INTRODUCTION

Educating medical students and other health professionals in training on the importance of healthy lifestyles for prevention and treatment of disease is essential to transforming healthcare. At the University of South Carolina School of Medicine Greenville (USC SOM Greenville), we are incorporating the ‘Exercise is Medicine’ Knowledge, Skills and Abilities into all 4 years of the undergraduate medical curriculum to inform future physicians on the medical benefits of exercise and physical activity. As a partner with the Greenville Health System (GHS), USC SOM Greenville is striving to transform healthcare for the benefit of the people and communities it serves by healing compassionately, teaching innovatively and improving constantly. In addition, USC SOM Greenville and GHS are fostering relationships with the local YMCAs to improve healthcare delivery in upstate South Carolina using the ‘Exercise is Medicine’ solution. The overarching goal is to demonstrate how physician-counselling and referrals for physical activity and exercise play a well-documented role in primary and secondary prevention for reducing morbidity and mortality from non-communicable chronic diseases. In partnership with the Institute of Lifestyle Medicine (ILM) at Harvard Medical School, USC SOM Greenville also strives to spearhead a ripple effect in exercise curriculum by modelling for other medical school leaders throughout the country on how to adopt similar changes in curriculum and training for medical school students. Physician education regarding the benefits of exercise is vital for transforming healthcare.

Exercise counselling as part of healthcare delivery would have numerous evidence-based benefits for prevention and treatment of multiple non-communicable chronic diseases (NCDs) including type 2 diabetes, hypertension, cardiovascular disease and various forms of cancer.1–4 In addition, physician-based exercise counselling likely would have a major impact on reducing associated healthcare costs.5 Unfortunately, the majority of physicians, traditionally trained to manage disease and injury, have not been educated in the medical, psychosocial and financial benefits of exercise. Physicians who have been surveyed about their reluctance to counsel on exercise cite a lack of time, poor reimbursement, a lack of confidence in the efficacy of their efforts and deficiency in their own personal levels of fitness as the reasons.6–8 Subsequently, physicians are ill-equipped to effectively counsel patients on exercise for prevention or treatment of disease.

Lack of exercise training in medical education

The lack of formal undergraduate medical education about the medical benefits of exercise and physical activity was recognised as early as 1975 in a survey that revealed that only 16% of medical schools offered a course geared towards exercise as part of Preventive Medicine.9 Subsequent surveys showed a little improvement. In 2002, while 64% of Deans reported that it was the responsibility of medical schools to educate students about the physical activity, only 6% of medical school leaders polled reported of having a core course or required curriculum addressing the exercise prescription.10 However, medical students themselves seem to recognise the need for a formalised curriculum in exercise as well as the lack of training they currently receive. While 47% of medical students agreed with the importance of writing an exercise prescription, only 10% of graduates felt capable of doing so.11 Therefore, most of the US medical students do not have the competence or confidence to counsel patients on exercise after they graduate from medical school.

The call for reform of medical education

The impetus for reforming medical education by training physicians to effectively and efficiently address the preventable causes of chronic disease is bolstered by several significant initiatives, including the planned 2015 revision of the Medical College Admissions Test to include ‘Psychological, Social and Biological Foundations of Behavior,’ as one of the four core sections12 and the call for medical education reform in the June 2012 report from the Bipartisan Policy Center (BPC) in Washington, DC: ‘Lots to Lose: How America's Health and Obesity Crisis Threatens Our Economic Future.’ The BPC's call to action specifies that “Nutrition and physical activity training should be incorporated into all phases of medical education—medical schools, residency programs, credentialing processes and continuing education requirements.”13 The Affordable Care Act, which will hopefully help transform the US health system from its current focus on disease treatment toward a focus on promoting health and wellness, will require health insurers to cover the recommended preventive services.14 The Global Advocacy for Physical Activity (GAPA), the Advocacy Council of the International Society for Physical Activity and Health (ISPAH), as one of the stated seven best investments for physical activity promotion, includes “Physical activity and noncommunicable disease prevention integrated into primary healthcare systems, with a focus on practical, brief advice and links to community-based supports for behaviour change.”15 Finally, the USA National Physical Activity Plan contains strategies in its Health Care sector that include: ‘(1) using a healthcare systems approach to promote physical activity and (2) including physical activity education in the training of all healthcare professionals.’16 As the healthcare model evolves into patient-centred care,17 physicians may be incentivised to focus more on personalised care with patient-meaningful outcomes such as autonomy, physical function and health-related quality of life. These changes should encourage medical educators and healthcare organisations to educate physicians in exercise and physical activity behaviour change counselling in order to improve the prevention and treatment of NCDs.

It is imperative that the medical benefits of exercise and physical activity are integrated into the education of every medical student from the beginning of their training. ‘Exercise is Medicine’, a global initiative founded in 2007 by the American Medical Association and the American College of Sports Medicine, aims to help improve the health and well-being of the nation through assessment of physical activity as a vital sign and physical activity prescription from doctors and other healthcare providers. The ‘Exercise is Medicine’ Education Committee has formalised knowledge, skills and abilities (KSAs) related to exercise and physical activity that every medical student should possess upon graduation. These include demonstrating proficiency in: (1) Physical Activity and Fitness Assessment, (2) Exercise Prescription and Implementation, (3) Exercise Counselling and Behavioural Strategies and (4) Physician's Personal Health.18 These competencies represent the framework needed to introduce a basic exercise curriculum into all medical schools. Training the students to integrate these competencies into their practice from the outset will create a new generation of physicians who have the skills and motivation to improve the health behaviours of their patients.

