Enhancing exercise curriculum in medical training at Loma Linda University School of Medicine

Exercise serves as a natural stressor on homeostatic mechanisms, providing an effective way to teach students about the physiological processes underlying stress responses and adaptation. Furthermore, long-term adaptations to chronic exercise offer important therapeutic benefits in managing a wide range of disease states. Therefore, exercise physiology and prescription are essential components of medical curricula designed to prepare physicians to counsel patients effectively. This is particularly important given that adult physical activity levels in the United States remain insufficient, especially in patients with chronic diseases. Recent guidelines provide comprehensive exercise curricula for medical education. Toward this end, we examined the current state and propose a future direction for medical exercise physiology education at Loma Linda University School of Medicine (LLUSM). We reviewed the existing preclinical and clinical medical curriculum, identified gaps, and formulated enhancements to align with recent consensus statements on exercise education in medical schools. Our unique approach builds upon our strong foundation in lifestyle medicine, integrating exercise physiology into a broader context of preventive and holistic healthcare. The analysis reveals that LLUSM dedicates 21 h to exercise within its 113-h lifestyle medicine core, supplemented by additional elective opportunities. The curriculum covers exercise effects on biochemical processes, physiological systems, and its role in disease prevention and treatment. However, gaps exist in exercise assessment and prescription skills, particularly in clinical years. To address these gaps, we propose developing a coordinated exercise thread across pre-clinical and clinical years. This includes introducing a foundational exercise physiology lecture, expanding exercise content in organ system-based pre-clinical blocks, and enhancing the clinical years to emphasize exercise assessment and prescription. The proposed curriculum aims to equip students with the knowledge and skills to confidently counsel patients on physical activity and prescribe exercise for both preventive and therapeutic purposes. We highlight the potential of this enhanced curriculum to improve students’ understanding of exercise physiology, its clinical applications, and its impact on patient wellness. By integrating exercise education throughout the medical curriculum, LLUSM aims to produce physicians who can effectively leverage physical activity as a powerful intervention for disease prevention and health promotion in healthcare delivery.

1 Introduction

1.1 Why exercise matters

Exercise is widely recognized as a potent, cost-effective intervention for the prevention and management of numerous chronic diseases, including cardiovascular disease, diabetes, and obesity (Hoffmann et al., 2016; Naci and Ioannidis, 2015). The physiological benefits of exercise ranging from improved metabolic health to enhanced cardiovascular and pulmonary function are well-established and provide a foundational understanding of physiological processes and health maintenance (Garry et al., 2002). This is especially crucial given that anywhere from about 23% to 45% of adults in the United States meet minimum recommended levels for physical activity, with even lower prevalence among patients with chronic diseases such as diabetes, hypertension, and cancer (Xu et al., 2023). The “Exercise is Medicine” initiative by the American College of Sports Medicine (ACSM) has built from these concepts to champion integrating exercise prescription into routine healthcare, emphasizing its critical role in patient care (Hill et al., 2015). Despite strong evidence supporting exercise as therapy, it remains underutilized, partly due to physicians’ limited training and confidence in prescribing physical activity effectively (Hoffmann et al., 2016; Mafi et al., 2013; Persson et al., 2013; Weiler et al., 2012).

1.2 The training gap

While the importance of incorporating exercise in clinical practice is clear, medical education programs in the United States largely lack comprehensive, standardized curricula on exercise physiology, testing, and prescription (Dirks-Naylor et al., 2021). A recent survey highlighted that only a small fraction of medical schools incorporate meaningful exercise education, with most providing minimal hours of instruction primarily in the preclinical years (Adedokun et al., 2021). This deficiency leaves future physicians ill-prepared to confidently counsel patients on physical activity, prescribe appropriate exercise interventions, or manage exercise safely in individuals with chronic conditions (Hoffmann et al., 2016; Persson et al., 2013; Weiler et al., 2012). The absence of wide spread implementation of robust, evidence-based longitudinal curriculum compounds this gap, limiting the capacity of physicians to integrate exercise as a therapeutic tool across specialties (Asif et al., 2022; Brennan et al., 2017; Sprys-Tellner et al., 2023; Trilk et al., 2019a).

To effectively address the training gap, it is essential to emphasize that medical students need a comprehensive understanding not only of exercise-induced physiological adaptations but also of the acute physiological responses during exercise, such as cardiovascular, respiratory, metabolic, and neuroendocrine changes. This knowledge allows future physicians to better interpret clinical exercise testing and manage patients with both chronic conditions and athletic pursuits. Additionally, there is a critical need to incorporate education on the identification of elite athletes, including the unique physiological demands and risks they face, as well as the ethical considerations surrounding supplement use and doping, emphasizing the importance of understanding who is subject to WADA (World Anti-Doping Agency) regulations and the implications of performance-enhancing substances (Pelobello et al., 2025; Tandon et al., 2015). Bridging this educational gap ensures that physicians are equipped to support both the general patient population and athletes with evidence-based guidance, ethical awareness, and specialist knowledge in sports medicine and doping prevention.

