The Professional Practice of
Exercise Physiology and Ethical Thinking
Tommy Boone, PhD, MPH, MA, FASEP,
EPC
Professor and Chair
Director, Exercise Physiology Laboratories
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN 55811
“Exercise physiologists
have not realized their professional strength. Will they wake up
before it is too late.” -- William T. Boone
Introduction
Several years ago I started thinking
about what it meant to be recognized as a professional. I soon found
out that the subject of professional development required considerable
reflection and analysis. Compared to physical therapy or nursing,
the process of professional development in exercise physiology has been
very slow. Instead of teaching courses about professionalism, ethics,
and standards, students in exercise science are taking courses one-step
away from a physical education degree. To be very frank, the prevailing
approach to "what is exercise physiology" in today’s academic institutions
isn't good. Very little attention, serious or otherwise, has been
given to the process of professional and organizational development.
Having failed to separate exercise physiology from exercise science, physical
education, and sports medicine isn’t just an ineffective way to think,
it is a disaster. To put it simple, the irregularities in the academic
course work have ensured that students are not at the same level as their
competitors. This is a pressing issue. The conflicts that have
resulted from it are real. Those who bother to get close to the shared
dilemma know that it is a problem that needs immediate correction.
What makes this scenario worse yet
is the sports medicine effort to certify fitness professionals that continues
to short change and disempower students who are earning an academic degree
in exercise physiology. The perception that the sports medicine way
is the way is contributing to the already boiling pot. The
ASEP goal is to educate professional exercise physiologists who are board
certified with a recognized standard of practice. Professors, who
have for decades been too narrowly specialized as researchers, ought to
be mandated by their academic chairpersons and students to provide support
and guidance in the professional development of exercise physiology.
This is one important step towards the professional application of exercise
physiology that must be engineered from within. In other words, academic
exercise physiologists must explain the new market conditions to their
chairs and/or deans and, most importantly, provide both a theory and application
based on the ASEP 21st century perspective. The goal is to help students
identify with and to hopefully understand the ASEP vision and professional
initiatives.
Reading materials and assignments
must reflect the importance of professionalism and ethical thinking.
The professors agenda, in addition to providing the theoretical constructs
and basic principles involved in research and application of physiology
to sports training, must include the means to enable students to not only
study for the ASEP board certification but to understand its market importance.
I believe that many exercise physiologists working in educational institutions
are ready for change. Also, I believe that students are especially
ready to be delivered from the non-exercise physiology curriculum of the
20th century. The academic exercise physiologists have a tremendous
responsibility to students who hope and expect to go beyond the context
of status quo. They want to be competitive with the peer counterparts
in other healthcare programs of study. If this were not the case
then there would simply be no reason for the ASEP organization. Of
course ASEP does exist because its membership is aware of the conflicting
values and differences within exercise physiology. In short, this
article argues that professionals must pay attention to issues of differences
and similarities if a full understanding of their practice is to be achieved.
Professionals and Their Practice
A central problem with the term
“professional” is the vast number of definitions [1]. Which criteria
do we use? Within this paper, the term will be defined around three
important concepts: (a) professionals possess an exclusive body of knowledge
and practice; (b) the practice of exercise physiology is based on
a code of ethics with an ethical concern for clients; and (c) professionals
are responsible to exercising control over who are exercise physiologists
and what defines their scope of practice.
Exercise physiology has a body of
knowledge that is unique to the decades of research by exercise physiologists.
However, there is neither agreement nor recognition of what exactly defines
the practice of exercise physiology. This is certainly part of the
reason for this article. With increased exposure of the ASEP standards
of practice, more exercise physiologists will realize that they have a
specific healthcare niche in society and, not unimportantly, that the niche
increases financial remuneration. Being paid well to practice exercise
physiology is important. Moreover, being recognized as experts in
the implementation of a body of knowledge is important. Although
this point may not yet be apparent or even accepted by some healthcare
professions, the solid research by exercise physiologists undergirds the
solution to numerous healthcare concerns.
Practitioners of any profession bring
to their practice the challenge of honest and fair interaction with clients.
Without a code of ethics, their altruism and their need for autonomy are
met with little actual effect. Ethical thinking is imperative.
It must be given a higher priority than technical, hands-on skills.
Hence, if exercise physiologists want to be professionals, they must be
proactive, and they must be actively engaged in discussions about the professional
development of exercise physiology. A professional strategy for responsibly
dealing with professional issues has been developed by the ASEP leadership.
The strength in defending its position comes not from reacting to sports
medicine’s low priority for exercise physiologists, but rather from the
need to provide increased career opportunities for all exercise physiologists.
This might be viewed as expected and, yet it has not been articulated before
the founding of ASEP. This is critical to understanding the ASEP
initiatives and, not surprisingly, the importance given to publishing articles
about professionalism and ethics and the increased awareness of the professionalization
of exercise physiology.
The argument of this article, then,
has been that exercise physiologists, as healthcare professionals, need
to include much more talk and discussion about the emerging profession
of exercise physiology. This involves telling everyone that exercise
physiology is no longer just about the elite of the profession. Every
member of the profession has the right to speak out on behalf of what is
exercise physiology and who is an exercise physiologist. In so doing,
each member is also responsible for the upkeep and the growth of the profession.
This means dealing issues about what constitutes the “practice” and concerns
about “defending” the practice. It means integrating ethics into
exercise physiology courses. It means explaining to students and
others why ethics should be taught in lectures and laboratory courses,
how it can be done, and what is expected to come from the ethical education.
Integrating Ethical Thinking in
Exercise Physiology Courses
“Ethical thinking”, as I use the
term, refers to standards of conduct that defines basic moral rules.
For example, exercise physiologists, like other professionals, are not
suppose to lie, cheat, steal, and so on. When individuals become
members of an organization, they are expected to live up to the profession’s
standards of conduct. In this case, exercise physiology ethics apply
to exercise physiologists who hold themselves to a higher standard of practice
than non-professionals. Teaching ethics is as important, if not more
important, than teaching the physiology of training. Students’ sensitivity
to ethical issues must be increased if exercise physiology is to avoid
serious ethical problems. For example, although it is common for
exercise physiologists to teach sports nutrition, what about the ethics
of sports supplements? Should exercise physiologists ask themselves
the following questions: “Is it ethical to encourage sports supplements?”
“Is it ethical to fund research projects driven by the supplement industry?”
"At what point is the use of supplements unethical?"
Knowledge of the practice of exercise
physiology includes more than understanding what is taught in college courses.
Part of understanding the practice is acknowledging the consequences of
failing to apply the knowledge in a faithful, ethical, and morally right
manner that benefits society. Only then can an evolving profession
rise to the calling of a profession. In short, if a professor of
exercise physiology gives students a chance to study ethical thinking,
students are more likely to avoid ethical mistakes, first, by learning
to live it and, second, as a professional. This is especially important
because, if other healthcare professionals understand the importance of
teaching ethics and are teaching professional ethics in their classes,
then exercise physiologists cannot avoid doing it as well.
This is why ethic thinking should be discussed in all the courses including
the ethics of research. At the present time, there are no data to
suggest that professors teach ethics in physiology of exercise or cardiac
rehabilitation courses. And, since most academic programs are not
entitled exercise physiology, there is little incentive to integrate ethics
into the obvious four courses (exercise physiology, kinesiology, and biomechanics,
and nutrition) taught throughout the exercise science programs of study.
Instead of having an exercise physiology
history whereby students were regularly instructed to read a code of ethics
for exercise physiologists, contemporary teachers are therefore less incline
to make a commitment of class time to discuss ethics. The reason
is simple: Class after class, year after year, no one expressed appreciation
for understanding the ethical implications of carrying out person and professional
responsibilities in the public sector. The idea of talking about
or planning for ethical thinking simply did not enter the minds of most
teachers. Hence, why would students question their teacher if lectures
on ethics were not part of the class agenda? The problem of course
is that they are not aware of a higher standard of professional conduct
to which every member of the profession is held accountable. And,
without the awareness of relevant standards of conduct (i.e., professional
ethics), problems are likely to arise in the practice of exercise physiology.
