JPEPFeb2007FutureofEPinHealthcare

The Future of Exercise Physiology in Healthcare
Tommy Boone, PhD, MPH, FASEP, EPC
Professor and Chair
Director, Exercise Physiology Laboratories
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN 55811

Have we forgotten that ancient definition of genius? -- “The courage to make mistakes.”

Why are most exercise physiologists interested in licensure and some are not? That question has been asked by only a few professionals in the field. In most cases, you’ll hear one answer. Licensure is the difference that really will make the difference! Or, is it because, frankly, I’ve been looking for the right answer for nearly a decade?

This article identifies my thinking this month. I think it is important to share my views with those who are interested in exercise physiology as a healthcare profession. I also believe it is important to publish how I think differently from other exercise physiologists. And, at the present time, the only logical way, if not the politically correct way, to do so is through the JPEPonline journal. Although JPEPonline is not a typical peer review journal, it is in my opinion one of ASEP’s critical pathways of increasing the exercise physiologist’s odds for success. Okay, given that the heart of this article is about licensure, why did I mention the PEPonline journal? The answer requires several responses, but for now, it is enough to state that established healthcare professions have one thing in common that exercise physiologists do not get.

Those who embrace it do so because they understand why it is needed. They also realize that the professionalism of a field depends on professional development and realistic thinking. Exercise physiologists, on the other hand, still embrace the discipline of research. But, however honorable yesterday’s thinking might be, such thinking is not enough. Professional development, which is critical to exercise physiology as a healthcare field, requires a change in thinking.

This, I believe, is at the heart of the 21st century exercise physiology. The willingness of exercise physiologists to change their thinking from a discipline to one of a profession is, in short, a major struggle. Many exercise physiologists would have the reader believe that it is not necessary at all. This is where the “political” part of this piece comes into play. In fact, it is clear that many exercise physiologists believe that politics is not a common reality in making personal changes. I have learned that every area of education and almost all aspects of life are driven by politics and old ideas.

The difficulty lies not so much in developing new ideas as in escaping from old ideas. – John M. Keyes

Of course exercise physiologists can say, “We have never let politics or old ideas get in the way of making the right decision.” The problem is that the evidence is otherwise. They are in denial. Thus, contrary to what they may say, what they think today and, perhaps, what they have been accustomed to for decades, it is not enough. They must learn how to think as healthcare professionals if their students are to achieve their dreams and reach their potential. This may not seem important right now because it is not obvious that the quality of their thinking keeps them from their realizing their potential.

Licensure is important but is it necessary for success? I don’t think so. Unfortunately, the greatest detriment to exercise physiologists’ success tomorrow is their thinking today. Success comes from thinking differently. It’s really very simple. Most people don’t think about it. In fact, Freking [1] reported that: “Since 2000, health insurance premiums have gone up 87%: wages 20%.” What is the implication? The rising cost of healthcare insurance is huge. In fact, Freking [1] states that the “…total cost of health insurance for individuals now averages $4,242 a year. For families, the costs average a whopping $11,480.”

With health insurance premiums rising faster than wages, it is smart to argue that exercise physiologists can only be successful if they are licensed professionals? I don’t think so. The goal is to make exercise available to society at a cost that makes sense and is affordable. This can be done via a reasonable fee-for-service to individual clients. This is exactly why exercise physiologists must continue to refine their professional practice. This is important. The only thing that stands between the exercise physiologist and his/her career needs is credibility. The ASEP leaders believe that exercise physiologists are healthcare professionals with credibility.

Do you have the faith that it is possible to be successful without licensure? Or, does your thinking lack the faith to believe that it is possible? Have you changed how you think about the ASEP organization? Are you continuing to allow politics to shape your attitude towards the professionalism of exercise physiology? Success is built on change. Why not start by changing how you think about ASEP? After all, the real issue may be “title protection, not licensure.” I wholeheartedly believe this, given the future costs of healthcare and other benefits, such as dental, vision, and life insurance along with pensions promised to active, retired state, and local employees [2]. There just simply isn’t enough money to pay for everything.

