Include your thoughts on both of these in your post: How do you feel about the following provocative editorial question and statement posed by Weiler? “Is it possible that there may be a time when a lawyer cross examines a doctor in the witness stand, asking why they did not address their sick or dead patients’ physical inactivity, citing clinical guidelines, because it is known to be one of the highest modifiable risk factors for morbidity and mortality?” Why do you feel this way?
Downloaded from bjsm.bmj.com on August 5, 2014 – Published by group.bmj.com
Editorial
Medicolegal neglect? The case
for physical activity promotion
and Exercise Medicine
Richard Weiler,1 Peter Feldschreiber,2
Emmanuel Stamatakis3
INTRODUCTION
DUTY OF CARE
Whether measured subjectively or
objectively, a large proportion of the
population are living sedentary and
physically inactive lives.1 2 This should
be a major public health focus given the
overwhelming evidence demonstrating that physical inactivity increases an
individual’s risk for all-cause mortality
and may be one of the leading causes of
non-communicable chronic disease in
the world, responsible for about 60% of
worldwide deaths3–6 and probably more
in developed countries.
Pandemic levels of physical inactivity result in a huge burden of unhealthy
consequences within populations and for
society, across all socioeconomic classes,
all ethnicities and phenotypes.
However, attempts to explain the
precise causes of chronic diseases and
resultant deaths, for each individual,
are very difficult. We are all exposed to
multiple risk factors in variable quantities throughout our lives and, currently,
these are virtually impossible to measure.
Consequently, despite our remarkable
growth in the medical field, explanations
for precise causes of death remain speculative. To attribute causal status of risk
factors for non-communicable disease
is fraught with difficulty both clinically
and medicolegally. For example, it is baffling that despite scientific progress since
Richard Doll’s landmark findings 60 years
ago, strongly linking smoking with lung
cancer,7 causation of smoking and lung
cancer has still not been upheld in a court
of law.8
Duty of care is a legal obligation imposed
on a doctor requiring, via the Bolam test,9
that their actions conform to those of a
responsible body of professional opinion,
even if others have a different opinion.
More recently, the Bolitho v City and
Hackney Health Authority case, entitled
a judge to choose between two bodies
of expert opinion and reject an opinion,
which is ‘logically indefensible’.10
In the UK, duty of care, in the form of
National Institute for Health and Clinical
Excellence and Royal College guidelines, currently represents an evidencebased responsible body of professional
opinion relating to clinical care. Medical
ethics, including patient autonomy, nonmaleficence, beneficence and informed
consent, guide our medical care, when
guidelines are not always appropriately
applied. Medical defence unions providing
medical indemnity repeatedly recommend
that our professional and clinical decisions
be documented in medical records and
note keeping, including those situations
when guidelines are not suitable.
Numerous responsible bodies of professional opinion have recognised the extensive evidence base, cost-effectiveness and
importance of physical activity promotion
as a primary prevention and secondary
treatment for various diseases. Physical
activity promotion features in 39 national
guidelines (table 1), even excluding physical activity–specific guidelines. On this
basis, if a doctor managing a patient with
any of these diseases has not followed
these guidelines and advised or signposted
appropriately on physical activity, then it
is possible that medical negligence has
ensued. Furthermore, would it be ‘logically indefensible’ for doctors not to promote physical activity for these patients,
regardless of their personal opinions and
learning needs?
Given the technology and functionality of primary care computerised medical
records, it would be relatively cheap and
1Homerton University Hospital NHS Foundation Trust,
London, UK
2Barrister, Medical and Healthcare Law, 4 New Square
Chambers, London, UK
3Department of Epidemiology and Public Health,
University College London, London, UK
Correspondence to Richard Weiler, Specialist
Registrar in Sport & Exercise Medicine, Homerton
University Hospital NHS Foundation Trust, Homerton
Row, London E9 6SR, UK; rweiler@doctors.org.uk
228
simple to embed such recommendations
within standard note keeping templates
to help guide practitioners through the
forgotten and fundamental basis of these
guidelines, ensure medicolegal defensibility, should the need arise, and reduce
the potential risk of medical-negligence
proceedings.
