Abstract
Background: Physicians’ exercise habits vary across different medical specialties and health service infrastructure. We assessed physicians’ exercise performance according to the recommendations of the 2020 European Society of Cardiology Guidelines. Methods: This cross-sectional study comprised 742 physicians of the Athens Medical Association (AMA), Greece. Utilizing a self-administered questionnaire, physicians’ exercise habits, demographics, specialty, and infrastructure [Hellenic National Health care System (HNHS) or Private System (PS)] were assessed. Subjects were categorized: Moderate-intensity weekly exercise ≥150 min. (Group A); Moderate-intensity weekly exercise <150 min. (Group B). Results: 53.4% of AMA members met the recommended exercise criteria, averaging 240 ± 285 min./week. Significant differences were noted between Group A and B in male sex (58.3% vs 43.1%, P < 0.001), Body Mass Index (24.7 ± 3.8 kg/m2 vs 26.2 ± 4.7 kg/m2, P < 0.001), Smoking (17.4% vs 23.5%, P = 0.04), Diabetes Mellitus (6.6% vs 11.8%, P = 0.01), and activity monitoring wearables usage (45.2% vs 29.8%, P < 0.001). Significantly more doctors in the PS categorized in Group A (P = 0.008). After adjustment for confounders, HNHS reported 33% decreased odds of achieving the exercise recommendations compared to PS (Odds Ratio: 0.676; 95% CI: 0.484-0.943, P = 0.03). Conclusion: Several factors affect adherence of AMA members to exercise goals. HNHS AMA doctors are less adherent to exercise recommendations, emphasizing the need to strengthen prevention strategies.
Keywords: physical activity, doctors, physicians, healthcare system, adherence
“Physicians working in PS are more likely to achieve the recommended exercise targets compared to their counterparts in HNHS.”
Introduction
Since 1953, when the health benefits of exercise were first demonstrated in a scientific study by Morris et al, 1 numerous studies have recognized its crucial role in multiple systems of physiology in the body.2-5 Particularly, regular physical activity is associated with a lower risk of cardiovascular disease (CVD) and all-cause mortality. 6 Moreover, a dose-effect relationship between exercise, CVD, and all-cause mortality has been reported, since a 20%–30% decline in adverse CVD events has been noted in individuals with an inactive exercise profile. 7 Exercise is also beneficial in respiratory diseases, as lung capacity, lung ventilation, and oxygen utilization capacity are improved8,9 Exercise interventions have a positive influence on metabolic disorders that impact people’s health and life quality, such as obesity, diabetes mellitus, nonalcoholic fatty liver disease (NAFLD).10-13 Finally, physical activity has increasingly been recommended to individuals with mental health diseases, a fact which is confirmed for patients with depressive and anxiety symptoms.14-16
Physicians deal with increased working hours, high levels of stress, and emotional exhaustion. Burnout syndrome is common among physicians. A study from US health care workers marked that 45.8% of physicians reported at least 1 symptom of burnout. 17 Emotional exhaustion, depersonalization, and low personal performance may be caused by burnout. 18 Physicians’ exercise habits have a major influence on their patients’ management, and their daily performance in decision-making. 19 However, there is limited availability of comprehensive data on exercise habits among physicians in Greece. Therefore, this study aims to evaluate exercise habits among members of the Athens Medical Association (AMA) who work in different workplaces.
Methods
Study Desing
An anonymous online survey was disseminated among the members of the Athens Medical Association (AMA). Every AMA member received an invitation to participate in the survey. Inclusion criteria encompassed active membership with the AMA, internet access, and the voluntary participation of physicians situated in Athens. Adhering to the principles outlined in the 2008 revision of the Declaration of Helsinki, the study maintained ethical standards. Participants gave informed consent before completing the questionnaire. The study protocol received approval from the AMA Board (Code:13/07/2023).
