Research article
Open Access

Medical Student Physical Activity Education – Staying Active to Actively Help Others

Alyssa Fenuta[1], Andrea Brennan[1], Rebecca Lau[1], Celina Shirazipour[1], Badr Hefnawi[1], Katrina D'Urzo[1], Ashley Johnson[1], Iain McPhee[1], Brittany McEachern[1], Jennifer Tomasone[1]

Institution: 1. Queen's University
Corresponding Author: Dr Jennifer Tomasone ([email protected])
Categories: Comparative Medical Education, Educational Strategies, Students/Trainees, Teaching and Learning, Research in Health Professions Education
Published Date: 22/10/2019

Abstract

Exercise is Medicine Canada (EIMC) at Queen’s University provided physical activity (PA) education to first year Ontario medical student conference attendees. 24 participants (23±2years) completed questionnaires one week prior (online/in-person) and one week after (online) the conference. The theory and evidence based content resulted in statistically significant increases in EIMC (χ²[1,N=24]=26.32,p<0.001) and Canadian PA guideline (χ²[1,N=24]=4.00,p=0.046) awareness. The presented material can be adopted in other settings to increase short-term awareness of EIMC and PA guidelines.

Keywords: medical school curriculum; physical activity education; Exercise is Medicine; guidelines

Introduction

Despite population-wide efforts to promote active lifestyles (“Participaction”, 2016), physical activity (PA) participation remains low, with ~15% of Canadian adults meeting national guidelines (i.e. 150 minutes of moderate-to-vigorous intensity PA weekly; Colley et al., 2011; Tremblay et al., 2011). PA education-related content is significantly lacking in the medical school environment (Cardinal et al., 2014), which may be contributing to this issue as physician PA counselling remains low (Glasgow et al., 2001). Research suggests personal PA habits of medical professionals predict their counselling practices, with physically active physicians more likely to provide PA counselling (Lobelo, Duperly and Frank, 2009). Increasing PA habits of medical professionals may improve PA counselling rates and population PA levels, as research suggests patients are more likely to participate in regular PA upon receiving physician PA counselling (Elley et al., 2003).

 

As a subset of the global movement Exercise is Medicine, Exercise is Medicine Canada (EIMC) strives to increase PA counselling habits of physicians to increase patient PA levels. The EIMC on Campus program promotes the EIMC mission at academic institutions providing opportunities for faculty, staff and students to lead PA promotion efforts on their campuses and in their surrounding communities. EIMC at Queen’s University, the first Canadian on-campus chapter, was established in 2013 consisting primarily of graduate students from the School of Kinesiology and Health Studies (e.g. exercise physiology, psychology, health promotion, strength and conditioning). The group is committed to delivering professional, evidence-based initiatives to meet the needs of community partners (e.g. Queen’s University School of Medicine, local Family Health Teams, etc.), and providing interdisciplinary approaches to implement PA prescription education opportunities within the medical school curriculum.

 

EIMC at Queen’s University was invited to participate in the 2015 Ontario Medical Students’ Weekend (OMSW) – “Be Well to Do Well”, a provincial conference introducing first year medical students to basic clinical skills and information. EIMC at Queen’s University delivered an evidence- and theory-based 40-minute workshop titled “Staying Active to Actively Help Others”. The workshop discussed the importance of PA for improving health, addressed student-specific barriers to maintaining regular PA levels, and provided strategies to meet the PA guidelines. The workshop was developed using the Theory of Planned Behavior (TPB; Ajzen, 2006), as it has demonstrated utility within PA promotion workshops for health care professional trainees (Tomasone et al., 2017). The TPB theorizes an individual’s attitudes, subjective norms and perceived behavioral control for performing PA influences the individual’s intention to increase PA levels. The workshop targeted the three constructs influencing medical students’ intention to perform PA.

 

The purpose of the study was to assess the changes in medical students’ awareness of EIMC and PA guidelines following the intervention. It was hypothesized that student awareness of EIMC and PA guidelines would increase after the workshop.

Methods

The study protocol was approved by the Health Sciences Research Ethics Board at Queen’s University and is part of a larger data set (unpublished). 

