– Written by Ben Tan, Singapore

EIM COMES TO SOUTHEAST ASIA

Since Exercise is Medicine^® (EIM) was launched in Singapore in 2011, the global initiative founded in 2007 by Dr Robert Sallis and the American College of Sports Medicine (ACSM) has also taken off in Malaysia, Indonesia, the Philippines and Thailand. While its form varies across different cultures and jurisdictions, the key pillars of EIM remain the same:

1. To make physical activity a vital sign.
2. To get more doctors and allied health and fitness professionals to prescribe exercise.
3. To put in place a framework for allied health and fitness professionals to work with physicians in implementing exercise prescription.
4. To get the public to ask for and expect physicians to discuss physical activity during each consultation.

This article will focus on the second pillar – exercise prescription.

THE NEED FOR EIM

A survey conducted in a cluster of primary care clinics in Singapore revealed that 86.5% of doctors claim that they discuss or prescribe exercise to their patients. However, when these very patients were asked if their doctor had discussed their exercise regimen (or lack of) with them, only 20% of patients said yes. As it turned out, in the course of a day’s work, doctors would see 60 to 80 patients and if he or she had discussed exercise with only a handful of these, the doctor would claim that he or she did discuss exercise. In that primary care setting, where the vast majority of patients had chronic diseases, conversations on exercise should have been the staple. More in-depth analysis revealed that doctors were reluctant to discuss exercise with their patients because they were pressed for time and they were not confident enough to do so. With 60 to 80 patients to see per day, it is understandable that the doctors had limited time to explain the diagnosis to the patient, let alone initiate a conversation on exercise. But why would doctors report that they are not confident in prescribing exercise? Surprising as it may sound, despite the overwhelming evidence on the benefits of exercise in the prevention and management of a whole multitude of medical conditions, exercise prescription is not taught in the undergraduate curriculum in Singapore’s medical schools. Singapore is not alone – the vast majority of medical schools around the world do not include exercise prescription in their curriculums. I am a sports physician and I was only taught exercise prescription at the postgraduate level. In many specialties, exercise prescription is not taught at all.

EIM SINGAPORE ESTABLISHES EXERCISE PRESCRIPTION COURSE FOR THE REGION

Exercise is Medicine^® Singapore (EIMS) hence set out to design an exercise prescription course to empower doctors to prescribe exercise in a time-efficient and safe manner, drawing from the rich content of the ACSM publications and position stands. Chapter contributors to the course syllabus and course text book¹ (Figure 1) include sports physicians, rehabilitative medicine physicians, a cardiologist, endocrinologist, psychiatrist, oncologist, respiratory physician, family physician, physiotherapist, exercise physiologist and clinical psychologist, among others – reflecting the relevance of exercise across so many fields of medicine. The first course was launched in Singapore in 2012. To date, 355 doctors and 184 allied health and fitness professionals have been EIMS certified (Figure 2). The courses are conducted monthly, to class sizes of up to 30. Areas covered in the 8-hour programme for doctors include:

• Introduction to EIMS and benefits of exercise.
• Pre-participation screening/risk assessment.
• Principles of exercise prescription.
• National Physical Activity Guidelines.
• Exercise prescription practicum (case studies and hands-on gym session).
• Exercise prescription in cardiovascular conditions.
• Exercise in diabetes/obesity/hyper-lipidaemia.
• Exercise in special groups (including depression, asthma, osteoarthritis, osteoporosis and common musculo-skeletal injuries).
• Motivation and counselling in exercise.

The course culminates in a multiple choice question examination and the certificates awarded to those who successfully complete the course are valid for 3 years. Certified participants are included in an online referral network that the public can access.

Even if a doctor were able to write an exercise prescription for his patient within a minute, he would not be able to guide patients unaccustomed to exercise through the prescribed exercises. Allied health and fitness professional are therefore invaluable in complementing doctors by supervising patients through the prescribed exercise programme.

