Impediments to Professionalism

Never cease to pursue the opportunity to seek something different. Don’t be satisfied with what you’re doing. Always try to seek a way and a method to improve upon what you’re doing, even if it’s considered contrary to the traditions of an industry. – Howard Marguleas

Can you believe that the percentage of men nurses in the

United States

only now approaches 10% of all nurses? Okay, can you believe that about 80% of physical therapists working in the

United States

in 2003 were women, and that in 2003 close to 90% of occupational therapists were women? These are the statistics published by the Bernard Becker Medical Library of the Washington University School of Medicine, St. Louis, Missouri [1]. Well, can you believe that there are thousands of exercise physiologists in the

United States

? Yet, hardly a single exercise physiologist is writing about the professionalism of exercise physiology or exercise physiology as healthcare profession. Talk about a serious issue before the members of exercise physiology.

Certainly, there must be more to exercise and its value to society than “one more research study about athletics.” Where are the exercise physiologists with an interest in and desire for professionalism? If nothing else, shouldn’t the college professors have an interest in talking and writing about exercise physiology as a profession or even an evolving profession versus a discipline of researchers? Shouldn’t they care about the professionalism of exercise physiology and, if they should be concerned, what are the ethical implications of getting involved in the discussion? This article is a brief look at the shortcomings of failing to understand and acting on the need for the professionalism of exercise physiology.

There are of course obvious reasons for professors to avoid the subject altogether, such as the risk of not getting tenure. Also, no one wants to be viewed as being on the outside looking in at their colleagues who aren’t interested in the ASEP organization. While both reasons are important considerations for not speaking out, to understand the problem of failing to support the American Society of Exercise Physiologists (ASEP) as the professional organization of exercise physiologists, one must look deeper into the culture of exercise physiology [2]. For example, why are exercise physiologists making choices that are not helping the profession? Why are they supporting the accreditation of non-exercise physiology degree programs? The answer it seems to me is that it is a way of thinking that has taken years in the making. Perhaps, the initial point of where it all began was in 1954 with the founding [3] of the American College of Sports Medicine (ACSM).

For decades the ACSM leadership emphasis on research to the exclusion of the professionalism of exercise physiologists appears to have convinced the doctorate level exercise physiologists that their way is the only way. So convinced that they are right, many college professors believe that a person cannot be an exercise physiologist without the doctorate degree. This is exactly why sports medicine exercise physiologists developed in the 1970s certifications with titles like exercise technologist, exercise specialist, and clinical exercise physiologist. Even today, they [3] continue to develop non-exercise physiology certifications (e.g., the health and fitness instructor certification, and the now, the personal trainer certification). I have personally been told to my face and via emails that anyone without the doctorate degree cannot be an exercise physiologist. They have convinced themselves that their thinking is right and acceptable. The pressure to keep exercise physiology unchanged from past thinking seems to be the right thing for them. Nothing seems to be wrong if it keeps everything the same.

We have all heard that “you are what you eat” but more relevant to your life is this statement “You are what you think”. There is a great deal of evidence to support the truth in this statement and still people continue to fill their thoughts with complete junk. – Bill Keefe [4]

This culture of failed thinking is at the heart of the problem each and everyone one of us is faced with. Also, the culture of yesterday’s thinking is designed to keep everyone on the same page of sports medicine. They reward those who support their thinking. This failure to update their thinking, especially to do whatever is necessary to empower all exercise physiologists is partly denial but largely ego. The question is not how did this happen, but why is continuing to happen? Why are the gatekeepers (mostly, college professors) tied to the history of yesterday? Nothing about the ASEP organization precludes research or the importance of continuing to engage in research opportunities or cooperating with other organizations. Nothing about the thinking of the ASEP leaders precludes that which has been learned from history. It simply cannot drive today’s thinking that requires a new way of thinking about exercise physiology.

All of this of course has forced me to ask the question, “What can I do to improve the world of exercise physiologists?” I suppose a big part of the problem is that ethical and professional dilemmas are new to exercise physiologists. Few, if any, college professors and/or exercise physiologists in the public sector have taken a course on professionalism or professional development while in school. Even today exercise physiologists who are not members of the ASEP organization do not have their own professional Code of Ethics [5]. It is all a very bad picture of failed leadership that has existed far too long. They continue to believe that exercise physiology is a scientific discipline dedicated to understanding the physiological and metabolic effects and adaptations to exercise and athletic performance. They have promoted the notion that there exist a “clinical exercise physiology” separate of exercise physiology, which simply isn’t true.

