6 July 2018

Let’s get personal when prescribing exercise

Obesity Patients

During medical school we always received advice on self-care. One of the most important aspects of this was developing interests outside of medicine, as well as exercising. 

I kept this in mind and fitted in gym and swimming around university classes, part-time work and exams. 

During internship and residency, I fell off the wagon a bit with managing exercise during night shifts, but I was on my feet a lot, which is probably why my fitness level and weight did not change much.

I started general practice training and again we had a session on self-care that reinforced a lot of the messages from medical school. I thought to myself: “I’m an old hand at this now, a few sessions of gym and swimming at my local centre, no sweat!” 

Slowly though, the weight started creeping up. I also found myself sluggish and my fitness wasn’t what it used to be. 

I was trying to fit in physical activity around what was essentially a very sedentary job with long hours as well as studying and training for my fellowship. The impact of sitting down for my job surprised me. My husband in the same field did not fare much better. 

In Australia, we all aren’t moving as much as we should. The Physical Activity and Sedentary Behaviour Guidelines released by the Department of Health in 2014 indicate that almost three quarters of all Australians are not active enough. 

As general practitioners we know that exercise can be prescribed for almost every chronic condition, including diabetes, heart failure, COPD, malignancy related fatigue, depression, anxiety; the list goes on. 

Before I could “prescribe” exercise for my patients it became important to recognise the barriers I was facing myself, to make time for exercise. I don’t think I have overcome all of them, but reflecting on them allowed me to understand my patients’ stories better.

I realised I had stopped prioritising my self-care, but also that I was looking at my past fitness levels as an unachievable goal. I couldn’t run as far or as fast, nor could I swim for as long.

With the hours that I was working I had fallen into a vicious cycle of catching up with chores and paperwork on my days off. The subtle and slow changes in my routine surprised even me. 

Instead of first telling my patients how much exercise they should be doing as per guidelines, I have now started asking them about their experiences with physical activity. What were things like when they were younger? What are some of the barriers stopping them from exercising?  It’s interesting because “lack of time” isn’t the only phrase I hear then. I have found out how, for some of my patients, they just don’t know where to start. 

They have also never considered their workplace as a point of intervention for physical activity. For quite a few, the idea of going to a gym can be quite intimidating and it opens a much deeper discussion about self esteem and body image. 

The conversation then moves to intervention. I ask them if they feel they are ready to change their current routine and, to quote an oft-used concept in general practice, make SMART (Specific, Measurable, Attainable, Relevant and Timely) goals.

I give them ideas, but also ask them if the goals we are discussing are attainable. Instead of “walking more”, we list out specific weekly goals,  such as walking for 15 minutes around the block for five days. 

We try and make the goals relevant to their chronic conditions. For example, if a patient with depression feels worse in the evenings we try and plan their exercise during this time. We also make time to regularly review their progress.

In terms of my personal experience, I have dedicated time on my days off to go swimming and attend exercise classes instead of being in the gym. It has made me a bit more accountable, but also improved my confidence with regards to my fitness level. 

At work I stand between consults while typing my notes and doing paperwork. I stand while eating lunch and do most of my procedures standing up, including infusions. 

I have been considering doing a course in simple exercises for common MSK conditions, so I can show my patients their stretches rather than printing them out for them. Exercise has always been an important part of overall wellbeing and I find that focusing on the wellbeing part rather than “kilograms lost” can often be more therapeutic for a patient.

It can be celebrated in small victories; such as my patient with osteoarthritis coming off her NSAIDs because of hydrotherapy; or my patient with insulin resistance getting her periods regularly because she has started walking to work and walking up and down the stairs instead of taking the lift. 

We don’t have to have all the answers for our patients, we might not even have all the answers for ourselves, but it becomes important to make the prescription for exercise more personal. 

Dr Aajuli Shukla is a general practitioner in Blacktown NSW, and GP Editor of The Medical Republic