Critics will argue that physical activity
promotion is a lifestyle choice, however,
so are smoking and alcohol consumption
and yet these are medically accepted risk
factors worthy of our clinical behaviour
change efforts and consultation time. In
many countries around the world, exercise and tailored physical activity are used
by trained Sport and Exercise Medicine
(SEM) specialists working within multidisciplinary teams, to both treat and prevent
various chronic diseases. Unfortunately,
in the UK, there are many patients with
chronic diseases, risk factors and comorbidities, who are essentially excluded from
physical activity. Their attending doctors
invariably lack the knowledge to provide
them with necessary physical activity and
behaviour change advice (or exercise prescription), are fearful of perceived physical activity risks and resulting litigation, or
cannot access specialist National Health
Service (NHS) SEM services, despite the
existence of an emerging trained specialist SEM workforce seeking NHS employment. Ironically, these patients stand to
gain the most from intervention (as does
the NHS), yet remain unlikely to receive
this advice, being advised to rest, risking
further health and well-being detriment.
The responsibility for delivering
Exercise Medicine in the UK is left in the
hands of doctors who do not understand
the basic science behind physical activity,
benefits, risks, doses or methods to change
complex physical inactivity behaviours.
Why can we rightly refer to a dietitian for
assistance with disordered eating habits
and still not refer to an SEM specialist on
the NHS for specialist Exercise Medicine
care, when appropriate?
AN INSTITUTIONAL AND EDUCATIONAL
PROBLEM
General Medical Council (GMC) guidance on ‘Good Medical Practice’ suggests
that doctors should ‘protect and promote
the health of patients and the public’.11
Yet physical activity promotion remains
un-rewarded in primary care,6 Exercise
Medicine is not on the core curriculum of
many medical schools12 and most doctors
are not trained to deliver physical activity
promotion and behaviour change.
Br J Sports Med March 2012 Vol 46 No 4
Br J Sports Med March 2012 Vol 46 No 4
NICE (2004)
Primary Care Society for
Gastroenterology (2006)
British Society of Gastroenterology
(2007)
Cardiovascular
NICE (2008, revised 2010)
NICE (2008)
NICE (2006)
NICE (2007)
NICE (2006, revised 2010)
British Cardiac Society, British
Hypertension Society, Diabetes UK,
HEART UK, Primary Care Cardiovascular
Society, The Stroke Association (2005)
Guidelines (2010)
Guidelines (2010)
2
3
4
7
8
9
10
11
13
12
6
5
NICE (2008)
1
Consensus guideline for the management of
symptomatic stable angina in primary care
Consensus guideline on reducing
cardiovascular events and pancreatitis
through the effective management of
triglycerides
Obesity: guidance on prevention,
identification, assessment and management
of overweight and obesity in adults and
children
Joint British Societies guidelines on the
prevention of cardiovascular disease in
clinical practice
Hypertension: management of hypertension
in adults in primary care
Myocardial infarction (MI): secondary
prevention in primary and secondary care for
patients following an MI
Identification and management of familial
hypercholesterolaemia
Lipid modification: cardiovascular risk
assessment and the modification of blood
lipids for the primary and secondary
prevention of cardiovascular disease (CVD)
Constipation in children and young people:
diagnosis and management of idiopathic
childhood constipation
Diagnosis and management of irritable
bowel syndrome (IBS) in primary care
Dyspepsia: management of dyspepsia in
adults in primary care
The management of adults with coeliac
disease in primary care
Guidelines for osteoporosis in inflammatory
bowel disease and coeliac disease
Guideline
Physical activity promotion features in 39 national guidelines
Gastrointestinal
NICE (2010)
Table 1
Continued
The management of hypertriglyceridemia is multifaceted, including a combination of lifestyle changes (including physical activity), risk factor
modification and drug therapy
Before a patient is referred for assessment by secondary care, it is important to give lifestyle advice including physical activity
Discuss lifestyle targets to increase aerobic exercise
People at high risk of or with CVD should be advised to exercise 30 min a day, of at least moderate intensity, at least 5 days a week, in line
with national guidance for the general population. People who are unable to perform moderate-intensity physical activity at least 5 days a week
because of comorbidity, medical conditions or personal circumstances should be encouraged to exercise at their maximum safe capacity.
Recommended types of physical activity include those that can be incorporated into everyday life, such as brisk walking, using stairs and
cycling. People should be advised that bouts of physical activity of 10 min or more accumulated throughout the day are as effective as longer
sessions. Advice about physical activity should take into account the person’s needs, preferences and circumstances. Goals should be agreed
and the person should be provided with written information about the benefits of activity and local opportunities to be active
People at high risk of or with CVD should be advised to exercise 30 min a day, of at least moderate intensity, at least 5 days a week, in line
with national guidance for the general population. People who are unable to perform moderate-intensity physical activity at least 5 days a week
because of comorbidity, medical conditions or personal circumstances should be encouraged to exercise at their maximum safe capacity.