The end result is that there are too many problems faced by students who think they are graduating as exercise physiologists even though many professors often argue otherwise. Apparently, they think that a career following the undergraduate exercise science degree means something other than actually locating a viable job with financial stability and respect. For example, consider the following University posting of “careers” after they graduate with a degree in Health and Exercise Science [6]:

It is not an occasional mis-use of words, but the ordinary statements that wear out ethical thinking. Under no circumstances does the “career statement” make any sense at all. One could attribute many things to this way of thinking. Yet, there is a point of no return in considering the problem of mis-leading undergraduate students. Aside from the huge ethical realm of consideration, there is the next to useless thinking that the degree itself has merit. Most unfortunately, the embracement of the history of sports medicine and exercise science, if not, the general laziness of the faculty allows programs of study that ultimately alienate students from serious career opportunities. Undoubtedly, this is a new phenomenon which exercise physiologists are not accustomed to, and for this reason it is necessary to demonstrate that the connection between ACSM and the continuation of exercise science majors is an untenable one.

Professors must start thinking about the students’ job problems and doing the right thing to correct them. They must get beyond the ease at which associating with a non-exercise physiology organization encourages sticking to established thinking. This brings us to the crux of the matter: Leaders are responsible for doing the right thing even if they are uncomfortable with it or do not know for sure why it is important. In fact, has anyone asked you personally to define “professionalism” or “ethical obligations” regarding the many aspects of exercise physiology (such as the role of sports nutrition in athletics and exercise physiology)? I don’t think so. This would lead us to conclude that because every system is in place to protect the ACSM organization that claims made by the ASEP leaders are unwarranted or meaningless. Admirable as this thinking is to sports medicine supporters, I am in strong disagreement with it. The basic reason for my disagreement is the realization that continuing with ACSM will lead to more problems for students of exercise physiology, which will prematurely restrict the exercise physiologist’s participation in healthcare.

Regardless of this understanding and the central meaning of exercise physiologists who are not affirming the ASEP organization, the process of professionalization is underway in exercise physiology. It may not be all that talked about or written about, but the emancipation of exercise physiologists is underway even though many members of the evolving profession have “lost their hold on what it is.” Of course, it also follows that the professional development of other healthcare professions and their respective members are decades ahead of the responsibility for and responsibility to the issues of their profession. It follows then that the members of physical therapy, occupational therapy, nursing, and others get it. They understand the importance of talking about ethical conduct and setting professional standards for education (i.e., accreditation). Medicine, law, ministry, and the academic occupations are recognized professions [7]. They meet the criteria for being a profession as, I think, exercise physiology does, too.

However, it seems to me that members of the exercise physiology field are not acting in their best responsible manner for their professionhood. This statement is important because it is true and thus, unfortunately, slows the professionalization process. It is also important because exercise physiologists should be doing something about it. This is a belief beyond self-interest and this, I believe, is exactly at the heart of what is exercise physiology (i.e.,the commitment to exercise to empower the welfare of others). While I don't speak for the ASEP leadership, I think this is their point of view, too. They believe that exercise physiologists must commit to an ideal that doesn’t exist within the sports medicine model. Hence, without a commitment to the ASEP Code of Ethics, the exercise physiologist is a highly educated “specialist” or “technician” whose knowledge is wasted without being part of a profession. This is what I have learned from my studies, and that which I’m happy to share with those who wish to make a similar journey. If I can inspire you to follow the ASEP path, this article will have served its purpose.

I should point out that the path of professionalism is not short. It is not learned in a day or two or even a month. There isn’t a fast way to get it. Once it is taken, it is a journey of commitment to competence and care of others and, yes, a way of thinking that departs from our usual history of exercise physiology. The teachability of professionalism is not questioned, but the failure to shape the professionalization of the students who are interested in exercise physiology is an obvious problem. ASEP as a professional society represents the profession of exercise physiology, but the professors are either looking the other way or have de-emphasize its importance (often because of their own self-interest). If professors were to take their moral purpose to heart, they would be concerned about the professional socialization of their students. And, if exercise physiologists, as healthcare professionals, are to have any unity of purpose, it is essential that they teach professionalism if they are to protect the profession from unsafe, dishonest, or untrustworthy fitness practitioners.