Description of the workshop

The “Staying Active to Actively Help Others” workshop was divided into three sections targeting the PA intentions and behavior of medical students.  Section 1 incorporated a 20-minute PowerPoint presentation addressing aspects of maintaining a physically active lifestyle in medical school and aimed to address the TPB constructs of attitudes, perceived behavioral control and intentions for PA engagement (Table I). First, attendees were introduced to the Canadian Society for Exercise Physiology PA guidelines for adults (Tremblay et al., 2011) including the recommended amount (minutes/week) and intensity of PA, and how to assess their own PA levels. Next, attendees were educated on the efficacy of PA as an intervention for improving cardiometabolic health, independent of traditional risk factors (e.g. cigarette smoking, blood pressure, cholesterol; Blair et al., 1996). Subsequently, PA barriers for medical students were addressed, and benefits of PA specific to medical students were described. Finally, to help medical students reach the PA guidelines, attendees were taught to create personal action and coping plans addressing common barriers to regular PA participation that medical students face and were provided with relevant examples. To address the TPB construct of subjective norms, Section 2 included a 10-minute pre-recorded video with three practicing physicians at different stages of their educational training and different specializations (i.e., 3rd year medical student, emergency room physician, family physician) . These healthcare professionals shared their personal challenges and successes to maintaining physically active lifestyles.  Section 3 included a 10-minute practical PA component where Canadian Society for Exercise Physiology (CSEP) certified personal trainers guided participants through a warm-up and 10 resistance band exercises targeting the entire body. The importance of cool-downs after PA was also discussed. Section 3 targeted the TPB construct of perceived behavioral control.  Together, the three sections provided workshop attendees with information regarding the benefits, challenges and importance of maintaining a healthy, active lifestyle throughout their medical careers.

 

Table 1. Description of the “Staying Active to Actively Help Others” workshop.

Presentation Sections

Content

TPB Construct Targeted

Delivered By

Time (min)

Section 1: PowerPoint Presentation

Educating on the PA guidelines

Attitudes

SKHS graduate students

 

20

Discussing benefits of physical activity

Attitudes

Providing evidence on efficacy of PA

Attitudes

Outlining medical school stressors and benefits of PA

Attitudes

Showing current activity levels of medical students

Attitudes

Describing link between personal PA habits and PA counseling

Attitudes

Discussing barriers to PA in medical school

Perceived behavioral control

Creating action and coping plans for overcoming barriers to PA

Intentions

Section 2:

Round Table Discussion

Examples of real-life challenges and successes to maintaining PA levels in the medical profession

Subjective norms

Perceived behavioral control

3 physicians (3rd year medical student, emergency room physician, family physician)

10

Section 3:

Practical PA

Demonstration of resistance band exercises

Perceived behavioral control

CSEP-certified Exercise Physiologists and Personal Trainers, SKHS and undergraduate/graduate students

10

Abbreviations: PA, physical activity; SKHS, School of Kinesiology and Health Studies; TPB, Theory of Planned Behavior; CSEP, Canadian Society for Exercise Physiology; min = minutes.

 

Participants

Individuals were eligible to participate in the evaluation if they were in their first year of medical school in Ontario and attending the 2015 OMSW. OMSW attendees were recruited via email to participate in an online Fluid Survey questionnaire. Individuals who were interested in participating were asked to read and sign the Letter of Information/Consent before completing the questionnaires. Workshop attendees also had the option of completing the pre-questionnaire in person at the beginning of the workshop. All participants recruited for this study completed the questionnaire: 1) one week prior (online) or immediately prior to workshop commencement (hardcopy), and 2) one week after the workshop (online).

 

Questionnaire measures

To test for length and item clarity, the survey was pilot tested by EIMC at Queen’s University members who were not involved in questionnaire development.

 

Demographics

Participants were asked general demographic information (e.g. age, gender, ethnicity, marital status, disability status), and questions regarding academic background (i.e. highest level of education completed; previous, current and anticipated future academic and medical involvement).

 

PA behavior and guideline awareness

Participants were asked about their awareness of EIMC and Canadian PA guidelines (Tremblay et al., 2011), including the spinal cord injury (SCI) and multiple sclerosis (MS) specific guidelines (CSEP, nd). For example, the question “Have you heard of the Canadian PA guidelines?” with response options “Yes” or “No” assessed guidelines awareness.

Results/Analysis

Data analysis

Chi-square tests were used to determine changes in awareness of EIMC and Canadian PA guidelines. Statistical significance was set to p < 0.05.

