WASHINGTON – When doctors talk about exercise, older adults listen, Shaun Nelson said at the annual meeting of the Gerontological Society of America.
A caring, empathetic physician who counsels patients aged 60 and older about exercise will probably make an impression, even if the doctor is not a paragon of fitness, said Mr. Nelson, an MPH candidate at the University of Illinois, Chicago, who conducted focus group interviews of 28 adults aged 60–74 years. As one woman noted during the interviews, “You like a doctor that seems to be worried about your welfare. … I guess if they were [role models] it might be better. But to me, that really wouldn't be a factor.”
Older adults are receptive to exercise counseling as a way to manage chronic pain and to avoid medication, Mr. Nelson said. One white male patient reported, “My cholesterol was up. And [the doctor] told me about it, and we set up a plan, again, to exercise more and to diet. Didn't even think of any type of drug–that wasn't even a consideration.”
In general, women were more likely to view a doctor's persistence in exercise counseling as caring rather than nagging, were more likely to fit in exercise when they could, and were more encouraged by qualitative benefits, such as better-fitting clothes. Men were more likely to view a doctor's persistent exercise counseling as nagging, were more likely to have a fixed schedule for exercise, and were encouraged by quantitative benefits, such as a lower blood pressure.
Black patients were less likely to have a long visit with their doctors and were less likely to consider water exercise because of fear of water and not knowing how to swim; white patients were more likely to express concerns about repeated dressing and undressing, and having to find a place to park at a gym.
Mr. Nelson's work was part of a grant from the Robert Wood Johnson Foundation to study physicians' and older adults' experiences with exercise counseling during an office visit. The grant also supported studies of the physician perspective conducted by Daphne Schneider, M.D., of Cornell University, New York, and Karen Peters, Dr.P.H., of the University of Illinois, Rockford.
Dr. Schneider interviewed a convenience sample of 37 public and private sector physicians in urban and suburban areas about discussing exercise with older patients. Sixty-two percent of the physicians specialized in family medicine, 33% specialized in internal medicine, and 35% were board certified in geriatrics. Their mean age was 46 years, and they had completed medical studies between 1963 and 2003. Most of the doctors were white (70%), and 51% were women.
All the physicians reported that they counseled some older patients about exercise, and nearly a third of them said that they counseled all patients about exercise. However, the physicians' perceptions varied as to their roles as exercise advocates. While most saw themselves as coaches/teachers, some saw themselves as authority figures whose words carried real weight with patients, and others said that the implementation of exercise recommendations would be better handled by a nurse-practitioner or trainer.
Physicians cited discussion of a patient's chronic condition, diagnosis of a chronic illness, or the possible need to start a new medication, as the best opportunities for exercise counseling. One physician told a diabetic woman that she might not need to use insulin if she could watch her diet and motivate herself to exercise. “She came back 3 months later and her hemoglobin A1C was less than 7. She had been swimming every day, sometimes she rode a bicycle, and she was saying how she felt much better, and her sugars were better, and she was happy,” the physician said.
Barriers to exercise counseling during an office visit included lack of training, lack of time, and lack of a reimbursement mechanism. As one physician noted, the complicated medical histories of geriatric patients often push exercise counseling to the bottom of a list of issues to be addressed in an office visit. From a financial perspective, “taking more time and doing exercise counseling looks like an unaffordable luxury,” the physician recounted.
Physicians who treat older patients in rural areas have issues similar to their suburban counterparts regarding exercise counseling for seniors. Dr. Peters analyzed results of a mail-in survey returned by 11 family physicians and one nurse-practitioner aged 31–54 years from her ongoing study of exercise counseling in rural Illinois counties. All the physicians in the rural study said that exercise was relevant to their older patients, and 75% said they recommended exercise in the context of chronic disease management; 58% said they recommended exercise in the context of weight loss and in the context of a routine health and physical exam.