Therefore, in essence, what I'm saying is this: The professionalism of exercise physiology cannot be taken for granted. Professionalism must be taught, and now is a critical break in our history to insist on the highest professional standards. The runaway involvement of fitness professionals throughout the

United States

is a mistaken arrogance that anyone can use exercise to build and heal others. Not surprisingly, the longer exercise physiologists fail to stand up and argue this point, personal trainers and other types of fitness instructors will continue to confuse and weaken the “exercise” marketplace. This is more than an idle observation. This is also why professionalism in exercise physiology requires a freedom from fitness practitioners who do not have a body of expert knowledge. It is inappropriate and potentially negligent to encourage non-professionals to use exercise in a therapeutic manner.

The important thing is that the full potential of the power of exercise as medicine is fully appreciated and increasingly so by physical therapists (refer to http://www.boonethink.com/). It doesn’t make sense that “exercise as medicine” should be supervised and implemented by so-called fitness professionals. This is especially true, given their indifference to exercise physiology as a healthcare profession like physical therapy and other healthcare professions. I have found that they often act compulsively if not obsessively in their own best interest and well-being. Make no mistake about it, just because a person declares him- or herself an exercise expert (or even looks the part) doesn’t mean that he or she knows anything about exercise. Exercise is not a static and lifeless accumulation of experiences by those who treasure it for their own sake. I can find no merit in this thinking, and I think it is now clear that those who do are not professionals. Knowing what one believes is right is not necessarily the right thing to do, especially when it lacks accountability.

Professionals have integrity, discipline, and commitment. They understand that exercise physiologists are responsible for providing quality care to their clients. This is not the case with non-professionals. Hence, this is why exercise physiologists should have “zero tolerance” for those who are not academically prepared. Commitment to the public good must be a shared ethical and professional devotion to the good of society. That is exactly why the ASEP leadership has a declared an exercise physiologist’s Code of Ethics, a related standards of professional practice, and required hands-on laboratory experiences that are evaluated via the EPC exam. Accountability and commitment to the public good are essential to professionalism. Also, commitment to independent judgment is critical to exercise physiology as an emerging profession. The need to act independently without the supervision of others is necessary to gain social recognition and respect. Yet, aside from the obvious steps of professional development, it seems that some exercise physiologists want everything now! It is as though the ASEP leaders are the problem behind the change process. Yet, for comparison only, why not consider the following:

The American Physical Therapy Association was originally called the American Women’s Physical Therapeutic Association. It was founded in 1921, and members were referred to as reconstruction aides. After World War I, physical therapists were regarded as technicians. It was not until 1950s that physical therapists acquired some authority to work without physician supervision. In 1968, California allowed legal direct access for physical therapy evaluations, followed by 30 other states into the 1990s [8].

Clearly, the professional development of physical therapy and other healthcare professions have taken a considerable amount of time in their development. Surely this must be understood in regards to the founding of the ASEP organization in 1997. There is much work to be done before exercise physiologists have any power to access monopoly of their services. Licensure itself is also time-consuming, especially since the work that goes into getting licensure is huge and often political. And, yet it may be appropriate to view exercise physiology differently than which the present system is understood. For example, if one were to identify the most important function of the physician’s monopoly in medicine, it would have to be their power to write prescriptions. Similarly, licensure defines physical therapy by controlling who can write “P.T.” at the end of their names. It might be important to recognize that otherwise many aspects of medicine and physical therapy are used everyday in a multitude of ways by any number of different occupations and individuals. This is equally clear with exercise as well, especially given that even with licensure anyone can still promote and/or argue for the benefits of exercise via different exercise programs.

The statement by McDonnel and Pascal raises the question, “What is it that exercise physiologists do or will do that separate them from all others interested in the healing power of exercise?” A significant part of the answer to the question lies in the ASEP Code of Ethics. It is important that all professionals have a code that provides guidance as to what is expected of each other as well as an understanding of the necessary restraints on self-interest in financial dealings. Having made this point, it is also critical to understand that the process of professionalization of exercise physiology is dependent upon exercise physiologists themselves and society as well; both may either grant or withhold professional designation. For many reasons, most being obvious to others, exercise physiologists must get this point if they are to achieve professional status.