Intel Corp. chairman Craig Barrett [3] said recently, “The healthcare system is out of control, it’s unstable, and it’s basically bankrupt, and it gets worse each….” There is good reason to believe that the issues that surround healthcare costs and pension plans will become a monumental problem. No wonder exercise physiologists should not put all their eggs into the basket of licensure, however important and supported by traditional thinking. Hence, to become the 21^st century healthcare professional they are, they must intentionally work at, shape, and act on alternative thinking that drives success.

Americans spend 16% of gross domestic product on health care. It is huge and only getting worse. And, as if it is a new problem to government officials, the lack of universal healthcare coverage to all citizens of the

United States

continues unabated. One-third of adults and more than half of all children do not have a primary care doctor. Federal spending for health care totaled more than $600 billion in 2005, or roughly one quarter of the federal budget. These numbers present a real problem for Americans. And, the only effective way to make sure exercise physiology is recognized as having a critical part in healthcare is to seize the moment. This is why the ASEP leaders have developed the infrastructure for professional development; the big-picture is focused on a bigger perspective than fitness gyms.

Exercise physiologists must become healthcare thinkers! But to take exercise physiology ideas to the next level, exercise physiologists must get past their traditional distractions and politics. Too much of it has cluttered the real issues and the imagination that is crucial to thinking creatively. This is why connecting the dots between ASEP and professionalism has been so slow. And, this is also why effective leadership in healthcare knows how critical it is to focus on what is important (e.g., vision, goals, and objectives). It’s all about creativity and seeing exercise physiology through new thinking that adds value to what exercise physiologists do. Understandably, this almost seems too obvious to write and yet so many colleagues are trapped by the status quo when they should be following the advice of Tom Peters: “Weed out the dullards – nurture the nuts.”

Exercise physiologists must, therefore, be willing to think outside the box. In fact, it is the most effective way to encourage the new healthcare reality even if it should take what may seem like forever. And, since there are many problems to deal with, given the politics and the neglected effort to support the ASEP leaders, it is still enough to think as Robert Schuller, founder of the Crystal Cathedral. He say, “Yard by yard, life is hard; but inch by inch it’s a cinch.” In other words, the will to win is everything! Nothing is harder to watch than someone attempting to do something without the will to meet the problem head on.

Only with great patience does one discern that, indeed, some exercise physiologists have been combative in politics and stubbornly so. These individuals are profoundly influenced by linkages for interest groups other than exercise physiology. Obviously, this is no secret. The discussion of exercise physiology is inseparably connected with sports medicine and exercise science. Two dangers lurk in the woods of the discussion of sports medicine per se. One is that a discussion of exercise physiology can get too far removed from the message of the ASEP leaders. A second danger is that fitness professionals and personal trainers can too readily identify with the whole of exercise physiology as a healthcare profession. This is the time of doing everything conceivable to develop exercise physiology. The existence of ASEP is an announcement calling for a response. The tension between the present and past thinking provides a fertile source of professional obligation.

The most unambiguous hope of every ASEP member of other exercise physiologists is to respond wholeheartedly to the ASEP vision and mission statements. In writing these statements, ASEP leaders linked and put into mutual relation the future expectation and expression of what is exercise physiology and who is an exercise physiologist.

Vision: To be recognized as the leading professional organization of American scholars and practitioners in the study and application of exercise physiology to fitness, health promotion, rehabilitation, and sports training. The Society is dedicated to unifying all exercise physiologists in the United States and worldwide to promote and support the study, practice, teaching, research, and development of the exercise physiology profession. Through proactive and creative leadership, the Society empowers its members to serve the public good by making an academically sound difference in the application of exercise physiology concepts and insights.

Mission: The American Society of Exercise Physiologists (ASEP), the professional organization representing and promoting the profession of exercise physiology, is committed to the professional development of exercise physiology, its advancement, and the credibility of exercise physiologists.

Exercise Physiology is the identification of physiological mechanisms underlying physical activity, the comprehensive delivery of treatment services concerned with the analysis, improvement, and maintenance of health and fitness, rehabilitation of heart disease and other chronic diseases and/or disabilities, and the professional guidance and counsel of athletes and others interested in athletics, sports training, and human adaptability to acute and chronic exercise.