 

Results

Both pre- and post-questionnaires were completed by 24 first year medical students [23±2 years (16 females; 8 males)] attending the OMSW-EIMC workshop. Before the workshop, less than one-third of participants had heard of the EIMC national (29.2%) and/or campus (33.3%) initiatives and half of participants met PA guidelines (Table II). Students reported greater baseline awareness of PA guidelines for able-bodied versus individuals with disabilities (e.g., MS, SCI) (62.5% vs. 8.3%). Statistically significant increases were found for awareness of the national EIMC initiative (χ²[1,N=24]=26.32, p<0.001), and Canadian PA guidelines for adults 18-64 years  (χ²[1,N=24]=4.00, p=0.046) following the workshop. Consistent with baseline trends a greater awareness for PA guidelines for able-bodied adults versus individuals with disabilities was evident post-intervention (87.5% vs. 8.3% for MS and 12.5% for SCI).

 

Table 2. Participants’ demographic characteristics.

Characteristics

n (%) / mean ± SD

Gender

 

Male

Female

8 (33.3)

16 (66.6)

Ethnicity

 

Caucasian

Asian

Native Canadian

15 (62.5)

7 (29.2)

2 (8.3)

Age (years)

23.04 ± 1.99

Sitting (hours/day)

8.23 ± 2.14

Walking (minutes/week)

242.83 ± 154.00

Moderate PA (minutes/week)

58.33 ± 67.90

Vigorous PA (minutes/week)

93.21 ± 74.77

Total Moderate-Vigorous PA (minutes/week)

151.54 ± 114.16

Participants who met the PA Guidelines

12 (50%)

Highest Level of Education Completed

 

University – Bachelor – Level Degree

University – Master – Level Degree

University – Doctorate – Level Degree

19 (79.2)

4 (16.7)

1 (4.2)

Previous Academic Program

 

Life Science/Health Science

Kinesiology/Exercise Science/Physical Education

Other

18 (75.0)

1 (4.2)

5 (20.8)

Medical School

 

Michael G. DeGroote School of Medicine (McMaster)

Queen's University

University of Toronto

Schulich School of Medicine (Western)

8 (33.3)

6 (25.0)

7 (29.2)

3 (12.5)

Anticipated Area of Practice

 

Emergency

Family Medicine

Geriatrics

Surgery

Obstetrician

Unsure

2 (8.4)

4 (16.7)

1 (4.2)

1 (4.2)

1 (4.2)

15 (62.5)

Note: n=24; PA: physical activity. All values are n (%) except for age and PA are mean ± standard deviation.  Some participants declined to respond to certain questions; hence, n < 24 for walking (N = 23) and sitting (N = 22). Examples of “Other” Academic Programs include arts and science, biochemistry, biology, chemistry, economics, medical science, neuroscience, mathematics, and psychology.

Discussion

The “Staying Active to Actively Help Others” workshop description is intended to facilitate incorporation of PA material into training of medical students. The PowerPoint presentation and video used in this workshop are available upon request from the corresponding author and their use is supported for disseminating PA information to physicians in training.  

 

The evidence- and theory-based workshop was successful in promoting short-term awareness of EIMC and PA guidelines. With foundations in the TPB, the workshop has the potential to bolster medical students’ PA cognitions. However, single event-based interventions that are successful in the short-term may not be sufficient for promoting long-term maintenance of attendees’ PA-related cognitions (Tomasone et al., 2017). Thus, while this intervention is beneficial and important, additional research is required to understand how to foster sustained long-term knowledge following a workshop-based intervention. The lack of baseline awareness of PA guidelines, particularly for individuals with disabilities, amongst physicians in training is an important consideration when designing future educational seminars to be incorporated into medical school training to help demonstrate the importance of exercise for all populations/patients.

 

Furthermore, while greater awareness of PA guidelines are important, awareness does not necessarily transfer to greater PA participation. It is important to address biopsychosocial barriers to PA participation amongst trainees (e.g. time, motivation, confidence to engage in behavior) given the variety of individual background experiences with PA (e.g. only 4% of participants in this study completed human movement degrees). If the ultimate goal is addressing physical inactivity, transferability to physicians’ personal PA behavior change will be essential for future intervention, as our findings suggest only 50% of study participants met Canadian PA guidelines. This is important, as research has demonstrated active health care providers are more likely to discuss PA participation with their patients and patients are more willing to exercise if their physicians regularly exercise (Lobelo, Duperly and Frank, 2009). Providing educational opportunities to address both physician PA and counselling behavior, such as the OMSW workshop and other EIMC at Queen’s University initiatives, will help continue to integrate this vital material into the medical school curriculum. Overall, increasing awareness and PA behavior amongst physicians in training may increase physician PA counselling behaviors and potentially their patients’ PA levels. 

