Why Doctors Don't Understand Exercise
by M. Doug McGuff, MD
In the past few years I have been a speaker at two large gatherings of HIT enthusiasts; the first was the convention of the SuperSlow Exercise Guild and the second was the HIT training seminar in Seattle, Washington. At both of these events the most common question I had to field went something like this..."Finally an MD who understands exercise! You seem to know so much about proper exercise; why don't all MD's understand exercise the way you do?". I always took this question as sort of a back-handed compliment because what the statement seemed to translate into was "Finally an MD who agrees with me! Most MD's disagree with me and are therefore idiots, but you agree with me and are thus not an idiot. Why don't all MD's agree with me?". There are many reasons why physicians don't understand exercise, and there as some things we can do to help I hope to offer some insight in this article.
Physicians are People
Contrary to popular belief, MD does not stand for "magical deity". Physicians are people doing a mundane, day-in-day-out job just like everyone else. Most doctors' jobs are not glamorous like what you see on TV, and most make much less money than you would imagine. About 50-70% of the care the average doctor delivers goes uncompensated, the work is dangerous (job related death is double that of a policeman) and the work is nasty. When I hear someone complain about their job I like to ask "how many times today did you have to put your finger in someone's ass?". I am not writing all this to complain about my lot in life, I actually love my job; I just want to point out that doctor's are not what you think they are.
Physicians are simply people. When it comes to exercise, there are probably less than 100 people on the face of the earth who truly understand exercise. There are probably thousands who "believe in" what those hundred people have to say, and I still count myself as one of the believers. Maybe as I approach 40 I will be able to as Arthur Jones put it..."unlearn most of what you thought you knew and then become capable of rational thought". So if you take a subsegment of "people", knowing that only about 100 understand exercise and label that subsegment "Physicians", it should not be surprising that so few understand exercise or believe in what you believe in.
Still, one would think that with a strong foundation in the basic sciences that most physicians would be able to see the logic of the arguments put forth by the SuperSlow Exercise Guild. What most people fail to realize is that all knowledge is contextual and if there has not been an opportunity to use that knowledge in a particular context, it will be extremely hard to understand anything within that context. This is true for physicians because practicing medicine has NOTHING to do with exercise. Practicing medicine has to do with illness, disability, self-abuse, psychological dependency, secondary gain, poor functional ability and generally an unwillingness on the part of the patient to participate in improvement. This is not to disparage my patients...we could all slip into this state because we are all much more fragile than we like to admit. Nevertheless, if humans lived on the African plains as gazelle, what we would call "patients" would there be called "lion poop".
A Mind Prepared
To answer the question of why I as a physician understand (or at least believe in) proper exercise one would have to look at my background. My interest in science began at age 15 when I came across a copy of Arthur Jones' Nautilus Training Bulletin #2. I was working as a janitor in a local Nautilus club in exchange for a membership. I took the book home and read it in one sitting, it was the first time I read an entire book in my life. This stimulated a lasting desire for scientific and technical knowledge. Arthur Jones is why I studied biology and chemistry in college and he is why I chose to go to medical school. Ironically he influenced my choice of specialty. Many have asked why I did not choose, Orthopedics or Physical Medicine and Rehabilitation. The answer is that both these specialties teach the incorrect concepts of exercise that Arthur has been fighting against his entire life. I simply could not choke down such nonsense in order to make it through the training. Luckily, I fell in love with Emergency Medicine and obtained my training and board certification in the field. I continued to pursue my interest in HIT until, in 1997, I opened my own licensed SuperSlow Facility. I have come full circle. My point is that as I went along, all the basic knowledge I gained was also filtered through the perspective of high intensity training. This sort of perspective is very rare and I hope it has given me some insights that will make my articles worth reading.