An Exercise Physiologist is a person who has an academic degree in exercise physiology, or who is certified by ASEP to practice exercise physiology [via the Exercise Physiologist Certified exam (EPC)], or who has a doctorate degree with an academic degree or emphasis in exercise physiology from an accredited college or university.

New things are happening in exercise physiology, especially in the discussion of professional norms: New ideas, new thinking, and new terminology or concepts for expressing who we are and what we do. All of this can easily be confusing and even discouraging. And so understanding contemporary exercise physiology, via the ASEP perspective, requires an analysis of the “why” behind the “what” of these changes, which is especially true for students. When students of exercise physiology do this, they discover the need for the professionalism of exercise physiology.

Professions are based on an understood reality. This reality is fundamental and at the heart of the founding of the ASEP organization. It is the collective experience and knowledge of “what is a profession?” Through experience professionals gain knowledge, just as exercise physiologists have done in their research. But, gathering data is not enough to satisfy the criteria for being a profession. There is another step, another way in knowing what must be done. This is the “judgment” and “understanding” that comes from comparative reading, analysis, and application of what other disciplines have done to become established professions. Unfortunately, although necessary, the process by which exercise physiologists separate yesterday’s thinking and experience from their new reality is never easy.

When exercise physiologists have an accurate grasp of professionalism and professional development, they will insist on one accredited academic major for all students. In an evolving profession, everyone has a responsibility for making it happen. Everyone contributes according to his or her own competence, while respecting differences in authority and responsibility. Mutual sharing in the teaching-research process is how exercise physiologists make it happen together toward a more complete grasp of the new reality. We need the collaboration of various perspectives, different experiences, raising new concerns and questions, and moving on with professional development. In time, exercise physiologists will come to understand the truth of their new reality.

This ongoing revision of exercise physiology today is an effort to incorporate the insights and advantages of the established healthcare professions while not ignoring the value and importance of the scientific body of knowledge generated by decades of research. This leaves little room for not acknowledging the obvious, that is, the need for a professional organization dedicated to exercise physiologists. And, if you have read this far, you may be wondering how to evaluate what exercise physiologists are saying about the American Society of Exercise Physiologists. How are we to regard these opinions when recognized and well-known exercise physiology textbook authors refuse to acknowledge their professional organization? Is not the voice of the ASEP leaders enough? Why do we need to give attention to those who support sports medicine and exercise science? They, having exploited the education of students for decades, are still indifferent to their issues and concerns.

The lost generation of students in the career sector without credible jobs is a curse on those who continue to concentrate their thinking on dead and worn-out ideas. For all these reasons, ASEP exists as a non-profit professional organization with its eye on the future activities of healthcare (and yes, athletics). This line of thinking is real. And, it is the fundamental conflict between exercise science and exercise physiology. In the end, ASEP will come out on top of its political opposition. The breakthroughs are hard-digging, but there is a growing consensus among students of exercise physiology that ASEP is the clearinghouse for professionalism, accountability, and credibility.

Hence, nationwide, the sorry history of failed certifications and likewise thinking is slowly but surely being replaced by a credible board certification. There is no limit to the possibilities of work in healthcare. The proliferation of disease and dysfunction with aging does not have to be handled in the traditional way of 3rd-party payers, but instead fee-for-serve. The federal budget and employers are able to keep pace with the high costs of healthcare. Board certified exercise physiologists will be instrumental in caring for clients of all ages and concerns. Clients will surrender to the EPC without going bankrupt. Poor people, young and old, and those with money will seek the services of the exercise physiologist. This idea and thinking is at the core of ASEP. It is just a matter of time before medical care becomes impossible to pay for.

