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Abstract
Background Physicians are increasingly being called upon to promote physical activity (PA) among patients. However, a paucity of exercise medicine teaching in the UK undergraduate medical curricula prevents students from acquiring the necessary knowledge and skills to do so. To address this issue, King's College London School of Medicine introduced an exercise medicine strand of teaching. This study evaluated the acceptability of exercise promotion behaviour change lectures and explored the knowledge and attitudes of the students who received it.
Methods Students were invited to complete a 6-item online questionnaire prior to and after exercise medicine lectures. The questionnaire assessed beliefs regarding the importance of PA in disease prevention and management, in addition to their confidence in advising patients on PA recommendations. A focus group (n=7) explored students’ attitudes towards and knowledge of PA promotion and exercise prescribing.
Results In total, 121 (15%) first-year and second-year MBBS students completed the questionnaire. Students’ beliefs regarding the importance of PA in managing disease and their confidence in PA promotion among patients increased after the teaching (p<0.001). More students were able to correctly identify the Chief Medical Officer recommended adult PA guidelines (p<0.05). Students were enthusiastic about the exercise medicine teaching, strongly supportive of its continued inclusion in the curriculum and advocated its importance for patients and themselves as future doctors.
Conclusions Behaviour change teaching successfully improved students’ knowledge of and confidence regarding PA promotion. These improvements are a step forward and may increase the rates and success of physician PA counselling in the future.
- Health promotion through physical activity
- Physical activity promotion in primary care
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Background
Physical inactivity is one of the most important public health problems of this century.1 WHO lists physical inactivity as the fourth leading risk factor for global mortality with major implications for general health and non-communicable disease (NCD) prevalence.2 Physical inactivity has significant financial costs for healthcare systems, estimated at £8.2 billion annually in the UK.3 There exists substantial evidence that physical activity (PA) is an effective intervention for preventing and managing many chronic diseases, including cardiovascular disease,4 diabetes mellitus,5 certain cancers6 and mental health illnesses.7 The Chief Medical Officer (CMO) has recognised the importance of PA for health and recommends that adults undertake 150 min of moderate intensity activity weekly.8 Both the Department of Health and National Health Service (NHS) and the National Institute for Health and Clinical Excellence have identified the ‘exceptional value for money’ that brief PA interventions in primary care offer.9 ,10 Consequently, physicians and other healthcare professionals are being encouraged to promote PA and implement national recommendations.1 ,11 ,12 However, the levels of PA promotion and uptake remain low, with a number of contributing factors being identified13; arguably, a lack of exercise medicine knowledge and training among healthcare professionals is a significant contributing factor.14
Exercise medicine is defined by the Faculty of Sport and Exercise Medicine (FSEM; UK) as: The use of physical activity and exercise as a health tool for primary and secondary disease prevention.15 The importance of teaching exercise medicine to UK undergraduate medical students has been recognised for at least 30 years.16 However, a 2010 study of 33 UK medical schools reported that less than half (40%) of the schools that responded included SEM teaching as part of their undergraduate curriculum.17 Furthermore, a recent survey found that only 56% taught students the government CMO recommended guidelines for PA.18 The average time spent in teaching PA science and promotion throughout the undergraduate curriculum was minimal (4.2 h). Consequently, a large proportion of final year medical students have limited knowledge of the risks of physical inactivity, recommended PA guidelines and confidence regarding patient counselling on PA.19 This paucity of undergraduate exercise medicine teaching runs contrary to clear recommendations from The Royal College of Physicians.20
A preventive medicine and nutrition programme was introduced at a US medical school in 2003, which resulted in a significant improvement in the confidence of their students when addressing the diet and exercise habits of patients.21 This is important, given that doctors who feel confident in their knowledge of exercise are significantly more likely to ask about, counsel on, and prescribe exercise to patients than doctors who feel their knowledge is inadequate.22
Behaviour change skills are fundamental to the delivery of most aspects of preventive medicine and clinical communication.18 Recognising the dearth of PA promotion in its own curriculum, King's College London School of Medicine (KCLSM) introduced a vertical stream of four 1-h exercise medicine lectures (written and delivered by JHMB) into its behaviour change core curriculum teaching for the 2012–2013 academic year (Otable 1). Examination questions based on these lectures have been selected and written by JHMB and included in the KCLSM question bank and will be used to assess students in their end-of-year examinations.
Outline of the sport and exercise medicine curriculum vertical stream
The aims of this study were:
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To test the acceptability of teaching behaviour change to medical students with regard to exercise prescribing;
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To assess the knowledge and attitudes of students to exercise medicine.
