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Dr. Mandelbaum Discusses with Medscape Orthopedics Why Doctors Aren’t Doing Enough to Get Patients to Exercise


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Doctors Aren't Doing Enough to Get Patients to Exercise

Bert R. Mandelbaum, MD, DHL (Hon)

|October 01, 2015

A Sports Doctor's Most Important Job

Like most physicians in the United States, sports medicine specialists get paid for fixing problems, not for preventing them. Patients come to us with a torn anterior cruciate ligament (ACL) injury or ulnar collateral ligament. We operate or prescribe therapy and coach them through rehabilitation. After performing these services, we get paid our fees.

But I believe that we all have a higher calling. Our most important job is to motivate our patients to take control of their fitness—and to get their family members to join them. And in the long run, what's best for our patients is best for us as well.

The idea that doctors should prescribe exercise goes back to the dawn of medicine. In the Greek pantheon, Panacea and Hygeia, the goddesses of intervention and prevention, were held in equal esteem as daughters of Aesculapius, the god of medicine. Even before Hippocrates, Herodicus, a fifth-century BCE Athenian physician, recommended treating patients with exercise.

What these forefathers of medicine understood, and what too many of us have forgotten, is that human beings are hardwired to be athletes. Homo sapiens evolved to go out and hunt and gather. That history is embedded in our genes. If we don't exercise, our bodies don't function well. And lack of exercise is contributing to most of the common diseases we now face.

The Leading Cause of Preventable Death

As Steven N. Blair, PhD, a professor of exercise science, epidemiology, and biostatistics at the Arnold School of Public Health at the University of South Carolina, has noted, inactivity has surpassed obesity and smoking as the leading cause of preventable death in the world.[1]

A rational healthcare system would provide incentives for physicians to encourage exercise. The potential impact of getting just a few people to exercise more can be huge. Diabetes costs the US healthcare system $245 billion per year.[2] Stroke adds another $34 billion.[3] Sarcopenia adds $19 billion.[4] All could be mitigated with exercise programs.

But the fact that we don't work in a rational system doesn't relieve us of the responsibility to lead, inspire, and motivate.

Three Vital Roles for Physicians

Physicians can reassume this vital role in three ways. First, we can serve as role models. We must show our patients that it's possible to stay fit despite the pressure of our demanding work. We should all set aside at least a few hours each week for our personal fitness.

Second, we can speak to our patients one-on-one. I'm always impressed by how ready my patients are to receive the encouragement to exercise, even those who haven't been active in many years. Just because someone is 150 pounds overweight, let's not believe that that's their desired situation. They're looking for a spiritual and emotional solution to their problem.

Likewise, when talking to some of our elderly patients, it may be tempting to conclude that their years of activity are behind them. But the research shows that exercise can have an important impact at any age. Master athletes have fitness levels equivalent to the average for people 20 years younger.[5]

People who play sports late in life also experience improvements in body composition and lipid profiles. They improve in almost every category, especially their quality of life.[5] In a study in Denmark, 45-year-old sedentary women who took up soccer significantly increased their bone density.[6]

I challenge people to just go out for a mild walk some early morning and see how they feel at the end. Virtually 100% of the time, they come back and say, "I feel great." We've got endorphins that make us feel good just by doing simple exercise. And it doesn't cost anything. Lately I've been coaching patients to use smartphone apps that help them track their calories. This allows them to compare a variety of activities and choose the type that suits them best.

Third, we can seek opportunities to speak to larger groups. We can approach schools, YMCAs, senior centers, and civic groups and offer to speak about aspects of fitness and injury prevention.

When I'm talking to large groups, I say, "My role here is to motivate and inspire you. I'd like all the athletes to stand up."

Typically, about 50% stand up. Then I say, "How many did high school sports, hike, or garden?"

Before you know it, we get everyone standing up. I say, "That's right. We are all athletes. It's the only way we are supposed to be as human beings."

Participating in sports is in our genes. Each of us wanders off course, whether because of babies or jobs. But once we discover what's inside us, we can get back on track.

Aside from a few research grants, I have never been paid to think in terms of prevention. But that's always been a focus of my work. It's why I helped create warm-up programs to prevent ACL injury. It's why I wrote The Win Within: Capturing Your Victorious Spirit.[7]

You're not likely to get reimbursed directly for this kind of work. But taking a public role can raise the profile of your practice and build your patient base.

And you can save more lives with inspiration than you ever will with a scalpel.


  1. Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med. 2009;43:1-2. Abstract
  2. The Cost of Diabetes. American Diabetes Association. June 22, 2015. Accessed September 28, 2015.
  3. Stroke Facts. Centers for Disease Control and Prevention. March 24, 2015. Accessed September 28, 2015.
  4. Janssen I, Shepard DS, Katzmarzyk P, Roubenoff R. The healthcare costs of sarcopenia in the United States. J Am Geriatrics Soc. 2004;52:80-85.
  5. Marcell, TJ. Sarcopenia: causes, consequences, and preventions. J Gerontol A Biol Sci Med Sci. 2003;58:911-M91-M916.
  6. Mohr M, Helge EW, Petersen LF, et al. Effects of soccer vs swim training on bone formation in sedentary middle-aged women. Eur J Appl Physiol. 2015 Aug 9. [Epub ahead of print]
  7. Mandelbaum, BR. The Win Within: Capturing Your Victorious Spirit. Austin, TX: Greenleaf Book Group Press; 2014.
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