1.3 Consensus guidance

To address these training gaps, a recent consensus statement from 2022 outlines comprehensive exercise curricula recommendations for medical students, residents, and fellowship programs (Asif et al., 2022). The consensus emphasizes that medical schools need to further augment exercise curriculum, focusing on exercise physiology, testing, and prescription, while providing students opportunities to practice implementing these skills. These recommendations underscore a vital opportunity for institutions dedicated to comprehensive health education to adapt and expand their curricula by incorporating core principles such as FITT-VP (Frequency, Intensity, Time, Type, Volume, Progression) and safety screening to ensure future physicians have the foundational knowledge necessary to prescribe exercise tailored to individual patient needs and health conditions (Bushman, 2018; Milani et al., 2024). Exercise prescription extends across widely diverse medical specialties with key examples including orthopedic medicine for rehabilitation, injury prevention, and post-surgical protocols; cardiovascular medicine for cardiac rehabilitation, stress testing, and heart failure management; preventive medicine for primary prevention and therapeutic interventions; endocrinology for diabetes management, metabolic syndrome, and glucose regulation; nephrology for chronic kidney disease modifications and dialysis considerations; neurology for neuroprotective effects and neurological condition management; pulmonology for COPD and respiratory rehabilitation; oncology for cancer-related fatigue and recovery support; and psychiatry for mental health treatment through physical activity (Luan et al., 2019).

1.4 LLUSM opportunity

Loma Linda University School of Medicine (LLUSM) exemplifies a commitment to comprehensive health education through its mission “To Make Man Whole.” The institution boasts one of the nation’s leading lifestyle medicine groups, recently achieving the American College of Lifestyle Medicine Platinum Plus certification for integration of evidence-based content in the medical curriculum. LLUSM’s lifestyle medicine thread comprises 113 core hours across basic science and clinical curricula. Students can also participate in various elective tracks, certificate programs, and clinical rotations focused on exercise and nutrition across the 4 year program. The program excels in nutrition education and its impact on health and wellness. LLUSM has also been awarded gold level status in Exercise is Medicine for its work in the medical curriculum and campus-wide outreach activities. Despite these strengths, an explicit, coordinated exercise curriculum spanning both preclinical and clinical years remains to be fully realized. Developing a systematic, longitudinal exercise thread aligned with curricular content presents an opportunity to bridge the education gap and empower future physicians with the confidence and competence to prescribe exercise as a standard component of patient care. The curricular analysis aims to evaluate LLUSM’s current exercise-related content, identify gaps, and propose a strategic framework for developing a cohesive, longitudinal, exercise thread throughout the medical education continuum. This work endeavors to enhance the capacity of future physicians to confidently prescribe exercise, ultimately advancing the goals of preventive medicine and holistic patient care.

2 Methods

This curriculum mapping and documentary analysis of the medical exercise teachings in the LLUSM was conducted as an audit in June 2024 in collaboration with the institutional curriculum committee. The analysis was to provide guidance and a roadmap for developing a coordinated medical exercise thread. For this initial exploration, we did not conduct empirical evaluation of student outcomes because our exercise curriculum is too early in development to yield meaningful insights from such assessments. No IRB determination was required as this was a curricular assessment and did not entail analysis of data from human subjects. The study identified strengths and gaps in the existing medical education program in relation to an ideal core curricula program (Asif et al., 2022). The analysis encompassed a comprehensive review of the foundational science concepts and organ systems-based blocks taught in the first and second years of the LLUSM medical curriculum on a block-by-block basis for the 2023–2024 academic year (Table 1). Additionally, clinical experiences related to exercise were evaluated through an examination of the learning objectives for each session (Table 2). This analysis established the exercise physiology concepts being taught and the exercise-relevant learning objectives currently assigned to students. Keywords such as “exercise,” “exertion,” “physical activity,” and “sports” were used to aid in identifying relevant instances. The pertinent learning objectives and outcomes are presented for each lecture, noting the instructional thread and block, as shown in Supplementary Tables 1–12. Lectures that included aspects of exercise physiology but lacked applicable learning objectives were also identified.

TABLE 1

Table 1. Basic science pre clinical organ system blocks.

TABLE 2

Table 2. Clinical clerkships.

The assessment of exercise instruction in the LLUSM curricula covered both the preclinical and clinical years of instruction, with data derived at the end of the instructional period in June 2024. For the preclinical portions, lectures were evaluated through a systematic process. Lecture notes were downloaded in PDF format from the instructional learning management system (Canvas) and compiled by each instructional block. Coursework for the clinical years was compiled independently as it is not contained in the Canvas learning system. These notes were then searched for instances where exercise appeared as learning objectives or directly within the lecture content (i.e., notes and slides) Curriculum Organization at LLUSM

3 Results

The Loma Linda University School of Medicine (LLUSM) curriculum spans 4 years, with 2 years of preclinical education followed by 2 years of clinical training. The preclinical curriculum adopts an organ systems-based “block” approach, with at least one basic science and one clinical science-oriented block director in most blocks (Tables 1, 2). Overlaying this structure is a series of “threads” that run throughout the preclinical curriculum, including Anatomy, Biochemistry, Cell Structure and Function, Evidence-Based Medicine and Information Sciences, Embryology, Genetics, Health Systems Science, Lifestyle and Preventive Medicine, Microbiology, Pathology, Pathophysiology, Physical Diagnosis, Pharmacology, and Physiology.

First-year students begin with two foundational blocks over a 17-week period, introducing basic science concepts and incorporating the gastrointestinal system and liver in the second block. Subsequent blocks cover Hematology and Immunology, Endocrine and Reproductive systems, Cardiovascular system, and Pulmonary system. The second-year curriculum includes Neuroscience and Psychiatric science, Renal and Urinary systems, and a Musculoskeletal and Skin block, concluding with an Application and Integration block to prepare students for the USMLE Step 1 exams and for transition to their clinical clerkships. Block lengths vary based on content breadth, with key concepts from various threads emphasized in relation to each system. The curriculum is enriched with laboratories, simulations, demonstrations, and exercises focused on interpersonal and team-building skills through team-based, problem-based, and case-based learning. The content of the blocks is updated regularly to maximize student learning.