Recommended types of physical activity include those that can be incorporated into everyday life, such as brisk walking, using stairs and
cycling. People should be advised that bouts of physical activity of 10 min or more accumulated throughout the day are as effective as longer
sessions. Advice about physical activity should take into account the person’s needs, preferences and circumstances. Goals should be agreed
and the person should be provided with written information about the benefits of activity and local opportunities to be active
Ascertain patients’ diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance
and written or audiovisual materials to promote lifestyle changes
Patients should be advised to undertake regular physical activity sufficient to increase exercise capacity. Patients should be advised to be
physically active for 20–30 min a day to the point of slight breathlessness. Patients who are not achieving this should be advised to increase
their activity in a gradual step-by-step way, aiming to increase their exercise capacity. They should start at a level that is comfortable, and
increase the duration and intensity as they gain fitness
Weight management programmes should include behaviour change strategies to increase physical activity and decrease inactivity. Interventions
in children should address lifestyle within the family and social settings. If a child, family or adult are unwilling to change, give them information
about the benefits of increased physical activity, losing weight and healthy eating. Ask about their related activity levels and beliefs
All patients should be advised to undertake regular weight-bearing exercise (including walking, using stairs, housework and gardening)
If no alarm signs and if not on drug with dyspeptic side effects, then offer simple lifestyle advice including weight reduction (ie, physical activity
and diet)
For osteoporosis risk and prevention recommend regular physical activity at annual review
Give information explaining the importance of self-help of IBS, including physical activity
Advise daily physical activity tailored as a part of ongoing maintenance
Physical activity recommendation
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Editorial
229
230
NICE (2006)
NICE (2009)
NICE (update 2009)
NICE (2009)
NICE (2006)
Endocrine
NICE (2009)
18
19
20
21
22
23
24
Diabetes UK (2005)
NICE (2006)
17
16
The British Thoracic Society and
Scottish Intercollegiate Guidelines
Network (2008, revised 2009)
Central nervous system
NICE (2007)
Respiratory
NICE (2004, updated 2010)
Continued
15
14
Table 1
Recommendations for the provision of
services in primary care for people with
diabetes
Type II diabetes: the management of type II
diabetes (update)
Bipolar disorder: the management of bipolar
disorder in adults, children and adolescents, in
primary and secondary care
Depression in adults with a chronic physical
health problem: treatment and management
Parkinson’s disease: diagnosis and
management in primary and secondary care
Schizophrenia: core interventions in the
treatment and management of schizophrenia
in adults in primary and secondary care
Depression: the treatment and management
of depression in adults
Chronic fatigue syndrome/myalgic
encephalomyelitis (CFS/ME) (or
encephalopathy): diagnosis and
management of CFS/ME in adults and
children
Dementia: supporting people with dementia
and their carers in health and social care
British guideline on the management of
asthma: a national clinical guideline
Chronic obstructive pulmonary disease
(COPD): management of COPD in adults in
primary and secondary care
Guideline
Continued
Integrate increasing physical activity into a personalised diabetes management plan including other aspects of lifestyle modification. Measure
blood pressure annually and offer and reinforce preventive lifestyle advice. Offer lifestyle advice (diet and exercise) at the same time for blood
pressure control. Start metformin treatment in a person who is overweight or obese (tailoring the assessment of body weight associated risk
according to ethnic group) and whose blood glucose is inadequately controlled by lifestyle interventions (nutrition and exercise) alone. Guidance
recommends trial of 3 months lifestyle interventions to control and reduce blood glucose and HbA1c before commencing medication
If the screening test is negative and the person has no symptoms of diabetes, they should be given advice on how to reduce their risk of
going on to develop diabetes and supported to lose weight and increase their physical activity levels. People aged 30 kg/m2) should be advised to increase their
physical activity levels, adopt a balanced diet and aim to reduce their calorie intake. Insulin should be considered in those who are not obese.
People aged >40 with diabetes who are asymptomatic should initially be treated with diet, weight control and increased physical activity.
They should be advised to increase their physical activity levels, adopt a balanced diet and, if they are overweight or obese, aim to reduce
their calorie intake. If blood glucose control is not achieved within 3 months, treatment with oral hypoglycaemic agents should be commenced.
Insulin treatment should be considered if blood glucose control is not achieved with diet, increased physical activity and combined drug therapy.