This is exactly why exercise physiologists must concentrate on the meaning, if not, ethical view of an academic degree. In short, it seems more than reasonable a fair conclusion that students should not be subjected to programs of study simply because they exist without students having any influence over the quality and purpose of the degree. Also, I am not alone in my conviction that professors have a moral obligation to ensure the correct terminology (e.g., degree title vs. professional title) is understood. This is not an unreasonable request, although it is true that ultimately this shared understanding will come from all exercise physiologists speaking with an agreed upon voice and vision. The shared vision, in particular, for the professionalism of exercise physiology must become reality if they are to attain professional credibility. It is time to admit that too much silence and failure to act can no longer be tolerated. The idea that “the cat has got your tongue” is not a proper excuse for remaining silent. Professionals with integrity do not have the automatic right to be silent, especially when their failure to act speaks volumes.

Another impediment to professionalism is the historical structure within college and university academic departments. Not surprisingly, the deeply held tradition of physical educators and their influence on the present day exercise science programs (and similar programs of study, such as kinesiology or health and sports sciences) is not easily broken or even re-written. Exercise physiologists are usually one group (often, a small one at that) among other groups, such as athletic trainers, physical educators, and diverse sports programs with past histories. Hence, the members of any given department with several academic majors are not likely to relinquish their sense of what the department represents. Exercise physiologists have it within themselves to present a strong case for converting exercise science to exercise physiology. The question is: “Will they act or will they continue to be silent?”

The hierarchical bureaucracy of sports medicine is of course an impediment to the realization of exercise physiology professionalism. The understanding of this belief is rendered from the knowledge that many professors are simply too overwhelmed by the sports medicine and exercise science way of perserving their niche. For one thing, the tenured professors are certain to impose their rules in the department and school’s role on junior faculty who seek tenure. Those who also believe that it is necessary to safeguard the sports medicine’s image in the United States are willing to exert their influence on students, faculty, and even administrators to keep students from attending the ASEP National Meeting. All of this should not come as a surprise to anyone. Consequently, the supporters of exercise science are enculturated in sports medicine; their beliefs and practices are resistant to efforts to professionalize exercise physiology via the ASEP efforts. Understandably, paradigms do not change easily.

Ironically though, this problem impacts not only the professionalization of exercise physiology but the education of students as well. The professors should be accountable to change that involves the academic and professional expectations of students, the dreams and hopes of the parents, and the obvious costs of college tuition. It makes no sense that bureaucratic governance of exercise science by sports medicine prohibits the professionalization of exercise physiology. When these professors should update the exercise science curriculum and change the title from exercise science to exercise physiology. They are not doing so. This is comparable to essentially to no change from the 20th century into the 21st century, which keeps exercise physiology in the culture of unprofessional thinking. This is why, in the eyes of established healthcare practitioners, exercise physiology is exercise science and both, therefore, are of secondhand quality. No wonder they are moving forward to incorporate exercise into their practice, and they are doing so without any objection from exercise physiologists. The resultant effect is twofold: (1) there is the potential for the loss of the exercise physiologist’s expertise in exercise; and (2) the very likelihood that exercise physiologists will be reduced to the non-professional status of fitness instructors and personal trainers.

Another impediment to the professionalism of exercise physiology is the physical education and sports medicine historical influence on the curriculum. Imagine, after 60+ years with exercise physiologists as teachers at the college and university level, they do not have a course in their curriculum that addresses professionalism. Of course, even making this point is to admit just how far exercise physiologists are behind other professionals. And, just because they give lectures, grade papers, do research and/or lab projects, and are engaged in a myriad of committees and other commitments (e.g., attend annual and regional conferences) does not excuse them of their professional responsibility to develop a professional culture of exercise physiology. The college professors must stop acting as gatekeepers to the ASEP efforts toward professionalism. Of course, the question is simply this: "Why not nurture the professional development of exercise physiology through keeping one’s distance with non-exercise physiologists?" And, another important question is, "Why not hold non-exercise physiologists responsible and accountable for their negative influence on the professionalism of exercise physiology?"

