Physical inactivity among physicians
Paul H. Gaertner; Whitmer B. Firor, MD; Lindsay Edouard, MB, MFCM Objective: To determine whether physicians in Saskatoon encourage their patients to be physically active through their advice and lifestyle. Design: Mail survey. Setting: Saskatoon. Participants: All 451 physicians holding privileges in the three Saskatoon hospitals who were in regular contact with patients. Outcome measures: Physical activity was quantified by means of the methods developed in the Canada Health Survey (CHS). Additional questions evaluated physicians' attitudes toward the importance of physical activity to themselves and their patients. Results: A total of 210 physicians (47%) returned the questionnaire. Of the respondents 30% were in the active category as compared with the national average of 39% (p < 0.05). This difference was accounted for mainly by the lower activity level of the male physicians aged 25 to 44 years. The difference is even more striking when the physicians were compared with people in managerial and professional occupations in the CHS, of whom 46% were active (p < 0.001). Surprisingly, in light of these results, most of the respondents felt that physical activity was important to themselves and to their patients. Conclusion: Although the physicians were less active physically than the general population they believed that exercise was important to them personally and that patients should be counselled about physical activity. Further study is needed to determine how applicable these results are to Canadian physicians in general.
Objectif: Determiner si les medecins de Saskatoon encouragent leurs patients a pratiquer l'activite physique par leurs conseils et leur mode de vie. Conception: Sondage postal. Contexte: Saskatoon. Participants: Les 451 medecins admis a pratiquer dans les trois h6pitaux de Saskatoon et en contact regulier avec des patients. Mesures des resultats: On a quantifie l'activite physique a l'aide des methodes de mise au point pour l'Enquete Sante Canada (ESC). D'autres questions ont permis d'evaluer l'attitude des medecins face a l'importance de l'activite, physique pour eux-memes et leurs patients. Resultats: Au total, 210 medecins (47 %) ont retourne le questionnaire. Trente pour cent des repondants etaient actifs, comparativement a la moyenne nationale de 39 % (p < 0,05). Cet ecart s'explique principalement par la baisse d'activite chez les medecins de sexe masculin ages de 25 a 44 ans. Le cas est encore plus frappant lorsque l'on compare les medecins a des sujets qui occupent des postes de professionnels et de gestion, dont 46 % sont actifs (p < 0,001). A la lumiere de ces resultats, il est etonnant de constater que la plupart des repondants estiment que l'activite physique est importante pour eux-memes et pour leurs patients. Conclusion: Meme si les medecins sont moins actifs physiquement que la population en general, ils croient que l'exercice est important pour eux personnellement et qu'il faudrait conseiller leurs patients au sujet de l'activite physique. Une etude plus poussee s'impose pour determiner dans quelle mesure ces resultats sont applicables aux medecins canadiens en general. Mr. Gaertner is a medical student, Dr. Firor is in the Department ofMedicine and Dr. Edouard is in the Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Sask.
Reprint requests to: Dr. Whitmer B. Firor, 65 Ellis Hall, Royal University Hospital, Saskatoon, SK S7N OXO MAY 15, 1991
CAN MED ASSOC J 1991; 144 (10)
1253
P hysical activity is increasingly recognized as an important component in the maintenance of health and an adjunct to the management of certain ailments, particularly cardiovascular disease.'-3 Physicians have an important role in guiding patients to adopt healthy lifestyles, and their example is as important as their spoken or written word.4 For example, physicians have led the way in stopping cigarette smoking - a recent survey5 has shown that fewer than 10% of Canadian physicians smoke regularly, as compared with approximately 30% of the general adult population. Similar data have been reported from the United States.6 This study was undertaken to determine whether Saskatoon physicians, through their lifestyle and their advice, are encouraging patients to adopt physical activity as part of healthy living.
