Professional Development of Exercise Physiology
J. Rob Lovrich
Board Certified Exercise Physiologist
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN 55811

"The profession of exercise physiology is poised for a great leap." -- Mel Sando

Since the creation of a national professional organization in 1997, great energy has been exerted to bring exercise physiology into its own as an independent health-care profession [1].  Of course, great leaps carry great risks.  While we, as exercise physiologists, contemplate the exciting future we envision for our profession, we should consider every possibility.  For example, it may happen that the leap falls short, that we jump from the proverbial frying pan into the fire, or that we simply mis-time our jump and have no opportunity to try again.  Or, we may succeed.  It is not the intention of this paper to advocate a course of action, nor is it to discourage anyone from putting forth their best efforts to achieve a goal in which they believe.  I do hope to facilitate discussion, to distill agreement, and to help continue the evolution of our profession.  I anticipate that my comments will be received in the spirit they are intended.

The need for exercise physiology has never been greater.  American society is more obese, more sedentary, and more advanced in age than ever before.  This much is incontrovertible.  The application of exercise physiology principles in a clinical setting holds a great deal of promise for these and other health-related issues [2].  Exercise and exercise prescription, coupled with the extensive body of research knowledge developed by exercise physiologists over more than half a century, are coming into their own as treatment modalities, sanctioned and encouraged by the medical community as a whole.  This market opportunity will not go unfulfilled, and no profession is more academically prepared than exercise physiology to step into the niche being created.  However, academic preparation is not enough. 

I stated earlier that the profession of exercise physiology is poised for a great leap.  It would be more accurate, perhaps, to say that the field of exercise physiology is poised for a great leap.  The profession of exercise physiology is, or course, uniquely qualified to supply the practitioners of exercise physiology, but the two are not completely inseparable.  The principles of exercise physiology can be practiced by non-EPs.  Some would argue, and I would tend to agree, that only academically prepared exercise physiologists are truly qualified to practice exercise physiology in a healthcare setting. The certification of professional competence known as the Exercise Physiologist Certified Exam is – or at least should be – the gold standard in determining who is and who is not properly prepared to practice exercise physiology (3). 

The public does not know about the ASEP "gold standard".   While there is a burgeoning market for exercise physiology services, there has not been a commensurate increase in public knowledge about where and from whom these services should originate.  The word ‘exercise’ is on many minds.  It has been included as part of a recommendation for healthy lifestyle for years, and universally advocated by organizations in both the public and private sectors. But for the millions who require or desire assistance with an exercise program, there has been no organized campaign to direct them toward a credible source of information and advice.  Clearly, this is to the detriment of professional exercise physiologists. 

The clinical application of exercise physiology can be defined by a scope of practice. The American Society of Exercise Physiologists has published a document describing this scope and its implications for exercise physiologists, called the ASEP Standards of Professional Practice [4].  The following is an excerpt from this document, delineating the scope of practice for professional exercise physiologists:

• Sports Programs  
              Sports director  
              Strength and conditioning coach  
              Director of state and national teams  
• College and University Programs  
               Professor  
               Researcher  
               Administrator  
              Wellness Coordinator  
• Community Practice  
               Manage health and wellness programs 
               Manage fitness and athletic programs  
               Direct corporate fitness/wellness programs  
               Health and fitness club instructor  
               Health/fitness director in correctional services  
• Clinical Practice  
               Test and supervise cardiopulmonary patients  
               Evaluate and supervise special populations  
                     Diabetics  
                     Obesity  
                     Rheumatoid arthritis  
                     Dyslipoproteinemia  
                     Cystic fibrosis  
                     Hypertension  
                     Children with heart disease  
                     Low functional capacity  
                     Pregnancy  
                     Exercise technologies in cardiology suites  
                     Work hardening  
                     Occupation rehabilitation  
• Government and Military Services  
               Fitness director/manager in military, including  
                     Air Force  
                     Army  
                     Careers in military services  
• Business with the Public Sector 
               Sports management  
               Consultant 
               Funcational biomechanist/ergonomics  
               Sport psychologist  
• Private Practice 
               Personal health/fitness consultant  
               Sport psychology  
               Sport biomechanics 
               Health risk manager  
• Sports Nutrition Programs 
                Exercise nutritionist  
                Exercise nutrition counselor  
• International Programs and Practice 
               Health/fitness promotion  
               Sports consultant  
               Affiliation with international organizations 

It should be noted that the above is not even an exhaustive list.  Tthe potential scope of practice for a professional exercise physiologist is limited only by his or her imagination [5].  For the purposes of this article, though, I will limit my definition of the scope of practice for EPs to the above list and, in particular, to the elements of clinical, community and private practice. According to ASEP, these things are the purview of the professional exercise physiologist. 