Resistance to the professionalism of exercise physiology is a serious problem, and it is a major failure on behalf of exercise physiologists. From what has been presented in this article, it is one thing for society not to warrant professional status to exercise physiology (should that ever be the case). It is altogether different for exercise physiologists to demonstrate to society that they are not capable of saving themselves. The apathy of many exercise physiologists, particularly in regards to the ASEP efforts, brings into question their narrow thinking and failure to achieve status worthy of their knowledge of the healthcare benefits of exercise and athletics. Why would other healthcare professionals care what exercise physiologists have to say since they have failed to pursue and defend the professionalism of exercise physiology? This is a huge problem for the evolving profession. Unfortunately, exercise physiologists have failed miserably to speak with one voice. Therefore, it is no wonder that students get a mixed message about the future of exercise physiology.

Given these impediments and the likelihood of the “sports medicine and exercise science” thinking to exist for many years to come, it may be a better strategy for the ASEP leaders to continue as they have with respect to their own definitions of exercise physiology and exercise physiologists. There is no reason to be timid in the quest for professional status. ASEP members can and should speak with a united voice on behalf of the ASEP organization and its efforts to achieve accountability and credibility in exercise physiology as a healthcare profession. A united voice is critical in handling the negativity and denial from others. Obviously, there has been more than enough rhetoric condemning the ASEP leaders and their efforts to professionalize exercise physiology. ASEP leaders understand this point all too well, but professionalism of exercise physiology is too important to the well-being of students, professors, and society to allow the non-exercise physiologists to stay in control.

The work of ASEP is to help ensure self-regulation and self-policing of exercise physiologists. It will be done through board certification (and eventually, licensure) and other more immediate credentialing to encourage and maintain high standards of professional competence and ethical responsibility. In addition to these considerations, efforts to professionalize exercise physiology are important towards improving social and economic status of exercise physiologists. After all, the college degree should provide reasonable security of career and socioeconomic mobility. Also, given that there is no way to avoid “fitness professionals” from engaging in the prescription of exercise (even unknowingly) suggests that exercise physiologists must place increased emphasis on putting the welfare of the public’s trust ahead of their economic interests. This point could be phrased as a maxim:

To quote Bacon [10], “It matters not what has been done, our business is to see what can be done.” In other words, the right road for exercise physiologists is not the study of the history of exercise science, but the active pursuit of the future of exercise physiology. ASEP exercise physiologists are interested in creating the future, not to cling to the past. Frankly, in many ways, the history of what is often called exercise physiology is irrelevant. The metamorphosis from “fitness instructor” to “healthcare professional” is the solid structure from which is capable of producing healthcare practitioners. It cannot plausibly be thought otherwise, for at the heart of the impediments to professionalism lies the fact that far too many exercise physiologists think of exercise physiology too narrowly. And, for this reason, it is too easy for exercise physiologists to get bogged down with routine and lose the larger perspective. This is both time-consuming and damaging.

Recently, I read that psychology is still an immature discipline with members who are still searching for the way forward [11]. Just imagine, if that is said of psychology, which has been with us forever, why would anyone think that exercise physiologists are suppose to jump hurdles faster than they should. Some things are majorly time-consuming, if not immutable. Exercise physiologists themselves, no matter how hard they want things to be different right now, must understand they can’t get what they want with the next breath. We are creatures of a process; often one that is in conjunction with already existing petitions to keep things as they have been. For many, the critical question that can be put to the exercise physiology community is whether anyone cares, and if so, how that “caring” is to be understood.

And, remember, it isn’t how big ASEP is right now or even whether the leadership has accomplished everything that others may think is necessary. No, it is about the passion of the members to stay the course and, frankly, given the obstacles before them, they have done just that and have done so reasonably well. Their willingness to see the ASEP vision through is what separates them from others. Their minds are inherently driven to empower all exercise physiologists, not just the doctorate ones. Those who don’t get it must take the time to rethink the problems of exercise science and the hopes and dreams of exercise physiology. It’s mind-boggling to think about how much energy gets wasted on exercise science and sports medicine. The past is over, and there is only one time for it. Today, we should live in the present. This shift in our understanding of exercise physiology is of vast importance, and it entails a corresponding shift in how we think about exercise physiology as a healthcare profession.

Hence, in summary, those of us who subscribe to ASEP, those of us who view exercise physiology as a profession rather a fitness (or research) discipline, those of us who rejoice in the existence of ASEP, regardless of the impediments, we are encouraged by the following “Bill of Rights.” It defines the “rights” of all exercise physiologists to [12]: