Dr. Ranit Mishori on Using Exercise as Medicine

It seems like new research comes out every week detailing another benefit of physical exercise. At this point, the list of diseases exercise helps treat and the physical, mental and emotional benefits it provides far exceeds the list of things exercise can’t help improve. And yet, amidst the backdrop of the opiate epidemic, fears of antibiotic resistance and still-rising incidences of obesity, metabolic disorders and other related health issues, many doctors still treat exercise as an offhand suggestion rather than a specific treatment protocol.

Dr. Ranit Mishori
Dr. Ranit Mishori

But as Dr. Ranit Mishori explained in a recent Washington Post editorial, “an official ‘doctor’s order’ for exercise… would be taken more seriously by patients than a mere suggestion.” Mishori follows a new movement in healthcare called “Exercise Is Medicine,” in which physicians actually prescribe exercise to their patients in lieu of drug therapy. The movement still faces hurdles in the medical community. However, it is gaining traction among doctors who recognized the benefits of exercise but weren’t comfortable formally prescribing it.

As future doctors move through medical school, they learn the uses and side effects of a wide variety of pharmaceuticals. For example, they might learn that medical literature indicates drugs A, B and C are particularly effective against condition X. Each of those drugs has its own side effects and contraindications. And doctors must balance these considerations against each patient’s particular condition and other medications. In residency, new doctors gain personal experience with these prescriptions and start to develop their own preferred treatments.

However, the benefits of exercise are not part of routine medical education or practice, Mishori told me. Medical schools don’t teach the subject in any great detail. Most doctors are well aware of the impact of exercise on overall wellness. But without formal instruction, many doctors hesitate to provide specific exercise recommendations in terms of type, duration and frequency. It is simply easier and more comfortable for doctors to write a prescription for a specific drug for a given condition after learning how that drug addresses the condition in medical school and observing that treatment protocol time and again in their professional practice.

According to Mishori, the Exercise Is Medicine initiative falls under the broader deprescribing movement. In a separate Washington Post article, Mishori wrote, “Too many patients are taking too many drugs, for too long, in too-high doses, suffering harmful effects.” Most doctors aren’t taught when it’s time to take a patient off a drug. But in most cases, drugs aren’t meant to be a long-term solution. Staying on prescription medication for too long can result in harmful side effects and addiction. Adverse interactions between different drugs may result when multiple doctors prescribe patients several medications over time. In contrast, exercise continues to benefit patients throughout their lifespan. And, aside from the occasional rolled ankle or overuse injury, it has minimal side effects.

Mishori, who earned an M.H.S. in International Health from Johns Hopkins Bloomberg School of Public Health and an M.D. from Georgetown University School of Medicine and directs Georgetown’s Department of Family Medicine’s Global Health Initiatives, told me she is a longtime exerciser who eventually found herself compelled to start treating exercise as medicine in her clinical practice. She described herself as “not an expert on exercise Rx but a mere dabbler.” Yet she has made good use of Exercise Is Medicine’s recommendations in interactions with her patients.

Mishori directed me to the movement’s website, where physicians can access evidence-based resources for exercise prescriptions. These include patient assessments and exercise guidelines. For example, “Sedentary adults should be encouraged to engage in low to moderate [physical activity] with a gradual progression to the recommended 150 minutes per week of moderate to vigorous [physical activity].” Additional recommendations include intensity and frequency of strength training and are broken down by patient age and activity level.

As the founder and leader of Georgetown’s Department of Family Medicine’s program on Health, Media and Primary Care, which assesses the intersection between media, evidence-based medicine and primary care and the director of Georgetown’s Practice-Based Research Network, Mishori found herself in position to put her appreciation of exercise, her belief in research and evidence-based medicine and the tools she found from Exercise Is Medicine into practice. In doing so, she has managed to overcome the first hurdle that dissuades many other physicians from prescribing exercise.

However, Mishori faces other challenges with this new approach. As she wrote in the aforementioned Washington Post piece:

“As a family physician who works with both affluent and poor patients, I realize that my use of this approach has exposed deep inequities in their access to resources. On the one hand, I get professional satisfaction from recommending hikes in Rock Creek Park, running along the Mall or singing in a chorus (partly because of the evidence and partly because those are activities I do myself). But can I really ask a patient who works two jobs and cares for her children to find 30 minutes a day to squeeze in a walk in a park? Or a patient who lives in an unsafe neighborhood to take a daily jog around the block?”

Still, one point in favor of exercise is you don’t need any resources besides your own body, Mishori told me. She recognizes the unique challenge each patient faces in incorporating exercise into his or her own lifestyle. Part of her practice involves helping patients make that adjustment. If patients don’t have the resources to join a gym, Mishori encourages them to take up jogging or walking. If they live in an unsafe neighborhood, Mishori helps them brainstorm a more comfortable location for their regular physical activity. She encourages her patients to exercise outside, noting anecdotal support for being in nature in addition to evidence favoring exercise. In our talk, she lamented that many people confine their exercise to staring at a TV from a cardio machine.

“We need to make sure that the resources are there, that the evidence of benefits is there and that we, as physicians, are well trained in how to push a change without causing any harm.”

Yet difficulties in following an exercise prescription aren’t limited to time, resource or location challenges. Adherence for prescription drugs hovers around 50% to begin with. And taking five seconds every day to pop a pill is far easier than carving out time for a workout. Mishori emphasized the Exercise Is Medicine movement represents a lifestyle change. Unlike many prescription regimens, it is not a quick and easy addition to one’s regular habits. But incorporating exercise into a regular lifestyle also offers greater benefits to patients. When people make time to take care of themselves, they see benefits in almost every aspect of their lives. At the same time, they decrease their reliance on pharmaceutical interventions.

Still, ever the adherent to evidence-based medicine, Mishori is waiting for meaningful research showing that exercise prescriptions are effective. There is evidence that those who do exercise experience a variety of benefits. However, it’s still not clear that exercise prescriptions translate to better health outcomes for patients. As Mishori writes, “Many trends begin as great, well-intentioned ideas. Before we start proselytizing, we need to make sure that the resources are there, that the evidence of benefits is there and that we, as physicians, are well trained in how to push a change without causing any harm.” Fortunately, Exercise Is Medicine and other resources are coming, there is evidence to support the health advantages of exercise, and physicians like Mishori are willing to learn new approaches and follow the latest research in order to provide the best possible care for their patients.

Dr. Ranit Mishori is a physician and writer whose twin careers in family medicine and international journalism create a unique perspective on the many issues involved in delivering healthcare here and abroad. From an early start covering wars and the plight of refugees for a global news organization, Dr. Mishori went on to study medicine and public health and has since built a multi-dimensional career that includes academia, scholarship and national leadership roles in public health, global health, medical education, clinical medicine, underserved populations, and human rights. She continues to report and write on health and medicine, publishing more than two hundred articles over the past seventeen years in media like the Washington Post, The NY Daily News, AARP – the Magazine and the Huffington Post, in addition to her publication of academic papers. She frequently represents Georgetown University on TV, radio, print and web-based news outlets.

Exercise Is Medicine is a joint initiative of the American College of Sports Medicine and the American Medical Association. This United States-based health movement aims to make physical activity assessment and promotion a standard in clinical care. Exercise Is Medicine connects healthcare with evidence-based physical activity resources for people everywhere of all abilities.