The telephone book disagrees. I looked up ‘exercise’ in the Yellow Page listings for Duluth and Minneapolis, Minnesota.  I found private health clubs, fitness centers, personal trainers, physical therapists, and physicians.  I did not find any exercise physiologists!  The tenets of exercise physiology, the defined and published scope of practice for professional exercise physiologists, are being practiced today by a large number and variety of people.  Even considering the possibility that some of these organizations employ professional EPs, it is clear that the market is shared.  A quick survey of the website of the American Physical Therapy Association reveals that exercise occupies a prominent and growing role in the practice of physical therapists nationwide [6]. The same holds true for the American Medical Association [7]. In fact, the AMA website offers the following as an official statement of policy:

"The AMA recommends that physicians: (1) stress the importance of exercise for all patients and explain its physiological and psychological benefits; (2) obtain a complete medical history and perform a physical examination that includes exercise testing for quantification of cardiovascular and physical fitness as appropriate, prior to the specific exercise prescription; (3) provide appropriate follow-up of patients' exercise programs; and (4) encourage all patients to establish a lifetime commitment to an exercise program." [8]

The scope of practice for exercise physiologists conflicts with that of physical therapists and physicians, at least.  Other practitioners of de facto exercise physiology are less well organized, and thus have no published scope of practice.  Nonetheless, it is logical to assume that personal trainers, for example, engage in exercise prescription, fitness counseling, and any number of other practices listed in the ASEP Standards of Professional Practice document. 

The encroachment of other professions on the scope of practice for professional EPs has spurred discussion of certification, licensure, and title protection to help defend the practical boundaries set forth by the ASEP document.  Among the goals and objectives of ASEP is the following:

"To participate in the development and implementation of public policies and procedures concerned with exercise physiology." [9]

In the state of Minnesota, ASEP lobbied this year to introduce a bill requiring licensure for all exercise physiologists.  While that effort has been postponed, the push to legislate the protection of the EP’s scope of practice is ongoing. The debate over whether licensure is in the best interest of the profession is also ongoing – even among the leadership of ASEP, there is no consensus on this issue [10].  Nonetheless, prevailing opinion appears to be in favor of continuing the drive toward legislation.  Ultimately, attempts to regulate the practice of exercise physiology by law amount to protection of the scope of practice as defined by ASEP. 

Herein lies the rub.  While the demand for exercise services grows, the attempt to protect the practicing EP’s scope of practice effectively restricts those entitled to fulfill that demand.  As of 2000, there were 111,480 active, licensed physical therapists in the United States; for physicians the number was 777,607 [11].  For an American population of roughly 300 million, that yields a ratio of roughly 300:1 – that is, one practitioner per 300 people in the country. The corresponding statistic for certified EPs: as of April, 2004 there were 110 EPCs [12], yielding a ratio of 2.7 million:1. Simply put, there are not enough EPCs to fulfill the burgeoning demand for exercise-related services. Not by a long shot. 

So as market demand widens, exercise physiologists appear dismayed that others have begun to step in to fulfill the needs of the public.  Our focus as EPs needs to be on becoming a force in the marketplace – asserting our role as specialists, and publicizing our expertise.  The demand for our services cannot be met by our numbers – better then to concentrate our efforts on excellence, and become the standard by which all other exercise practitioners are judged.  ASEP is doing just that: by restricting the EPC exam to those with appropriate academic preparation, ASEP ensures the quality of those bearing the credential.  With regard to other, non-EPC practitioners, it is my position that they are at this juncture a necessary evil – prohibiting them from practicing will not benefit us; rather it will only force the public to seek fulfillment of their needs from even less-reputable sources.  Likewise with the proliferation of certifications from ACSM, ACE, and others: far from cutting into the scope of practice for EPs, in my view they are expanding it.  Exercise physiologists are the specialists, and over time those with the credentials and knowledge will be recognized as such.  Our job is not to be the only game in town; it is to be the best.

 
References
1. Boone, T. (2001). Professional Development of Exercise Physiology.  Lewiston, NY:The Edwin Mellen Press.
2. Boone, T. (2002). Exercise is Therapy, Prevention, and Treatment: An Exercise Physiologist’s Perspective. Professionalization of Exercise Physiologyonline. Vol 5 No 3.
3. Boone, T. (2004). The EPC Exam:  A Challenge for Academicians. Professionalization of Exercise Physiologyonline. Vol 7 No 3. 
4. American Society of Exercise Physiologists. ASEP Board of Certification: Standards of Professional Practice. http://www.asep.org/standards 
5. Boone, T. (2003).  The Entrepreneurship of Exercise Physiology. Professionalization of Exercise Physiologyonline. Vol 6 No 3.
6. American Physical Therapy Association. (2004). APTA website. http://www.apta.org/ 
7. American Medical Association. (2004). AMA website. http://www.ama-assn.org/  
8. American Medical Association. (2004). AMA Policy Finder. http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-25.995.HTM  
9. American Society of Exercise Physiologists. (2004). ASEP Goals and Objectives. http://asep.org/goals.htm
10. Boone, T. (2004). Questions Exercise Physiologists Should Ask Themselves. Editorial appearing on the website of the American Society of Exercise Physiologists. http://asep.org/licensure.htm 
11. Bodenheimer, T. and Grumbach, K. (2002). Understanding Health Policy: A Clinical Approach. New York, NY: Lange Medical Books.
12. American Society of Exercise Physiologists. (2004). ASEP Directory of board-certified EPCs. http://asep.org/boardcertifiedexercisephysiologists.html