 

There are limitations to our study design warranting discussion. Due to the nature of the OMSW, participants self-selected to attend the “Staying Active to Actively Help Others” workshop, thus attendees may have been pre-disposed to be interested in PA prior to intervention exposure. Additionally, our sample size, although unique in involving medical students from several medical schools, was relatively small. Finally, the content delivered primarily targeted the importance of medical students’ personal PA habits throughout their studies due to the workshop’s time constraints. Additional investigations building upon the current study’s findings should provide the evidence required to promote the implementation of mandatory PA education and prescription courses within the medical school curriculum.

Conclusion

The description and evaluation of the “Staying Active to Actively Help Others” workshop, which included content based on the TPB, provides an important starting point for addressing the lack of education regarding PA in medical students’ training.  This information can be used to target gaps in the current medical school curriculum so to increase awareness of PA benefits and resources amongst trainees, as well as encourage future physicians to view exercise prescription as a vital part of holistic, preventative medicine across the lifespan.  The workshop increased awareness of EIMC and PA guidelines amongst first year Ontario medical students attending the 2015 OMSW. It is evident that greater awareness of the 1) EIMC initiative and 2) PA guidelines are needed amongst first year Ontario medical students. Increased awareness of EIMC, and other evidence-based PA resources and/or workshops, will support future physicians seeking to acquire knowledge about PA throughout their training. EIMC at Queen’s University is committed to partnering with medical educational programs and institutions to implement the changes necessary so future and current physicians are equipped with the knowledge, tools and confidence to be active themselves and discuss PA with their patients.

Take Home Messages

  • Currently there is an alarming gap in PA content provided to physicians in training.
  • This is the first study to describe an evidence- and theory-based PA-promotion workshop, intending to facilitate PA material into a medical student conference.
  • Increased awareness of evidence-based PA resources will support future physicians seeking to acquire PA knowledge.
  • Increasing awareness and PA behavior amongst physicians in training may increase physician PA counseling behaviors and potentially their patients’ PA levels.
  • Local Exercise is Medicine Canada chapters could be valuable sources of support to consult when considering how to implement PA education into the medical school curriculum.

Notes On Contributors

Alyssa Fenuta is currently completing her doctorate studies in the Human Vascular Control Laboratory investigating nitrate supplementation's influence on oxygen delivery and exercise performance. Within the School of Kinesiology and Health Studies at Queen's University she is also involved as a teaching assistant for the Exercise, Disability and Aging Mini-stream. This undergraduate certificate specialization program is closely affiliated with the Revved Up program where she serves as a personal trainer creating adapted exercise programs for individuals with mobility impairments and intellectual disabilities.

Dr. Andrea Brennan is a current postdoctoral fellow at the Translational Research Institute for Metabolism and Diabetes where she focuses on aging, exercise, and bioenergetics using a variety of cellular, clinical, and intervention methodologies.

Rebecca Lau was most recently working on her MSc in Biomechanics, investigating how assistive devices affect walking performance.

Dr. Celina Shirazipour is a Research Scientist and Acting Assistant Professor at the Research Center for Health Equity in the Samuel Oschin Comprehensive Cancer Institute of Cedars-Sinai Medical Center. Dr. Shirazipour’s area of expertise is behavioral sciences, particularly health promotion and sport and exercise psychology. The overarching goal of her research is to promote physical activity participation for individuals with illnesses and injuries resulting in impairment.

Badr Hefnawi is currently completing his final year in dentistry at McGill University, Montreal, Quebec, Canada. He is also working as a dental officer in the Canadian Armed Forces. 

Katrina D’Urzo, BKin, MSc is a medical student at the Royal College of Surgeons in Ireland.

Ashley Johnson is currently a PhD candidate at Queen’s University in Kingston, Ontario. Ashley is passionate about supporting communities in their health promotion efforts through her research, work and volunteer efforts. Ashley’s research focuses on investigating the structures and conditions that contribute to sustainable multi-sector partnerships in community health promotion. 

Iain McPhee defended his MSc at Queens in October 2016. He worked for 2 years on Parliament Hill, and is now medical student at McGill University (grad class 2022).

Brittany McEachern has obtained her Master of Science in Physical Therapy and now works as a Registered Physiotherapist at Humber River Hospital in Toronto, Ontario. She continues to be involved in knowledge translation research and is eager to incorporate research into her clinical practice. 

Dr. Jennifer Tomasone’s research to date has focused on knowledge translation, or closing research-to-practice gaps, for physical activity behaviour change for persons with physical disabilities and cancer.