Allied health and fitness professionals including nurses, physiotherapists, occupational therapists, podiatrists, dietitians, exercise physiologists, sports trainers, personal trainers, coaches and physical education teachers undergo a variation of the doctors’ course that places more emphasis on supervising a patient through an exercise prescription. The minimum eligibility criteria for the allied health and fitness professional course is a diploma as well as a recognised clinical or fitness certification.

With minimal adaptations, such as substitution with the respective country’s national physical activity guidelines, both the primary care physicians’ course and the allied health and fitness professionals’ course have been rolled out in Malaysia, Indonesia, the Philippines and Thailand. To ensure consistency and harmonisation across borders, all courses in Southeast Asia follow the same course structure, in terms of content, duration, assessment and validity period. This harmonisation has made possible the cross-recognition of the EIM Exercise Prescription Certification within Southeast Asia. Indeed, doctors in Indonesia may be certified in Singapore and be appointed as teaching faculty to instruct the EIM courses in Malaysia, Indonesia or the Philippines.

The ACSM is well aware that cultural differences exist even within the same region and has exercised much flexibility in allowing each country to customise the course to suit its own context. For example, in Indonesia, where the vast majority of personal trainers do not hold diplomas, the eligibility criterion was lowered to remove barriers to those interested in learning how to prescribe exercise in a structured, safe and efficient way. With regards to course fees, as the norms vary from country to country as well – in Singapore, where doctors are accustomed to paying for courses, a fee is levied; whereas in the Philippines, where fees are usually not charged for short medical courses, EIM courses are mostly free.

ACHIEVING CRITICAL MASS

EIM would like to see exercise prescription become the norm in the doctor’s consult room, rather than the exception. By depending on doctors voluntarily signing up for EIM Exercise Prescription courses, it would be difficult to achieve a critical mass of doctors to make exercise prescription the norm. Hence, EIM Singapore adopts a systematic approach in signing up doctors, targeting areas where exercise prescription would have the greatest impact:

• Family medicine residents: doctors from a dominant healthcare cluster specialising in family medicine all undergo the EIMS Exercise Prescription course as a compulsory component of their family medicine residency. In time, the majority of family physicians will be EIMS certified.
• Singapore Armed Forces (SAF) Medical Officers: all male doctors in Singapore are drafted for national service. Before they complete their national service, all SAF Medical Officers are required to undergo the EIMS Exercise Prescription course. With this initiative alone, more than half of the doctors in Singapore (i.e. all male doctors) will eventually be formally trained in exercise prescription.
• National Kidney Foundation (NKF): with 31 dialysis centres across Singapore, the NKF is the largest dialysis provider for patients with renal failure. The managers of all 31 centres and all NKF clinical exercise physiologists are EIMS certified in exercise prescription. This ensures that all NKF patients incorporate exercise in the management of their renal disease.
• Sports Medicine Diploma: a Sports Medicine Postgraduate Diploma course will be launched in 2017. This course is targeted at doctors who have an interest in sports medicine. The EIMS Exercise Prescription course and certification will be part of this postgraduate diploma.

EIMS has also initiated discussions with the largest medical school in Singapore to incorporate exercise prescription at the undergraduate level.

With such a systematic approach, the days where doctors complain of a lack of confidence or time in prescribing exercise will soon be a thing of the past.

IMPROVING HEALTHCARE IN THE REGION

Through EIM, the ACSM plugs a major gap in our healthcare system – it empowers our doctors, working together with allied health and fitness professionals, to effectively promote physical activity to patients. All doctors should actively promote physical activity, with or without EIM certification. The EIM Exercise Prescription course simply empowers those who are not already confident, to do so.

The support from the ACSM has been excellent, from resourcing to ensuring harmonisation across the globe.

Ben Tan M.B.B.S., D.F.D. (CAW), M.Sp.Med., F.A.M.S., F.A.C.S.M.

Chairman, EIM Singapore and EIM South East Asia

Contact: benedict_tan@cgh.com.sg

References

1. Tan B, Ng CS, Lim I, eds. Exercise is Medicine Singapore Exercise Prescription Guide. Singapore: Marshall Cavendish Editions 2015.