The third year (MS3) clinical curriculum consists of six core clerkships: Internal Medicine, Family Medicine, Pediatrics, Surgery, OB-GYN, and Neurology/Psychiatry, each lasting 6 or 8 weeks. Students also participate in 2 week-long “advanced integration weeks” featuring seminars on whole-person care and health-systems science, along with two 2-week elective opportunities. A Preventive and Lifestyle Medicine thread is integrated into each core clerkship through assignments specific to typical patients or populations encountered.

In the fourth year (MS4), students complete four core rotations: a sub-internship, intensive care, Preventive Medicine and Population Health (each 4 weeks long), and Emergency Medicine (2 weeks). Additionally, they have a 4-week selective and 14 weeks of electives. The MS4 Preventive Medicine and Population Health rotation includes lectures on core public health concepts, Health System Science, Quality Improvement, and Lifestyle Medicine, emphasizing clinical applications.

3.1 Lifestyle medicine and exercise curricula at LLUSM

Loma Linda University School of Medicine features a robust lifestyle medicine thread spanning all 4 years of the curriculum, driven by the preventative medicine group. The program delivers 113 core hours of required lifestyle medicine curricula. A total of 21 h of the curricula are specifically focused on exercise. Students can participate in up to an additional 265 h of elective lifestyle medicine activities. A 2-week lifestyle medicine selective course is offered during the preclinical years, along with a Lifestyle Medicine Certificate Track. This track, available to a select group of students, includes focused sessions such as culinary medicine classes, leadership in a capstone project, aerobic and resistance workouts, lectures from experts, and an independent research project.

Critical exercise concepts are integrated throughout the preclinical curriculum, beginning with the first foundation block (Supplementary Tables 1–12; Asif et al., 2022; Humphries et al., 2018; Humphries et al., 2021). The content covers the effects of exercise on biochemical/metabolic processes, cardiovascular and pulmonary systems, laboratory values, and its role in disease prevention and treatment. Some lectures mention exercise without corresponding learning objectives. Several demonstrations and labs focus exclusively on exercise, including exercise testing, physiological changes during varying exercise levels, and its application in disease treatment and prevention. The preclinical curriculum aligns well with focus areas outlined in consensus documents (Asif et al., 2022; Humphries et al., 2018, 2021). Exercise concepts are also incorporated into non-typical presentations throughout the curriculum, connecting exercise physiology to all body systems. The Frequency, Intensity, Time, Type, Volume, and Progression (FITT-VP) model is introduced, along with fundamental components of formal exercise prescriptions (Bushman, 2018; Milani et al., 2024).

In the clinical years (third and fourth), exercise education emphasizes patient care and the promotion of physical activity to prevent disease complications, progression, and premature death. Supplementary Tables 11, 12 outline the content covered during the Family Medicine 3rd year rotation and the Preventive Medicine and Population Health 4th year rotation. These clinical sessions include workshops on modifying exercise prescriptions for musculoskeletal conditions, motivational interviewing, and “exercise as medicine.” Students gain hands-on experience in applying lifestyle medicine principles, including performing exercise tests with patients.

Medical students learn to assess patients’ exercise habits and develop and implement exercise prescriptions based on individual abilities, needs, goals, and resources. They are taught to modify prescriptions considering factors that may affect FITT-VP components, such as injuries, disease states, pain, age, weight, and personal goals. Emphasis is placed on supporting patient autonomy by teaching autoregulation principles and using subjective intensity to guide objective exercise intensity for appropriate progression over time.

3.2 Exercise curricula in other schools of medicine

Several North American medical schools and residency programs have published elements of their exercise-centered curricula (Garry et al., 2002). The University of South Carolina School of Medicine Greenville (SOMG) along with LLUSM pioneered the integration of exercise and lifestyle medicine into its medical education curriculum, with an outline of the process for SOMG being published recently (Trilk et al., 2019a,b). SOMG and LLUSM are the first medical schools in the country to fully incorporate exercise and lifestyle medicine into all 4 years of its program, with the exercise component being more expansive at SOMG than what is currently offered at LLUSM. The curriculum at SOMG covers topics such as exercise physiology, physical activity, healthy eating, stress management, and other lifestyle factors crucial for preventing and treating chronic diseases. While the exact number of hours of exercise curricula are not published, evaluation of their curricula on their website (Curricula, 2025) shows that exercise physiology appears in 18 case study sessions, 18 additional slide decks, and five webinars. This comprehensive approach not only equips future physicians with knowledge to counsel patients effectively but also promotes self-care and resilience among medical students. LLUSM along with SOMG have been recognized by the American College of Lifestyle Medicine with the highest “Platinum Plus” certification for incorporating over 100 h of evidence-based lifestyle medicine content into their curricula.