With medical inflation far outpacing inflation in general, American firms are scaling back the health coverage they offer. The share of workers who receive health insurance from their own employer has fallen from almost 70% in the late 1970s to around 50% today. In the past five years, the proportion of firms offering medical benefits has fallen from 70% to 60%, with the steepest decline among small firms and those employing the low-skilled. -- The Economist, 2006 [4]

The healthcare crisis is growing and it is getting worse. Yet, exercise physiologists are hardly debating the subject or their role in the prescription of exercise in healthcare matters. Redmond [5] says, “It is a human catastrophe that continues to immiserate and impoverish millions of people.” Just imagine, it is common knowledge that more than 40 million Americans are without health insurance and some 60+ million will experience a lack of coverage during the year. It seems obvious with me that the political system is completely in the pockets of those with money, namely insurance and drug companies, hospitals, and doctors. Instead, it should be a system that delivers preventive and healthcare services to everyone in the society at a reasonable cost. Individuals are paying more out of pocket and receiving fewer benefits. Exercise physiologists can help, given that they are experts in the use of “exercise as medicine.” Also, they are not tied to the insurance industry as licensed healthcare professionals.

There are certain assumptions and beliefs that are basic indisputable truths. The power of exercise in dealing with health matters is one such truth. Recently, I posted the following on www.boonethink.com [6]: “The power of exercise to decrease the incidence of hypertension, stroke, ischemic heart disease, osteoporosis, diabetes, and cancer is indisputable. Yet, however obvious this is to exercise physiologists who get it, there are far too many who still don’t get it. I’ve often wondered why this is so, especially given the understanding that “if you don’t use it, you lose it” and “if you do use it, you postpone disease and/or dysfunction.” Physical therapists understand this point all too well. Note the following in a Guest Editorial [7] regarding “The Role of Aerobic Exercise in Physiotherapy Practice.”

One of the most significant facts revealed throughout the Internet are websites by physical therapists who are moving in on the practice of exercise physiologists. For example, consider the following content published Sutter Davis Hospital [8]. “The Sutter Physical Therapy and Fitness Center therapists provide evaluation, education, and training for patients in the proper use of exercise to restore function and relieve pain. They offer low-cost memberships to the public and members have access to treadmills, free weights, elliptical trainers, upright and recumbent bikes, stepper, selective resistance equipment, dual pulley systems, upper body ergometers and gym balls, as well as personal trainers and massage therapists. The Fitness Center also offers Focus on Health Programs at a cost of $220:

This is a deplorable situation that will become increasingly a center of controversy if and only if exercise physiologists get beyond their fitness instructor or fitness professional mentality. The ASEP vision for the future is the solution to a fresh start; one unshackled from past thinking. The importance of the vision is implicit in the infrastructure of ASEP. One of the functions of structure is to anticipate the value of what we are, as scientific and critical thinkers of the power of exercise. The atmosphere of basic trust is a prerequisite for transforming exercise physiology from a discipline into a profession. The exercise physiologist responds and reacts to the ASEP initiatives in accordance with what Arieti [9] calls the imperative attitude. In other words, exercise physiologists ought to do what the professional organization wants them to do because the organization exists for them.

Perhaps, it is time that exercise physiologists understand that professionalism and credibility are not free. Neither is something to be picked up with a fitness instructor or exercise specialist certification. Indeed, we should know this and we should teach our students to know that their American dream, the college career, is constantly in peril and that no generation of students can be free from the obligations of professional development. Granted, it is difficult and it is not without hard work for most students and professors to see beyond their private worlds. But it is not impossible. The point I want to stress is that you must confront yourself in order to discover the truth about what you should do. “Stretching your mind” is not a bad thing. No one else can do this for you. You must do it on your own, and once you do it you will understand that ASEP is essential.

Becoming a professional is not as complex as others have stated. Most importantly, it is born out of a societal need for services rendered by experts in a particular area of work. Exercise physiologists fill this need, having their roots in exercise prescription and the scientific application of exercise to disease and dysfunction. Like other healthcare professionals, they have formalized the practice of exercise physiology.

2. Porterfield, B. (2006). Retiree Healthcare Costs Overwhelming. abcNEWS. [Online]. http://abcnews.go.com/Health/wireStory?id=2485444

7. Brooks, D. and MacKay-Lyons, M. (2006). Survival of the Fittest: The Role of Aerobic Exercise in Physiotherapy Practice. Physiotherapy Canada. 58:1:3-4.

9. Arieti, S. (1966). The Will To Be Human. New York, NY: Dell Publishing Co., Inc.