How to encourage patients to start barbell training, as a family doctor?

[aWalkingShadow]

As the title says, as a family doctor, how do you encourage your patients to start squatting and deadlifting?
I'm currently only an MS2 who plans to go into family medicine, but I've been thinking about how to go about counseling patients regarding adding lifting weights to their exercise regime. Because unlike healthy diets and aerobic exercise, I feel that most patients don't fully appreciate the benefits of lifting weights, and see it as more of being an activity mostly for young males.

How would you convince a patient to take up lifting weights, beyond just explaining its benefits? Also, how would you address their concern that they don't have access to a good coach (or that they can't afford a good coach) to teach them how to perform the lifts properly?

[Jordan Feigenbaum]

From a previous thread:

Do you have any recommendations, beyond the above, about how to encourage patients in need to obtain appropriate care (i.e. strength training)?

Jordan Feigenbaum:
This is an interesting problem, Dr. Supples, and I thank you for bringing it up.

We have a few major issues as I see it:

1) When seeing ambulatory patients who would benefit from progressively overloaded barbell-based resistance training, what is the recommendation we as physicians should be giving in the outpatient setting?

Answer: I think the lack of resources, which include (but are not limited to) a good referral network to get patients to legitimate coaches, allocation of funds to pay for the training, and time for the health professional to spend with the patient to explain the benefits, methodologies, and implementation strategy of such a program create a huge obstacle for folks in the trenches.

The recommendation, "Do progressively overloaded barbell-based resistance training as described in the book, Starting Strength: Basic Barbell Training 3rd Edition" is correct for nearly all persons who can ambulate and defecate without assistance. I would argue that even patients with multiple comorbidities, but who can still meet the walk and poop criteria can do this without extensive medical observation or screening given the relative risk vs. benefit. The number needed to treat (NNT) is going to vary depending on the outcome sought and the pathology of the patient, but the number needed to harm (NNH)- e.g. who is actually going to do worse with exercise via injury or exacerbation of their disease process is likely to be exquisitely high.

For reference, the NNT's for LBP, Depression, Cardiac Rehab (after MI), or physical deconditioning resulting in increased fall risk are 3-5, ~7, 20-30, and ~1 based on current evidence. There is no known data for NNH that I am aware of, so at the end of the day you have to ask yourself, "What is the real risk of recommending resistance training to this patient?" I think you'd likely say "some low, but non zero amount of risk of harm to the patient"- to which I would agree, but the benefits almost undoubtedly outweigh the risk.

2) When recommending resistance training to a patient, how should we best ensure compliance?

Answer: Great question. We know that folks who are apparently highly motivated, as evidenced by their registration for this forum and logging workouts, only "do the program" about 2% of the time. We could probably also assume that the folks here represent a fairly healthy, ambulatory cross section of the general population and their results/compliance are less generalizable to those with actual medical problems. We know that with coaching at virtually any level, e.g. an SSC overseeing 80 people 1x/wk intermittently in a busy college gym or an online coach who provides feedback after each session, improves outcomes with virtually no clinically significant difference in outcomes, e.g. strength and anthropometric measurements. In short, good coaching that is administered - even when infrequently- markedly improves compliance and subsequent outcomes.

So, what to do? I would agree that some professional follow up, e.g. with a coach, likely improves compliance and outcomes, as measured by whatever battery of tasks or questionnaires you'd like to administer. I would disagree however, that a typical physical therapist is armed with enough knowledge to take a patient through a legitimate resistance training program and evidence on their failure to obtain the expected outcomes from "periodized and supervised" training programs that have been reported in the literature support my stance. In short, I would caution against routine referral to PT because I don't think they're doing anything positive for the patient (but potentially for the economy).

Yes, it feels good to recommend therapeutic exercise and insurance will likely cover some PT appointments for this. And yes, this likely takes you off the hook for any responsibility for your recommendation to undergo therapeutic exercise (unless you missed a dissecting AAA and they go to do a 20lb leg press at the PT office and hemorrhage into their abdomen), but this is one of those times where being 100% safe equates to being 100% ineffective and is not without a significant (IMO) opportunity cost.

So, ideally there would be a network of well trained coaches you could refer to that would administer "therapeutic exercise" based around the iron and the patient's would be okay with the self-pay model. A referral to the SSOC or Barbell Medicine would work if the patient is isolated geographically from an in-person coach, but an SSC or similar who is available for in-person coaching would work well here too, obviously.

I don't think there's good evidence to support that folks who "have skin in the game", e.g. a financial investment in coaching or gym membership, do better than those who don't (but still have access to a coach and gym), but rather that those with a coach do better than those who do not. Similarly, those who regularly train do better than those who do not. No real argument here, I hope.

3) How do you convince a patient to 1) do a proper strength program (supervised if deemed necessary) and 2) pay for that supervision (if necessary)?