The University of Calgary introduced exercise content in 2019 through a 2-h “Flipped Classroom” session during the first year of medical school. This includes a 1-h podcast lecture covering core objectives and a 1-h in-person workshop where students collaborate on case studies and address questions about exercise assessments and prescriptions. Queen’s University implemented a multi-year approach in 2016, adding 2.5 course hours in the first year and 3.5 h in the second year. The University of British Columbia enhanced their physical exercise curricula in 2016 by introducing workshops, lectures, and integrated physical activity objectives across the curriculum. They offer two lectures in the first year and one in the second year, focusing on the physician’s role in supporting patient physical activity. Similar to LLUSM, physical activity content is incorporated into lectures related to chronic disease prevention. The University of British Columbia also uses small group learning sessions for practicing motivational interviewing and exercise prescription skills, with practice cases extending into the third-year family medicine clerkship (Capozzi et al., 2022).

Sidney Kimmel Medical College offers a 2.5-h elective dedicated to fitness-related case studies and physical activity engagement. This session has shown positive impacts, with participating students demonstrating increased comfort in providing exercise recommendations to patients and displaying significantly more knowledge compared to non-participants (Pancio et al., 2023). While institutions employ varied curricula, all demonstrate the value of teaching exercise, even as a minor component of the preclinical or clinical curriculum.

4 Discussion

This comprehensive analysis of LLUSM’s curriculum reveals that exercise education is interspersed throughout the 4-year curriculum that includes foundational concepts and clinical application. The preclinical curriculum delivers dedicated exercise content across systems-based blocks, emphasizing physiological mechanisms, disease prevention, and the FITT-VP prescription model. Clinical training transitions this knowledge into patient care through hands-on experience with exercise prescriptions, motivational interviewing, and individualized modifications based on patient-specific factors. While there is a need to more fully develop a longitudinal thread approach and cohesion across the sessions, the individual learning sessions have strength as they reinforce exercise concepts across multiple organ systems and develop students’ competency from basic science understanding to clinical implementation of exercise as medicine.

4.1 The future of exercise curriculum at LLUSM

Expanding exercise education at LLUSM, and following the lead of SOMG (Curricula, 2025; Trilk et al., 2019a), will serve multiple purposes. Students will gain a greater appreciation and understanding of exercise as medicine, including patient assessments and prescriptions. This enhanced learning will also improve students’ comprehension of how acute and chronic exercise stress impacts on the human body in terms of normal physiological processes, homeostatic relationships, adaptations, and pathophysiological states. The vision aligns with consensus documents but builds upon LLUSM’s strong foundation in lifestyle medicine, which provides directed education on various lifestyle pillars including physical exercise, stress management, proper nutrition, substance avoidance, social connections, and sleep (Trilk et al., 2019b).

A review of the current curriculum (Supplementary Tables 1–12) in relation to the 2022 consensus document reveals gaps and unique teaching opportunities (Asif et al., 2022). To address these and build on curricular strengths, the proposal is to develop an educational thread focused on exercise across pre-clinical and clinical years, integrating it into the curriculum to streamline, organize, and expand upon existing foundations of exercise physiology, assessment, and prescription. Figure 1 outlines key structural elements for this expanded curriculum.

FIGURE 1

Figure 1. Integration of basic sciences and clinical clerkships in medical exercise physiology. The future of medical exercise physiology at Loma Linda University School of Medicine (LLUSM) is envisioned as a comprehensive and integrated program spanning both preclinical and clinical years. During the first 2 years of the basic science preclinical curriculum, students will learn the foundations of exercise physiology through a diverse array of educational methods, including lectures, demonstrations, case studies, and laboratory sessions. This approach aims to provide a robust theoretical understanding of exercise physiology and its impact on human health. As students transition into their clinical years, the focus will shift toward practical application of this knowledge. The curriculum will emphasize learning how to perform exercise assessments and functional tests, enabling students to evaluate patients’ physical capabilities accurately. Students will also develop skills in prescribing tailored exercise regimens for their patients and monitoring their progress over time. A key aspect of this clinical training will be learning to work collaboratively with other healthcare providers to form patient-centered care teams, recognizing the interdisciplinary nature of effective healthcare delivery. This program vision is grounded in the 2022 consensus statement (Asif et al., 2022), which provides a framework for exercise education in medical schools. However, LLUSM’s approach uniquely builds upon its existing emphasis on lifestyle medicine, integrating exercise physiology into a broader context of preventive and holistic healthcare. This combination of evidence-based exercise science and lifestyle medicine principles aims to produce physicians who are well-equipped to leverage physical activity as a powerful tool for both prevention and treatment of various health conditions. Created in BioRender. Wilson, S. (2025) https://BioRender.com/e3igblr.

The proposed expanded exercise thread would include focused selectives coordinated with lifestyle medicine, exposing students to additional content. Improving exercise content will require collaboration with block directors and individual instructors. Implementation is expected to span several years based on planning timelines. Thread directors would work closely with instructors to design new lectures or incorporate relevant learning objectives into existing lectures, particularly for topics not currently covered thoroughly.

The dedicated exercise thread could enhance current formal exercise-related sessions in the preclinical years, such as those covering cardiopulmonary responses to exercise, drugs in sports, cardiac rehabilitation, and sessions involving demonstrations, problem-based learning, or laboratory activities (Supplementary Tables 1–10; Asif et al., 2022; Curricula, 2025). In the clinical years, the curriculum could build upon existing content and refine the focus on performing exercise assessments and writing prescriptions, aligning more closely with national and international consensus materials (Asif et al., 2022; Curricula, 2025; Humphries et al., 2018, 2021). This comprehensive approach aims to provide students with a robust understanding of exercise physiology and its clinical applications throughout their medical education.

