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ENVIRONMENTAL MEDICINE

Integrating a Missing Element into Medical Education

Andrew M.Pope and David P.Rall, Editors

Committee on Curriculum Development in Environmental Medicine

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1995



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Environmental Medicine: Integrating a Missing Element into Medical Education ENVIRONMENTAL MEDICINE Integrating a Missing Element into Medical Education Andrew M.Pope and David P.Rall, Editors Committee on Curriculum Development in Environmental Medicine Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1995

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Environmental Medicine: Integrating a Missing Element into Medical Education National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I.Shine is President of the Institute of Medicine. This project was supported by funds from the Agency for Toxic Substances and Disease Registry, the National Institute for Occupational Safety and Health, and the Environmental Protection Agency (contract number U61/ATU398777–01). Library of Congress Catalog Card No. 94-74838 International Standard Book Number 0-309-05140-1 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, D.C. 20055 Call 800–624–6242 or 202–334–3313 (in the Washington Metropolitan Area). B461 Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Environmental Medicine: Integrating a Missing Element into Medical Education COMMITTEE ON CURRICULUM DEVELOPMENT IN ENVIRONMENTAL MEDICINE DAVID P.RALL (Chair), Director (Retired), National Institute of Environmental Health Sciences, Washington, D.C. M.BROWNELL ANDERSON, Assistant Vice President, Educational Programs, Association of American Medical Colleges, Washington, D.C. ELIZABETH L.BOWEN, Assistant Professor, Department of Family Medicine and Medical Education, Morehouse School of Medicine, Atlanta L.THOMPSON BOWLES, President, National Board of Medical Examiners, Philadelphia EDDY A.BRESNITZ, Director, Division of Occupational and Environmental Health, and Professor and Chair of Community and Preventive Medicine, Medical College of Pennsylvania and Hahnemann University School of Medicine, Philadelphia MARK R.CULLEN, Director, Occupational and Environmental Medicine Program, and Professor of Medicine and Public Health, Yale University, New Haven RICHARD J.JACKSON,* Chief, Division of Communicable Disease Control, California Department of Health Services, Berkeley KARL T.KELSEY, Associate Professor, Occupational Health Program, Harvard School of Public Health, Boston HOWARD M.KIPEN, Associate Professor and Director of the Division of Occupational Medicine, Environmental/Occupational Health Sciences Institute, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Piscataway, New Jersey SHARON L.MORRIS,** Senior Lecturer and Director, Continuing Education, Department of Environmental Health, University of Washington, Seattle KATHLEEN M.REST, Assistant Professor, Department of Family and Community Medicine, University of Massachusetts, Worcester DONALD E.WILSON, Dean, University of Maryland School of Medicine, University of Maryland, Baltimore Liaison to the Institute of Medicine’s Board on Health Promotion and Disease Prevention EULA BINGHAM, Professor of Environmental Health, College of Medicine, University of Cincinnati, Ohio Study Staff Andrew M.Pope, Study Director Carrie E.Ingalls, Project Assistant Michael A.Stoto, Director, Division of Health Promotion and Disease Prevention Linda A.DePugh, Administrative Assistant Judith Doody, Financial Associate Laura Baird, Librarian *   Appointment ended September 1, 1994. **   Appointment ended May 1, 1994.

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Environmental Medicine: Integrating a Missing Element into Medical Education Acknowledgments The committee wishes to acknowledge and express its gratitude to several individuals for their participation in committee workshops and other activities that assisted the committee in the preparation of this report: Charles Becker, Jack Berberich, Gershon Bergeisen, Eula Bingham, Jonathan Borak, Kay Doggett, Ruth Etzel, Linda Frazier, George Gebus, Bernard Goldstein, Jerome Goldstein, Daniel Goodenough, Elizabeth Gresch, Michael Hosokawa, Annette Kirchner, Heidi Klein, Philip Landrigan, Melissa McDiarmid, Hugh McKinnon, Frank Mitchell, Dorothy Moore, Julia Moore, Michael Parkinson, Maureen Paul, Harry Pettengill, Gerald Poje, John Randall, Boyd Richards, Meta Snyder, Barry Stern, Frank Stritter, Neal Vanselow, and Greg Wagner. The committee would also like to thank William Wiese, University of New Mexico School of Medicine, and Nancy Koff, University of Arizona, who prepared provocative, informative background documents for the committee. These documents were valuable in generating vigorous discussion and productive thought in relevant areas. The committee also thanks Gina Solomon for her assistance in the compilation of case studies in environmental medicine, and Edmund Kelly and Nora Howley of the Association of Occupational and Environmental Clinics, and Rosemary Sokas, of George Washington University, for their assistance and contributions. The sponsors of this project, the Agency for Toxic Substances and Disease Registry, the National Institute for Occupational Safety and Health, and the Environmental Protection Agency, are gratefully acknowledged for identifying the subject of this report as an important area, and for supporting the conduct of the study. In particular, Max Lum, Diane Narkunas, and Donna Orti of ATSDR were critical to the initiation of the

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Environmental Medicine: Integrating a Missing Element into Medical Education study and valuable sources of information throughout its conduct. Lastly, a debt of gratitude is owed to the IOM staff. No effort of this kind can be accomplished without the hard work and dedication of a talented staff. The committee thanks the following IOM staff members: Laura Baird, director of the IOM Library; Mike Edington, managing editor; Carrie Ingalls, project assistant; and Andrew Pope, study director. In particular, Carrie Ingalls is acknowledged for providing research, clerical, and administrative support beyond the call of duty, putting in tireless hours in identifying, collecting, and preparing resource materials, and formatting the camera ready copy of the report for publication—all while carrying a full load of coursework in a Master of Public Health program.

