PEPonline
Professionalization
of Exercise Physiologyonline

An international electronic
journal for exercise physiologists
ISSN 1099-5862
Vol 3 No 6 June 2000


 
The Professionalization of Exercise Physiology: A Critical Essay
Stanley P. Brown, Ph.D., FACSM
Associate Professor of Physical Therapy
Department of Physical Therapy
Southwest Baptist University
Bolivar, MO 65613-2496

This paper addresses fundamental issues regarding the professionalization of exercise physiology. In doing so a contrast is provided between two fields of study, one professional (physical therapy) and the other disciplinary (exercise physiology). The exploration of the differences between these two "linked" fields is timely, because of the current effort to "professionalize" exercise physiology.  At stake in this debate are issues of encroachment as clinical exercise physiology strives for further recognition.

Introduction
HEALTH CARE is in a revolutionary state of change broadly related to how health services will continue to be delivered in a cost-effective manner. One of the manifestations of this fundamental change is for established health care specialties within a discipline to become more competitive with each other over the scope of practice, such as that which is occurring between internal medicine and family practice medicine regarding primary care. This competition manifests itself cross-disciplinary as well when medicine and nursing compete for access to primary care dollars, or chiropractic care and physical therapy competitively lobby state legislatures over scope of practice related to manipulation. The present article is focused on a third manifestation which occurs when an emerging clinical discipline proposes to fill a self-stated void in clinical practice. The competitiveness with established clinical disciplines is self-evident. The present article is an attempt to draw a distinction between physical therapy and clinical exercise physiology in scope of practice by striving to show a difference between the two clinical specialties in their relative degree of "professionalism". 

American society is an economic driven entity in which consumers determine the outcome, success, and ultimately the professionalization of a discipline. The historic success of the established allied health professions was probably not based on a cold calculated strategy by professional groups to change their professional status.  Neither did professionalization happen by accident. The "need" and the "value" that consumers associate with services provided by particular allied health professionals was probably the fundamental reason for recognition of their profession. Today, there is a concerted effort by leaders in the emerging clinical discipline of exercise physiology to fill a perceived void in clinical practice.  The professionalization issue is important because charges of encroachment are sure to arise over the effort to "professionalize" exercise physiology.  While the progress made towards the professionalization of exercise physiology is laudable, as a field matures it is important to recognize critical issues so that a proper philosophical underpinning can be assumed. The purpose of this paper, therefore, is to communicate important foundational concepts in the debate on the professionalization of exercise physiology.

A Call to Professionalism 
The professionalization of exercise physiology over the last three decades has manifested itself most importantly in four ways: 

  • The development (starting in the 1970s) and promotion of rigorous clinical certification programs by the American College of Sports Medicine (ACSM) (1);
  • Lobbying efforts over the last decade to enact state licensing legislation for clinical exercise physiologists (2);
  • The establishment in 1997 of the American Society of Exercise Physiologists (ASEP) with its stated purpose being to professionalize the field; and 
  • Most recently, the development by ACSM of a national registry of clinical exercise physiologists (first national registry exam was offered in June 2000) (3).
While these activities are important developments toward the professionalization of the field of exercise physiology, the current promotion of the field on the national level as an emerging new health care profession should be critically analyzed by advancing reliable philosophical and historical arguments as to what constitutes a health care profession. 

In this paper the term health care profession is applied to those groups assuming a leadership role in the care of patients, and those that have a self-contained body of knowledge, are able to function autonomously, and are sanctioned by law to "practice".  The thesis of this paper is that although exercise physiology has a vital niche in health care, this role most properly falls under the label, paraprofessional. This idea is developed in this paper by examining physical therapy, and comparing this established health care profession with that of the emerging profession of clinical exercise physiology. To orient the reader, Table 1 presents some common related terms as defined by the allied health reference text, Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health. 

Table 1. Definition of key terms.

Allied Health - a broad field of study encompassing diverse health care professions, including clinical laboratory personnel, physical therapy, occupational therapy... It does not include physicians, nurses, dentists, or podiatrists.
Allied Health Professional - a person with special training and licensed when necessary, who works under the supervision of a health professional with responsibilities bearing on patient care.
Paraprofessional - a person specially trained in a particular field or occupation to assist a professional such as a physician.
Profession - a calling or vocation requiring specialized knowledge, methods, and skills, as well as preparation ... in the scholarly, scientific, and historical principles underlying such methods and skills. A profession continuously enlarges its body of knowledge, functions autonomously in formulation of policy ...

