients are most likely to follow an exercise prescription when I connect it to disease they are currently dealing with.“
Overcoming Referral Barriers
You must be ready to handle the wide variety of training clients that can come to you by medical referrals; appropriate preparation is crucial for credibility and future professional collaboration.
Ask yourself some key questions:
· Am I prepared to receive referrals seeking rehabilitation from injuries, chronic illness, surgeries, etc.?
· Do I have the professional relationships, guidance and respect within the medical community to service medical conditions?
· Can my skills as a fitness professional be advanced to provide a significant return on investment (ROI), such as reciprocation with the medical professionals?
If the answer to any of these questions is “no,” then you may need to go back to the educational drawing board and/or start making more connections in the medical community to better establish yourself.
From the medical clinician’s perspective, they have a wide range of professionals from which to choose. Referrals should reflect the needs of the particular patient in question. Healthcare professionals can be part of the regular exercise promotion team or, in some locations, may be under one roof. Some may form a “virtual team,” working in different locations but working together and communicating regularly about individual patients.
According to Jones and Phillips (2009), the physician-fitness professional team may include:
· physical therapist
· occupational therapist
· athletic trainer
· sports psychologist
· health educator
· addiction counselor
· social worker
· certified athletic trainer
It is clear that exercise physiologists must become leaders in the rationale for medically-directed exercise prescriptions. Even when medical doctors express an interest in the prescription of exercise, the true role of its application should exist with exercise physiologists (Boone, 2006).
In addition, Jones and Phillips (2009) state that the time has come for physicians to become strong advocates for exercise. The goal of both professions is to treat the client, who may also be a patient (Boone, 2006).
There are some medical offices and programs that are beginning to progressively collaborate with fitness centers or individuals who have advanced credentials. According to Unger and Vuckovich (2011),
A few progressive physical therapy centers are taking a proactive approach and developing exercise-based post-rehabilitation programs within their facilities to enhance and extend the healing process.”
The bar has been raised and fitness professionals must advance their skills and be prepared to receive the referrals necessary for the continuation of care for the patient/client.
Initiating Communication with Medical Providers
When meeting a client for the first time, it is important to first collect the client’s medical history, then review goals and perform an assessment. If the client is dealing with medical issues, you should immediately send a letter to the attending physician asking for the client’s medical release. A phone call may also be helpful if the physician is available to speak with you. Below is sample text for a letter to the physician, based on your initial meeting.
Jane Doe has presented for post-rehabilitation. I need your approval as her attending physician for the exercise program suggested below. Please review the program and provide any comments or suggestions. If everything is in order, please sign the attached medical release and return to me at [My Health Club], fax number: xxxxx.
Physical assessment results:
· Weak gluteals, especially left gluteal
· Weak abdominals
· Somewhat deconditioned
Suggested exercise program:
· Supine: isometric abdominal holds (transverse, and multifidus)
· Supine: hip bridges (gluteal low-level lifts, both legs to one leg)
· Supine, seated and standing: pelvic floor tightening exercises
· Standing band row: with lumbo-pelvic “locked” with small ball between knee
· Proprioception: balance on one leg
· Machines for seated chest press, lats
· Wall (quads) ball squats with small ball between knees
In addition, I will try and stabilize her lumbo-pelvic region (glutes, transverse, multifidus, adductors, pelvic floor, diaphragm, external rotators, etc.)
Thus far, I have met with [Client] twice. She responded well. However, before we continue, I would like to obtain your approval so that you can redirect my suggested exercises, if necessary. Thank you, and I look forward to receiving the medical release.
At this point, the medical provider can:
1. determine your skills and focus on the proposed exercise prescription;
2. easily correct or provide direction and comments without re-inventing the prescription.
Getting started may take time as a result of waiting for the referral and there are some things the fitness professional can do. Keeping in mind that safety is the most important focus, there may be some things that can be accomplished prior to receiving the medical release.
There are occasions when a fitness professional will have a “gung-ho” individual that doesn’t want to wait for the medical release. Professionally, and with full understanding of their health history, the fitness professional can initiate some activity as long as they have written permission from the client and the results of the movement screen assessment. Individual cases must be reviewed prior to starting with a client. However, if the client is insistent on starting prior to the release, use a heart rate monitor during sessions and keep the heart rate maximum below 65%. Simply walking, stretching, and some single joint movements might be appropriate.
Your ability to communicate effectively is very important during your initial meetings. Fully explain the programmed exercises and progressions so that the client understands what is to come as he or she advances.
On occasion, medical professionals may not respond to you. When this occurs, contacting the medical provider’s staff may be warranted. Professional networking involves more than the physician, physician assistant, or nurse. It may involve the office manager or the individual that answers the phone. If the call or letters attempts don’t produce response, you might ask the client obtain a medical release directly from the provider or from another medical professional. Keep in mind, the medical professional may not fully understand the services fitness professionals can provide. If this is the case, you can educate and inform the medical provider. Additionally, endorsement from an existing medical professional can also provide great assistance and be a “breakthrough.”
Once a medical professional consistently has positive experiences with your work, the dialogue and collaboration can continue with great results. Keep in mind that maintaining synergy with the medical professional is much easier than recreating another relationship.
Networking with the Medical Community
Finding creative ways to meet medical professionals in the community or fitness facility can help build your network. Consider trying the following approaches:
· Attend a social, fundraising or sporting event where medical professionals might be attending.
· Approach medical professionals who are members of your fitness facility.
· Attend a medical office open house.
· Attend a medical appointment with permission of the medical professional as well as the client. For example, you could attend an appointment with your client’s physical therapist, sports medicine physician, surgeon, family practice physician, etc.
Fitness and medical professionals alike are responsible to communicate and collaborate more effectively with each other, with the ultimate goal of assisting the client/patient to heal and be healthy. As a fitness professional, your business will grow as you develop the technical, communication, and networking skills described in this article and begin to work more effectively as part of a collaborative team to assist the growing number of clients who present with health issues.
1. Boone, T. (2006) Exercise Physiology and Exercise as Medical Treatment, Professionalization of Exercise Physiology (PEP online), 9, 12, December.
2. Graham, R., L. Dugdill, and N. Cable. (2005). Health professionals’ perspectives in exercise referral: implications for the referral process, Ergonomics, 48, 11-14, 1411-1422.
3. Jones, A., D. Chan, S. Fu, S. Ngai, and S. Ho. (2009). Exercise prescription – a collaboration between medical practitioners and physiotherapists, The Hong Kong Practitioner, 29, August, 1-9.
4. Jones, S. and E. Phillips (2009). ACSM’s Exercise is Medicine: A Clinician’s Guide to Exercise Prescription, Lippincott Williams and Wilkins.
5. Micaela Fitness. (2011). Montreal Personal Training and Nutrition, www.micaelafitness.com
6. Sallis, R. (2011). Editorial: Developing healthcare systems to support exercise: exercise as the fifth vital sign, British Journal of Sports Medicine, 45: 3, 473-474.
7. Sallis, R. (2009). Editorial: Exercise is medicine and physicians need to prescribe it, British Journal of Sports Medicine, 43, 1, 3-4.
8. Unger, A., and M. Vuckovich. (2011, February). Exercise: The Ideal Post-Rehabilitation Prescription, Natural Awakening, Chicago North and North Shore Edition.
9. Williamson, PhD, Wendy A. (2010). Medical Exercise Positioning: A Business Tool Kit, ASCS Health and fitness Journal, January/February 2010, 14(1).