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

from 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. more


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