What Constitutes a Health Care Profession?
This paper differentiates between the terms professionalism and professional. While the former term may be applied readily to superior job performance, the later is strictly used of individuals who practice a profession and is not intended to connote competence. Whereas attaining professional recognition is highly desired by occupational groups who wish to be recognized for performing their job in a "professional" manner, competence per se does not automatically make one a professional, since the designation, professional, is reserved for individuals who are in the "professions". 

In the 19th century and 20th centuries, it was widely recognized that there were only three professions: theology, law, and medicine.  As sanctioned by society, only the professional was qualified in the knowledge base, and could by law engage in professional practice. There were rigorous academic and practice standards (especially in the 20th century as these professions developed) to be met before one was allowed to enter any of these professions. However, the term profession as it is used today has been diluted as to become all inclusive.

How does this relate to the current effort to "professionalize" exercise physiology?  Given the philosophical premise and historical precedence that the term, profession, should be used narrowly, we must ask how the field of exercise physiology can achieve this status. Although it is generally recognized that the list of professions is longer today than at other point in our history, that list is not as extensive as many may think. 

Purtilo and Cassel (4) mention five critical characteristics important for health care professions: 

  • Self-governed autonomy
  • Social value
  • Specialized knowledge
  • Representative organization, and 
  • Lifetime commitment. 
Many of these five characteristics have been proposed elsewhere using different terms (5,6).  If this list truly represents the critical characteristics of health care professions, a potential problem exists for exercise physiology and other so-called health care professions. In the case of clinical exercise physiology, the greatest avenue for professional recognition is viewed to be within health care, yet based on philosophical grounds, this avenue to professionalization may provide significant stumbling blocks due to Purtilo and Cassel's characteristics mentioned above. 

Comparing Exercise Physiology to Physical Therapy
The rationale for the preceding statements is largely based on essentially the same debate that has shaped the field of physical therapy over the last 20-30 years.  During this time there was a national call for physical therapy to define itself based on body systems, with the claim that in doing so a professional niche would be more readily apparent.  In 1983, for example, the House of Delegates of the American Physical Therapy Association (APTA) defined physical therapy as "a health care profession whose primary purpose is the promotion of optimal human health and function through the application of scientific principles to prevent, identify, assess, correct, or alleviate acute or prolonged movement dysfunction" (emphasis added) (7).  In the 29th Mary McMillan Lecture at the 1998 national APTA conference, and subsequently published in the journal, Physical Therapy, Dr. Shirley Sahrmann of Washington University called for physical therapy to "solidify our identity as a profession by developing the concept of movement as a physiological system (emphasis added) and by accepting the role of practitioners responsible for a system of the human organism (emphasis added) (7).  This call recognized that the well-established and accepted health care professions are defined by their role as experts on a particular anatomical or physiological system (Purtillo and Cassel's characteristic of specialized knowledge) (8).  This is a very important approach to take, because by defining the body system and then establishing exclusivity in the application of the knowledge base within a scope of practice, a strong case is made for the establishment of a "niche" within health care.

However, as leaders in physical therapy advance this kind of argument to establish their niche of specialized knowledge, those with primary training in physiology would challenge these individuals to demonstrate unequivocally that movement is a "physiological system" as opposed to a state of being having physiological response and adaptation properties. Moreover, movement is not "a system of the human organism" as suggested, any more then is sleep, for instance. In fact, physical therapy (like clinical exercise physiology, as we will see in the remainder of this paper) has not presented a convincing case of what their knowledge base is independent of other clinical disciplines.  Movement, kinesiology, or exercise cannot be the exclusive domains of physical therapy since they are studied and applied in many clinical arenas including medicine, nursing, occupational therapy, respiratory therapy, athletic training, and clinical exercise physiology.  However, as we will see, physical therapy is advancing in this tact by developing within their scope of practice the diagnosis of movement dysfunction.