A new school of thought

The University of South Carolina School of Medicine Greenville (USC SOM Greenville), the 136th accredited medical school in the USA, is located on the campus of the Greenville Health System (GHS), the 13th largest healthcare delivery system in the country. The School, built for 21st century community health needs, welcomed its Charter Class of 53 students in July 2012. The guiding vision of USC SOM Greenville and GHS is to transform healthcare for the benefit of the people and communities it serves by healing compassionately, teaching innovatively and improving constantly, and to deliver patient-centered healthcare with confidence and compassion. From its inception, the USC SOM Greenville has committed to becoming an innovative, dynamic institution that fosters new ideas and encourages its faculty, physicians and medical students to think outside of the box for innovative teaching and provision of optimal healthcare. In particular, USC SOM Greenville is committed to demonstrating how physician-prescribed exercise plays a well-documented role in reducing morbidity and mortality from chronic diseases. Because of these goals, USC SOM Greenville fully integrates ‘Exercise is Medicine’ throughout all 4 years of the undergraduate medical curriculum.

The ‘Exercise is Medicine’ KSAs are used to develop an exercise-based curriculum and are seamlessly integrated into all modules of the curriculum (eg, Structure and Function, Mind Brain and Behaviour, Medicine and Society and Clinical Diagnosis and Reasoning). With the full support of Dean Jerry Youkey, MD, the administration and the faculty, USC SOM Greenville has focused on exercise and physical activity as the first health behaviour to target for integration within the undergraduate medical school curriculum. The active, student-centred and integrated learning curriculum allows medical students to understand and synthesise the physiological mechanisms explaining the association between exercise and disease prevention and treatment, improve their communication skills by learning to guide patients along the behaviour change continuum of exercise adoption and maintenance and learn how to become ‘partners in care’ with community physical activity resources, which is consistent with the evolution of patient-centred care. Finally, but just as essentially, the importance of student health is modelled through faculty-led external activities including the USC SOM Greenville Running Club, Cycling Club, Yoga Club, Soccer Tournaments and this year's inauguration of the USC SOM Greenville Organic Garden. This modelling encourages physicians-in-training to not only provide excellent prevention-based patient care but also to improve physician self-care. The ‘Exercise is Medicine’ competencies will not only highlight the preparation of future physicians to become primary drivers of healthier behaviour but also identify and resolve the potential barriers to exercise counselling in healthcare delivery.

It is imperative that if undergraduate medical education teaches the ‘Exercise is Medicine’ competencies that third and fourth year students and residents graduate into a health-care delivery system that promotes and supports these practices. Therefore, USC SOM Greenville has partnered with Greenville Health System to execute a critical role in implementation of the ‘Exercise is Medicine’ Solution across the System. A physical activity vital sign is being added to GHS's Electronic Medical Record (EMR) systems through a simple, two-question addition based on the questions used in the Kaiser Permanente system for several million patients in Southern California,19 and toolkits are being disseminated to train practicing physicians on how to counsel on exercise and safely and effectively refer the patients to ‘Exercise is Medicine’ credentialed National Commission for Certifying Agencies (NCCA)-certified fitness providers through the Greenville YMCAs. Incorporating the ‘Exercise is Medicine’ Solution on the healthcare delivery side will facilitate medical students and practicing physicians to work in an environment that supports physician assessment and counselling on exercise and physical activity. The integration of ‘Exercise is Medicine’ throughout the medical school curriculum, healthcare delivery system, and Greenville community, along with faculty development and research/scholarship related to the medical benefits of exercise in the clinical setting, will be the hallmark of USC SOM Greenville and GHS.

Moving forward in partnership with the Institute of Lifestyle Medicine (ILM) at Joslin Diabetes Center, Harvard Medical School, USC SOM Greenville strives to spearhead a ripple effect in exercise curriculum by modelling for other medical school leaders on how to adopt similar changes in their curriculum and training for medical school students. The USC SOM Greenville hosted the first national Lifestyle Medicine Think Tank on 9–10 September, 2013 (http://www.greenvillemed.sc.edu/LifestyleMedicine.php). Along with the representatives from the American College of Sports Medicine, National Institutes of Health, American Medical Association, Association of American Medical Colleges, National Board of Medical Examiners, Bipartisan Policy Center and other key stakeholders, the Lifestyle Medicine Think Tank explored how best to integrate lifestyle medicine competencies that included exercise education into the nation's medical school curricula. Sponsored by the Josiah Macy Jr. Foundation, the Lifestyle Medicine Think Tank concluded with a vision, goals and strategies that will be published and were presented at the Bipartisan Policy Center public meeting Training Doctors for Prevention-Oriented Care: Teaching Nutrition and Physical Activity in Medical School on October 2013 (http://bipartisanpolicy.org/events/2013/10/teaching-nutrition-and-physical-activity-medical-school-training-doctors-prevention). Across the nation, experts are being assembled who are committed to incorporating exercise and physical activity education into medical education, with USC SOM Greenville and ILM leading the charge. Incorporating ‘Exercise is Medicine’ into medical education is vital for transforming healthcare in America and across the world.