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Environmental Medicine: Integrating a Missing Element into Medical Education Preface In its broadest sense, the environment is one of the major determinants of human health and well-being. Healthy environments promote individual and community health; unhealthy environments can create substantial morbidity, mortality, and disability, in addition to sapping the economic welfare of societies. In a previous report, produced by the Committee on the Role of the Primary Care Physician in Occupational and Environmental Medicine, the Institute of Medicine (IOM) called on primary care physicians to enhance their roles in occupational and environmental medicine, noting that these providers often serve as the point of first contact for persons with work- and environment-related health problems or risks (Institute of Medicine, 1988). At the same time, IOM found that the training of primary care physicians in occupational and environmental medicine is lacking at all levels of medical education. The present report continues and expands upon the work of the previous IOM committee. It reflects the deliberations of a new committee (Committee on Curriculum Development in Environmental Medicine) formed to recommend a curriculum in environmental medicine for undergraduate medical students. During the study, the committee considered both the content of an environmental medicine curriculum and the more difficult problem of implementing such a curriculum in medical education programs. Although its charge was to focus on undergraduate medical education, it was difficult for the committee to conceive of accomplishing its objectives solely within those confines. The continuum of undergraduate, graduate, and continuing medical education seemed a more appropriate, if not necessary focus, because environmental medicine

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Environmental Medicine: Integrating a Missing Element into Medical Education permeates the entire spectrum of medical practice and should similarly reach throughout the continuum of medical training. Some of the discussion in this report therefore refers to residency training and continuing medical education. This report incorporates portions of the committee’s interim report issued in 1993, and uses the six competency-based learning objectives set forth in that report as a central theme for recommending implementation strategies. The primary strategy, simply stated, is to integrate environmental medicine into existing courses and clerkships rather than defining and carving out new blocks or courses in an already crowded curriculum. The committee believes that the addition of new blocks or courses is not a viable option at this time, and that integrating environmental medicine is not only the most expeditious approach to achieving the stated objectives but is also the most appropriate approach given the pervasive and fundamental nature of the effects of the environment on health. The committee’s own vision for training leaders in environmental medicine has thus been tempered with a strategy for implementing a realistic curriculum that all medical schools can embrace and deliver to their students. Of great importance to the report’s practical value as an immediate tool are Appendixes A, B, C, and D, which follow the main text. These provide detailed information on available educational resources and teaching aids and include 55 case studies that can be used to facilitate the integration of environmental medicine into both education and practice. The report articulates a coherent general program of action and provides practical advice to individual educators, students, and practitioners who either are interested in integrating more environmental medicine content into medical education or need resource information to help them address clinical situations. In summary, the committee intends for this report to serve as a tool that can be used immediately by interested faculty, students, and practitioners who want to integrate and enhance environmental medicine in medical education and practice. In addition, we hope to convince others of the fundamental importance of environmental medicine, the need for integrating it into medical curricula, and the ease with which a curriculum can be enhanced with this information. The committee is confident that integrating environmental medicine into medical education will substantially enhance the competence of tomorrow’s physicians in addressing the growing environmental health concerns of their patients and communities. David P.Rall, M.D., Ph.D. Chairman

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Environmental Medicine: Integrating a Missing Element into Medical Education Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   5     Definition and Scope of Environmental Medicine,   8     Role of the Physician,   9     Recent History,   9     A Continuum of Roles,   10     Origin and Organization of the Report,   11 2   CURRICULUM CONTENT   14     Components of a Curriculum,   14     Competency-Based Learning Objectives,   17     Conclusions and Recommendations,   21 3   IMPLEMENTATION STRATEGIES   22     Curriculum Access Points and Teaching Strategies,   24     Competencies 1 and 2,   24     Competency 3,   26     Competency 4,   29     Competency 5,   30     Competency 6,   32     Enhancing Faculty Awareness,   34     Some Long-Term Strategies,   34     Some Short-Term Strategies,   35

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Environmental Medicine: Integrating a Missing Element into Medical Education     Conclusions and Recommendations,   38     Integrating the Curriculum,   38     Developing Faculty,   39     Continuing Education,   40     Evaluating Progress,   41 4   CHANGING MEDICAL EDUCATION   44     Calls for Reform in Medical Education,   44     Barriers and Opportunities,   45     Barriers,   46     Opportunities,   48     Conclusions and Recommendations,   51 5   CONCLUDING REMARKS   52     REFERENCES   54     APPENDIXES   59     A Taking an Exposure History,   61     B Medical School Courses and Clerkships: Access Points for Integrating Environmental Medicine,   97     C Case Studies in Environmental Medicine,   121     D Resources: Agencies, Organizations, Services, References, and Tables of Environmental Health Hazards,   909     E Committee and Staff Biographies,   971

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Environmental Medicine: Integrating a Missing Element into Medical Education ENVIRONMENTAL MEDICINE

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