Every course should address some aspect of standards and ethical thinking.
Do Exercise Physiologists Have
a Practice?
Without question, exercise physiologists
have a defined body of knowledge. Clearly, however, many exercise
physiologists do not seem to understand this point. The body of knowledge
is derived from decades of scientific research on health, wellness, lifestyle
factors, athletics, fitness, and rehabilitation. The majority of
the research is linked to the academic setting, promotion, and tenure of
university faculty members. This is a common impetus among teachers
and most academic disciplines that evolve into professions. Some
research that also supports the exercise physiologists’ knowledge based
comes from clinical, strength and conditioning, and healthcare oriented
work by both doctorate and non-doctorate prepared professionals.
However, this raises two questions: First, are exercise physiologists,
doctorate prepared or otherwise, ready to acknowledge that they have a
scientific based body of knowledge? Second, are they ready to exert
a monopoly control? Answers to these questions still await the inevitable
progression of a discipline (or occupation) to a profession, as it is challenged
by the indifference of important members of the evolving profession who
are poorly motivated to recognize the need for change.
Do exercise physiologists have a
practice bears repeating. They do. But, the practice will only
be defined with a collective understanding and coming together that shares
a common vision. This is exactly what the ASEP leadership hs done
to distinguish exercise physiology from sports medicine. Like any
other practice defined by members of an organization, the conduct of the
members is controlled within the profession. Once established, primarily
by either board certification or licensure, the profession controls the
practice. This is critical to an independent market niche with important
professional and financial implications. Also, of critical importance
is the fact that the evolving profession exists to benefit society.
In other words, part of what constitutes a profession is a strong sense
of responsibility to others and not to one’s personal gain and/or career.
Pprofessionals must contribute to the social well-being of society by putting
their clients’ needs ahead of their own, and by holding themselves accountable
to standards of competence and conduct [2].
Aside from understanding that exercise
physiologists do have a practice and are valued in society as healthcare
professionals, there are too few exercise physiology programs. And,
consistent with common knowledge, the majority of the programs are geared
towards fitness instruction. There is little to no curriculum revisions
that would indicate incremental changes in the academic preparation of
exercise physiology students. It seems that professors are not as
interested in serving students (i.e., beyond their usual class lectures)
as they should be. Since the founding of ASEP, the implementation
of the accreditation procedures and the launching of the board certification
for exercise physiologists have been slow. Yet, professors have a
tremendous amount of power that could command change. It is my contention
that professors must increase their awareness of and sensitivity to the
students’ sources of conflicts.
The Professors’ Dilemma
Professors face an interesting dilemma
in the face of exhortations to proceed with research without professionalism.
In the simplest terms, to continue exactly along the same path as decades
reveal is to appear to be useless if not selfish in helping students become
professionals. Today’s instruction must clearly present issues and concerns
that revolve around and from professionalism, describe and plan for conflicts
between loyalty to the present educational approaches and concern for ethical
thinking. This is especially important to reducing the ambiguity
between fitness professionals (personal trainers) and exercise physiologists.
It is also a daunting task, but one that is neither trivial nor anti-intellectual.
Among other things, it is taking responsibility for one’s actions and mistakes
and also being able to comprehend the necessity for the professional development
of exercise physiology. There is complete justification for saying
this [3].
ASEP exercise physiologists understand
the importance of ethical thinking, professionalism, and the professional
challenges ahead of them. They value the ASEP accomplishments, look
forward to the increased diversity in career options, and the agenda that
is fundamental to an entirely new menu of services and goods as a healthcare
professional. In general, they do not suffer from groupthink.
I’ve argued elsewhere that much of the unresolved issues of the change
process within the college environment and/or sports medicine is linked
to groupthink [4]. Certainly well intended professors will
have to settle their own personal and professional value conflicts between
sports medicine and exercise physiology. It would be wrong to imagine
that sports medicine is professionally accountable for exercise physiology
judgments when the notion of competence is underpinned by the distinction
from within an established or otherwise evolving profession. Those
who do not understand this point need to take more seriously the history
of what it means to belong to and practice a profession.
