Active Voice: AHA Frames Guideline for Non-Physician Supervisors of Clinical Exercise Tests

By Jonathan N. Myers, Ph.D., FACSM, and William G. Herbert, Ph.D., FACSM

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM.

Jonathan N. Myers, Ph.D., FACSM, completed his doctoral studies in exercise physiology at the University of Southern California. He is coordinator for the cardiology department's exercise laboratory at the Palo Alto VA Medical Center and is a clinical professor of medicine at Stanford University. Much of his work has focused on epidemiology studies that have demonstrated the importance of exercise tolerance and physical activity in modulating risk for cardiovascular events. Dr. Myers has authored or co-authored guidelines on exercise testing and related topics for numerous organizations, including ACSM, the American Heart Association and the American Thoracic Society.

William G. Herbert, Ph.D., FACSM, is professor emeritus in the Department of Human Nutrition, Foods and Exercise at Virginia Tech in Blacksburg. Much of his research and writing relates to exercise testing and physical activity interventions in coronary heart disease and obstructive sleep apnea, but he also has contributed to the literature on standards of care, legal issues and safety in adult exercise programs. He has been a member of the writing teams for several ACSM publications, including ACSM's Guidelines for Exercise Testing and Prescription, and chaired the Committee for Certification and Education, ACSM Clinical Exercise Physiology Practice Board and chief editor of SMB.

This commentary presents the authors' views on the above-titled American Heart Association Scientific Statement that was recently published in the journal Circulation. Dr. Myers chaired the multidisciplinary writing team and Dr. Herbert was a contributor.

The exercise test continues to have an important place in clinical medicine. Not only does the test help guide decisions regarding diagnosis and/or medical interventions, it remains valuable for evaluating the effects of therapies and setting exercise recommendations for patients. The knowledge and training required to properly conduct an exercise test are of central relevance to the clinical exercise physiologist. However, previously published guidelines on clinical competency for performing exercise testing have been directed toward physicians. If and when a non-physician should independently supervise a clinical exercise test and among which types of patients has remained uncertain. Early versions of exercise testing guidelines, beginning in the 1970s, recommended that a physician be available at all times to directly supervise an exercise test. This was due to the perceived risk associated with the test, particularly among patients with known disease. Since that time, surveys of event rates during exercise testing have consistently indicated that attendant serious events are extremely rare. In addition, significant changes in clinical practice patterns with exercise testing have continued to evolve over time. In contemporary exercise laboratories, physicians often provide supervision or oversight, but are less frequently present in the testing room. In fact, the majority of such tests today are administered by non-physicians (exercise physiologists, nurses, physical therapists or technicians)?including those tests performed among high-risk patients. As these changes have evolved, ambiguity has arisen regarding the physician's role relative to the non-physician. While ACSM has provided the standard for certification programs for clinical exercise physiologists, there remains uncertainty regarding the cognitive and procedural skills necessary from both a practical and legal standpoint regarding who should supervise an exercise test in clinical settings.

In September 2014, the American Heart Association (AHA) published a Scientific Statement entitled, "Supervision of Exercise Testing by Non-physicians." This document provides guidance for the clinical performance and supervision of exercise testing by non-physicians in the current era, while extending prior recommendations from the ACSM, AHA and American College of Cardiology directed toward physicians. Importantly, the document also provided specific guidance in terms of the type of physician supervision required. Three categories of supervision were defined, depending on the type of patient being tested: (1) personal supervision, requiring a physician's presence in the room; (2) direct supervision, requiring a physician to be in the immediate vicinity or on the premises or the floor and rapidly available should emergencies arise; and (3) indirect supervision, requiring physician availability by phone or pager. The statement responds to the need to specify the appropriate education, training, experience and cognitive and procedural skills necessary for non-physicians to conduct exercise testing and to delineate standards that maintain patient safety. The statement also responded to the need to provide physicians with guidance in terms of cognitive and procedural skills that strengthen their ability to supervise non-physician health professionals who perform exercise testing.

One of the key consensus recommendations from the document was that, in most cases, clinical exercise tests can be supervised safely by properly trained non-physician health professionals. This recommendation, however, is predicated on the individual non-physician meeting competency requirements for exercise test supervision, being fully trained in cardiopulmonary resuscitation, and supported by a physician skilled in exercise testing or emergency medicine. Other key features in this document include: (1) the expectation that the supervising physician will maintain competency standards for exercise testing; and (2) the requirement that the non-physician supervisor is competent and able to effectively screen for high-risk patients and alert the physician supervisor, when appropriate. For further important features, see the full-text article online.

The statement provides support for practices that have been routine in clinical settings for nearly two decades, wherein the non-physician often has been the supervisor who is present in the exercise lab and conducts the test. Importantly, however, it also confirms the physician's paramount role as final authority for the safety and quality of testing and interpretation. Thus, the statement acknowledges the non-physician's value, not merely as a less expensive physician surrogate, but also as a highly trained professional who brings skills that are complementary to those of the physician. This new scientific statement from the AHA brings some long-needed clarity to a procedure that remains a major part of many clinical practices.