Physical activity RX: development and implementation of physical activity counselling and prescription learning objectives for Canadian medical school curriculum.

Physical activity is an important component of health and well-being, and is effective in the prevention, management, and treatment of numerous non-communicable chronic diseases. Despite the known health benefits of physical activity in all populations, most Canadians do not meet physical activity recommendations. Physicians play a key role in assessing, counselling, and prescribing physical activity. Unfortunately, many barriers, including the lack of adequate education and training, prevent physicians from promoting this essential health behaviour. To support Canadian medical schools in physical activity curriculum development, a team of researchers, physicians, and exercise physiologists collaborated to develop a key set of learning objectives deemed essential to physician education in physical activity counselling and prescription. This commentary will review the newly developed Canadian Physical Activity Counselling Learning Objectives and give case examples of three Canadian medical schools that have implemented these learning objectives.

Introduction

In 2018, the Medical Council of Canada (administrators of the Medical Council of Canada Qualifying Examination, MCCQE) changed their evaluation criteria to include up to 20% disease prevention and health promotion content in the MCCQE, setting the requirement for graduating medical students to understand interventions that promote health and prevent disease at primary, secondary, and tertiary levels.[1],[2] Physical activity is a modifiable health behaviour that plays a significant role in the prevention and management of Canada’s leading chronic diseases. It is currently estimated that 5.3 million deaths per year are due to inactivity, accounting for 9% of annual global deaths.[3] If inactive people became active, it is estimated that 6% of the burden of disease worldwide due to coronary heart disease, 7% due to Type 2 diabetes, and 10% due to both breast and colon cancers could be eliminated.[3] In fact, physical activity has often been referred to as the ‘wonder drug’, that if implemented widely, could prevent and manage substantial disease burden and contribute to significant health care savings. In Canada, the estimated direct and indirect cost of physical inactivity in 2009 was $6.8 billion.[4] Even just a 1% improvement in physical activity in Canada could save $2 billion dollars per year by the year 2031.[5]

In 2020, the Canadian Society for Exercise Physiology published 24-Hour Movement Guidelines for Adults 18-64 Years and 65+ Years, adding to their existing 24-Hour Movement Guidelines for Children and Youth and the Early Years.[6] These guidelines replace the previous Canadian Physical Activity Guidelines, and now include recommendations for physical activity, limiting sedentary time, and sleep. Despite previous Canadian Physical Activity Guidelines being widely available for many years prior to the release of these 24-Hour Movement Guidelines, only 13% of Canadians report having awareness of these guidelines, and only 16% report meeting the recommendations of 150 minutes of moderate to vigorous physical activity (MVPA) per week accumulated in bouts of 10 minutes or more.[7],[8] Relative to the new 24-Hour Movement Guidelines, only 49% of Canadians aged 18-79 accumulate at least 150 min of MVPA weekly.[8] This demonstrates a significant translational ‘valley of death’ between the unwavering evidence for the benefits of physical activity and sustained activity levels. For an intervention that plays such a significant role in health promotion and chronic disease management, this is simply not acceptable.

The physicians’ role in physical activity promotion

Physicians play a key role in assessing and prescribing health behaviours and offer a consistent and trusted opportunity to reinforce this important public health message to patients.[10],[11] Unfortunately, it is well known that physicians do a poor job of taking physical activity histories, providing activity recommendations, and supporting health behaviour change.[2] One of the key reported barriers to prescribing and counselling on physical activity is the lack of consistent training in medical education, leading to reduced confidence and prioritization of physical activity counselling in clinical practice.[12],[13] Including physical activity counselling and prescription training in medical education has the potential to improve understanding of the role and benefits of activity among future healthcare providers, while also reinforcing activity as an intervention these healthcare providers can and should promote to patients. Reinforcing the importance of this intervention in medical education will help to diminish the concerns around lack of understanding among physicians and will also help to strengthen the value physicians place on the role of physical activity in managing disease.

Physical activity in medical curriculum

In 2016, the Canadian Medical Association (CMA) suggested that Canadian medical schools should update their curricula to include physical activity prescription and referral to physical activity specialists.[14] As this suggestion was not mandated, curricula updates were at the discretion of each institution and unfortunately, a lack of standard curriculum recommendations for Canadian medical schools remains.[14] An informal survey of student representatives from each Canadian medical school, conducted by our group in 2019, found that of the 16 medical schools who responded, only 50% (8/16) reported any type of physical activity counselling curriculum.[15] Of those eight schools, across all years of pre-clerkship medical education, representatives reported an average duration of only 130 minutes spent on physical activity counselling. Only 6/16 schools reported recollection of physical activity curriculum being examined, and alarmingly, none of the school representatives reported feeling competent in the material.[16]

As a group of researchers, exercise physiologists, and physicians across Canada, we developed a set of physical activity learning objectives for Canadian medical schools, based on previously published objectives in the USA.[16] The Physical Activity Counselling and Prescription Learning Objectives, outlined in Appendix A, were iteratively reviewed by experts in the area, including Physical Activity researchers, Clinical Exercise Physiologists, and Sport Medicine and Physical Medicine & Rehabilitation physicians. The objectives are meant to guide medical schools in the development of relevant curriculum, allowing for differences in curriculum delivery across the country. Examples of how these objectives have been implemented at the University of Calgary, Queen’s University and the University of British Columbia are outlined in Appendix B.

The Physical Activity Counselling Learning Objectives were designed in two parts, including the Core Curriculum, and an Expanded Curriculum. The Core Curriculum was selected by the committee of experts as being essential to understanding the evidence supporting physical activity for chronic disease prevention and management, the role of the physician in assessment, prescription, and counselling, the updated movement guidelines, and effective behaviour change strategies. The Expanded Curriculum was designed to offer additional topics if there was available time and expertise in the curriculum. Some of the topics in the Expanded Curriculum, like ‘Cardiopulmonary and Metabolic Responses to Physical Activity’ may also be covered in other learning sessions, including the cardiology curriculum.

These learning objectives are meant to provide a starting point for medical schools across Canada, as they assess their current curricula and aim to meet the CMA recommendations to include physical activity counselling curriculum. They are also meant to best prepare medical students for the Medical Council of Canada MCCQE examination and clinical practice. As rates of chronic disease continue to rise, it is imperative that physicians implement physical activity assessment, prescription and behaviour change support in their clinical practice. Without adequate training in medical school, this is not achievable. Our hope is these objectives will be used to form the basis of strong physical activity curriculum development in Canadian medical schools.