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Abstract
Regular physical activity provides a variety of health benefits and is proven to treat and prevent several non-communicable diseases. Specifically, physical activity enhances muscular and osseous strength, improves cardiorespiratory fitness, and reduces the risk of hypertension, coronary heart disease, stroke, type 2 diabetes, mental health disorders, cognitive decline and several cancers. Despite these well-known benefits, physical activity promotion in clinical practice is underused due to insufficient training during medical education. Medical trainees in the USA receive relatively few hours of instruction in sports and exercise medicine (SEM). One reason for this shortage of instruction is a lack of curricular resources at each level of medical education. To address this need, the American Medical Society for Sports Medicine (AMSSM) assembled a group of SEM experts to develop curricular guidance for exercise medicine and physical activity promotion at the medical school, residency and sports medicine fellowship levels of training. After an evidence review of existing curricular examples, we performed a modified Delphi process to create curricula for medical students, residents and sports medicine fellows. Three training level-specific curricula emerged, each containing Domains, General Learning Areas, and Specific Learning Areas; options for additional training and suggestions for assessment and evaluation were also provided. Review and comment on the initial curricula were conducted by three groups: a second set of experts in exercise medicine and physical activity promotion, sports medicine fellowship directors representing a variety of fellowship settings and the AMSSM Board of Directors. The final curricula for each training level were prepared based on input from the review groups. We believe enhanced medical education will enable clinicians to better integrate exercise medicine and physical activity promotion in their clinical practice and result in healthier, more physically active patients.
- physical activity
- training
- sports medicine
- preventive Medicine
- education
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Introduction
Up to 80% of diseases in the USA. are due to lifestyle behaviours.1 One of the most effective interventions for the treatment and prevention of non-communicable diseases is physical activity and exercise. Despite the proven benefits of regular physical activity on cardiometabolic parameters, mental health and cognition, many medical professionals feel ill equipped to counsel patients on appropriate lifestyle behaviours centred on physical activity.2 This is partly due to training deficiencies during medical education.3–6 For instance, the average that American medical schools require is only 8 hours of curriculum on physical activity over the 4 years of training.7 Similarly, the average offered by primary care residency programmes was only 3 hours per year of didactic training on physical activity, nutrition and obesity, while a survey of American sports medicine fellowship directors found that 63% of fellows were not taught how to write an exercise prescription.2 8 Without fundamental knowledge in exercise medicine and proper training on how to promote physical activity in clinical practice, use of this low-cost, evidence-based intervention for the prevention and treatment of chronic diseases will remain limited. Additionally, because physical inactivity and several associated non-communicable diseases disproportionately affect marginalised communities including under-represented minorities and persons of colour, there is an urgent need for broader education and implementation of physical activity promotion to foster equitable healthcare delivery.9–11
To address this training deficiency in medical education, the American Medical Society for Sports Medicine (AMSSM) assembled a group of experts in sports and exercise medicine (SEM) education to design a series of curricula in exercise medicine and physical activity promotion (EM-PAP) to be implemented at the medical school, residency and sports medicine fellowship levels. The curricula have a particular focus on the promotion of physical activity in clinical practice and include components related to medical knowledge and experiential training. By developing this resource, we hope to enable medical schools and specialty training programmes to deliver high-quality education in the field of EM-PAP.
Implementation
We believe EM-PAP curricula should be a core component of basic medical education, residency and sports medicine fellowship training. However, we also recognise the ability to initially satisfy all elements within each curriculum is aspirational, especially as programmes develop new educational resources. In particular, the comprehensive nature of the outlined curriculum for sports (and exercise) medicine fellowship training may be difficult to complete within a 1-year time frame, and we anticipate that further experience will be gained through clinical practice and continued medical education. EM-PAP education is recognised as a critical gap for learners and the adoption of any curricular elements will likely yield an improvement in the knowledge and ability of trainees to apply EM-PAP within their clinical practice. While the ability to differentiate between basic and advanced curricular elements would be ideal, programmes should consider implementation based on resource availability within their institution. Additionally, the numbers of procedures and experiences that are presented in this document are based on consensus opinion since objective data to create established benchmarks do not yet exist. These curricula are presented in their entirety to encourage and assist medical schools, residencies, and sports medicine fellowships to place a greater focus on EM-PAP education.
Methods
The EM-PAP group included nine experts in SEM who have clinical and educational (eg, presentation, publication or implementation experience) experience in physical activity promotion. For each of the three curricula (medical school, residency and sports medicine fellowship), a modified Delphi process was followed. After a review of curricula examples in EM-PAP, two members of the group (IA and JD) created a draft curriculum for each training level, with resulting questions created for each of the three curricula.12 13 These questions were presented to the larger group via an anonymous survey using Survey Monkey. The questionnaires were distributed via a link embedded within an email. Members of the group were given approximately 2 weeks to complete the questionnaires; a reminder email was sent 1 week prior to the due date. Questionnaires were closed after reaching a 100% response rate from all nine members.
