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field of environmental medicine, the report recommended that physicians improve their ability to identify conditions caused by environmental contaminants, to obtain patient histories that include environmental risk conditions, and to make appropriate diagnoses and referrals.

“The Green Book” states that most individuals with occupational or environmental illnesses obtain their medical care from physicians who are not specialists in either occupational or environmental medicine. Primarily for this reason, the report states that “at a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals for follow-up” (Institute of Medicine, 1988:5) The report also states that primary care physicians should know basic principles of disease related to chemical exposure; know how to take an appropriate exposure history; be sensitive to the ethical, social, and legal implications of the diagnosis of environmental disease; and be alert to opportunities to prevent or mitigate illness and exposure. Two subsequent IOM reports addressed the related topics of medical information needs (Institute of Medicine, 1990) and the physician shortage in occupational and environmental medicine (Institute of Medicine, 1991).

As follow-up to the previous IOM reports in this area, the Agency for Toxic Substances and Disease Registry requested that the IOM address issues related to enhancing the content of environmental medicine in medical education; additional support was subsequently provided by the Environmental Protection Agency and the National Institute for Occupational Safety and Health. With the understanding that all medical schools are different and that what is learned is more important than what is taught, the IOM committee responded to its charge by establishing competency-based learning objectives that it felt should apply to all graduating medical students. In order to facilitate the achievement of these objectives and to implement a strategy of enhancing the integration of environmental medicine in medical education, the committee compiled a series of case studies that should be used for teaching and learning about the fundamental and myriad effects of the environment on health. It is the sense of this committee that using these cases and others like them will help teach the basic and clinical sciences and enhance the capabilities of future physicians to practice medicine.

The committee is optimistic about the ease with which these competencies can be taught, the eagerness with which they will be learned, and the improvements that will be experienced in the practice of medicine as a result of their achievement and application.

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