Exercise as Medicine
By Dr. Neda Amani Golshani
Primary care physicians working with the fitness community can play a critical role in helping patients adopt a regular exercise program.
About 20% of family physicians report discussing physical activity with their patients. But physicians also report numerous barriers to action. These barriers include lack of time, lack of financial compensation and lack of knowledge about proper nutrition and exercise techniques.
Despite the fact that most physicians receive no training in exercise prescription or the therapeutic uses of exercise, patients are increasingly looking to their trusted primary care physicians for lifestyle counselling.
One study asked patients to respond to the statement, “If my doctor advised me to exercise, I would follow his/her advice.” Responses showed that 58% agreed with the statement, and 35% strongly agreed.
Exercise versus drugs
When I was in medical school, I learned about more than 50 various medical cocktails that could be prescribed for the 20 or so diseases most commonly seen in general practice. (It is interesting to note that most of my patients prefer to do anything other than take prescribed drugs for their various ailments.)
But one year after graduating from my family medicine residency in 2000, I realized that most of my patients were suffering from diseases that could be treated or prevented with healthier eating, regular exercise and/or weight loss. It was clear to me that I had a unique opportunity to help them by showing them how to adopt healthier lifestyle habits.
Using my own basic knowledge (I’ve always been interested in nutrition, am a runner and swimmer and used to lead group exercise classes) I started teaching my patients the basics of healthy eating and exercise in my office. Some patients would chuckle as I lied down on my office floor to show them how to do a proper sit-up or another simple exercise.
Because the Ontario Health Insurance Plan (OHIP) doesn’t provide funding for lifestyle education, I wasn’t reimbursed for this time.
Physicians and personal trainers work together
When the results from this initial, very basic counselling proved to be positive, I developed and designed a formal 10-week program, with the help of two personal trainers, called The Real You Exercise Prescription program.
Its purpose is to help patients learn the basics of physical activity – stretching, cardiovascular exercise and resistance training – with the assistance a personal trainer. Once or twice a week patients meet with a personal trainer in my clinic to learn exercises they can safely do at home or at a gym. Sessions are held in a small open area in the back of my clinic and use free weights, balls and mats donated by a local physiotherapist
Provincial government support varies
For the first 100 or so patients, I charged patients a nominal fee of $40 to $100 for the 10 20-minute sessions. I also billed OHIP for one patient visit to cover an appointment early in the process where I did a physical assessment and answer any questions they had.
In 2003, I wrote a letter to the Ontario Ministry of Health advising them of the program. The ministry warned me not to continue the program as my services were “not medically necessary.”
After numerous unsuccessful efforts over the past four years to have the program covered by OHIP, I decided to increase the fee to $500 for the program. The fee needed to cover the expenses but still be affordable.
Positive outcomes for patients
We have had over 200 patients enroll in the program thus far. The program has been modified to include 10 weeks of 60-minute exercise sessions with the personal trainer and three or more nutrition and behavioural counselling sessions with myself. OHIP is billed for the sessions I provide.
Many patients who complete the program report that they have greater confidence and have overcome their fear of exercise. When they finish the program, many of them join a fitness centre, get involved with sports activities or continue to work with a personal trainer.
The best outcome of the program is that I have been able to successfully treat many medical conditions – arthritis, diabetes, hypertension, dyslipidemia, depression, insomnia, pain from various muskuloskeletal conditions, PMS, menopause, etc. – either partially or completely with exercise.
Having seen the many positive results of such an intervention firsthand, I now recommend exercise as the first line of treatment for more than 50% of the most common conditions I see in my clinical practice.
Funding necessary to be viable
This type of program can exist across the country with minimal funding, and I have had many family physicians express a strong interest in providing such a program to their patients. Our principle barrier to offering the program in Ontario, at no cost, is our current health care funding system which doesn’t recognize this type of intervention as “medically necessary.”
Despite full support from the Ontario College of Family Physicians, we are unable to offer the program under the current Ontario Ministry of Health funding model.
My colleagues, Dr. Calvin Stewart and Dr. David Stewart, two family physicians in Lethbridge, Alberta, have developed and offer a similar program. Because they are able to bill for the services provided by their personal trainers and nutritionists, they can provide the program to their patients at no cost. They bill the province of Alberta directly for an office visit (as I had done in my office initially but was later advised not to). They have enrolled over 600 patients in their program and become a referral centre for patients from other cities in Alberta.
The word doctor in Latin means “to teach.” As Thomas Edison stated: “The doctor of the future will give no medicine but will interest his patients in the care of the human frame and in the cause and prevention of disease.” Our challenge is to create a medical system to realize this vision.
Dr. Neda Amani Golshani works in Toronto and Ottawa as a family physician and is creator of The Real You Exercise Prescription program. She is the in-house doctor and health expert for Women Moving Forward™, the Champion Physician for Active Living for Ontario and a regular speaker and presenter. You can reach her at info@therealyou.ca.
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