Each questionnaire posed a series of questions around topic areas with members agreeing or disagreeing on a topic’s inclusion in the curricula. Members were given the option of commenting on the topics and making suggestions for improvement. Each response to a question involved a 5-point Likert scale as to whether the topic should be included in the curricula: 1=strongly disagree to 5=strongly agree. An element was included if 80% of participants agreed or strongly agreed it should be part of the curricula. Results of the survey, commentary and additional suggestions were collated and circulated to the group with the option of further open comment. It was not possible for the collator to identify who had provided particular comments. Where appropriate, follow-up or revised questions on the topic areas were posed in the next iteration of the questionnaire through the Delphi process.
To ensure a sequence of foundational elements, the curriculum for medical education was developed first, followed by the residency programme and then the sports medicine fellowship curriculum. The curricula are hierarchical; the top level contains the ‘Domains’, the second level contains ‘General Learning Areas’ (GLA) and each GLA is divided into ‘Specific Learning Areas’. Before finalising the curricula, open review and comment by a second group of 10 experts in EM-PAP, a group of five sports medicine fellowship directors with proficiency in medical education and representing a variety of fellowship settings, two experts in the field of diversity, equity and inclusion, and the AMSSM Board of Directors, was conducted. The suggested changes were used to strengthen the language within the document, while not fundamentally altering the Delphi process for the curriculum.
Results
Tables 1–3 depict curricula for medical students, residents and sports medicine fellows, respectively. Considerations for optional training as well as suggestions for assessment and evaluation are also provided.
Medical school education curriculum
Residency education curriculum
Fellowship education curriculum
Optional content for student training enhancement in EM-PAP
For students who desire more education in EM-PAP
Participate in a scholarly project.
Create quality improvement (QI) Initiative.
Participate in (or organise) journal clubs related to exercise medicine and physical activity.
Present and discuss the benefits of exercise with a community group facing barriers to physical activity.
Serve as a longitudinal health coach, with a focus on exercise and physical activity, for a core panel of patients with chronic disease and track their disease outcomes.
Serve longitudinally as an exercise/physical activity mentor for patients with (or at-risk for) adult and/or paediatric obesity.
Create patient education handouts or infographics.
Create exam/test questions.
Assessment and evaluation of medical school student performance in EM-PAP
Examples of student assessment
Using a standardised checklist, (eg, Observed Structured Clinical Examination (OSCE)) observe a student counselling a patient on exercise/physical activity.
Using a standardised checklist, (eg, OSCE) review a written exercise prescription from a patient encounter.
Administer a short answer or essay exam to assess student learning of EM-PAP curriculum content.
Review a written description of what the student would do in response to a presented case to assess student learning of EM-PAP curriculum content.
Allow the trainee to evaluate the EM-PAP programme with an opportunity to incorporate the trainee’s suggestions for programme improvement.
Optional content for resident training enhancement in EM-PAP
For residents who desire more education in EM-PAP
Participate in a scholarly project related to EM-PAP or lifestyle medicine.
Create a QI Initiative related to EM-PAP or lifestyle medicine.
Participate in or organise journal clubs related to EM-PAP.
Present and discuss the benefits of exercise and physical activity with a community group.
Serve as a longitudinal health coach, with a focus on exercise and physical activity, for a core panel of patients with chronic disease while tracking their physical activity and disease outcomes.
Serve longitudinally as an exercise/physical activity mentor for patients with or at risk for paediatric obesity.
Create patient education handouts or other enduring materials as resources.
Create exam/test questions related to EM-PAP.
Assessment and evaluation of resident performance in EM-PAP
Examples of resident assessment
Using a standardised checklist (eg, OSCE), evaluate a resident counselling a patient on exercise medicine and physical activity.
Using a standardised checklist (eg, OSCE), evaluate a written exercise prescription from a patient encounter.
Administer a short-answer or essay exam to assess resident learning of EM-PAP curriculum content.
Evaluate a written description of what the resident would do in response to a patient case to assess learning of EM-PAP curriculum content.
Allow the trainee to evaluate the EM-PAP programme with an opportunity to incorporate the trainee’s suggestions for programme improvement.
Optional content for fellow training enhancement in EM-PAP
For fellows who desire more education in EM-PAP
Participate in a scholarly project related to EM-PAP.
Create a QI Initiative related to EM-PAP.
Participate in journal clubs related to EM-PAP.
Present and discuss the benefits of exercise and physical activity with a community group.
Serve as a longitudinal health coach, with a focus on exercise and physical activity, for a core panel of patients with chronic disease while tracking their physical activity and disease outcomes.
Serve longitudinally as an exercise/physical activity mentor for patients with or at risk for paediatric obesity.
Create patient education handouts or other enduring materials in EM-PAP as resources.
Create exam/test questions related to EM-PAP.
Assessment and evaluation of fellow performance in EM-PAP
Examples of fellow assessment
Using a standardised checklist (eg, OSCE), evaluate a fellow counselling a patient on exercise medicine and physical activity.
Using a standardised checklist (eg, OSCE), evaluate a written exercise prescription from a patient encounter.