An Unwanted Burden
Still, many SuperSlow instructors have complained to me how certain physicians have disallowed a medical clearance for a client to train for reasons that obviously are not entirely rational. But these same instructors usually tell their prospective clients to get clearance from their doctor before beginning training. They do this with at least a gut realization that doctors are people, and therefore probably understand much less about safe exercise than they do, yet they insist on medical clearance. Well folks, in this scenario let's not forget who's balls are on the chopping block. The instructor is deferring liability which should be his (because he is the expert) onto the physician (who really doesn't understand exercise). So the doctor, being uncertain, dictates some silly limitation of exertion and the instructor is indignant. Well if you want to change things for the better, then relieve the doctor of this burden. Do not insist on medical clearance to exercise at your facility. Pay for malpractice liability and tell your clients that you are the expert on exercise and if you hurt them they can sue you for the liability. If you don't have the guts to do this, then don't complain. Realize I am not getting on a "high horse" here...I have arranged the corporate structure of Ultimate Exercise so as to keep any medical liability out of my business. I do not give medical clearance for anyone to train. While I don't require medical clearance for all clients, if a client has a medical problem I will not train them without their doctor's blessing. So, as you can see, I'm as much a part of the problem as I am a part of the solution. But I'm not alone as almost every book written on weight training (including books on HIT) have a "get permission from your doctor" disclaimer. Two notable and brave exceptions are Ken Hutchin's SuperSlow Technical Manual and Mike Mentzer's Heavy Duty I&II...Bravo Gentlemen!
Anatomy of a Lawsuit
Have you ever wondered why physicians always seem to recommend walking as a form of exercise for their patients? Do you wonder why the Surgeon General's report on physical fitness recommends walking, taking the stairs instead of the elevator, parking at a far parking space, gardening or mowing the lawn as a way to exercise. As an emergency physician I can tell you these activities are far from safe...I can't begin to tell you how many pedestrians I've seen hit in a parking lot, how many people killed or maimed falling down steps, how many fingers sheared off while gardening, and how many hands and feet lost to lawnmowers. Why would anyone recommend something that is so dangerous? This is especially perplexing given the almost complete lack of exercise effect from these activities.
To find the answer to the above question let us delve into what is at the darkest corner of any doctor's mind when he recommends a form of exercise....the lawsuit. This thinking is usually on a subconscious level but it still affects the choices made. The requirements of medical malpractice are 4 fold. They are: Duty, Negligence, Harm and Proximate Cause. Duty means that you had a responsibility to the patient's best interest; this is automatic in the doctor patient relationship. Negligence means that you failed in protecting the patient's interest, but negligence is not enough, harm actually had to occur. Most important the negligence had to be a "proximate cause" for the harm that occurred. In a legal sense activities of daily living such as walking, taking stairs, doing lawnwork or housework cannot be upheld as proximate cause because these are activities we have to do anyway on a daily basis. Now you can see why such recommendations are so popular. If such reasoning seems cowardly to you then I can only say you have probably never spent even an hour with your balls on the chopping block. Malpractice insurance typically covers up to 1 million dollars per occurrence and 3 million dollars accumulated. Many lawsuits can go up to tens of millions of dollars. Just because you have exceeded your malpractice liability does not mean you don't owe the rest of the money. The court will take everything you currently own and garnish your future wages. Such a scenario will make you an abject slave for the rest of your life. If you want to solve the problem of "medical clearance" with your clients, all you have to do is be willing to play the game of malpractice roulette...be my guest.
I want to conclude by saying that the tide is turning. There is starting to develop at least a handful of physicians who at least believe in proper exercise...maybe even a couple who understand it. The writing of Ken Hutchins has offered a logical argument against the aerobics philosophy of exercise. The country seems to be figuring out that aerobics doesn't work and the fitness industry has at least one foot in the grave. In the age where we call a janitor a "sanitation engineer", I think people are realizing that an "exercise physiologist" is really what used to be called a phys-ed major. The time is ripe to put to rest all the myth and superstition surrounding exercise. I hope I can be around to put at least one nail in that coffin.