The question that comes to mind is
whether student power, independence of exercise physiology practice, and
financial stability are important to professors. The issue of jobs
in the public sector versus career opportunities is the reason for full
involvement of the academic community. Until they are fully committed
to the profession of exercise physiology, identify with it and ASEP as
a profession and professional organization, respectively, and are dedicated
to its future development, exercise physiologists will probably spend considerable
time and effort in an uphill battle with society and other healthcare professions.
What exercise physiologists can do is to unite and to organize themselves
around the ASEP initiatives. Further, they need to become involved
in understanding organizational politics and participate, where possible,
in important legislation that influences their practice. Still further,
exercise physiologists need to demonstrate standards of quality performance,
accountability, and professionalism along with establishing a support system
for exercise physiologists.
The Paradigm Shift in Exercise
Physiology
Almost from the inception of exercise
physiology from the ASEP perspective, societal needs and healthcare concerns
have been the driving force behind the establishment of the exercise physiology
standards of practice that guide the profession today. Although it
isn’t recognized among fitness experts, exercise specialists, and clinical
exercise physiologists, exercise physiology board certification (if not
licensure as well) is a given in today’s healthcare system. In time,
an exercise physiology practice act defined by state legislation will regulate
the practice of exercise physiology to protect the public and make exercise
physiologists accountable for their actions. Imagine the quality
of exercise physiology in just a few years after credible exercise physiologists
are in the work force. Imagine the care of clients and the growth
and opportunities after established standards of a minimum education and
course work are in place.
Indeed, unlike many other professions,
exercise physiologist have invested in and integrated scientific based
knowledge with the intent to exam, measure, and apply to better the health
of clients throughout the public sector. Although presently insulated
to some degree from their objective of practical and meaningful application
to society, the objective of exercise physiology directed healthcare is
a force of change. The wide variety of settings, including private
practice [5], hospital driven fitness facilities, business driven health
promotion centers, personal home health and fitness care, exercise physiology
department operated fitness and/or rehabilitation programs, community based
educational settings, and exercise physiology research represent career
options. Exercise physiologists should be prepared to promote an
interdisciplinary education, establish new alliances with other healthcare
occupations, and demonstrate their cardiovascular physiology niche through
the use of computer driven metabolic technology and interactive software.
The exercise physiologist of the
future will need to practice with professional self-reliance, personal
independence, and flexible decision-making skills based on an expanding
scientific base of exercise physiology knowledge. A working knowledge
of basic business principles, leadership and management skills, andcomputer
and laboratory competencies, as well as the professional delivery of high-quality
data and information to healthcare clients are part of the paradigm shift
in exercise physiology. Of course, at present, the students’ education
is not what it should be to make the shift a reality. Therefore,
it is imperative that the faculty and administrators responsible for undergraduate
education step up to the plate and make necessary program changes.
Healthcare issues and concerns will always exist. The population
is always getting older. There will always be the need for scientific
based exercise physiology healthcare professionals to tackle the consumer
driven health, fitness, and rehabilitation problems.
Making Good Judgments and Decisions
The ability to use knowledge and
make decisions is fundamental to critical thinking. Exercise physiology
education will need to prepare students for making good judgments and decisions.
Professors will need to teach students to develop critical thinking skills
[6], including how to evaluate and learn from out of the box thinking [7].
The knowledge and thinking required by exercise physiologists as healthcare
professionals go far beyond what is currently required of new graduates.
Exercise physiology professors and students must understand not only their
body of knowledge, but also understand its professional application to
society. In other words, exercise physiologists must learn how to
think professionally in addition to their usual research thinking.
Decisions will need to be made about curriculum changes as well as an understanding
of the client’s knowledge of lifestyle risk factors and motivation to live
a healthier lifestyle. Professors will be challenged to provide educational
and laboratory experiences to prepare students for careers in the consumer-driven
healthcare system. Students will need the ability to make good judgments,
to use logical and analytic skills in conjunction with intuitive and out
of the box problem-solving abilities, and to choose appropriate courses
of action for clients.