Oral and written information about diabetes and its management should be provided in appropriate languages and media at each point of the
care pathway as part of a structured education programme, meeting nationally agreed criteria
For people with persistent subthreshold depressive symptoms or mild-to-moderate depression, consider offering one or more of the following
interventions, guided by the person’s preference: individual guided self-help based on the principles of cognitive behavioural therapy (CBT),
computerised cognitive behavioural therapy (CCBT), a structured group physical activity programme
Regarding sleep disturbance, recommend taking regular physical exercise where this is possible for the patient. For patients with persistent
subthreshold depressive symptoms or mild-to-moderate depression and a chronic physical health problem, and for patients with subthreshold
depressive symptoms that complicate the care of the chronic physical health problem, consider offering a structured group physical activity
programme
Should have annual physical review, usually in primary care, to assess lipid levels, plasma glucose levels, weight and blood pressure (see NICE
guidelines above when appropriate)
Physical health should be monitored at least once a year with focus on cardiovascular disease risk assessment in line with NICE lipid
modification guideline as higher risk than general population (refer to guidelines numbers 6 and 7 above)
For the secondary prevention of dementia, vascular and other modifiable risk factors (eg, smoking, excessive alcohol consumption, obesity,
diabetes, hypertension and raised cholesterol) should be reviewed in people with dementia, and if appropriate, treated (ie, includes physical
activity from obesity, hypertension, diabetes and cholesterol guidelines, when appropriate)
Physiotherapy should be available to enhance aerobic capacity, improve movement initiation and functional independence
Healthcare professionals should advise people with CFS/ME on the role of rest periods, how to introduce rest periods into their daily routine and
the frequency and length appropriate for each person. This may include: limiting the length of rest periods to 30 min at a time. Introducing ‘low
level’ physical and cognitive activities (depending on the severity of symptoms)
Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for
an acute exacerbation. Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually
MRC grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had
a recent MI. The rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and
behavioural intervention. Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required to gain these
Physical training improves indices of cardiopulmonary efficiency and should be seen as part of a general approach to improve lifestyle and
rehabilitation in asthma, with appropriate precautions advised about exercise-induced asthma
Physical activity recommendation
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Editorial
Br J Sports Med March 2012 Vol 46 No 4
Br J Sports Med March 2012 Vol 46 No 4
NICE (2006)
NICE (2008)
British Society for Sexual Medicine
(2009)
British Association of Urological
Surgeons (2004)
Obstetrics and gynaecology
PCOS UK (2006)
Royal College of Obstetricians and
Gynaecologists (2007)
Royal College of Obstetricians and
Gynaecologists (2007)
National Association for Premenstrual
Syndrome (2003)
Musculoskeletal
NICE (2008)
NICE (2009)
SIGN (2003)
Other
British Lymphology Society (2009)
NICE (2004)
26
27
28
29
31
33
35
36
37
39
34
32
30
Urology
NICE (2010)
continued
25
Table 1
Strategy for lymphoedema care
Falls: the assessment and prevention of falls
in older people
Osteoarthritis: the care and management of
osteoarthritis in adults
Low back pain: early management of
persistent non-specific low back pain
Management of osteoporosis
Treatment guidelines for premenstrual
syndrome
Management of premenstrual syndrome
Long-term consequences of PCOS
Diagnosis and management of polycystic
ovary syndrome (PCOS)
Primary care management of male LUTS
The management of lower urinary tract
symptoms (LUTS) in men
Urinary incontinence (UI): the management
of UI in women
Chronic kidney disease (CKD): early
identification and management of CKD in
adults in primary and secondary care
Guidelines of the management of erectile
dysfunction (ED)
Guideline
Maintenance therapy includes a programme of exercise and movement to maximise lymph drainage
Strength and balance training is recommended. Those most likely to benefit are older community-dwelling people with a history of recurrent falls
and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and
monitored by an appropriately trained professional
Everyone with osteoporosis will benefit from a good calcium intake and weight-bearing exercise. All healthcare professionals should
encourage regular exercise, such as walking, to promote good bone and general health. High intensity strength training is recommended as
part of a management strategy for osteoporosis. Low impact weight-bearing exercise is recommended as part of a management strategy for
osteoporosis
Exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity or disability. Exercise should
include local muscle strengthening and general aerobic fitness
Advise people to stay physically active and exercise
All sufferers benefit from simple advice related to dietary changes, exercise, relaxation, stress avoidance and lifestyle modification
General advice about exercise, diet and stress reduction should be considered before starting treatment
An increase in physical activity is essential, preferably as part of the daily routine. 30 min/day of brisk exercise is encouraged to maintain health,