Methods A questionnaire was distributed in January 1990 to all physicians holding privileges at any of the three hospitals in Saskatoon who were in regular contact with patients. This target population of 451 physicians was considered to include all those in clinical practice in Saskatoon. An additional mailing was carried out 3 weeks later to increase the response rate. To compare the patterns of physical activity of the surveyed physicians with those of the general population we decided to include relevant questions from the Canada Health Survey (CHS).7 Additional questions evaluated the attitudes of physicians toward physical activity and its place in patient management. The questionnaires were self-administered and anonymous; personal information was restricted to age, sex and type of practice - general or
specialty. Although the quantification of habitual physical activity is difficult we adopted the methods of the CHS.7 Its physical activity index is a summation of the frequency of each type of activity performed over the 2-week period preceding the survey multi-
plied by its duration and metabolic cost. The resultant categories varied from I (inactive) to V (very active). Because the CHS7 considered only those in categories IV and V to meet the levels required to maintain good fitness, only physicians in those categories were considered to be active in our study. Statistical analysis was carried out with the use of BMDP Bio-Med statistical packages (BMDP Statistical Software Inc., Los Angeles). Statistical significance was assessed through either x2 analysis for cross-tabulations of frequency distribution or the test of a difference between two proportions from independent samples.
Results A total of 210 (47%) of the 451 questionnaires were returned. The physical activity level of the physicians who responded to the first mailing was only marginally higher than the level of those who responded to the second (31% and 28% respectively in the active category). We compared the age and sex distribution of the respondents with membership figures from the Saskatchewan Medical Association (SMA), to which virtually all physicians in clinical practice in Saskatoon belong. The proportions of male and female respondents closely reflected those in the physician population in Saskatoon (Table 1). However, the response rate among those aged less than 45 years was greater than might have been expected from the breakdown of SMA membership by age. Therefore, to avoid bias comparisons of the levels of activity reported in this study and in the CHS were adjusted for age. Of the surveyed physicians 30% were active, as compared with 39% of the population in the CHS (p < 0.05). The difference was even greater when physicians were compared with people in managerial or professional occupations, of whom 46% were classified as active (p < 0.001). These differences are mostly attributable to the lower physical activity level of male Saskatoon physicians (Table 2) below 45 years of age (Table 3). Type of practice did not affect activity level.
-a SK a, ~able -.ge arnc sex distrCuuuu ed tc; a questionnaire orn physical activity ar:3M Saskatchewan Medical Association (SMA Respondents "',c i.- raracte r!St ic
-251.5
ry$a.'l .9'i; ,: 65
Survey; no. (and O/%) of respondents Physician CHS survey 32 (28) 2437 (42) 22 (31) 1308 (36) 3 (30) 367 (24)
p value
< 0.01
NS NS
Table 4: Physicians' ratings of statements on physical activity
Statement encourage patients to be physically active instruct patients about health benefits of physical activity I consider the providing of information to patients on activity to be the physician's responsibility view physical activity as important to me
personally 'Rating of 1
MAY 15, 1991
=
very unimportant, 2
=
1
Rating;* no. of responses 2 4 3
12
23
27
11
24
13 2
5
Total
86
33
181
43
80
23
181
19
29
87
43
191
9
28
102
64
205
unimportant, 3 = neutral, 4
=
important, 5 = very important. CAN MED ASSOC J 1991; 144 (10)
1255
physicians are still regarded by patients as credible sources of information.6"'5"'6 This is nowhere better seen than in the campaign against cigarette smoking, in which the medical profession has shown leadership by both public advocacy and personal example.5 If our results can be generalized it is thus unfortunate that Canadian physicians are not leading the promotion of physical activity. An earlier study of the physical fitness of Ontario physicians reached similar conclusions and also emphasized the importance of the physician as role model.4 Since only 47% of the physicians in our study returned a completed questionnaire our results may not represent Saskatoon physicians in general; indeed, the respondents were younger than expected from the SMA breakdown. However, any bias would likely result from a preponderance of physicians who value exercise, and our results are more likely to overestimate than to underestimate the activity level of Saskatoon physicians. The comparison between the responses from the first and second mailings would seem to bear this out. Furthermore, the response rate of 47% is similar to that reported in a recent survey of general practitioners.'7 The estimation of activity patterns, exercise habits and physical fitness levels of large populations is a statistical minefield at best,'2"8 and comparisons with the CHS suffer from limitations: the CHS was carried out as far back as 1979 and was administered differently; in addition the results showed provincial, seasonal, and urban and rural differences. Nevertheless, we attempted to overcome these limitations by using the same questions and comparing our study group with the CHS managerial and professional group. We were unable to