The study instrument was a self-administered questionnaire designed to gather comprehensive data about specific characteristics of physicians. These data included characteristics of the population, including physicians’ demographics, exercise habits, field of specialization, and health service infrastructure [work in Hellenic National Health care System (HNHS) or in Private System (PS)]. The parameters covered in the survey, along with the available choices for responses were as follows:
1. Age, height, weight, sex, smoking habits [Never Smoking, Ex-Smoking, Current Smoking (Tobacco/e-cigarette)].
2. History of Cardiovascular Disease and Diabetes Mellitus.
3. Marital status (Married/Divorced/Single/Widowed) and Parental status.
4. Services provision (Public hospital/Military/Private hospital/Private practice/Residency/Rural doctor/Unemployed) and Health service infrastructure (HNHS/PS).
5. Divisions of medical specialties (Surgery/Internal medicine/Diagnostics and Laboratory/Mental Health) and participation on 24-hour shifts.
6. Self-reported Minutes of moderate-intensity exercise training (time of high intensity was doubled to assess moderate-intensity time).
Exercise Evaluation
According to the 2020 European Society of Cardiology (ESC) Guidelines, it is recommended that healthy individuals of all age groups should engage in at least 150 minutes of moderate-intensity endurance exercise (MIEE) training per week or 75 min of vigorous-intensity endurance exercise (VIEE) per week. 6 Total minutes of moderate-intensity endurance exercise were calculated as follows: TOTAL= (MIEE)+2x (VIEE). Participants were categorized into 2 groups based on their adherence to ESC Guidelines: 1. Group A, those who engaged in moderate-intensity endurance exercise for 150 minutes or more per week; 2. Group B, those whose weekly moderate-intensity endurance exercise duration was less than 150 minutes.
Statistical Analysis
All statistical calculations were performed using IBM SPSS software (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp). Continuous variables were tested for normality with Kolmogorov-Smirnov test and by P-P plots and they were presented as mean ± standard deviation. Categorical variables are displayed as frequencies and percentages. Differences between categorical variables were tested by forming contingency tables and performing χ2-tests. In our analysis, continuous variables were assessed for statistical significance using the t test. A logistic regression analysis was performed to determine independent predictors of adherence to the ESC Guidelines recommendations for exercise across physicians, with the results presented as odds ratios (OR) with 95% confidence intervals (CIs). P-values <0.05 were considered statistically significant.
Results
Baseline Characteristics of Population
The questionnaire was mailed to all AMA members who were registered to the newsletter list, with responses received from 768. Twenty-six responses were removed because of the incompleteness of the data, and finally 742 responses were analyzed (Table 1).
Table 1.
Baseline Characteristics of Population.
| Subjects | 742 |
| Male sex, % (n) | 51.2 (380) |
| Age, years | 50.1 ± 12.8 |
| BMI (kg/m 2 ) | 25.4 ± 4.3 |
| Smoking habits | |
| Never smoking, % (n) | 55.5 (412) |
| Ex-smoking, % (n) | 24.2 (180) |
| Current smoking, % (n) | 20.2 (150) |
| Tobacco, % (n) | 60.0 (90) |
| e-cigarette, % (n) | 40.0 (60) |
| Cardiovascular disease, % (n) | 4.6 (34) |
| Diabetes mellitus, % (n) | 9.0 (67) |
| Mobility issues, % (n) | 5.4 (40) |
| Divisions of medical specialties | |
| Internal medicine, % (n) | 55.9 (415) |
| Surgery, % (n) | 31.9 (237) |
| Diagnostics and laboratory, % (n) | 9.9 (66) |
| Mental health, % (n) | 3.2 (24) |
| Services provision | |
| Public hospital, % (n) | 23.0 (171) |
| Military, % (n) | 3.0 (22) |
| Private hospital, % (n) | 21.0 (156) |
| Private practice, % (n) | 29.6 (277) |
| Residency, % (n) | 8.9 (66) |
| Rural doctor, % (n) | 0.8 (6) |
| Unemployed, % (n) | 3.6 (27) |
| Health service infrastructure | |
| GNHS, % (n) | 38.0 (282) |
| Private system, % (n) | 62.0 (460) |
| Marital status | |
| Married, % (n) | 61.4 (456) |
| Divorced, % (n) | 10.0 (74) |
| Single, % (n) | 27.1 (201) |
| Widowed, % (n) | 1.5 (11) |
| Parental status | |
| Parents, % (n) | 43.5 (323) |
| Participation on shifts, % (n) | 39.6 (294) |
| 1-3 shifts per month, % (n) | 7.7 (57) |
| 4-5 shifts per month, % (n) | 10.5 (78) |
| 6-8 shifts per month, % (n) | 16.4 (122) |
| >8 shifts per month, % (n) | 5.0 (37) |
| Minutes of moderate-intensity endurance exercise training (min) | 239.6 ± 285.2 |
* BMI: Body mass index; GNHS: Greek National Health care System; min: minutes.