4.2 Foundational content

Acute and chronic exercise stresses offer a unique approach for medical students to learn fundamental biochemical, anatomical, and physiological concepts. Exercise is traditionally used to understand homeostatic relationships between body systems and responses to stress, aspects that can be enhanced in future iterations of the LLUSM curricula. Faculty can leverage exercise to help students better comprehend pathophysiological responses to various conditions, such as cardiopulmonary responses to anemia, shock, anxiety, metabolic disorders, osteoporosis, and high altitude exposure (Table 3). This approach could aid in understanding how pathologies disrupt biochemical pathways and organ systems, and how the body attempts to maintain homeostasis.

TABLE 3

Table 3. Selected schools of medicine and residency programs with exercise curricula.

Revising the LLUSM curriculum requires significant forethought due to planning and implementation timelines. Introducing an exercise physiology lecture early in the Foundations I block (Table 1 and Supplementary Table 1) would help frame the thread and emphasize the importance of exercise to students. This lecture could cover acute effects of exercise on cell and tissue function, focusing on glycolysis, TCA cycle, oxidative phosphorylation, muscle physiology, and other biochemical processes related to exercise intensity and duration, helping students understand mechanisms associated with core concepts. Exercise’s prominent role in all body systems could be expanded in each organ system block, with basic physiological responses such as cardiac output, ventilation, and oxygen consumption highlighted in cardiovascular and pulmonary blocks. Establishing a foundational understanding of exercise’s impact on various organ systems and chronic training adaptations provides a platform for students to develop exercise assessment and prescription skills later in their education.

Incorporating lifestyle medicine and exercise principles early in the preclinical years offers a unique opportunity to promote students’ health through changes in their own exercise habits. Multiple studies have shown positive correlations between academic performance, student wellbeing, and engagement in lifestyle interventions, including exercise (Behringer et al., 2022; Chomitz et al., 2009; London and Castrechini, 2011). Providing students with knowledge of lifestyle medicine enhances their ability to apply these principles in their future practice, which has been shown to increase career satisfaction and decrease burnout (Brennan et al., 2024; Pollard et al., 2023).

4.3 Exercise selectives as directed learning

The 2-week selectives offered to first and second-year students in the LLUSM program provide a unique opportunity for curriculum enhancement. Students currently choose from various interests such as ultrasound, leadership, business, and lifestyle medicine. Exercise-focused selectives can be revised and expanded to reinforce concepts learned in pre-clinical blocks, complement the lifestyle medicine thread, and provide additional training in exercise prescription. These selectives could serve as a method for students to develop critical skills in exercise assessment and laboratory testing (e.g., VO₂ max testing) and could involve case-based and patient-centered learning sessions. Students could learn to integrate endurance and resistance training and other forms of exercise into patient care. Additionally, these selectives could offer opportunities to interact with and shadow exercise professionals in patient care and performance settings.

The overarching goal of exercise selectives is to foster physicians who are confident, exemplary, and effective in prescribing exercise for both healthy and healing patients. Lectures and independent research during these selectives could explore topics such as gathering health data through smart devices, exercise prescription principles, effects of training and overtraining, recovery and recuperation, and other pertinent subjects. Students could also create and implement personal exercise plans during the school year. The 2-week time frame allows for in-depth discussions on a broad range of topics, as well as interactive sessions where learning objectives can be applied, such as resistance training sessions or cardiopulmonary testing. Ultimately, education on how and when to write exercise prescriptions is anticipated to increase students’ confidence and understanding in improving patient health and fitness (Pancio et al., 2023).

4.4 Exercise assessments

The utility and value of teaching medical students how to to be familiar with and conduct exercise assessments and monitoring are significant and would be addressed during the clinical years. As with other laboratory tests and clinical assessments, practitioners should understand the indications, measurements, and outcomes of various forms of physical testing. Exercise assessments provide crucial insights into patient diagnoses, guide treatment plans, and help monitor rehabilitation and fitness progress. These tests are also valuable for patient education, allowing individuals to better appreciate their physical condition by comparing their results to healthy ranges for their demographic.

Physical tests commonly used in clinical settings that students should understand include various measurements of functional capacity, such as VO₂ max testing, cardiac stress testing, the six-minute walk test, the shuttle walk test, and step tests (Choudhary and Choudhary, 2008). However, students could also learn a wide range of directed tests, including the exercise-induced bronchoconstriction test and assessments focused on strength (e.g., rep maximum testing, dynamometry, and force plates), as well as flexibility and range of motion (e.g., goniometer and inclinometer). Students should be informed about advanced contemporary medical devices (e.g., portable VO₂ metabolic analyzers) that can be integrated into clinical practice to enhance patient care. Additionally, they should be introduced to a broad range of wearable technologies capable of comprehensive personal monitoring, including metrics such as heart rate, heart rate variability, pulse oximetry, sleep patterns, and related physiological measures. Incorporating these assessments into the curriculum could lead to increased opportunities for interprofessional collaboration with exercise professionals in physical therapy, exercise physiology, medical fitness, and personal training.

By learning to perform and interpret these assessments, medical students would gain a more comprehensive understanding of patient health and fitness levels, enabling them to provide more targeted and effective care. This knowledge would also enhance their ability to communicate with patients about their physical condition and progress, potentially improving patient engagement and adherence to treatment plans.