Scope of Practice
It is clear that exercise physiology is not being defined by physiological systems. Recently, the exercise physiologist was defined as a person who has been awarded a baccalaureate degree in exercise physiology (9).  It is readily apparent, however, that this definition is circular, does not explain anything to the public or to fellow health care professionals, and is would probably do little to accomplish the goal of professionalization. The definition advanced by the ACSM through its scope of practice statement communicates the idea that clinical exercise physiologists may include in their practice a wide variety of disease states (3).  However, this way of defining the exercise physiologist is also problematic, because it does not establish a professional niche, since it fails to clearly delineate an area of expertise in the body.

If an attempt were made to define the exercise physiologist in the way physical therapy has sought to define itself, would this approach work? In addition, what body systems could be chosen?  The ACSM has advanced the idea that the registered clinical exercise physiologist is capable of providing services for patients with cardiovascular, pulmonary, metabolic, orthopedic, neuromuscular, inflammatory, and immunologic disorders (3).  Yet, providing exercise services to these patients is not the same thing as defining one's expertise on particular anatomical or physiological systems.  However, this way of defining the "profession" of exercise physiology would be problematic, since this does not establish specialized knowledge for clinical exercise physiology.  Yet, the content base of exercise physiology is easily shared by physical therapy, medicine, and nursing.

Autonomy in Patient/Client Management
While the profession of physical therapy is certainly not as well developed as medicine, it is, nevertheless, a clinical specialty that is making great strides towards autonomy, and is clearly well in ahead of clinical exercise physiology. The reason for this is that the therapist manages patients with movement dysfunction by integrating the six elements of patient/client management: examination, evaluation, diagnosis, prognosis, intervention, and outcomes (10).  While, these activities may involve consultation with other health care professionals, the physical therapist has a degree of is autonomy that may never be rivaled by clinical exercise physiology in the management of movement dysfunction.  Although not specifically included in the list provided by Purtilo and Cassel, the idea of autonomy in patient/client management is extremely important because it distinguishes professional practice in health care from those duties performed by paraprofessionals. Autonomy in patient/client management means that within the specialized knowledge (although as we have seen, physical therapy also has a problem claiming specialized knowledge) base of the health care profession, the clinician/ professional has the range of authority to determine the most appropriate intervention designed to maximize outcomes. Autonomy in patient/client management is a proposed sixth characteristic that effectively limits which health care field can aspire to professional status. 

Contrary to physical therapy practice, the exercise physiologist does not function within a patient/client management model. For instance, what diagnoses would exercise physiologists provide, and for what system(s) are these diagnoses provided? According to the scope of practice for exercise physiologists advanced by the ASEP (11), "the certified exercise physiologist can function in the use of exercise for the diagnosis (emphasis mine), prevention and rehabilitation of diseases, and in the research of diseases or disease processes that can be influenced by exercise".

If diagnosis is part of the scope of practice of the exercise physiologist (not stated by ACSM, but incorporated by ASEP), how is this diagnostic ability imparted to exercise physiology/science students in academic programs, and are these medical, nursing, or  movement dysfunction diagnoses?  In either case exercise physiology would be of violation of state licensure laws, because these diagnoses are under the purview of the licensed physician, nurse, and physical therapist, respectively.

Before a diagnosis can be made there must be an examination.  However, in exercise physiology, how are independent examinations made, what systems are examined, and what are the tests employed in these examination?  Historically, the clinical exercise physiologist uses the ergometer, electrocardiogram, and open circuit spirometric technique to assess the functional capacity of the cardiorespiratory system. However, these examinations and/or tests are ordered, often performed, and interpreted by the licensed physician.  The role of the exercise physiologist in this model is that of a paraprofessional, functioning under the purview of the physician, or just as often, the nurse.  While exercise prescription affords the exercise physiologist some "professional" role, this is often coopted by the physician as well. 

The definition of physical therapy is based on the concept of movement as a physiological system. While this definition is suspect based on philosophical grounds, physical therapy is nevertheless striving to establish a professional niche. If it is successful in this attempt it should have sustained success if it continues to emphasize this self-selected definition to the public, other allied health professions, and the medical community.  Health care practice within clinical kinesiological science is recognized today to be the purview of the physical therapist, not clinical exercise physiology.  Exercise physiology must find a niche, not shared by other allied health fields, to be recognized as a profession. 

