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Opening a Closed Door: How to Gain Access to the Medical Suite

Your passion is to help people maintain or regain optimal health and fitness. Under current law and standards, you are only permitted to work with clients who are already-fit and healthy or have been released for independent exercise and have passed your health screening questionnaire. But those are not the people you yearn to work with. The clients you seek must have authorization or approval from a medical provider before you can proceed.

How often have you met with a potential new client, asked them to get clearance from their doctor, and then never seen them again? Or, a client develops a new pain or problem and you refer them for consultation and that ends the relationship. Another frequent scenario: Your client has followed through with your request only to be referred by their primary care provider for a cardiac treadmill test, but your concern about their low back pain or shoulder dysfunction was not addressed. Success as a medical fitness specialist is dependent upon working relationships with medical professionals. In order to establish those relationships, the aspiring medical fitness trainer needs a better understanding of the medical system. What follows are a few insights into the medical system that medical fitness specialists need to understand.

Recognize how busy the medical practitioner might be

“Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients.”1[i]. Today, the average primary care provider is responsible for roughly 2,300 patients, so not quite 21.7 hours of work/day, but more than any individual can possibly provide.

In order to cope with the workload, doctors must rely on their support staff to help whenever possible. Do not be alarmed or offended if your inquiries are met by a nurse or medical assistant. Most providers simply do not have the time to meet with you for an introduction or discussion. On the flip side, most doctors would love to have effective, safe, and reliable resources for their patients who need to lose weight, get fit, manage diabetes, recover from surgery or cancer treatment, etc. They need you.

Understand the current reimbursement rules

In most cases, providers cannot bill for services unless the patient is in the room with them. Therefore, time spent talking on the telephone, responding to emails, or filling out forms is usually unreimbursed time. This means that your client will probably need to actually make an appointment to be assessed and cleared for exercising with you. To streamline the process, send a letter with your client introducing yourself and what you do. Include a form stating your concerns and your proposed training plan. Design the form to be easy to read, with a simple agree or disagree that can be checked or circled and space for the provider’s signature. You might also want to leave room for comments and questions. If you have received a response from a provider, you should consider sending intermittent progress reports updating the provider about your mutual client/patient.

Be familiar with HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect an individual’s medical confidentiality, particularly when changing jobs which at that time meant changing health insurance providers. Unfortunately, the law is complicated and places multiple restrictions on who members of a medical team can talk to about a patient’s medical condition.

As an unlicensed party, the fitness professional is not privy to “protected health information” (PHI) without direct written consent from the patient (your client). Due to these restrictions, the medical providers cannot fill out or respond to your request for information or clearance without your client’s “written” consent. If the client takes the form and returns it to you, this action implies they have agreed to share the information. If you send the form directly to the provider, that permission has not been granted unless the client has signed a HIPAA release form allowing the doctor to share personal health information with you personally.

The aforementioned are a few reasons why you may have perceived a wall or barrier between you and medical providers. One solution is to ask your client if you might accompany him or her to the appointment to obtain medical clearance or guidance. That way the medical provider would have a specified time and be reimbursed for addressing your concerns. You would be communicating directly with the medical provider and not support staff, and it would be easiest for the client/patient. It is also a way to introduce yourself to the medical provider and initiate a working relationship. Although you will probably not be compensated, it may be well worth your time in the long run.

Once you have made it into the office with your client, now what?

Know your details

Because there are so many different avenues to becoming certified as a personal trainer, there can be large differences in the knowledge base and competence of one trainer compared to another. The aspiring medical fitness professional must have a thorough understanding of the pathophysiology of the conditions they will be working with in order to communicate effectively with medical providers. In addition, you need skill and experience in the programs you design and utilize with your clients. Be able to back up your training plans with published research.

Recognize that a medical fitness professional has a fund of knowledge that the medical provider does not have

Exercise science is not covered in medical school curricula. Medical school is about illness and disease, not health and fitness. Generally speaking, the average MD knows very little about exercise science. Most do not know about the effects of eccentric versus concentric loading, how to train for endurance versus strength, what to do to improve stability, balance, and core strength. Fitness professionals are not inferior to medical professionals; you have a different knowledge base. Recognize and believe that you have something to offer. You may not know all of the anatomy and biochemistry that the doctor does, but you have a basic understanding of your client’s condition and you know the potential benefits of your interventions. Share this information with the medical providers.

Stay within your scope of practice

Because personal trainers and medical fitness specialists are not licensed by any governmental or legal agency, and because laws vary from state to state, there is no clear definition of the skills and competencies of a medical fitness specialist. Working outside of your scope of practice can lead to civil and even criminal penalties[ii]. Therefore, for the time being, if you want to work with clients struggling to manage chronic illnesses, recover fully from injuries or surgeries, etc., you need to work under the wing of medical professionals who have prescriptive authority – those professionals in the medical field licensed to diagnose problems and prescribe treatment.

