Competency 6. Graduating medical students should be able to understand the ethical and legal responsibilities of seeing patients with environmental and occupational health problems or concerns.

Rationale. Many states have reporting requirements for occupational and environmental diseases. Beyond compliance with legal reporting requirements, physicians may have ethical obligations to report environmentally related conditions to local authorities, especially when other members of the public may be at risk. In addition, patients may need their physicians’ assistance in obtaining the compensation and remediation allowed them by law. Physicians should have a basic understanding of their legal and ethical responsibilities and know where to go for help.

With the common acknowledgment that the environment is a vitally important factor in health and in a wide range of illnesses, it follows that every medical school graduate should be knowledgeable and competent in the basic elements of environmental medicine. Thus the committee believes that every medical school graduate should master the six competencies in environmental medicine described in this report and integrate environmental and occupational history-taking into daily practice. Employing this knowledge and these competencies will provide a basis for a more appropriate interaction with patients and the community regarding the impact of environmental medicine and will expand physicians’ knowledge and improve their clinical expertise.

The committee believes that developing the ability to obtain a thorough environmental and occupational history is a fundamentally important component of the competencies, because if done correctly, such a history provides the primary information needed for diagnosis, referral or treatment, and prevention of environmental and occupational illnesses and injuries. A focus on the history can, indeed should, lead to the knowledge, skills, and attitudes encompassed in the other competencies. The elements of such a history have been well described, and a variety of forms and tools have been developed for both teaching and practice purposes (Agency for Toxic Substances and Disease Registry, 1992; American Lung Association of San Diego, 1983; California Public Health Foundation, 1992; Connecticut Department of Health Services, 1992; Goldman and Peters, 1981). Appendix A of this report contains a good example of such a history that was prepared by the ATSDR and peer reviewed by several experts in the field.

Direct discussion of the foregoing competency-based objectives continues in Chapter 3, where each competency is discussed in terms of likely access points in the curriculum for their integration and possible teaching strategies. Chapter 4 then considers the general structure and characteristics of medical education today and reflects on both the barriers to and opportunities for introducing these six objectives into the curriculum.