Exercise occupies an unusual place in healthcare.
We know physical activity reduces cardiovascular risk, improves metabolic health, preserves function and supports quality of life. Yet despite decades of evidence, exercise is still often treated differently from almost every other medical intervention.
A physician may tell a patient to exercise more, but once that patient leaves the office, the healthcare system often has little visibility into what happens next.
Did they start? Was the plan appropriate? Did pain, fear or competing responsibilities get in the way? And if they stopped, did anyone understand why?
These questions were at the centre of a recent conversation between Dr. David Alter, cardiologist and founder of My Heart Fitness™, and Carmen McDonald, a health coach who has worked with the program.
Their perspectives approached the same challenge from different directions: clinical prescription and behavioural implementation.
Together, they raised a fundamental question:
If exercise is medicine, who helps the patient actually take it?
What Changes When We Treat Exercise Like Medicine?
For Dr. Alter, treating exercise as medicine means moving beyond vague lifestyle recommendations.
Like medication, exercise has a dose, frequency, intensity and safety considerations. The appropriate prescription for someone with cardiovascular disease may look very different from one for someone already active.
The type of activity matters. So does progression. An effective prescription must account for the patient's medical conditions, physical abilities and therapeutic goals.
But that doesn't mean every walk needs to be medicalized.
Exercise can still be recreation, social connection, stress relief and enjoyment. For some patients, however, exercise also serves a therapeutic purpose. In those cases, simply advising someone to "exercise more" is hardly an adequate prescription.
And even the most clinically appropriate prescription doesn't guarantee that someone will follow it.
As Carmen explains:
"Medicine can tell us why, what, how, what's safe. That doesn't mean someone will actually do it."
That is where clinical care meets the realities of human behaviour.
The Clinical Recommendation Is Only the Beginning
A patient can understand perfectly well that exercise is good for them and still struggle to become active.
They may have knee pain. They may worry about becoming short of breath. They may have tried exercising before but stopped. Perhaps the goals were unrealistic, or work and family responsibilities simply took priority.
The recommendation can be clinically correct and still fail in practice.
Carmen describes health coaching as helping patients translate recommendations into achievable actions. This often involves identifying barriers, building confidence, adjusting expectations and helping individuals gradually develop the skills to manage their own behaviour.
The distinction matters.
Prescribing exercise and helping someone successfully incorporate it into their life are related, but they are not the same job.
What Medication Adherence Can Teach Us About Exercise
One particularly interesting part of the conversation emerged when Dr. Alter asked Carmen to consider medication adherence.
Imagine a patient is prescribed a statin but stops taking it.
From a clinical perspective, we can document whether the patient was adherent. But knowing they stopped taking their medication tells us very little about why.
Perhaps they're concerned about side effects. Maybe they read something online that worried them. Perhaps they don't believe the medication is necessary or never fully understood its benefits.
A health coach approaches the problem by looking for the barrier behind the behaviour.
The same principle applies to exercise.
When a patient isn't following an exercise prescription, simply documenting non-adherence isn't particularly informative.
Was the exercise dose too ambitious? Did pain develop? Was the patient afraid? Did their circumstances change?
The answer determines what should happen next.
For Dr. Alter, one principle remains essential: the patient ultimately still needs to do the exercise. They have to actually "take the exercise pill."
But Carmen's perspective adds another dimension. The answer isn't necessarily to repeat the instruction more forcefully. It's to understand what's preventing the behaviour and help the patient move forward.
This is where accountability and autonomy can work together.
Real Life Doesn't Behave Like a Controlled Trial
The conversation also highlights a tension between clinical measurement and everyday life.
Medicine relies on numbers: blood pressure, cholesterol, blood glucose, medication adherence and exercise volume. Those measures are essential for understanding progress and outcomes.
But human behaviour is influenced by factors that are difficult to control.
People travel. They get sick or injured. Work becomes demanding. Family responsibilities change. Motivation and confidence fluctuate.
As Carmen puts it:
"Research needs control, but people don't live controlled lives."
That isn't an argument against measurement. It's an argument for interpreting measurement in context.
A single difficult week doesn't necessarily mean an exercise intervention has failed. A temporary decline in activity might reflect illness, travel or changing circumstances.
Repeated patterns, however, can reveal something more meaningful.
Rather than looking only at whether someone met an exercise target this week, we can examine their trajectory over time.
Is their activity generally increasing? Are they becoming more consistent? Do certain barriers repeatedly interfere? Are they progressing toward a sustainable level of activity?
The direction and consistency of behaviour may tell us more than any single snapshot.
And importantly, the goal isn't to turn every patient into an athlete.
For someone who is completely sedentary, even modest increases in activity can produce meaningful health benefits. What matters is establishing an appropriate starting dose, progressing safely and helping the patient sustain that behaviour.
Better Integration, Not Blurred Roles
The solution isn't to turn physicians into full-time health coaches or ask health coaches to make clinical decisions outside their scope.
Their roles are different, but complementary.
Physicians assess medical risk, establish safety parameters and define appropriate therapeutic targets. Health coaches help uncover the behavioural barriers that determine whether patients can follow through.
The challenge is that these two worlds often operate separately.
Carmen notes that health coaches in Canada do not routinely communicate with physicians. A coach may understand why a patient is struggling, yet have no established pathway for sharing that information with the clinical team.
Similarly, a physician may recognize that a patient needs behavioural support but have limited means of connecting that patient to ongoing assistance.
The opportunity isn't to merge these roles.
It's to connect them.
Bridging the Gap Between Prescription and Real Life
This is part of the challenge My Heart Fitness™ is working to address.
Our approach is built around four connected functions: Prescribe, Activate, Monitor and Respond.
The clinician establishes an appropriate exercise prescription, accounting for dose, intensity, modality, safety and progression.
Patients receive education and behavioural support to help translate that prescription into action.
Longitudinal monitoring provides visibility into exercise activity and progress between clinical visits.
And when a patient begins to disengage, the response should be informed by what's actually happening.
Not simply another reminder to exercise, but an effort to understand what changed.
Was the prescription inappropriate? Did pain develop? Did motivation decline? Did competing responsibilities interfere?
Connecting clinical and behavioural information creates an opportunity to respond more meaningfully.
So, Is Exercise Wellness or Clinical Care?
The answer is both.
Exercise can be recreation, prevention and part of everyday wellness. But for the right patient, at the right dose and for the right indication, it can also be part of clinical treatment.
The more useful question isn't whether exercise belongs to medicine or wellness.
It's how those two worlds work together.
Medicine can help determine why exercise matters, what is appropriate and what is safe. Behavioural support can help patients overcome the barriers that prevent them from following through. Monitoring can provide visibility into what happens between visits.
And the patient remains at the centre of the entire process.
Because prescribing exercise and helping someone actually exercise are two different things.
If exercise is medicine, we need to get better at both.
Watch the Full Conversation
Watch Dr. David Alter and Carmen McDonald discuss exercise as medicine, health coaching, adherence, behaviour change and how clinical care can better connect with everyday life.
[WATCH THE FULL CONVERSATION →]
About My Heart Fitness™
My Heart Fitness™ is building clinical prevention infrastructure designed to help healthcare teams prescribe, activate, monitor and respond to physical activity over time.