Dr. Robert Butler MD, founder of the National Institute on Aging once said: “If exercise could be packaged in a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” There are pockets here and there in the US where medical providers and fitness professionals work together. In many cases, there is a visionary medical provider at the helm of an interdisciplinary team. In other cases, fitness professionals have worked hard to become part of a medical delivery model.[iii] The more medical fitness specialists that can take the leap and align themselves with medical providers, the more people will be helped.

This article was featured in MedFit Professional Magazine. Get your free subscription to read more great content like this!


Dr. Mary Hoagland-Scher,MD is a board-certified family physician who practiced medicine for 30 years. When she entered medical school, her goal was to help people stay healthy. As the focus of western medicine shifted away from health to disease management with a strong emphasis on pharmaceutical and or surgical intervention, she became uneasy with her role and decided to discard her prescription pad and learn new tools. Now as a NASM Certified Personal Trainer she is working to shrink the gap between fitness and medicine.

References

  • [i] Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation Justin Altschuler, MD, David Margolius, MD, Thomas Bodenheimer, MD and Kevin Grumbach, MD Ann Fam Med September/October 2012 vol. 10 no. 5 39
  • [ii] For an excellent discussion of this issue, see: Abbott, Anthony Ed.D, FACSM, FNSCA. Scope of Practice, ASCM Health and Fitness Journal ,Sept/Oct 2018, Vol 22 Issue 5 pp 51-55
  • [iii] Watch MedFit TV webinar by David Rachal III, “Exercise Prescription: Integrating Services with Medical Professionals and Insurance Providers”
trainer-resistance-band-senior-woman-client

You Are The Solution

This article is meant to be a wake-up call to the fitness industry. The health of our population and country are at stake. While advancements have extended our country’s overall lifespan, it has occurred primarily through the use of medications and life-saving procedures rather than through lifestyle changes. The stark reality is that the overall health of Americans is declining as evidenced by the $3.5 trillion spent every year on health care expenditures.

Another alarming statistic is that between 1997 and 2016, there were approximately 4.5 billion prescriptions written per year. 70% of Americans take at least one and 20% take five or more prescription medications (Preidt 2017). The majority of these medications were taken to address lifestyle-related diseases and the subsequent impacts of poor nutrition choices and lack of physical activity. Additionally, many prescription and over-the-counter medications are used to treat osteoarthritis, the most common cause of physical disability in the world. While genetics, weight, and age have been considered as underlying factors, the decrease in quantity, as well as quality, of physical activity have been shown to be much greater factors to the onset and prevalence of osteoarthritis in modern society (Wallace 2017, Osar 2018).

While often attributed to causes outside one’s control (i.e. genetics), the fact is that the diseases contributing to the greatest number of deaths (heart disease, cancer, and Type 2 diabetes) and disability (osteoarthritis) are directly related to controllable factors. While each has a genetic component, lifestyle has a much greater impact on the incidence and prevalence of these diseases. One of most important and underappreciated components in the overall decline in one’s physical, physiological, and cognitive health, is the lack of physical activity. Less than 20% of the population meet the daily physical activity guidelines and less than 5% of the adult population participates in 30 minutes of physical activity. Even more disturbing is that more than 78 million U.S. adults and 12 million children are obese.

Dr. Caldwell Esselstyn has been attributed with the quote, “Genetics loads the gun, lifestyle pulls the trigger.” This suggests that lifestyle is as important as genetics in the expression of many chronic diseases. This sentiment is reiterated in a recent study from Bodai et. al (2018). “Epidemiological, ecologic, and interventional studies have repeatedly indicated that most chronic illness, including cardiovascular disease, cancer, and type 2 diabetes, are the results of lifestyles fueled by poor nutrition and physical inactivity.”

The health of our population and country is at stake. This is a call for fitness professionals to step up and recognize that you are the first line of defense against the deleterious impacts of lifestyle diseases. It is your responsibility to educate your communities that lifestyle changes, incorporating proper nutrition as well as increased physical and cognitive exercise, should be the first step in addressing chronic lifestyle diseases. You can continue to change the health of our nation by implementing evidence-based nutrition, exercise, and cognitive training programs. Be the solution your clients, your community, and our country needs by investing in advanced education in nutrition, exercise, movement, and cognitive training. Create relationships with allied health professionals so that we can collectively educate, collaborate, and coordinate the changing of our nation’s health care system.

This article was featured in MedFit Professional Magazine Winter 2020 issue. Subscribe to MedFit Professional Magazine to read more great content like this!