use the data from the 1988 follow-up study to the CHS,'3 since they were not available until after ours had been collected. In addition, the questions in the 1988 survey were somewhat different from those used in 1979. The CHS suggested that all Canadians, barring infirmity or frank medical contraindication, should strive to maintain physical activity in the moderate to high categories (IV to V), a recommendation with some scientific basis. A sedentary lifestyle is beneficial to almost no one and inappropriate to those advocating leadership in health promotion. The follow-up study to the CHS has shown that the overall activity level of Canadians has increased,'3 a finding that makes our results even less encouraging. Possibly Saskatoon physicians are not representative of Canadian physicians as a whole. The only other known Canadian study that examined physical fitness directly rather than levels of physical activity reached a conclusion similar to ours.4 However, medical education and training in Saskatoon are no different from those elsewhere in Canada. If our conjecture is correct -that our 1256
CAN MED ASSOC J 1991; 144 (10)
findings reflect an unhealthy lifestyle imposed on medical students and postgraduate trainees - then our results should be generalizable to other areas of Canada. Physical inactivity among physicians may interfere with their acting as effective role models. Further studies are needed to confirm and explain our observations. We thank Doug Hall for assisting with the data analysis and Nadia Haatvedt and Tiffany Blair for helping with the preparation of the manuscript. We also thank the Saskatchewan Medical Association and the Saskatchewan Heart and Stroke Foundation for assisting with the study.
References 1. Shephard RJ: Exercise in secondary and tertiary rehabilitation: costs and benefits. J Cardiopulm Rehab 1989; 9: 188194 2. Powell KE, Thompson PD, Caspersen CJ et al: Physical activity and the incidence of coronary heart disease. Annu Rev Public Health 1987; 8: 253-287 3. Berlin JA, Colditz GA: A meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol 1990; 132: 612-628 4. Shephard RJ: The fitness of family physicians in Ontario. Ont Med Rev 1969; 36: 111-115 5. Sullivan P: Most doctors have butted out, initial CMAJ survey shows. Can Med Assoc J 1988; 138: 160 6. Fortmann SP, Sallis JF, Magnus PM et al: Attitudes and practices of physicians regarding hypertension and smoking: the Stanford Five City Project. Prev Med 1985; 14: 70-80 7. The Health of Canadians: Report of the Canada Health Survey, Dept of National Health and Welfare, Ottawa, 1981 8. Rynearson RR, Roberts JW, Stewart WL: Do physician athletes believe in pre-exercise examinations and stress tests? N Engl J Med 1979; 301: 792-793 9. Wells KB, Lewis CE, Leape B et al: Do physicians preach what they practice: a study of physicians' health habits and counseling practices. JAMA 1984; 252: 2846-2848 10. Elmore JG, Kaplan SM, Merians D et al: Teaching physicians to practice what they will preach. JAMA 1985; 253: 29582959 11. Canada Fitness Survey: Fitness and Lifestyle in Canada, Canada Fitness Survey, Ottawa, 1983 12. Stephens T, Jacobs DR Jr, White CC: A descriptive epidemiology of leisure-time physical activity. Public Health Rep 1985; 100: 147-158 13. Stephens T, Craig CL: The Well-being of Canadians: Highlights of the 1988 Campbell's Survey, Canadian Fitness and Lifestyle Institute, Ottawa, 1990 14. Somerville KA: Participaction Saskatoon: a Local Promotional Campaign for Physical Activity and Fitness (master's thesis), University of Saskatchewan, Saskatoon, 1983 15. Anda RF, Remington PL, Sienko DG et al: Are physicians advising smokers to quit? JAMA 1987; 257: 1916-1919 16. Wyshak G, Lamb GA, Lawrence RS et al: A profile of the health-promoting behaviors of physicians and lawyers. N Engl J Med 1980; 303: 104-107 17. Leclere H, Beaulieu MD, Bordage G et al: Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems. Can Med Assoc J 1990; 143: 13051315 18. Siscovick DS, LaPorte RE, Newman JM: The disease-specific benefits and risks of physical activity and exercise. Public Health Rep 1985; 100: 180-188 LE 15 MAI 1991
Paul H. Gaertner; Whitmer B. Firor, MD; Lindsay Edouard, MB, MFCM Objective: To determine whether physicians in Saskatoon encourage their patients to be physically active through their advice and lifestyle. Design: Mail survey. Setting: Saskatoon. Participants: All 451 physicians holding privileges in the three Saskatoon hospitals who were in regular contact with patients. Outcome measures: Physical activity was quantified by means of the methods developed in the Canada Health Survey (CHS). Additional questions evaluated physicians' attitudes toward the importance of physical activity to themselves and their patients. Results: A total of 210 physicians (47%) returned the questionnaire. Of the respondents 30% were in the active category as compared with the national average of 39% (p < 0.05). This difference was accounted for mainly by the lower activity level of the male physicians aged 25 to 44 years. The difference is even more striking when the physicians were compared with people in managerial and professional occupations in the CHS, of whom 46% were active (p < 0.001). Surprisingly, in light of these results, most of the respondents felt that physical activity was important to themselves and to their patients. Conclusion: Although the physicians were less active physically than the general population they believed that exercise was important to them personally and that patients should be counselled about physical activity. Further study is needed to determine how applicable these results are to Canadian physicians in general.