The distribution of sex among the population was relatively balanced, with males comprising 51.2% (n = 380) of the total population. The mean age was 50.1 ± 12.8 years indicating a middle-aged adult population, and the average body mass index (BMI) was 25.4 ± 4.3 kg/m2. Moreover, the data revealed a diverse range on physician’s smoking habits, as 55.5% (n = 412) reported never having smoked; individuals who have quit smoking constituted 24.2% (n = 180) of the population; and current smokers accounted for 20.2% (n = 150) of the participants. Particularly, insight into the smoking patterns and preferences show that tobacco products were used by 60.0% (n = 90) of the smoking population and e-cigarettes (vaping/heated tobacco) were used by 40.0% (n = 60). The prevalence of selected health conditions indicated that 4.6% (n = 34) of the study population has been diagnosed with cardiovascular disease and Diabetes Mellitus was reported by 9.0% (n = 67) of the participants.
Our study also delved into the professional background of the participants by categorizing them into divisions of medical specialties. Most responders were specialized in Internal Medicine (55.9%, n = 415); 31.9% (n = 237) of the participants had a Surgical specialty; Diagnostics and Laboratory specialties were represented by 9.9% (n = 66) of the study population; and only a small minority of the population represented by 3.2% (n = 24) of participants were of Mental Health specialties.
The largest proportion of participants was engaged in PP (29.6%, n = 277), followed by those working in public hospitals (23%, n = 171), and private hospitals (21%, n = 156). Smaller segments of the population were in residency (8.9%, n = 66). Regarding health service infrastructure, 38% of professionals are part of the HNHS, while 62% operate in PS.
Finally, among the study participants, a total of 39.6% (n = 294) were engaged in shift work, with 7.7% (n = 57) working 1-3 shifts per month, 10.5% (n = 78) working 4-5 shifts, 16.4% (n = 122) working 6-8 shifts, and 5.0% (n = 37) working more than 8 shifts per month.
Physicians Exercise Habits
Physicians reported a weekly moderate-intensity exercise training of 240 ± 285 minutes. Of the physicians 53.4% (n = 396) achieved the goal of ESC Guidelines (Group A) (Table 2). There was no difference between Group A and Group B regarding age (50.2 ± 12.3 years vs 49.9 ± 13.3 years, P = 0.73). Between Group A and Group B there was a difference in BMI (24.7 ± 3.8 kg/m2 vs 26.2 ± 4.7 kg/m2, P < 0.001). Moreover, there was a difference in male sex prevalence (58.3% vs 43.1%, P < 0.001), current Smoking habits (17.4% vs 23.5%, P = 0.04), and diabetes mellitus prevalence (6.6% vs 11.8%, P = 0.012) between Group A and Group B (Figure 1). There was no difference regarding marital and parental status between Group A and B. Interestingly, physicians who achieved the ESC Guidelines goal (Group A) more frequently used wearable activity trackers compared to Group B subjects (45.2% vs 29.8%, P < 0.001).
Table 2.