Level of Training
Exercise physiology is currently in a period of unprecedented growth as an academic discipline, with its knowledge base applied to the clinical setting widely recognized as vital in the care of a number of patient populations. However, exercise physiology clinical practice does not constitute "professional" practice, as narrowly defined in this essay, but rather as an important paraprofessional activity which is becoming more and more accepted. 

The extent of clinical education the masters level (most commonly being used in health care settings) exercise physiology student receives is far less than students in the health care professions. Table 2 shows how typical master's degree programs in exercise science compare with entry level master's degree programs in physical therapy, and with several doctorally trained health care professionals. As can be seen, the master's degree in exercise science/ physiology when compared to the entry-level master's program in physical therapy has far fewer hours devoted to clinical education. 

Table 2. Comparison in four categories of course requirements of six professional doctoral programs with that of an entry-level master's degree program in physical therapy and an exercise science program.a
 
Credit
Hours
Course
Category		 ESb PT OD PharmD DC DPM DDS MDc
Basic
Science		 27 30 51 25 100 48 40 723
Diagnosis & Treatment 0 38 60 52 117 60 65 723
Professional
Socialization		 0 5 5 21 15 10 6 42
Clinical
Education		 3d 17e 52 28 23 59 45 4753
Total 30 90 168 126 245 177 156 6241

aTable adapted from Sahrmann (7). 
ES = Exercise Science
PT = Physical Therapy
OD = Optometry
PharmD = Pharmacy
DC = Chiropractic
DPM = Podiatry
DDS = Dentistry
MD = Medicine
bRepresents a typical 30 semester hour exercise science master's program. 
cData are clock hours required by a medical school in the Midwest. 
dRepresents approximately 150 clock hours which may vary between academic programs. 
eRepresents approximately 920 clock hours. 

The amount of clinical education completed by the health care professionals in this list is roughly equal to the basic science training they receive. The exceptions are physical therapy and chiropractic, which have more hours devoted to basic science, and medicine with far more hours devoted to clinical education.  The clinical experience received by exercise science/ physiology students is, largely, observational, often with little or no direction being given to the student.  A shared responsibility between the clinic and the academic department is typically not very strong in cardiopulmonary rehabilitation "internship" experiences, for example. This relationship should be a close, formal, working relationship between an on-site clinical instructor and a person within the academic department directing meaningful follow-up and instruction. This is the model of clinical education currently practiced in academic physical therapy and other allied health professions, such as athletic training and occupational therapy.

The model currently followed for exercise science/physiology students wishing to pursue cardiopulmonary rehabilitation may lead to questions regarding the quality of the product being developed for clinical positions.  Academic programs should consider whether the amount of clinical training currently being given to these students required to attain the academic credential is adequate. A strong move toward professionalization will have been made when this problem is solved.  However, given the earlier premise about specialized knowledge and autonomy in patient/client management (notice the diagnosis and treatment category is zero for the typical exercise science program), leaders in the field should be content to establish the exercise physiologist as a "stand alongside" (para) professional.  Regardless of one's opinion, a better clinician will be developed if these graduate programs can be made over into "professional" programs, with far more hours devoted to clinical experience before granting the degree.  However, these degrees are usually graduate master's degrees with an emphasis on research (in programs requiring a terminal thesis).  Should this model be continued or should it become a professional master's degree (with greatly expanded academic hours) where the graduate is not required to be competent in research to qualify for practice as is the case for the clinicians mentioned in Table 2? 

Discipline or Profession?
Exercise science (and its academic subdisciplines) has (have) experienced remarkable development over the last 30 years and currently stands at the dawn of a new millennium as an extremely well established academic discipline (12,13).  This growth in exercise science is partly evidenced by the increase in the amount of federal funding provided exercise science research over the last two decades.  Funding from the National Institutes of Health will continue to have a large influence on basic and applied research directly related to exercise science (13).  In view of the fact that exercise science is firmly established as an academic discipline, how does this affect the current drive to "elevate" one of its subdisciplines, exercise physiology, to professional status?  To answer that question, it is important to briefly delve into the relationship between a discipline and a profession.

Physical therapy and exercise physiology/science are related through a shared body of knowledge -- movement (14).  In professional terms the goal of both exercise physiology and physical therapy is to bring patients to a better functional outcome. Yet, physical therapy is a recognized profession, while exercise physiology is a recognized academic subdiscipline of the discipline of exercise science.  For a particular profession there is always a closely related academic discipline(s) (14).  This relatedness centers on the body of knowledge of both the discipline and the profession. 