Methods
Lecture curriculum
SEM encompasses many facets including promoting wellness through the use of PA and preventing injury by providing safe advice about exercise.23 ,24 The lecture content was written to include these facets tailored around guidance from the General Medical Council's ‘Tomorrow’s Doctors’.25 The aims and objectives were set and the vertical stream of lectures was timetabled at an appropriate point within the basic clinical sciences, scenario teaching and pathology and therapeutics structure at KCLSM.26
Quantitative data collection
First-year and second-year undergraduate medical (MBBS) students were contacted via email prior to lectures 1 and 3 (the first SEM lectures the students had received) and invited to complete a confidential six-item online questionnaire both before and after the teaching, comprising identical questions. The questionnaires were completed in October 2012. Students’ beliefs regarding PA as a part of the healthcare paradigm, as well as their confidence in advising patients on PA, were collected. Knowledge of the CMO adult PA guidelines was also assessed. Following the intervention, students’ views were sought on the quality and usefulness of teaching received.
Qualitative data collection
Students who had attended their respective lectures were recruited via email to participate in a focus group held in January 2013. A focus group was chosen to capitalise on dynamic communication between the participants and the opportunity to explore possible consensuses regarding the teaching intervention.27 The principal facilitator for the focus group was a final year medical student (PRJ), who holds a degree in SEM, and moderation was performed by the KCLSM Health Promotion lead (AW). The participating students knew neither the principal facilitator nor the moderator. Seven medical students (3 first and 4 second year) participated. Participation was voluntary and written consent was obtained from each participant before the focus group. Anonymity and confidentiality were emphasised. The focus group session was scheduled for 60 min. Questions explored the students’ exposure and attitudes towards PA prior to medical school and their opinions on the information presented during the lecture. OBox 1 is the focus group topic guide. The session was recorded and transcribed verbatim for analysis. After reading the transcript and field notes, a coding framework was developed. The transcript was imported into NVivo V.10.0.2 (QSR International, Melbourne, Australia) qualitative data analysis software and coded line-by-line. Thematic analysis was employed to explore the data.
Topic guide for the focus group
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The contribution of physical activity (PA) to health, prior to medical school
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How the lecture(s) influenced their attitudes towards:
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PA and disease prevention/management
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PA and the role of the doctor
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Importance of PA promotion for their future careers
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The Chief Medical Officer recommended guidelines
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Medicine, the usefulness of the lecture(s) at their stage of training
Statistical analysis
Statistical analyses for quantitative data were performed using SPSS for Mac V.19.0.0 (IBM, New York, USA). Paired t tests assessed the statistical significance of pre–post course differences. Means were calculated to determine the opinions of the teaching intervention. The statistical significance of pre–post course students who correctly identified the CMO recommended PA guidelines was assessed using McNemar's test. Statistical significance was set at a p value less than 0.05.
Results
Questionnaire
Baseline and follow-up surveys were completed by 63 (15%) and 58 (15%) students, respectively, of the 790 year 1 and year 2 students (403 and 387 students, respectively).
Table 2 displays the change in students’ beliefs about PA and confidence in both advising patients on PA and knowledge of the CMO's adult PA guidelines.
The proportion of students who correctly identified the CMO adult PA guidelines was 63% prior to teaching and 77% after teaching (p<0.05).
Students’ beliefs and confidence regarding physical activity*
The students’ views regarding the quality and usefulness of the teaching are displayed in Otable 3.
Students’ views regarding the quality and usefulness of teaching*
Focus group
Four main themes were identified during focus group transcript coding.
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What influenced the students’ knowledge and attitudes of PA prior to medical school?
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School experience
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The students described having had limited formal teaching at school regarding the role of PA in maintaining a healthy lifestyle:
When it came to actually learning about exercise, we never learnt about it if I'm honest…unless you did PE GCSE. It never came up at all. The focus was on alcohol, drugs and sex, that was what the focus was on when it came to lifestyle.
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Promotion through media
It's one of those issues that keeps coming up in the media now. So even though we weren't formally taught it at school, it's just one of those things you see everywhere in public advertising.
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Perceptions of PA and its consequences
When I used to think about exercise I used to think “I need to go down to the gym or something”. I never really factored in that if I did power walking or badminton that would actually count. The focus is shifting towards…making people realise that exercise can be something you really enjoy.
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What was taken from the teaching?
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Strength and scope of the evidence supporting PA
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When we had that lecture it hit home and suddenly you realise exercise does affect all these other things that you really hadn't thought about prior to that.
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Importance of PA in medical education and practice
It's just another aspect of medicine, without it our medical knowledge just wouldn't be complete.
One student, having been on a general practice placement with a GP keen on PA promotion, described the insight into a patient's lifestyle and that inquiring about their exercise habits can offer, potentially identifying issues that can be addressed in the consultation:
I think you get a real glimpse into someone's lifestyle by asking them how much they're doing.
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Preventive medicine
It's made me realise we can do more for our health, no matter how advanced we become in treating patients, unless they work for themselves they're always going to be ill.
The focus before was on curing patients, but now the shift should be towards preventing disease.
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The doctor's role
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Is it our job to engage patients about exercise?
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We have to deal with the consequences. Same with alcohol and smoking, we deal with the consequences so if we advise our patients to drink less and smoke less, we should be advising them to exercise more.
