Taking It out of the Office
“Is every kid I see today going to be obese?” a frustrated colleague asks me. “I feel like that’s all I’m seeing in the office!” Whatever your specialty and wherever your practice, whether you see children or their grandparents, chances are you’re seeing your patients get heavier. In Chula Vista as in other communities, underserved patients present to their doctors not only with high rates of obesity, but also shouldering the highest burden of preventable diseases such as diabetes and hypertension.
We know that exercise is an important part of the solution, and our patients know it too. But for our patients who live and work below the poverty line, getting out to walk for exercise in their neighborhoods may not be easy. Poorly lit streets, no sidewalks, and community violence can keep even the most motivated family indoors. Finding affordable, safe, and structured exercise programs can be a challenge. How do we encourage exercise in these high-risk communities in a way that brings reality into the equation?
The answer to this question is certainly not in the office. Part of my colleague’s frustration comes from knowing that physicians and patients just don’t have enough time together. A typical office visit today takes 15–20 minutes, and community clinics in underserved areas can be even busier. Patients can be frustrated as they try to communicate “just one more thing” to their physicians, and doctors have the impossible task of delivering important preventive care messages in their brief time together.
One study at Duke found that it takes an average of 7.4 hours to deliver preventive messages to an average patient panel and an additional 10.6 hours for patients with chronic disease. After seeing more and more underserved patients in my practice who desperately needed to exercise, I began to wonder, “Even if I deliver a message that sticks with patients, how do I identify and minimize those barriers to exercise that may be specific to my lower SES patients?”
In Chula Vista, I’ve begun to answer this question by finding a perfect partner for public health: the Chula Vista Parks and Recreation Department. The Chula Vista Physicians Winning with Recreation (CV PoWeR!) program is the result of a partnership between the department and area physicians that is designed to provide reliable, safe, and structured physical programs to children, adults, and seniors through a point of care “recreation prescription” that allows them to exercise for free. Whether it’s swimming or after-school programs for the kids, a walking club for adults, or chair yoga and tai chi for seniors, there is something for everyone.
When I presented the idea to Parks and Recreation director, Buck Martin, and assistant director, Ed Hall, there was no hesitation. We sat down and looked over the recreation brochure and put together several age-group-specific activities that could be represented on the “recreation prescription.” While there was some initial concern about costs to the city having an increased number of non-paying participants, it soon became apparent that we could create this program without raising the city’s overhead. For instance, who is using the other half of the pool when the high school water polo team is practicing in the deep end? The city is paying to heat the pool, and provide a lifeguard, so why not offer self-directed water aerobics in the shallow end for free to Dr. Smith’s group of patients with osteoarthritis who can’t bear weight without pain?
As we went through the recreation brochure, we all began to realize that by matching a knowledge of recreation programming with the insight of a physician partner who can talk about the health needs of the community in a meaningful way, something special can happen. The CV PoWeR! program has opened access points for the underserved in new and exciting ways, and, though additional study is needed, we hope that community members at the highest risk for preventable disease are getting healthier.
Our success in Chula Vista encouraged me to start www.RecreationRx.org to help promote partnerships between physicians and recreation organizations working in areas of unmet need throughout the state of California. The website is designed to be informative, but also as a tool to help new programs manage themselves. The site has a “Program Forum” that can serve as the administrative home to new programs. “Program Champions” can receive orders for new prescription pads, get and receive feedback, place important files (orientation guides for participating doctors, etc.), and moderate a discussion board that is specific to their program. By housing this resource for new programs, my hope is to facilitate new program development and to make it easy for programs to share their experiences.
In the summer of 2008, the County of San Diego will pilot a recreation prescription program modeled after CV PoWeR! that will be the first regional program of its kind. As city, county, and state budgets shrink, the need to address health disparities among the underserved is increasing. By finding community partners with similar goals, physicians can maximize their efforts in the office and help patients tackle the barriers they face as they strive to live longer and healthier lives.