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Professions Commission projected a system that would be more oriented on health, would stress disease prevention and health promotion, and would be population based to respond to the increasing attention paid to social and environmental risk factors (O’Neil, 1992; Pew Health Professions Commission, 1991). In this context, the Pew commission articulated a responsibility for health professionals to understand, maintain, and improve community health and thus the need for future physicians to understand the societal and environmental determinants of health. Other studies have noted the need to shift the focus of medical education from acute to chronic conditions and from an infectious to a biopsychosocial model of health and disease (Association of American Medical Colleges, 1992a).

Many of the reform proposals pose opportunities for integrating environmental medicine into medical education in the sense that: environmental medicine is responsive to the calls for cross-disciplinary teaching; environmental medicine melds basic and clinical science and reinforces the basic and biomedical sciences throughout the course of medical study; it moves training away from tertiary-care teaching hospitals and into the community; and it emphasizes student-directed, problem-based learning (Association of American Medical Colleges, 1992a,b; Marston, 1992; O’Neil, 1992). Environmental medicine is also central to primary care.

Despite the plethora of studies, reports, and recommendations, however, actual efforts to respond to the calls for change have been less than noteworthy and successes have been few (Anderson, 1993; Enarson and Burg, 1992). There is, nonetheless, a steady and growing interest among medical schools in reform, presenting a window of opportunity for environmental medicine. The key to seizing this opportunity is realistic implementation strategies for importing knowledge about the environment and its role in health into mainstream medical education. Chapter 3 of this report described some potentially effective implementation strategies; the remainder of this chapter describes potential barriers and opportunities that may be encountered in attempting to modify medical school curricula.

BARRIERS AND OPPORTUNITIES

For decades, the basic structure of the medical school curriculum has changed very little. Medical school curricula, although superficially varied, are designed to prepare students for graduate medical education and practice. The four years of medical school are commonly divided into two years of discipline-oriented preclinical (basic science) studies followed by two years of clinical studies. Clinical education has traditionally occurred in the hospital, although students increasingly learn in outpatient, ambulatory care facilities. At many medical schools, the fourth year is primarily student-designed, and students spend much of their time in elective study. This period also involves time spent interviewing for future residency positions. To the extent that the preclinical and



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