Administer a short-answer or essay exam to assess fellow learning of EM-PAP curriculum content.
Evaluate a written description of what the fellows would do in response to a patient case to assess learning of EM-PAP curriculum content.
Allow the trainee to evaluate the EM-PAP programme with an opportunity to incorporate the trainee’s suggestions for programme improvement.
Discussion
Regular exercise and physical activity are proven to enhance health, well-being and address a number of chronic diseases faced by patients today. However, there is a gap between these known benefits and the implementation of exercise and physical activity promotion in clinical practice, due in part to deficiencies in training and education. The International Syllabus in Sport and Exercise Medicine Group developed an international syllabus for SEM specialty training.12 13 Our group, appointed by the AMSSM, sought to take this work further by proposing curricula across the US medical education spectrum (medical student, resident and fellow), while also providing practical elements to help solidify medical knowledge into clinical practice. Additionally, since the length of training programmes vary across the world, it was important to develop curricula that could be used within similar medical education systems. These proposed curricula provide a standard set of objectives to improve trainee education, but also offer flexibility in how they may be incorporated within a given institution or training programme.
To promote use in clinical practice, the proposed curricula include a combination of theory and practical experiences to solidify understanding. The medical school curriculum offers content to be incorporated longitudinally using exercise prescriptions for commonly encountered medical conditions, and to facilitate discussion of how disease can be modified by exercise and physical activity. Importantly, if the proposed curricula are incorporated, every physician completing medical school will have the skills necessary to prescribe physical activity for commonly encountered medical conditions. Within residency, the promotion of physical activity and exercise may be incorporated into an existing curriculum, or as a part of a broader lifestyle medicine curriculum that includes training in how to promote physical activity, healthy nutrition, and proper sleep hygiene. Finally, the curriculum for EM-PAP within sports medicine fellowship training includes a more focused, in-depth experience. Experiences and clinical encounter benchmarks may vary based on institutional and programmatic resources and infrastructure; however, the curriculum offers a framework for incorporating experiences to better prepare the trainee for clinical practice. Ultimately, physicians who have the ability to properly promote exercise and physical activity as a form of medicine in their clinical practices can have a dramatic impact on health outcomes for their patients at a reduced cost to the healthcare system.14–16
While the curricula offer guidance on physical activity promotion at various levels of medical education, there are some limitations worth noting. For instance, institutions and programmes may differ in the timing, approach, and evaluation of how trainees are educated. These differences may alter how the principles of the proposed curricula are implemented. Nevertheless, the curricula capitalise on foundational elements and core disease processes that are taught at each level of training. Thus, our hope is that these components can be taught with minimal additional resource utilisation. With regard to residency education, benchmarks for the number of clinical encounters will likely vary because there are significant differences between specialties. Implementation and necessary modifications may occur at the discretion of the programme to best fit their training paradigm. Finally, these curricula have a particular focus on clinical experience and training. They are meant to complement, rather than replace, existing content on the overall benefits of exercise and physical activity.
Future directions include the development of specific educational content within the proposed curricula and standardised assessments that could drive curriculum change at all levels. This may include online modules that could be adopted by training programmes worldwide. Similar educational material has been created through international collaboration (eg, Sports Cardiology ECG Interpretation Training Modules) and has formed the basis for elevating the knowledgebase in general medical and SEM trainees. When developing the suggested resources for use in medical curricula, the end users of the resources (eg, medical students/trainees and patients) should be included, especially those from under-represented groups who are at highest risk of lifestyle diseases, and less likely to meet PA guidelines. This will ensure the resources are relevant to the end users, and thus improve the likelihood of uptake and impact of the resources.
Conclusion
The adoption of lifelong exercise and physical activity habits can dramatically improve the health of patients and populations. Physicians must be appropriately trained to be effective at counselling patients and promoting physical activity. The proposed curricula are the first published guidelines to offer programmatic elements for longitudinal training in EM-PAP for medical students, residents and sports medicine fellows at US medical institutions. We believe access and implementation of these curricula will facilitate training of physicians competent in promoting exercise and physical activity within their clinical practices for the betterment of the health and well-being of their patients.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to acknowledge the many experts in the field who generously reviewed this manuscript and offered valuable feedback: Aaron Monseau, Paul Gubanich, Jennifer R. Maynard, David Ross, Andrew Gregory, NiCole Ruth Keith, Nailah Coleman, Cindy Lin, Cynthia R. LaBella, Liz Joy, Keri Denay, Mats Börjesson, Brandee L. Waite, Lailah Issac, Martin Schwellnus, Robert E. Sallis, Stephanie A. Kliethermes and Nicola Sewry.
References
Footnotes
Twitter @janesthornton, @DreznerJon
Contributors IA and JD conceived the idea and drafted the initial manuscript. All of the authors contributed to data collection and review of the final manuscript.
Competing interests Oosterhealth Charitable Foundation (Boston, MA) has provided financial support for this work.
Provenance and peer review Not commissioned; externally peer reviewed.