Exercise Performance According to ESC Guidelines.
| Moderate-Intensity Endurance Exercise Training Per Week ≥150 min. (Group A) | Moderate-Intensity Endurance Exercise Training Per Week <150 min. (Group B) | P-value | |
|---|---|---|---|
| Subjects, % (n) | 53.4 (396) | 46.6 (346) | |
| Age, years | 50.2 ± 12.3 | 49.9 ± 13.3 | 0.73 |
| BMI, kg/m2 | 24.7 ± 3.8 | 26.2 ± 4.7 | <0.001 |
| Male sex, % (n) | 58.3 (231) | 43.1 (149) | <0.001 |
| Smoking, % (n) | 17.4 (69) | 23.5 (81) | 0.041 |
| Cardiovascular disease, % (n) | 4.3 (17) | 4.9 (17) | 0.69 |
| Diabetes mellitus, % (n) | 6.6 (26) | 11.8 (41) | 0.012 |
| Parents, % (n) | 43.9 (152) | 43.2 (171) | 0.84 |
| Married, % (n) | 62.1 (223) | 68 (233) | 0.11 |
| Use of wearable activity trackers, % (n) | 45.2 (179) | 29.8 (103) | <0.001 |
| Divisions of medical specialties | |||
| Surgery, % (n) | 44.7 (131) | 55.3 (106) | 0.47 |
| Internal medicine, % (n) | 51.8 (215) | 48.2 (206) | |
| Diagnostics and laboratory, % (n) | 51.5 (34) | 48.5 (32) | |
| Mental health, % (n) | 66.7 (16) | 33.3 (8) | |
| HNHS, % (n) | 47.2 (133) | 52.8 (149) | 0.008 |
| Private system, % (n) | 57.2 (263) | 42.8 (197) | |
Categorical variables are presented as valid percentages and continuous variables as mean ± standard deviation. ESC: European Society of Cardiology; HNHS: Hellenic National Health System; BMI: Body mass index.
Figure 1.
Baseline Characteristics Between Physicians Who Achieve The Goal of 2020 ESC Guidelines for Moderate-Intensity Endurance Exercise (MIEE) (Group A) and their Counterparts who do Not Achieve it (Group B). (A) Box-plots of Body Mass Index (BMI) in the Group A and Group B. BMI was Significantly Lower in Group A Compared to Group B (p<0.001); (B) Male Physicians Show Higher Adherence to Exercise Recommendations (p<0.001); (C) Active Smoker were Fewer in Group A Compared to Group B (p=0.04); D) Participants with Diabetes Mellitus were Fewer in Group A Compared to Group B (p=0.01).
Finally, there was a difference between HNHS (Group A: 47.2%; Group B: 52.8%) and PS (Group A: 57.2%; Group B: 42.8%) (P = 0.008) in the ratio of exercise goal achievement (Table 2, Figure 2). Even after adjustment for the confounders revealed important in Table 2, HNHS physicians have 33% decreased odds of achieving the recommended weekly exercise training (Odds Ratio: 0.676; 95%CI 0.484-0.943, P = 0.02) compared to PS physicians (Table 3).
Figure 2.
The Impact of Wearable Activity Trackers and Health Service Infrastructure on Physicians’ Exercise Performance. (A) Physicians Who Use Wearable Activity Trackers Show Higher Adherence to Recommended Exercise Levels Compared To Non-Users (p<0.001); (B) Physicians Who Work in the Hellenic National Healthcare System (HNHS) show Lower Adherence to ESC Recommendations Compared to in Private System (PS) Physicians (p<0.001).
Table 3.
Logistic Regression Analysis for Exercise Performance According to ESC Guidelines.
| Odds Ratio | 95% Confidence Intervals | P-value | ||
|---|---|---|---|---|
| Lower Limit | Upper Limit | |||
| Age, years | 1.005 | 0.992 | 1.018 | 0.49 |
| Sex (male) | 2.295 | 1.650 | 3.194 | <0.001 |
| BMI, kg/m2 | 0.882 | 0.845 | 0.920 | <0.001 |
| Diabetes mellitus | 0.619 | 0.354 | 1.084 | 0.09 |
| Smoking | 0.721 | 0.495 | 1.051 | 0.09 |
| Use of wearable activity trackers | 0.619 | 0.354 | 1.084 | <0.001 |
| Hellenic national health system | 0.691 | 0.496 | 0.961 | 0.03 |
In categorical variables as reference category was set male sex, diabetic subjects, active smokers, users of wearable activity trackers and subjects who work Hellenic National Health System. *95% Confidence intervals are provided. BMI: Body mass index; ESC: European Society of Cardiology.