Answer: Another great question. I think that as a medical professional who has been exposed to training himself (or if your wife is reading- herself), you are in a unique position to extoll the benefits of training to your patients whom you've built rapport with. I do not think this can be passed on to mid levels or other staff who do not have this experience, as they cannot possibly make as strong a case as you can. I do not think you need to "sell training" for any training professional whom you are associated with, but leveraging your medical knowledge and training experience to suggest how a patient's life can be changed through training...well, that's Barbell Medicine my friend and we need an army of providers to make a difference

[aWalkingShadow]

Thanks for your response, Jordan.

So, in summary, it seems that you would refer patients to see a local SSC (or SSOC if no local SSC available), correct?

Do you think it would be wise to also offer lesser alternatives in order to hopefully improve the likelihood of the patient starting barbell training in the first place?
For example, offering a list of recommendations in order from best to worst.
1) See a local SSC
2) See a SSOC.
3) Read Starting Strength and find a personal trainer who focuses on the main lifts.
4,5) Read Starting Strength and find any personal trainer OR do the program unsupervised.
6) Do machine work.

It seems to me that there are multiple conversations I need to have with the patient; first that strength is important -> barbell training is the best way to get strong -> paying for a qualified coach gives best results.
You briefly touched on this, but is there a good way of convincing patients to pay for a qualified coach, especially since coaching is relatively expensive (and probably isn't covered by insurance??)?

[Jordan Feigenbaum]

The corrections are as follows:

2) I would refer patients to SSOC if they're a novice with no medical comorbidities or did not require nutritional counseling, but if they do have medical comorbidities, need nutrition counseling, or are not a novice, they should come to Barbell Medicine.

3) I would never recommend this. No benefit for $$$

4) Read SS. Do program unsupervised.

6) Sure, better than nothing.

I don't know if multiple conversations are needed unless they're not in a position to change behavior. If you wanted to put a patient on a medication, would you have to have multiple conversations about it with them first? Sometimes yes, of course. On the other hand, for better or worse we are in a unique position where we can influence what people do because of our training. So, I would directly tell them what I want them to do, why I want them to do it, how to do it (and give educational materials), cover expected roadblocks/obstacles/side effects, and have a short term follow up to go over it again.

[aWalkingShadow]

I can understand that hiring a random personal trainer who doesn't know how to squat would be a bad idea. But what about hiring a coach whose client's training revolves around the barbell movements; why would this be a bad idea? For example, why not refer patients to a local powerlifting gym so that they can learn how to perform the squat/bench/deadlift/press?
If a local SSC or SSOC/Barbell Medicine are not viable options for some reason, why jump straight to the option of doing the program unsupervised? My main concern with unsupervised training would be that some patients may be afraid of hurting themselves through improper form and therefore becomes less motivated to do the program. At least with a coach from a powerlifting gym, I might be moderately confident that the coach knows what proper form looks like, and can guide the patient.

Can you go over some expected roadblocks/obstacles/side effects that a patient may encounter? Off the top of my head, I can think of: injuries, stalling, headaches/dizziness/blurry vision from Valsalva, urinary incontinence in females at maximal loads, callus formation, flexibility issues, too weak for bar. (Looking at this list, simply going over just the roadblocks seems to be a long conversation. How would it be possible to fit it all into 10-15 minutes?)

[Jordan Feigenbaum]

I can understand that hiring a random personal trainer who doesn't know how to squat would be a bad idea. But what about hiring a coach whose client's training revolves around the barbell movements; why would this be a bad idea? For example, why not refer patients to a local powerlifting gym so that they can learn how to perform the squat/bench/deadlift/press?

My experience has been that these people are usually TERRIBLE at coaching the lifts, program poorly, do not encourage training in a healthy manner, are somewhat intimidating if an actual PL gym, and cost resources that don't ultimately improve outcomes.

If a local SSC or SSOC/Barbell Medicine are not viable options for some reason, why jump straight to the option of doing the program unsupervised? My main concern with unsupervised training would be that some patients may be afraid of hurting themselves through improper form and therefore becomes less motivated to do the program. At least with a coach from a powerlifting gym, I might be moderately confident that the coach knows what proper form looks like, and can guide the patient.

The evidence overwhelmingly suggests otherwise, as injuries incurred during training are extremely rare compared to other activities. Furthermore, there's no evidence that having a coach decreases the incidence of injury. So, why waste the resources? You have to be good at communicating, explaining, and addressing concerns with patients. I don't think pawning them off on a useless coach is a good idea. It's equivalent to ordering PT for a chronic injury state. Wasteful and useless.

Can you go over some expected roadblocks/obstacles/side effects that a patient may encounter? Off the top of my head, I can think of: injuries, stalling, headaches/dizziness/blurry vision from Valsalva, urinary incontinence in females at maximal loads, callus formation, flexibility issues, too weak for bar. (Looking at this list, simply going over just the roadblocks seems to be a long conversation. How would it be possible to fit it all into 10-15 minutes?)

When you order a new medication for someone, what do you discuss with the patient before they go home with a new bottle of pills? You hit the highlights, address immediate concerns, assess for understanding, schedule your follow up appropriately. Nothing useful can be done within 10-15 minutes in a primary care, so I don't think that's a reasonable expectation.