PEPonline Professionalization of Exercise Physiologyonline An international electronic journal for exercise physiologists ISSN 1099-5862 Vol 3 No 8 August 2000 Meeting the Standards of a Profession Jesse Pittsley, MA and Patrick Riley, MA, ATC, CSCS College of St. Scholastica Duluth, MN RECENTLY, Brown (1), a faculty member of the Physical Therapy Department at Southwest Baptist University, wrote a very thought provoking article regarding concerns about the professionalization of exercise physiology.  The characteristics of self-governed autonomy, social value, specialized knowledge, a representative organization, and lifetime commitment were discussed throughout the article.  The author also compared and contrasted exercise physiology with physical therapy to examine professionalization.  Without such debate, the field of exercise physiology may very well remain stagnant as it has been for some years.  The points brought forth by Brown examine important issues about exercise physiology and what constitutes professionalism.  Although Brown's thoughts expressed in the June article were well written and interesting, we found several deficiencies in the logic used in the arguments presented.  The purpose of this article is therefore to analyze the statements and examples presented by Brown.  Granted, we understand that exercise physiology has much to accomplish in regards to professionalism. Brown compares physical therapy and exercise physiology throughout his article.   In his comparison,  he states that, "Contrary to physical therapy practices, the exercise physiologist does not function within a patient/client management model (1)."   To support this statement, he argues that the exercise physiologist's inability to diagnose devalidates the exercise physiologist as a health care professional.  To open this argument a quote is taken from the Scope of Practice for ASEP exercise physiologists.  The quote reads, "the certified exercise physiologist can function in the use of exercise for the diagnosis (emphasis his), prevention and rehabilitation of diseases, and in the research of diseases or disease processes that can be influenced by exercise (2)." Citing this quote as evidence, Brown states that exercise physiology sees the diagnosis of disease as being within its scope of practice.  It is our view however that Brown misinterprets the statement.  To assist in correctly understanding the quote, we would like to examine a statement made earlier in the Scope of Practice document regarding the "Exercise Physiologist Certified (EPC).   That is, "The EPC is a broadly trained and competent professional who can function in fitness, allied health and wellness, clinical work settings, and athletics that require the use of exercise for the purposes of developing and maintaining good health and fitness, disease diagnosis, physiological assessment, rehabilitation, and athletic performance (2)."  It is our interpretation that the exercise physiologist uses exercise as part of the complete diagnostic process, but does not claim to actually make any diagnosis. We think that the statement coincides with important aspects of other professionals who have a part to play in the diagnostic process.   As an example, a certified athletic trainer is considered a professional by the American Medical Association (3, 4).  Yet, making a diagnosis is not within the athletic trainer's scope of practice.  The athletic trainer does, however, play a vital role in the diagnostic process by having the training and skills necessary to form a clinical impression of any given injury situation (3).  That impression is then passed on to the supervising physician.  The physician then, in turn, makes the diagnosis.  It is apparent to us that the exercise physiologist does have the academic training and applied skills to offer an assistive-judgment about stress test portocols and performances.  The exercise physiologist with an academic degree in the field should have the specialized knowledge to understand and to make a professional judgement about a patient's (or an athlete's) physiologic adjustement (or the lack thereof) in response to a stress test or rehabilitation program.  Furthermore, just because the exercise physiologist does not perform an independent diagnosis, he or she does not automatically forfeit the right to be called a professional.  Brown further states that because these tests and/or rehabilitation programs come as a result of a physician's orders, the exercise physiologist must be called a "paraprofessional (1)."   This type of thinking isn't consistent with the idea underlying the ASEP Scope of Practice.  Again, we believe it is important to draw from the experience of other health care professionals.  Take, for example, the nurse who has the training and skills to make independent decisions and yet the care provided by the nurse is based on a physician's orders (5).  In fact, the historical role of nursing has been to assist physicians (5).  To our understanding, no one has precluded the nurse from the ranks of the professional. By comparison, the certified athletic trainer operates very closely with the team physician and base many of their actions on the orders of the physician.  Once a diagnosis has been made and rehabilitation orders given, it is up to the athletic trainer to administer rehabilitation (4).  The athletic trainer then proceeds with rehabilitation, making adjustments along the way.  As is commonly understood, the physician stays involved with follow-up visits and is available should the athletic trainer require consultation.  Just because physicians make the diagnosis and order the rehabilitation of an athlete, it does not make the athletic trainer a "stand alongside paraprofessional (1)" whose purpose is to assist the physician.  They operate as a team with the athletic trainer providing the care that both trainers and physicians deem appropriate.  Similarly, when a patient is referred for cardiac and/or pulmonary rehabilitation, it is the exercise physiologist's responsibility to administer the program.  The director of the cardiopulmonary rehabilitation team, like the director of the sports medicine team, is the physician.  But, like the athletic trainer, it is up to the exercise physiologist to administer the program.  This means determining mode, duration, and intensity of exercise that is safe and effective for the patient.  The exercise physiologist uses specialized knowledge to identify when program modification and future interaction with the physician is necessary.  Granted this may not be the scenario for every rehabilitation program, it is clear however, that throughout the process, the exercise physiologist is responsible for making decisions regarding the patients' well being.  Brown implies that the training exercise physiologists receive is insufficient compared to other professionals in the clinical realm (1).  