By understanding the importance of
ethical thinking [8] and by using critical thinking skills, exercise physiologists
will demonstrate to the public that they are prepared to make accurate
decisions about healthcare. None of this is going to be easy.
Paradigm shifts are always a challenge [9]. The ASEP leadership [10]
knew this from the beginning, but it took responsibility for establishing
the standards of practice for exercise physiologists and for guaranteeing
the competence of those who claim the title of exercise physiologist.
Since 1997, the ASEP leadership has upheld the belief that baccalaureate
[11] should be the entry-level degree for professional exercise physiologists.
The belief is based on several assumptions. First, exercise physiology
is a healthcare profession. Second, as professionals, their practice
is directly linked to the health and well being of society as well as having
knowledge to impart regarding rehabilitation and athletics. As their
services become more recognized and accepted by members of society, the
demand will increase. This will result in an increase in depth and
breadth of scientific knowledge of the services of exercise physiology
practitioners.
The rationale for enhancing critical
thinking is tied to expanded educational hands-on opportunities and professional
thinking and preparation for entry into practice [12]. It is based
on independent reason, personal and/or professional reflection, knowledge
from course study and/or laboratory thinking, and situational events that
bring together bits of action oriented knowledge and sensible ethical decisions.
Ethics in exercise physiology, like other healthcare professions, is based
on ethical principles and the ASEP Code of Ethics. It is the professional
method of knowing what is right or wrong. Hence, ethical thinking
protects society by providing a clear demarcation line between what is
right and what is wrong in situations where it is not clearly apparent.
The key to developing these skills is the recognition and acceptance of
the ASEP Code of Ethics. Unfortunately, as stated earlier, the exercise
physiology Code of Ethics is completely new to exercise physiology.
The emphasis on moral responsibility and ethical decision-making has created
tension and conflict among certain members of the profession. For
example, sports nutritionists have a history of encouraging sport supplement
usage without dealing with the ethical issues. Should athletes, regardless
of age, be encouraged to consume supplements and/or drugs? The resolution
of ethical dilemmas like ergogenic aids is never an easy task.
Final Thoughts
We have come a long way as exercise
physiologists. First, there were physiologists, medical doctors,
and physical educators in terested in fitness and training for athletics,
better health and even for war. Then, exercise physiologists branched
out to develop adult fitness programs in which the members served as subjects
for a variety of research projects. What came from much of this work
was the obvious by those who understood the benefits of regular exercise.
In the early 1970s it was proposed that adults with coronary artery disease
and those who suffered from heart attacks could be helped by regular exercise.
Programs grew across the country. In time, it became obvious that
women should be tested and exercised as well. Increasingly, the doctorate
prepared exercise physiologists benefited from the research. Master
prepared students were hired as exercise specialist or as individuals with
training in graded exercise testing and measurements that assessed the
cardiovascular system (VO2 max in particular).
With increasing number of exercise
physiologists working in the clinical realm, they adapted to the "clinical"
exercise physiology title. They were not exercise physiologists if
they did not have the doctorate degree. Frankly, this was the beginning
of the division between those have it and those who don't. In time,
not having the doctorate degree was compensated by the selected use of
the title. And, yet at the same time, no serious changes in the academic
programs allowed for the title or proved that the non-doctorates were credible.
In part, the American Association of Cardiovascular Pulmonary Rehabilitation
organization was formed to help create guidelines and consistency in working
with heart and pulmonary patients. The effort misfired early
on with the involvement of nurses. Almost anyone would agree that
the AACVPR organization is directed by nurses. Not once has it stepped
up to the plate to further the education or the credibility of the master
prepared exercise physiologist.
This is a reasonable analysis and
one that bears directly on the founding of the ASEP organization.
ASEP is completely and profoundly about students and the professionalism
of exercise physiology. In just six years, ASEP has produced a credible
professional organization for all exercise physiologists. And, now
we can talk about a code of ethics, accreditiation, certification, standards
of practice, and what it means to be a professional exercise physiologist
with his or her own professional organization to support and regulate the
profession.
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