Objectif: Determiner si les medecins de Saskatoon encouragent leurs patients a pratiquer l'activite physique par leurs conseils et leur mode de vie. Conception: Sondage postal. Contexte: Saskatoon. Participants: Les 451 medecins admis a pratiquer dans les trois h6pitaux de Saskatoon et en contact regulier avec des patients. Mesures des resultats: On a quantifie l'activite physique a l'aide des methodes de mise au point pour l'Enquete Sante Canada (ESC). D'autres questions ont permis d'evaluer l'attitude des medecins face a l'importance de l'activite, physique pour eux-memes et leurs patients. Resultats: Au total, 210 medecins (47 %) ont retourne le questionnaire. Trente pour cent des repondants etaient actifs, comparativement a la moyenne nationale de 39 % (p < 0,05). Cet ecart s'explique principalement par la baisse d'activite chez les medecins de sexe masculin ages de 25 a 44 ans. Le cas est encore plus frappant lorsque l'on compare les medecins a des sujets qui occupent des postes de professionnels et de gestion, dont 46 % sont actifs (p < 0,001). A la lumiere de ces resultats, il est etonnant de constater que la plupart des repondants estiment que l'activite physique est importante pour eux-memes et pour leurs patients. Conclusion: Meme si les medecins sont moins actifs physiquement que la population en general, ils croient que l'exercice est important pour eux personnellement et qu'il faudrait conseiller leurs patients au sujet de l'activite physique. Une etude plus poussee s'impose pour determiner dans quelle mesure ces resultats sont applicables aux medecins canadiens en general. Mr. Gaertner is a medical student, Dr. Firor is in the Department ofMedicine and Dr. Edouard is in the Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Sask.
Reprint requests to: Dr. Whitmer B. Firor, 65 Ellis Hall, Royal University Hospital, Saskatoon, SK S7N OXO MAY 15, 1991
CAN MED ASSOC J 1991; 144 (10)
1253
P hysical activity is increasingly recognized as an important component in the maintenance of health and an adjunct to the management of certain ailments, particularly cardiovascular disease.'-3 Physicians have an important role in guiding patients to adopt healthy lifestyles, and their example is as important as their spoken or written word.4 For example, physicians have led the way in stopping cigarette smoking - a recent survey5 has shown that fewer than 10% of Canadian physicians smoke regularly, as compared with approximately 30% of the general adult population. Similar data have been reported from the United States.6 This study was undertaken to determine whether Saskatoon physicians, through their lifestyle and their advice, are encouraging patients to adopt physical activity as part of healthy living.
Methods A questionnaire was distributed in January 1990 to all physicians holding privileges at any of the three hospitals in Saskatoon who were in regular contact with patients. This target population of 451 physicians was considered to include all those in clinical practice in Saskatoon. An additional mailing was carried out 3 weeks later to increase the response rate. To compare the patterns of physical activity of the surveyed physicians with those of the general population we decided to include relevant questions from the Canada Health Survey (CHS).7 Additional questions evaluated the attitudes of physicians toward physical activity and its place in patient management. The questionnaires were self-administered and anonymous; personal information was restricted to age, sex and type of practice - general or
specialty. Although the quantification of habitual physical activity is difficult we adopted the methods of the CHS.7 Its physical activity index is a summation of the frequency of each type of activity performed over the 2-week period preceding the survey multi-
plied by its duration and metabolic cost. The resultant categories varied from I (inactive) to V (very active). Because the CHS7 considered only those in categories IV and V to meet the levels required to maintain good fitness, only physicians in those categories were considered to be active in our study. Statistical analysis was carried out with the use of BMDP Bio-Med statistical packages (BMDP Statistical Software Inc., Los Angeles). Statistical significance was assessed through either x2 analysis for cross-tabulations of frequency distribution or the test of a difference between two proportions from independent samples.
Results A total of 210 (47%) of the 451 questionnaires were returned. The physical activity level of the physicians who responded to the first mailing was only marginally higher than the level of those who responded to the second (31% and 28% respectively in the active category). We compared the age and sex distribution of the respondents with membership figures from the Saskatchewan Medical Association (SMA), to which virtually all physicians in clinical practice in Saskatoon belong. The proportions of male and female respondents closely reflected those in the physician population in Saskatoon (Table 1). However, the response rate among those aged less than 45 years was greater than might have been expected from the breakdown of SMA membership by age. Therefore, to avoid bias comparisons of the levels of activity reported in this study and in the CHS were adjusted for age. Of the surveyed physicians 30% were active, as compared with 39% of the population in the CHS (p < 0.05). The difference was even greater when physicians were compared with people in managerial or professional occupations, of whom 46% were classified as active (p < 0.001). These differences are mostly attributable to the lower physical activity level of male Saskatoon physicians (Table 2) below 45 years of age (Table 3). Type of practice did not affect activity level.
-a SK a, ~able -.ge arnc sex distrCuuuu ed tc; a questionnaire orn physical activity ar:3M Saskatchewan Medical Association (SMA Respondents "',c i.- raracte r!St ic
-251.5
ry$a.'l .9'i; ,: 65
Survey; no. (and O/%) of respondents Physician CHS survey 32 (28) 2437 (42) 22 (31) 1308 (36) 3 (30) 367 (24)
p value
< 0.01
NS NS
Table 4: Physicians' ratings of statements on physical activity
Statement encourage patients to be physically active instruct patients about health benefits of physical activity I consider the providing of information to patients on activity to be the physician's responsibility view physical activity as important to me
personally 'Rating of 1
MAY 15, 1991
=
very unimportant, 2
=
1
Rating;* no. of responses 2 4 3
12
23
27
11
24
13 2
5
Total
86
33
181
43
80
23
181
19
29
87
43
191
9
28
102
64
205
unimportant, 3 = neutral, 4
=
important, 5 = very important. CAN MED ASSOC J 1991; 144 (10)
1255
physicians are still regarded by patients as credible sources of information.6"'5"'6 This is nowhere better seen than in the campaign against cigarette smoking, in which the medical profession has shown leadership by both public advocacy and personal example.5 If our results can be generalized it is thus unfortunate that Canadian physicians are not leading the promotion of physical activity. An earlier study of the physical fitness of Ontario physicians reached similar conclusions and also emphasized the importance of the physician as role model.4 Since only 47% of the physicians in our study returned a completed questionnaire our results may not represent Saskatoon physicians in general; indeed, the respondents were younger than expected from the SMA breakdown. However, any bias would likely result from a preponderance of physicians who value exercise, and our results are more likely to overestimate than to underestimate the activity level of