The knowledge of movement derived from the academic discipline of exercise science is translated into practice by the physical therapy profession.  The two fields work in a symbiotic relationship (see Figure 1).  The flow of information between the discipline and profession occurs in both directions.  Professions often function as a guide for the discipline, which often may lead the discipline to alter a theory, based on observations made in the day-to-day practice of the profession.  Abernethy and co-workers write, "Disciplines therefore seek to understand subject matter and professions to implement change based on this understanding" (14).  However, it is important to recognize that the discipline may engage in applied research and the profession may also be the site for original research (14). 

Figure 1. Working relationship between the discipline of exercise physiology and physical therapy, a movement profession.
 
Exercise Physiology Physical Therapy
Discipinary Concerns Professional Concerns
Definitions Objectives
Descriptions Programs
Relationships Patient/Client Management
Causes Optimal Outcomes
Effects Applied Research
Applied and Basic Research

The profession of physical therapy, relies on its disciplinary fields (i.e., exercise physiology, biomechanics, neuroscience, anatomy) to furnish it with knowledge about movement so that its practice (examination, evaluation, diagnosis, prognosis, intervention, and outcomes) can be valid and reliable (15).  To say that exercise physiology is a profession is to do away with this vital link between discipline and profession.  This, to say the least, is fraught with difficulties, for if exercise physiology is a profession, what is its related discipline?


 References
1. Kenney, W.L. (1995). ACSM's Guidelines for Exercise Testing and Prescription (fifth edition). Baltimore: Williams & Wilkins.
2. Louisiana clinical exercise physiologists licensing act (R.S. 37:3421-3433). Louisiana Register 1997;23(4):405-412.
3.  The ACSM registered clinical exercise physiologist: the premier clinical credential for graduate-level exercise physiologists. Certified News. 1998;8:5.
4.  Purtilo, R.B., Cassel, C.K. (1993). Ethical Dimensions in the Health Profession. Philadelphia: W.B. Saunders Company.
5.  Boone, T. (1999). Rising to the level of "profession". Professionalization of Exercise Physiologyonline [Online]. Available:www.css.edu/users/tboone2/asep/feb1.htm. [Accessed January 28, 2000].
6.  Flexner, A. (1915). Is social work a profession? School and Society. 1:901-911.
7.  Sahrmann, S.A. (1998). Twenty-ninth Mary McMillan lecture: moving precisely? or taking the path of least resistance. Physical Therapy. 78:1208-1218.
8.  Kendall, F.P. (1980). Fifteenth Mary McMillan lecture: this I believe. Physical Therapy. 60:1437-1443.
9.  Boone, T. (1999). Defining the exercise physiologists. Professionalization of Exercise Physiologyonline [Online]. Available:www.css.edu/users/ tboone2/asep/may2.htm. [Accessed January 28, 2000].
10.  Guide to Physical Therapy Practice. Alexandria, Virginia: American Physical Therapy Association; 1999.
11.  Scope of practice for ASEP exercise physiologist certified. American Society of Exercise Physiologists Web site. Available:www.css.edu/users/tboone2/asep/ jan14f.htm. [Accessed January 17, 2000].
12.  Blair, S.N. (1999). Sports medicine and exercise science in the 21st century. Sports Medicine Bulletin. 34(2):8.
13.  Baldwin, K.M. (1999). Research in sports medicine and exercise science in the 21st century. Sports Medicine Bulletin. 34(3):9.
14.  Abernethy, B., Kippers, V., Mackinnon, L.T., Neal, R.J., Harrahan, S. (1997). The Biophysical Foundations of Human Movement. Champaign, IL: Human Kinetics.
15.  Winstein, C.J., Knecht, H.G. In: Rothstein JM, ed.(1991).  Movement Science. Alexandria, VA: American Physical Therapy Association. 

Address correspondence to:
Stanley P. Brown, PhD, FACSM
Associate Professor of Physical Therapy
Department of Physical Therapy
Southwest Baptist University
Bolivar, MO 65613-2496
Phone: 417-328-1672
FAX: 417-328-1658
email: spbrown@sbuniv.edu
Copyright ©1997-2000 American Society of Exercise Physiologists. All Rights Reserved.

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