4.5 Exercise prescriptions

During clinical years, it is crucial for students to learn how to prescribe exercise effectively. Competent exercise prescription builds upon students’ critical knowledge and expertise in exercise physiology foundations and assessment techniques. Developing exercise prescriptions and related training programs serves distinct purposes depending on the context. Rehabilitation programs are tailored to restore physical function following injury or illness, fitness-oriented regimens aim to maintain overall health and prevent chronic disease, while performance-focused plans push physiological capacities to maximize sport-specific outcomes. Building skill sets to develop exercise programs from the early stages of medical school will enable practitioners to confidently discuss exercise with patients, answer their questions, and write formal exercise prescriptions tailored to patients’ specific needs and health status.

The LLUSM program is exploring the implementation of tasks that require students to develop physical activity plans for individual patients, considering their goals, abilities, health, and disease statuses, in line with consensus documentation (Asif et al., 2022; Humphries et al., 2018, 2021). These skills can be taught through lectures and practiced in clinical skills labs, patient interviews with standardized patients, and case-based learning exercises with teammates throughout the preclinical and clinical years. Students should be taught to identify and address health systems science-related barriers to exercise participation, including financial constraints, physical limitations, environmental access issues, psychosocial challenges, and the like. These educational sessions will prepare future physicians to confidently discuss intervention options and provide individualized, realistic recommendations that promote sustained physical activity and improve patient care outcomes. During clinical rotations, students would have opportunities to apply these skills through discussions of exercise with their patients.

These prescriptions would follow the FITT-VP Model (Zaleski et al., 2016). The intensity of exercise would be determined by assessing various patient parameters, including heart rate reserve, maximum heart rate, maximum oxygen uptake, personal rating of perceived exertion, and strength-based concepts such as reps in reserve, velocity-based training, and percentage of repetition maximum. The prescription would then be developed using the patient’s assessed values, taking into account their overall condition, potential limitations due to disease status (if any), relevant surgical and medical history, and their individual goals whether they be related to health or sport performance (Luan et al., 2019). This comprehensive approach ensures that exercise prescriptions are tailored to each patient’s unique circumstances, maximizing the potential benefits while minimizing risks.

4.6 The patient care network

Healthcare professionals need a fundamental understanding of how different professions function to work harmoniously toward the overarching goal of providing patients with well-rounded and cohesive care (Wener et al., 2022). Prescribing exercise in a clinical care setting depends on developing an appropriate patient-care network, which includes physical therapists, nurses, respiratory therapists, and other healthcare professionals. The ideal of holistic patient care is reflected in consensus documents, which describe an expansive list of healthcare professionals (Asif et al., 2022; Humphries et al., 2021).

Loma Linda University School of Medicine provides medical students with opportunities to learn how to develop networks during their preclinical and clinical years, as well as through residency. This enables them to foster interdisciplinary collaboration among healthcare professionals and more readily provide comprehensive patient care. Within the framework of exercise as a prescriptive tool, collaboration between physicians, exercise physiologists, physical therapists, medical fitness professionals, personal trainers, and sports coaches is especially impactful (Asif et al., 2022). Such collaboration allows patient care concerns to be addressed from multiple angles with minimal conflicts. Rehabilitation and preventive exercise regimens can be better integrated into the patient’s treatment plan when practitioners work in tandem with other exercise-oriented healthcare professionals.

These collaborative relationships can be fostered and built during medical training through participation in interdisciplinary workshops and interactive sessions, starting as early as the preclinical years. By exposing students to various healthcare disciplines and their roles in exercise prescription and patient care, LLUSM can prepare future physicians to effectively coordinate and contribute to multidisciplinary teams by understanding the indications and qualifications of an appropriate exercise professional referral (Bantham et al., 2024). This approach not only enhances the quality of patient care but also promotes a more comprehensive understanding of the role of exercise in health and disease management across different healthcare specialties.

4.7 Looking to the future

There is a significant need for practitioners to prescribe exercise to their patients for disease prevention and treatment, necessitating medical schools to equip their students with the best possible knowledge and skills to provide optimal patient care. Importantly, medical schools should also empower their students with the knowledge to engage in their own exercise routines. To this end, medical schools provide foundational teaching and knowledge as students prepare for their USMLE step examinations, and the COMLEX-USA exams for osteopathic programs. For instance, the USMLE Step 1 exam materials outline exercise content and concepts related to normal patient development from infancy to older adulthood, as well as the structure and function of the musculoskeletal and cardiovascular systems (USMLE, 2024). Given that knowledge of exercise concepts is expected, it is crucial to include aspects of an exercise thread throughout the medical curricula. Medical education directors and professors should be attuned to the expectations of board examination test writers and adequately prepare students to become successful practitioners.

The envisaged exercise thread at LLUSM encompasses learning about the impacts of exercise on physiological systems in normal and disease states, as well as preparing practitioners to assess and prescribe exercise; following the lead of SOMG (Curricula, 2025; Trilk et al., 2019a). The preclinical years would focus on providing content-rich and discrete objectives within lectures throughout each organ system-based block, along with opportunities for demonstrations, laboratories, case studies, or intensive selective sessions (Figure 1). Clinical years would then concentrate on building students’ confidence and competence, enabling them to properly assess and prescribe exercise to their patients, while also becoming physical activity champions in their communities. This comprehensive approach aims to create well-rounded physicians who understand the importance of exercise in healthcare and can effectively integrate it into their practice, ultimately leading to improved patient outcomes and public health.