Saskatoon physicians. The comparison between the responses from the first and second mailings would seem to bear this out. Furthermore, the response rate of 47% is similar to that reported in a recent survey of general practitioners.'7 The estimation of activity patterns, exercise habits and physical fitness levels of large populations is a statistical minefield at best,'2"8 and comparisons with the CHS suffer from limitations: the CHS was carried out as far back as 1979 and was administered differently; in addition the results showed provincial, seasonal, and urban and rural differences. Nevertheless, we attempted to overcome these limitations by using the same questions and comparing our study group with the CHS managerial and professional group. We were unable to use the data from the 1988 follow-up study to the CHS,'3 since they were not available until after ours had been collected. In addition, the questions in the 1988 survey were somewhat different from those used in 1979. The CHS suggested that all Canadians, barring infirmity or frank medical contraindication, should strive to maintain physical activity in the moderate to high categories (IV to V), a recommendation with some scientific basis. A sedentary lifestyle is beneficial to almost no one and inappropriate to those advocating leadership in health promotion. The follow-up study to the CHS has shown that the overall activity level of Canadians has increased,'3 a finding that makes our results even less encouraging. Possibly Saskatoon physicians are not representative of Canadian physicians as a whole. The only other known Canadian study that examined physical fitness directly rather than levels of physical activity reached a conclusion similar to ours.4 However, medical education and training in Saskatoon are no different from those elsewhere in Canada. If our conjecture is correct -that our 1256
CAN MED ASSOC J 1991; 144 (10)
findings reflect an unhealthy lifestyle imposed on medical students and postgraduate trainees - then our results should be generalizable to other areas of Canada. Physical inactivity among physicians may interfere with their acting as effective role models. Further studies are needed to confirm and explain our observations. We thank Doug Hall for assisting with the data analysis and Nadia Haatvedt and Tiffany Blair for helping with the preparation of the manuscript. We also thank the Saskatchewan Medical Association and the Saskatchewan Heart and Stroke Foundation for assisting with the study.
References 1. Shephard RJ: Exercise in secondary and tertiary rehabilitation: costs and benefits. J Cardiopulm Rehab 1989; 9: 188194 2. Powell KE, Thompson PD, Caspersen CJ et al: Physical activity and the incidence of coronary heart disease. Annu Rev Public Health 1987; 8: 253-287 3. Berlin JA, Colditz GA: A meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol 1990; 132: 612-628 4. Shephard RJ: The fitness of family physicians in Ontario. Ont Med Rev 1969; 36: 111-115 5. Sullivan P: Most doctors have butted out, initial CMAJ survey shows. Can Med Assoc J 1988; 138: 160 6. Fortmann SP, Sallis JF, Magnus PM et al: Attitudes and practices of physicians regarding hypertension and smoking: the Stanford Five City Project. Prev Med 1985; 14: 70-80 7. The Health of Canadians: Report of the Canada Health Survey, Dept of National Health and Welfare, Ottawa, 1981 8. Rynearson RR, Roberts JW, Stewart WL: Do physician athletes believe in pre-exercise examinations and stress tests? N Engl J Med 1979; 301: 792-793 9. Wells KB, Lewis CE, Leape B et al: Do physicians preach what they practice: a study of physicians' health habits and counseling practices. JAMA 1984; 252: 2846-2848 10. Elmore JG, Kaplan SM, Merians D et al: Teaching physicians to practice what they will preach. JAMA 1985; 253: 29582959 11. Canada Fitness Survey: Fitness and Lifestyle in Canada, Canada Fitness Survey, Ottawa, 1983 12. Stephens T, Jacobs DR Jr, White CC: A descriptive epidemiology of leisure-time physical activity. Public Health Rep 1985; 100: 147-158 13. Stephens T, Craig CL: The Well-being of Canadians: Highlights of the 1988 Campbell's Survey, Canadian Fitness and Lifestyle Institute, Ottawa, 1990 14. Somerville KA: Participaction Saskatoon: a Local Promotional Campaign for Physical Activity and Fitness (master's thesis), University of Saskatchewan, Saskatoon, 1983 15. Anda RF, Remington PL, Sienko DG et al: Are physicians advising smokers to quit? JAMA 1987; 257: 1916-1919 16. Wyshak G, Lamb GA, Lawrence RS et al: A profile of the health-promoting behaviors of physicians and lawyers. N Engl J Med 1980; 303: 104-107 17. Leclere H, Beaulieu MD, Bordage G et al: Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems. Can Med Assoc J 1990; 143: 13051315 18. Siscovick DS, LaPorte RE, Newman JM: The disease-specific benefits and risks of physical activity and exercise. Public Health Rep 1985; 100: 180-188 LE 15 MAI 1991