Discussion
This study investigated the exercise habits of physicians within the AMA, revealing insights into the various factors that influenced their adherence to recommended physical activity levels according to the 2020 ESC Guidelines. Notably, slightly over half (53.4%) of the participants achieved the recommended 150 minutes of weekly moderate-intensity exercise, with a remarkable variance observed between physicians’ different workplace environments and certain demographic and lifestyle factors.
One of the key findings of this study is that physicians working in PS are more likely to achieve the recommended exercise targets compared to their counterparts in HNHS. Morishita et al. also reported that primary care physicians employed at clinics tend to engage in more physical activity compared to their counterparts working at university hospitals, polyclinic hospitals, or general hospitals. 20 This could reflect differences in work pressures, flexibility in scheduling, or access to exercise facilities. Interestingly, knowledge of recommended Guidelines for physicians is essential for balance-related clinical care practices. Particularly, Pronk et al. reported that only 70.9% of primary care physicians were aware of physical activity recommendations. 21 However, another study noted that only 34% of US adults say they received advice on exercising during their most recent visit to the doctor. 22 Several studies have underlined the role of physicians’ exercise habits to counseling offered to their patients, as doctors who are physically active themselves are more likely to consult physical activity and exercise.23-29
Additionally, certain demographic and lifestyle factors are shown to affect exercise adherence. The higher exercise adherence among non-smokers and those with lower BMI suggests that a holistic approach to wellness, encompassing smoking cessation and weight management, could further enhance physical activity levels among physicians. Moreover, our findings show that the adherence to exercise recommendations appears to be higher among male physicians compared to their female counterparts, which is also by Janes et al. as more male physicians than female physicians reported exercising 3 times a week for 20 minutes (60% vs 46%). 30 Finally, wearables play a significant role in promoting exercise adherence, since they may serve as a motivational tool or provide more opportunities for self-monitoring and goal setting, which are known to enhance physical activity. Notably, Tricás-Vidal et al reported that the use of tracker devices was related to lower cardiovascular disease mortality risk related to sitting time, 31 and users had significantly higher self-reported walking, moderate physical activity, and total physical activity, and significantly lower sedentary time than non-users. 32
Conclusion
In conclusion, this study revealed that over half of the physicians in the AMA adhere to the recommended levels of physical activity, with those in PS more likely to meet these Guidelines than their counterparts in the HNHS. The use of wearable activity trackers, along with demographic factors such as sex, BMI, and smoking status, significantly influences exercise adherence. The findings underscore the importance of promoting physical activity among physicians, not only for their own healthy lifestyle but as a model for patient care practices.
Footnotes
Author Contributions: Concept, S.L., D.L., G.E.Z., S.P., Design, K.A.P., E.O., G.S., Acquisition, G.M., P.T., I.G., P.P., V.K., E.K., V.L., Analysis, S.L., D.L., I.G. G.E.Z., S.P., V.L., E.O., Interpretation, G.M., P.T., P.P., V.K., E.K., K.A.P., G.S., Draft, S.L. G.M., D.L., P.T., I.G., P.P., G.E.Z., Revision, V.K., S.P., E.K., V.L., K.A.P., E.O., G.S.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Statement
Etical approval
The study was conducted in accordance with the Declaration of Helsinki and received approval from the Athens Medical Association Board (Code:13/07/2023). Participants gave informed consent before completing the questionnaire.
ORCID iDs
Panteleimon Pantelidis https://orcid.org/0000-0001-5394-832X
Vasiliki Kalogera https://orcid.org/0000-0003-1639-2929
Evangelos Oikonomou https://orcid.org/0000-0001-8079-0599
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