5 Limitations

There are several important limitations to this study. As a single-site curriculum audit, the findings may not be generalizable to other institutions with different educational structures, resources, or student populations, especially given our institutional strength in lifestyle-medicine. In addition, the analysis relied exclusively on materials obtained from the learning management system and associated curricular documents. Because these documents are generated by a wide array of instructors the content may be subject to inconsistencies in how material is labeled, delivered, or updated. Steps were taken to mitigate potential bias as several authors are directly involved in the delivery, oversight, or administration of the curriculum under review. To address this, data were extracted and analyzed systematically by multiple team members. The findings were cross-validated, and all interpretations were discussed as a group to ensure transparency and minimize subjective influence.

6 Conclusion

This curricular analysis illustrates that the LLUSM education program is poised to establish a systematically constructed exercise thread that spans all 4 years of training, integrating foundational exercise physiology and lifestyle medicine with clinical application in patient care. The long-term effectiveness of this curriculum will depend on continuous iterative evaluation based on direct feedback from student learners combined with objective oversight from faculty to ensure content relevance and pedagogical effectiveness. Future curriculum development must draw from contemporary sources and evidence-based practice guidelines while remaining responsive to evolving societal health needs, particularly the growing burden of chronic diseases linked to sedentary lifestyles. By implementing this comprehensive, feedback-driven approach, LLUSM can prepare future physicians who are confident and competent in prescribing exercise as medicine, ultimately improving patient health outcomes through enhanced counseling and evidence-based physical activity interventions.

Glossary of terms

ACSM logic model/pre-participation screening: American College of Sports Medicine guidance for determining exercise readiness, indications for medical clearance, and safety considerations.

Autoregulation and subjective intensity: Teaching on adjusting training load based on patient-reported effort (e.g., RPE) to individualize progression safely over time.

Blocks: Organ systems-based, time-delimited course units (e.g., Cardiovascular, Pulmonary, Endocrine/Reproductive, Hematology/Immunology, Musculoskeletal/Skin, Neuroscience/Psychiatric, Renal/Urinary, Application & Integration) in which exercise content is integrated within relevant threads.

Contemporary sources: Current guidelines and consensus frameworks used to judge currency and relevance of exercise content (e.g., Physical Activity Guidelines, ACSM resources, Exercise is Medicine materials), ensuring alignment with evidence-based standards.

Electives: These are student-chosen rotations or experiences where students have complete freedom to select from a wide range of options based on their interests, career goals, or desire for additional exposure to specific specialties. Students are not required to complete any particular elective, and these may include rotations in any medical specialty, research opportunities, or even experiences outside their primary field of study.

Exclusion criterion: Sessions without explicit exercise content or LOs (e.g., general biochemistry, anatomy, pathology, or pharmacology topics without exercise linkage) were excluded. Disease modules with no exercise framing or application were excluded from exercise LO counts.

Exercise as medicine/rehabilitation: Sessions emphasizing preventive and therapeutic roles of physical activity, including cardiac rehabilitation phases, benefits, and indications.

Exercise physiology demonstration/lab: Practical sessions measuring physiologic responses to isometric and dynamic exercise (e.g., handgrip, cycling), redistribution of cardiac output, ventilatory control, VO2max concepts, and training adaptations.

Exercise prescription (clinical): Structured application of FITT/FITT-VP to create or modify patient-specific exercise plans considering comorbidities, age, tolerance, injuries, and goals; includes progression strategies such as autoregulation and use of subjective intensity.

Exercise-relevant content: Any curricular material (lecture, lab, simulation, case, demo, or assessment) that explicitly references physical activity or exercise, exercise testing, training adaptations, or uses exercise as a context for physiological or clinical concepts (e.g., exercise effects on cardiovascular, pulmonary, endocrine, or metabolic systems; exercise in disease prevention/treatment; safety screening; rehabilitation).

Exercise-relevant learning objective (LO): A stated objective that explicitly includes exercise or physical activity as a knowledge, skill, or application target (e.g., “list exercise recommendations,” “design an exercise prescription using FITT-VP,” “describe physiologic responses during exercise,” “modify exercise for disease states”). Objectives that only implicitly relate to exercise without naming it were not counted as exercise-relevant unless linked to an exercise-specific session.

FITT/FITT-VP: A prescriptive framework for exercise—Frequency, Intensity, Time, and Type, with Volume and Progression—used to evaluate and design patient-specific exercise prescriptions.

Inclusion criterion (content-only mention): Single-slide or brief mentions of exercise without a mapped exercise LO were flagged as “mentions only” and described qualitatively but not counted toward exercise-relevant LO totals. These were included in narrative mapping to illustrate longitudinal exposure but excluded from quantitative LO counts.

Inclusion criterion (session-level): Sessions were included if they contained at least one exercise-relevant LO or devoted explicit content to exercise (e.g., exercise physiology demos/labs; “Exercise is Medicine”; cardiac rehabilitation; safety screening such as PAR-Q/ACSM logic model; PAVS; FITT/FITT-VP; VO₂max; exercise adaptations; exercise in disease prevention/management). Example inclusions from Table 1 include sessions on exercise physiology demos, cardiac rehab/Exercise is Medicine, exercise in hypertension management, pulmonary responses to exercise, integrated effects of exercise, and exercise prescription in MSK conditions.

Mapping: The process of linking session titles and learning objectives to exercise-relevant criteria across threads and blocks to quantify exposure and identify gaps.

Mentions vs. mapped LOs: “Mentions” are brief references to exercise within a session; “mapped LOs” are formal learning objectives explicitly tied to exercise. Only mapped LOs are included in quantitative tallies; mentions are reported qualitatively.