To support this statement, he provides a compilation of the number of hours required for different disciplines to complete their academic preparation in the four major categories of basic science, diagnosis and treatment, professional socialization, and clinical education (5).   In this comparison, several professions are examined at differing levels of academic preparation.  For example, the hours required for a master's degree in exercise science are compared to the preparation required to be a physical therapist, Doctor of Chiropractic, a Doctor of Medicine, and several others.  It should be noted that much of the information in the table appears to be presented for informational purposes and is not intended to be used in the argument.  Several examples make unequal comparisons, which should not be the case, including the comparison between the master prepared individual and the doctorate prepared individual.  The three to four (sometimes five) years of additional preparation to obtain a doctorate degree increases the number of preparation hours depending upon the acadmeic track identified by the individual.  With the master to doctorate comparison excluded, one must then compare two individuals with the master's degree.   At many institutions, a master's degree in physical therapy is a 5.5 to 6-year program (including the science prerequisites and liberal arts courses).  At the College of St. Scholastica, after three years of undergraduate work the individual is accepted into the physical therapy program for 2.5 to 3 additional years of study (6).  Comparing this volume of course work to the common one to two-year master's degree programs in exercise physiology/science is once again an unequal comparison.  To establish an equal analysis, a comparison should be drawn between an exercise physiologist with both bachelor's and master's degrees in exercise physiology and a master prepared physical therapist.  In the basic science category, by the nature of the discipline, exercise physiology has at least equal emphasis in this area.  While physical therapists take courses such as muskuloskeletal and neuromuscular evaluation and management/treatment, exercise physiologists are enrolled in courses such as cardiovascular physiology and applied exercise physiology.  With this difference in curriculum, the science emphasis shifts towards exercise physiology.  Since exercise physiologists are not legally allowed to make diagnoses, it would stand to reason there are no courses in any exercise physiology curriculum with "diagnosis" in the title.  Additionally, since exercise physiologists do not provide "treatment" in the same sense a doctor, nurse, or PT would, the word "treatment" would, again, not appear in any course title.  Thus, this comparative category is invalid.  However, such courses as physiological assessment, exercise testing and prescription, and electrocardiography connote an evaluation and/or treatment theme.  As for professional socialization, there may be a component of some clinical exercise physiology courses that address such topics.  However, this area may be a shortcoming in some programs.  This possible deficiency is a topic that may need to be addressed by the ASEP accreditation committee.  Finally, the category of clinical education lists the number of hours the students are required to complete their clinical experience.  The ASEP accreditation model requires a semester long internship with a minimum of 400 hours of practical experience to be eligible for certification.  Many undergraduate programs list an internship as a graduation requirement (6).  An additional internship would be required of those who wish to pursue a clinical emphasis at the graduate level (6).  Adding this graduate internship increases the total number of clinical hours to exceed 800.  This number is comparable to the number of internship hours required by many physical therapy programs (6).  This analysis demonstrates that a master prepared exercise physiologist has comparable practical preparation to that of a master prepared physical therapist.  Brown gives the reader historical perspective by noting that in the late 19th and early 20th centuries, the only three professions were medicine, theology, and law.  By today's standards, this view is outdated.  He further states that, "The term profession as it is used today has been diluted (emphasis added) to become all inclusive." (1)  Because of the historical precedent set by the earlier thinking, the term profession has been (and, as suggested by Brown), should be used narrowly.  The problem with the precedent, if the idea is to exclude exercise physiology, is that precedents can and do change.  This is evidenced by the inclusion of occupational therapy, nursing, and athletic training among the ranks of the professions.  If the precedent for change and adaptation to new thinking had not evolved over time with society's needs, we would still have only three professions.  Take physical therapy, as an example.  It has evolved over the past 75 to 80 years to become an accepted profession (2).  Today, the state of exercise physiology is not unlike physical therapy of yesterday.  Exercise physiology has evolved immensely across several decades, and continues to evolve from a well organized discipline of study to a profession.  Much of the professsionalization of exercise physiology has been triggered by the high-quality scientific research that is also used to serve its targeted market (as defined by ASEP's Scope of Practice).  These qualities, along with several others previously mentioned, qualify exercise physiology as a profession.  With the establishment of ASEP, members of the exercise physiology profession have laid the foundation that physical therapy and other professions established years ago (5, 7).  ASEP is a national representative organization that will aid exercise physiology as it develops and evolves within our changing society.  The precedent has been set for exercise physiology to become a profession. References 1. Brown, S.P. (2000). The professionalization of exercise physiology: a critical essay. Professionalization of Exercise Physiologyonline, 3(6). Available: www.css.edu/users/tboone2/asep/ProfessionalismCriticalEssay.html 2. Scope of practice for ASEP exercise physiologist certified. American Society of Exercise Physiologists website. Available: http://www.asep.org/asep/asep/jan14f.htm 3. About NATA. National Athletic Trainers' Association website. Available: www.nata.org/brochures/about/htm 4. Arnheim, D.D., Prentice, W.E. (1997). Principles of Athletic Training, 9th Edition. Madison, WI: Brown and Benchmark. 5. Potter, P.A., Perry, A.G. (1997). Fundamentals of Nursing. Chicago, IL: Mosby. 6. The College of St. Scholastica. (1999). Undergraduate and Graduate Catalog. Duluth, MN: Department of College Communications. 7. APTA history. American Physical Therapy Association website. Available: www.nata.org/brochures/about/htm   Copyright ©1997-2000 American Society of Exercise Physiologists. All Rights Reserved. ASEP Table of Contents Questions/comments