but to lose weight, or sustain weight loss, 60–90 min/day is recommended. Concurrent behavioural therapy improves the chances of success of
any method of weight loss
Women diagnosed with PCOS should be advised regarding weight loss through diet and exercise
Lifestyle modifications can greatly reduce the risk of ED, and should accompany any specific pharmacotherapy or psychological therapy. The
potential advantages of lifestyle changes may be particularly pronounced in those with psychogenic ED, but patients with serious medical
illnesses such as diabetes may also benefit from these changes, for example, weight loss (ie, diet and physical activity)
Not all patients require treatment, and primary care management should include reassurance, watchful waiting, advice on lifestyle (ie, including
physical activity) and a review of their current medication
Offer men with LUTS suggestive of overactive bladder supervised bladder training, advice on fluid intake and lifestyle advice (ie, including
physical activity)
Women with UI or overactive bladder syndrome who have a BMI greater than 30 should be advised to lose weight (ie, including physical
activity)
Encourage people with CKD to take exercise, achieve a healthy weight and stop smoking
Physical activity recommendation
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Editorial
231
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Editorial
Regulatory authorities, such as the GMC,
are now responsible for standards of medical education, in a position to focus future
medical practice and ensure that preventive medicine and wellness promotion feature as highly as treatment of illness in the
future. The GMC regulates undergraduate
medical education and, regrettably, physical activity does not feature as a curricula
requirement (Tomorrow’s Doctors 2003
and 2009). In addition, it is not specifically
covered in GMC medical school quality
assurance reviews. The GMC, like doctors,
may have a responsibility and duty of care
to the public and their future members to
review medical school curricula requirements relating to the promotion of health
and prevention of disease with greater
emphasis and guidance for physical activity
education. Only then, will future doctors
be optimally educated to deliver behaviour
and lifestyle change for the prevention and
treatment of illness, which are embedded
within ever-increasing guidelines.
UK PUBLIC HEALTH STRATEGY
In the UK NHS, the introduction of the
Responsibility Deal and GP commissioning, will probably place more health
strategy decisions in the hands of corporate stakeholders and ‘willing providers’.
Hidden agendas, such as profitability,
may influence important public health
rationing decisions and perceived unprofitable physical activity promotion
and Exercise Medicine may well continue to suffer. Unfortunately, very few
private stakeholders stand to benefit
from better population health, which,
worryingly, means that corporate agendas could direct national health strategies and leave Exercise Medicine largely
aspirational and marginalised. In brief,
for the current evidence base to be translated into commissioned NHS Exercise
Medicine services in the UK, there is an
urgent need for strong evidence to demonstrate cost-effectiveness, improved
patient care pathways and outcomes for
such services.
232
SUMMARY
Accepted 27 April 2011
Medical science has shown that low cardiorespiratory fitness (resulting from sedentary behaviour) is one of, if not, the
most important risk factors for all-cause
mortality,13 yet clinical practice, medical education and public health strategy
continue to focus on all other risk factors except sedentary behaviour. Physical
activity promotion is embedded within
a large number of ever-increasing clinical
guidelines with strong supporting evidence, both medical and cost-effective,
delivering positive clinical messages and
medicolegal responsibility to healthcare
practitioners.
Is it possible that there may be a time
when a lawyer cross examines a doctor
in the witness stand, asking why they did
not address their sick or dead patients’
physical inactivity, citing clinical guidelines, because it is known to be one of
the highest modifiable risk factors for
morbidity and mortality? Physical activity promotion is one of the first treatment
recommendations in numerous clinical
guidelines with a good reason and should
no longer be medically neglected.
Physical activity failings are institutionally embedded within our environment,
medical practice, education and culture.
The public are being let down on physical activity promotion, treatment choices
(eg, Exercise Medicine), preventive medicine, the sedentary environment, corporate influences, a lack of physically active
medical role models and failed by a lack
of funding for physical activity and inactivity research. All resulting in between
approximately 27–59 million14 people
in the UK alone, when measured subjectively and objectively, respectively,15
literally sitting in a pre-disease or disease state caused by physical inactivity –
probably the biggest silent killer of our
times.
Published Online First 2 June 2011
Competing interests None.
Provenance and peer review Not commissioned;
externally peer reviewed.
Br J Sports Med 2012;46:228–232.
doi:10.1136/bjsm.2011.084186
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Medicolegal neglect? The case for physical
activity promotion and Exercise Medicine
Richard Weiler, Peter Feldschreiber and Emmanuel Stamatakis
Br J Sports Med 2012 46: 228-232 originally published online June 2,
2011
doi: 10.1136/bjsm.2011.084186
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