Acknowledgements

The authors wish to thank the 2015 OMSW organizing committee (Queen’s University School of Medicine, Kingston, ON, Canada) for inviting EIMC at Queen’s University to participate and evaluate the workshop, all of the medical students who participated in the “Staying Active to Actively Help Others” workshop, B. Elsolh (Queen’s University School of Medicine, Kingston, ON, Canada), Dr. R. Diklich (Windsor Regional Hospital, Windsor, ON, Canada) and Dr. A. D’Urzo (University of Toronto Faculty of Medicine, Toronto, ON, Canada) for providing their insight into the importance of being physically active as a medical student and/or practicing physician, and A. Epp-Stobbe (Queen’s University School of Kinesiology and Health Studies, Kingston, ON, Canada) and R. Thomas (Queen’s University School of Kinesiology and Health Studies, Kingston, ON, Canada) for assisting with the resistance band portion of the workshop.

Bibliography/References

Ajzen, I. (2006) ‘Constructing a TpB Questionnaire’, Hepatology (Baltimore, Md.). https://doi.org/10.1002/hep.22759.

 

Blair, S. N., Kampert, J. B., Kohl, H. W., Barlow, C. E., et al. (1996) ‘Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women’, Journal of the American Medical Association. https://doi.org/10.1001/jama.276.3.205.

 

Cardinal, B. J., Park, E. A., Kim, M. and Cardinal, M. K. (2014) ‘If Exercise Is Medicine, Where Is Exercise in Medicine? Review of U.S. Medical Education Curricula for Physical Activity-Related Content’, Journal of Physical Activity and Health. https://doi.org/10.1123/jpah.2014-0316.

 

Colley, R. C., Garriguet, D., Janssen, I., Craig, C. L., et al. (2011) ‘Physical activity of canadian children and youth: Accelerometer results from the 2007 to 2009 canadian health measures survey’, Health Reports.

 

Elley, C. R., Kerse, N., Arroll, B. and Robinson, E. (2003) ‘Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial’, BMJ, 326(7393), pp. 793–793. https://doi.org/10.1136/bmj.326.7393.793.

 

Glasgow, R. E., Eakin, E. G., Fisher, E. B., Bacak, S. J., et al. (2001) ‘Physician advice and support for physical activity. Results from a national survey’, American Journal of Preventive Medicine. https://doi.org/10.1016/S0749-3797(01)00350-6.

 

Lobelo, F., Duperly, J. and Frank, E. (2009) ‘Physical activity habits of doctors and medical students influence their counselling practices’, British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.2008.055426.

 

Tomasone, J. R., Sweet, S. N., McReynolds, S. and Martin Ginis, K. A. (2017) ‘A multilevel modeling approach to examining the implementation-effectiveness relationship of a behavior change intervention for health care professional trainees’, Translational Behavioral Medicine. https://doi.org/10.1007/s13142-017-0526-9.

 

Tremblay, M. S., Warburton, D. E. R., Janssen, I., Paterson, D. H., et al. (2011) ‘New Canadian Physical Activity Guidelines’, Applied Physiology, Nutrition, and Metabolism. https://doi.org/10.1139/h11-009.

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

The study protocol was approved by the Health Sciences Research Ethics Board at Queen’s University and is part of a larger data set (unpublished). The ROME/TRAQ approval number is 6016224.

External Funding

This article has not had any External Funding

Reviews

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Megan Anakin - (28/10/2019) Panel Member Icon
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Thank you for submitting this article. Physical activity education is an important area of the medical curriculum to research. I appreciate that the authors provide a detailed description of their workshop. The description of the methods and results address the aim of the study. At present, the opening paragraph of the discussion focuses on the value of the workshop and how the reader can access the workshop materials. The authors may wish to consider enhancing the discussion section to first discuss the significance of the results in relation to the aim of the study. The authors also discuss increasing physical activity behaviour, however, this study’s design only addressed physical activity awareness. The authors may wish to consider being cautious about their claims about a change in physical activity behaviour. To enhance the discussion of the study’s limitations, the authors may wish to read: Lingard, L. (2015). The art of limitations. Perspectives on medical education, 4(3), 136-137. This article raises a topic that will be of interest to medical educators and other healthcare professionals.
Felix Silwimba - (22/10/2019)
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this is an innovative study. it recommends for inclusion of PA in medical education curriculum. this approach should be recommended for all medical schools.