Dr. Evan Osar, an internationally recognized speaker, author, and expert on assessment, corrective exercise, and functional movement. Dr. Osar is committed to educating and empowering fitness professionals while helping them develop relationships with allied health professionals. He is author of the Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction and has developed the industry’s most complete training certification, the Integrative Movement Specialist™. With his wife Jenice Mattek, he created the online educational resource. For more info, visit IIHFE.com

References

Bodai, B. I., Nakata, T. E., Wong, W. T., Clark, D. R., Lawenda, S., Tsou, C., … Campbell, T. M. (2018). Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival. The Permanente journal22, 17–025. doi:10.7812/TPP/17-025

Centers for Disease Control and Prevention. Osteoarthritis. Retrieved from https://www.cdc.gov/arthritis/basics/osteoarthritis.htm

Centers for Disease Control and Prevention. Leading Causes of Death. Retrieved from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

Centers for Medicare & Medicaid Services. National Health Expenditure Data. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

Osar, E. (2018). The Fundamentals for Training the Older Client with Osteoarthritis. Retrieved from https://www.ptonthenet.com/remote-learning

Preidt, R. (2017). Americans Taking More Prescription Drugs Than Ever. https://www.webmd.com/drug-medication/news/20170803/americans-taking-more-prescription-drugs-than-ever-survey

U.S. Department of Health & Human Services. Facts and Statistics. Retrieved from https://www.hhs.gov/fitness/resource-center/facts-and-statistics/index.html

Wallace, IJ., Worthington, S., Felson, DT., Jurmain, RD., Wren, KT., Maijanen, H. Woods, RJ., Lieberman, DE. (2017). PNAS. 114(35): 9332-9336.

team hands

Collaborative Thinking in Health & Wellness

Over the past 18 months, I have seen my primary M.D. three times, enjoyed the services of my favorite massage therapist six times, visited my chiropractor nine times, chatted with a local R.D. twice and seen my personal trainer regularly. And not one of them even asked if I was seeing any of the others, much less inquiring what their treatments or approaches to treatments might be. To me, that is like trying to achieve success with a baseball team where the 1st base coach, 2nd base coach, 3rd base coach and pitching coach never communicate with each other.

Success cannot occur in a vacuum, neither can true individual health & wellness, yet for decades these medical, fitness & wellness providers have proffered their services in distinct and distinctly separate spaces.

Even as the internet has made access to information easier and facilitated the sharing of knowledge, including private, HIPAA compliant information, these providers continue to operate in “informational silos.”

It is true that in the past some of these providers may have held less than favorable opinions of some of the other providers, but that is, and certainly should be, a thing of the past. No longer will M.D.’s consider Chiropractors “quacks”, R.D.’s claim nutritionists “just don’t know enough”, and Physical Therapists think of Personal Trainers as ”wanna-be P.T.’s who couldn’t hack the education.” Science, knowledge and time have evolved all these disciplines into valuable, useful and incredibly beneficial specialties, each offering specific training and specific methods to apply to their patients/clients. And all those patients/clients typically can benefit from their combined expertise and knowledge.

No longer is it sufficient to simply treat the symptoms. Real wellness needs to encompass the patient/client holistically… address the symptoms, understand the cause, strengthen the mind, examine the diet, resolve the issue and prevent future occurrences. And isn’t that best accomplished by viewing patient/client wellness as a Team Sport?

Over the years I have had the pleasure of knowing and speaking at length with many of these medical, fitness & wellness providers, and not one of them indicated there is anything in their training that says “Thou Shalt Not Collaborate.”

We are not talking about “asking for help.” Rather we are simply saying to include those other practitioners in the conversation. Instead of the M.D. telling the patient to “walk more to improve cardio health”, why not conference call with the Personal Trainer and discuss the walking program that is most appropriate. Let the Physical Therapist inform the Personal Trainer of any specific issues to address or avoid. Allow the Massage Therapist to work with the Chiropractor to ensure optimum results from both. In other words, (and the simplicity of all this may surprise you), just TALK TO EACH OTHER.

So, let’s start to make that happen. For more than 20 years my company has helped health clubs and fitness centers create mutually beneficial relationships with Physical Therapy practices, Chiropractic offices, Registered Dietitians, Nutritionists and Massage Therapists. Now is the time to extend the conversation, and, to return to my baseball metaphor, get ALL the coaches working together to create truly Championship results.

Join Cosmo for his upcoming MedFit webinar on this topic:


Cosmo Wollan is the Senior Executive at Synergy Cubed, a premiere consulting firm providing customized solutions to the health & fitness, parks & recreation, medical fitness and corporate wellness industries since 1994. His Fitness Industry clients have engaged him as an expert problem-solver in profit center development, retention strategies, customer engagement, sales training, programming design, operational streamlining and health club management.