Motivational interviewing (MI) for physical activity: Behavior-change counseling skills used to enhance exercise adoption and adherence within clinical clerkships.

Non-typical presentations: Integration of exercise-related mechanisms or prescriptions into less obvious contexts (e.g., endocrine regulation during exercise, pulmonary diffusion limits at high altitude or with ILD during exercise, autonomic responses, thermoregulation with exertion), used to reinforce cross-system relevance.

PAR-Q: Physical Activity Readiness Questionnaire used to screen for exercise safety and the need for medical clearance prior to activity.

PAVS: Physical Activity Vital Sign; a brief screening tool to assess a patient’s weekly physical activity used within clinical teaching on counseling and prescription.

Safety screening: Teaching related to identifying contraindications and precautions for exercise (e.g., signs suggestive of cardiovascular, metabolic, or renal disease; when to refer; cardiac rehabilitation indications/contraindications).

Selectives: These are structured educational experiences that students must complete as part of their curriculum requirements, but they retain some element of choice in the specific topic or focus area within predetermined categories. For example, LLUSM offers 2-week selectives in the first and second years where students choose from multiple facets of medical practice including “the art of health, transformative health care, the business of medicine, leadership, simulation, and ultrasound.” While students have choice in their selective topic, completing a selective is mandatory for graduation, whereas electives are optional additional experiences.

Threads: Longitudinal curricular elements spanning multiple blocks [e.g., Lifestyle and Preventive Medicine (LPRV), Physiology (PHYS), Pathophysiology (PPHY), Pharmacology (PHAR), Physical Diagnosis (PDX), Biochemistry (BCHM), Cell Biology (CELL)] that can host exercise-relevant sessions or objectives.

Data availability statement

The original contributions presented in this study are included in this article/Supplementary material. The datasets generated during this study, along with Supplementary material, are available from the corresponding author upon request.

Author contributions

EY: Data curation, Conceptualization, Methodology, Writing – review & editing. Investigation, Writing – original draft, Formal analysis, Visualization. BB: Visualization, Formal analysis, Writing – original draft, Methodology, Investigation, Data curation, Conceptualization, Writing – review & editing. SP: Writing – review & editing, Writing – original draft. DR: Methodology, Validation, Conceptualization, Data curation, Supervision, Writing – review & editing, Writing – original draft, Project administration. CW: Writing – review & editing, Conceptualization, Validation. JM: Writing – review & editing. AB: Writing – review & editing, Conceptualization. DA: Writing – review & editing, Conceptualization. AM: Conceptualization, Validation, Formal analysis, Writing – original draft, Investigation, Data curation, Writing – review & editing. SW: Resources, Investigation, Validation, Software, Writing – review & editing, Funding acquisition, Supervision, Conceptualization, Writing – original draft, Formal analysis, Project administration, Methodology, Visualization, Data curation.

Funding

The author(s) declare financial support was received for the research and/or publication of this article. This study was funded in part by the Loma Linda University School of Medicine.

Acknowledgments

EY, BB, and SP were each research fellows with the Macpherson Society Summer Research Scholarship program.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Generative AI statement

The authors declare that Generative AI was used in the creation of this manuscript. We used AI tools to improve the grammar and to generate a consistent writing style between various co-authors who wrote different sections.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/feduc.2025.1660929/full#supplementary-material

Abbreviations

ACL, anterior cruciate ligament; ACSM, American College of Sports Medicine; ANAT, anatomy; A-V, Arterio-venous; BCHM, biochemistry; BMI, body mass index; CBC, complete blood count; CBTL, Case-Based Team Learning; CELL, cell structure and function; CNS, central nervous system; COMLEX-USA, Comprehensive Osteopathic Medical Licensing Examination of the United States; COPD, chronic obstructive pulmonary disease; EBMIS, evidence-based medicine and information sciences; EIM, Exercise is Medicine; EMBR, embryology; FFA, free fatty acids; FITT, frequency, intensity, time, type; FITT-VP, Frequency, intensity, time, type, volume, and progression; GENE, genetics; GH, growth hormone; GI, gastrointestinal; hPL, human placental lactogen; HSS, health systems science; LCME, Liaison Committee on Medical Education; LLUSM, Loma Linda University School of Medicine; LMS, learning management system; LPRV, lifestyle and preventive medicine; MCL, medial collateral ligament; MICR, microbiology; MS3, third-year medical student; MS4, fourth-year medical student; MSK, musculoskeletal; MTP, metatarsophalangeal; OB-GYN, obstetrics and gynecology; OSA, obstructive sleep apnea; PAR-Q, Physical Activity Readiness Questionnaire; PATH, pathology; PAVS, Physical Activity Vital Sign; PCO2, partial pressure of carbon dioxide; PDX, physical diagnosis; PHAR, pharmacology; PHYS, physiology; PPHY, pathophysiology; RBC, red blood cell; RPE, rating of perceived exertion; SOMG, University of South Carolina School of Medicine Greenville; STEP, standardized test for the evaluation of performance; T2DM, type 2 diabetes mellitus; TBL, team based learning; TCA, tricarboxylic acid; TLC, total lung capacity; TUE, therapeutic use exemption; USADA, United States Anti-Doping Agency; USMLE, United States Medical Licensing Examination; VAQ, ventilation-perfusion; VO2, Volume of oxygen (maximal oxygen uptake/consumption); WADA, World Anti-Doping Agency; WBC, white blood cell; WHO, World Health Organization.

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