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14 CURRENT EDUCATION AND TRAINING The earlier lOM committee concluded that (~) the care of inclividuals with occupationally and environmentally- relatecl exposures ancl/or conditions requires mastery of a special body of knowledge, skills, and attitudes by the primary care or other first contact physician, and (2) all levels of medical education -- undergracluate, graduate, and continuing education -- are currently deficient in OEM training. Only 66 percent of U.S. medical schools specifically teach occupational medicine as part of the required curriculum; among schools that require such teaching (about hale, the mean required curriculum time over 4 years is 4 hours. A 1987 Association of American Medical Colleges (MMC) survey of medical school gracluates found that occupational medicine was taken as an elective by only 1.4 percent, the least frequently selected elective reported.79 An MMC survey in 1988 found that only one of 127 medical schools reported having a required course in environmental health, although 100 schools reported that environmental health concepts

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15 were taught in other courses.20 A survey of 89 departments of internal medicine with divisions of general internal medicine found that only 20 programs (22 percent) offered clinical occupational medicine experience to medicine residents, elective in almost all cases.27 , , ad, ~ ~ ~e ~ The deficiency in numbers of academic faculty in occupational and environmental medicine is well-documented. In one survey of 102 medical schools, only 59 percent reported having even a single faculty member with special interests in occupational medicine.22 In another survey of 127 medical schools only 37 faculty were identified as specializing in occupational medicine. Specialty training in occupational medicine at the graduate level is largely confined to the 29 occupational medicine residency training programs approved by the Accreditation Council for Graduate Medical Education (ACGME). Most residency programs are based in either schools of public health or medicine, although some are jointly sponsored by schools of public health and medicine. In some instances trainees have dual status as occupational medicine residents and department of medicine fellows. The ACGME does not accredit any occupational and environmental medicine training as a clinical medical subspecialty. lt is estimated that about 70 resident physicians are produced each year who are deemed eligible to sit for the certification examination in occupational medicine by the only extant certifying bocly, the American Board of Preventive Medicine. The Subcommittee conceives three levels of specially prepared specialists and clinicians to provide needed OEM

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16 training and care (Figure 2~. As is described further in the following sections, different levels of certification will recognize their competencies. Figure 2. Levels of OEM Physician Expertise Domain I Certification OEM Specialist OEM Clinician Primary Care Physician public health agency full-time faculty research consultation industry clinical faculty consultation community hospital industry practitioner ABPM (OEM) ABIM or ABFP ABIM or ABFP CAQ in OEM ABIM or ABFP OEM = occupational and environmental medicine ABPM = American Board of Preventive Medicine ABIM = American Board of Internal Medicine ABFP = American Board of Family Practice CAQ = Certificate of Added Qualifications