The students were keenly aware that simply telling patients to exercise more was unlikely to be of benefit and that their role would be to help each patient identify and tailor PA to their own individual circumstances and requirements:
As a doctor, you should be able to personalise what you're saying and not just prescribe. I think that's an important part of a doctor promoting healthcare. Not just saying it because that's…not really going to help.
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How to use the guidelines
I think a doctor's role is to interpret the guidelines for the patient.
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Usefulness of the teaching
This is medicine put in practice, this is what I'm going to be seeing when I graduate. This is what I'm going to see in real life.
The students were unanimous in their desire for more exercise medicine teaching and its place within the curriculum at KCLSM, articulating that its importance is such that the lecture content should be examinable:
I actually wish we had more.
Given the strength of the figures that show its benefits, yes [it should be examined].
In addition to helping the students understand the importance of PA for patients’ health, the lectures motivated the students to be more conscientious of their own health and PA:
When you actually do go through the lectures and look at the data deeper and you see the correlation between getting heart disease and the amount of exercise, that's when I realised that I need to start exercising!
Discussion
This study demonstrates that a simple teaching intervention significantly improved preclinical medical students’ confidence in their ability to counsel patients on the health benefits of PA. Explanation of the mechanisms and evidence supporting exercise as a tool for health positively influenced students’ attitudes towards its application within the healthcare paradigm. Knowledge of the recommended PA guidelines also improved. Given that self-efficacy among doctors regarding exercise medicine predicts the propensity to engage patients regarding exercise habits,22 this study suggests that a brief course on exercise medicine could improve the levels and quality of PA counselling among tomorrow's doctors.
As far as we are aware, this is the first study to assess the knowledge and attitudes of undergraduate medical students to behaviour change teaching on exercise medicine in the UK. Results of the mixed methods analysis complemented each other, the qualitative findings providing context and understanding to the quantitative data.
Participants were from one medical school, which limits the generalisability of the findings and may not be representative of students at other medical schools. The low response rate to our online questionnaire (15%) and potential non-responder bias is a limitation of this study. Given the large size of the KCLSM year groups, this did not result in low study power for the quantitative analysis. The small focus group size may not have been representative of all students for the qualitative analysis. It remains to be seen whether the positive attitudes elicited and knowledge gained by students during the study will be maintained throughout their medical training and into their professional careers. A long-term follow-up of study participants is planned to determine this.
The current vertical stream of SEM teaching at KCLSM ends for students in year 3, it is possible that SEM will be forgotten in the later clinical years.28 Clinical teaching predominates in years 4 and 5; however, advising patients on PA and exercise may be underutilised in medical practice,29 ,30 and therefore its use is unlikely to be reinforced sufficiently to students in a clinical setting. Therefore, future teaching plans include standardised SEM teaching in year 5, probably in the form of a lecture or a workshop. In addition to the written examination, SEM questions already included at KCLSM and SEM-based Objective Structured Clinical Examinations stations are also planned within the behaviour change assessment.
Conclusion
Behaviour change teaching on exercise medicine is acceptable to undergraduate medical students and successful in positively changing their attitudes towards PA promotion. Despite the paucity of PA teaching in the UK medical school curricula, students are vocal on the importance of PA promotion in their careers and for their future patients’ health. With the burden of NCD close to overwhelming the NHS, UK medical schools can ill-afford to neglect PA promotion teaching any longer. Tomorrow's doctors realise that prevention is at least as important as cure. It is time the curricula reflected that.
What are the new findings?
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This was the first study to implement and assess exercise medicine behaviour change teaching at a UK medical school.
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Medical students’ attitude towards the importance of physical activity (PA) promotion significantly increased following their teaching, as did their knowledge of recommended PA guidelines and their confidence in advising patients about PA.
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Students felt that the content of the lecture was relevant and useful to themselves as undergraduates and that they would welcome more exercise medicine teaching in the future.
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Behaviour change teaching on exercise medicine is an acceptable and successful method by which to teach medical students the importance of PA for health.
How might it impact on clinical practice in the near future?
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This paper highlights the positive impact exercise medicine teaching has on student attitudes towards and knowledge of physical activity and should encourage other medical schools to include exercise medicine teaching in their curriculum.
Acknowledgments
The authors would like to thank Dr Despo Papachristodoulou for her efforts to bring SEM into the undergraduate curriculum at KCLSM, Dr Chris Rufford for critically reviewing the manuscript, Simon Power for his assistance in distributing the questionnaire and all the students who participated in the study.
References
Footnotes
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Contributors PRJ and JHMB conceived the idea. PRJ, JHMB and AW designed the questionnaire. PRJ and AW collected the data. PRJ performed data entry and data analysis. PRJ drafted the initial paper and all authors contributed equally to the drafting and writing process. All authors critically revised and approved the final version of the manuscript.
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Competing interests None.
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Ethics approval Ethical approval was granted by King's College Research Ethics Committee as part of a wider study on health promotion and social determinants of health.
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Provenance and peer review Not commissioned; externally peer reviewed.