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CHAPTER 4
Recommencled Interventions in
the Education of Future Physicians
The teaching of environmental and occupational medicine to future primary
care physicians needs to be significantly changed at both the undergraduate and
graduate levels of medical education (Rest et al., 1983b; Cullen, 1987; Demers
et al., 1987; Levy, 1987; Sokas and Cloeren, 1987~. Currently, most medical
schools provide little or no identified curriculum in this area (Levy, 1985~. The
teaching of environmental and occupational medicine is important not only for
the concepts and factual information that could be conveyed but also for the
signal that the teaching of this information sends to students and residents.
Medical school education to a large extent defines the boundaries of medical
practice. This section focuses on this important aspect of fostering the role of
primary care physicians in occupational and environmental medicine. It defines
educational objectives, delineates major barriers, and recommends inte~ven-
tions to address these problems.
The committee recognizes that there are problems in inserting new material
in the medical curriculum. Medical schools are being called on to devote more
time to the expanding scientific base of medical practice, while at the same time
they are being asked to expand clinical instruction in geriatrics, nutrition,
cancer, and other subjects.
EDUCATION OBJECTIVES FOR UNDERGRADUATE MEDICAL EDUCATION
Undergraduate medical education should lay the foundation for training
physicians to incorporate occupational and environmental factors into the
etiologic investigation of disease. Because occupational and environmental
medicine is largely based on general preventive medicine principles, didactic
and clinical training that provides an adequate focus on preventive activities of
all types and in relation to all organ systems is key to achieving the minimal
competencies iclentified in this section. This training necessarily includes solid
grounding in epidemiology and toxicology and an understanding of the con
4/
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cept of risk and its application to groups and individuals.
The undergraduate should be able to elicit basic information about those
occupational and environmental factors that may affect an individual's health.
Central to this task is learning to perform an occupational and environmental
health screening history. The undergraduate should be able to routinely incor-
porate this history into the traditional health history and have an adequate
understanding of the complexity of the work in order to recognize occasions
when more specific information is necessary for a full evaluation.
The undergraduate should appreciate the relation between exposure dose
and host response. This relation includes recognition of important factors that
contribute to exposure dose, including route of absorption, metabolism and
degradation, and time~ose characteristics, such as the role of acute versus
chronic exposure, in contributing to cumulative dose and latency. An apprecia-
tion that most diseases caused by chemical and physical agents are associated
with long latent periods from first exposure until disease manifestation rein-
forces the need for detailed history taking of often remote occupational and
environmental exposures.
The undergraduate should know where and how to obtain information
sources about occupational and environmental diseases. The undergraduate
should be aware of the availability of texts; data bases (such as TOXLINE); and
federal, state, and local agencies.
The undergraduate should recognize the special medical, ethical, legal, and
economic factors in caring for patients with occupational and environmental
diseases. Specifically, this includes an appreciation of workers' compensation
and other disability systems, familiarity with institutions and agencies that may
play a role in disease prevention, and appreciation of the relevant aspects of the
employee-employer relationship.
EDUCATIONAL OBIECr~FS FOR GRADUATE MEDICAL EDUCATION
With the expectation that the undergraduate educational objectives de-
scribed have been achieved, the overall goal of residency training is to further
prepare physicians to recognize, diagnose, and treat occupational and environ-
mental health conditions and risks pertinent to their current and future
practice. The knowledge and skills needed for the successful incorporation of
occupational and environmental factors into clinical practice will necessarily
vale by specialty and subspecialty area. But in all fields, postgraduate training
should include familiarity and experience with the most prevalent occupational
and environmental conditions that will be encountered. For example, in
orthopedic training, physicians should appreciate the potential contributions of
workplace factors to acute and chronic low back pain, both because workplace
factors may be of etiologic importance and because back pain, regardless of
causation, may affect the ability of the individual to function at work.
In addition to recognizing the role of work and the environment on health,
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the physician in residency should become familiar and comfortable with carry-
ing out the attendant responsibilities of caring for working patients, such as
dealing with the workers' compensation system and participating in the assess-
ment of impairment.
Because the committee anticipates that primary care physicians wall bear the
bulk of responsibility for patients with occupational and environmental disease,
the following section specifies educational objectives for graduate training in
internal medicine and family practice.
Internal Medicine and Family Practice
The committee believes that the funclamental tool to be mastered at the
residency level is the occupational and environmental health history; trainees
should team to take both an occupational and environmental screening history
and a more in~epth history directed by the indiviclual's complaints and
findings. General toxicologic principles, similar to those reamed in pharmacol-
ogy, should be sufficiently understood that they can be applied to the individual
patient. These include knowledge about exposure routes (in the occupational
setting, usually dermal or inhalation or both), general mechanisms of action (for
example, differences between cellular toxins and carcinogens), latency, and
other exposure dose-response and time-response characteristics. At the individ-
ual patient level, the primary physician has both legal and medical responsibili
ties to assess the likelihood! that diseases are related to occupational or env~ron-
mental hazards. The physician must recognize that the degree of certainty
brought to such determinations varies for each setting. For example, for legal
purposes, a disease is usually considered occupational or environmental if it is
more likely than not (51 percent likelihood) that it was caused or aggravated by
workplace or environmental exposure.
Listed below are certain criteria that should be considered and understood by
trainees in determining the potential work or environmental relatedness of
diseases, recognizing that, depending on the circumstances and characteriza-
tion of the disease process, only some criteria may be met in any individual
patient (Levy and Wegman, 1983; Rest et al., 1983b; Rosenstock and Landrigan,
1986~. Successful application of these criteria employs skills and knowledge
previously identified as objectives for training.
The following are criteria for the work or environmental relatedness of a
. .
c Diagnosis:
I. The symptoms, signs, and laboratory tests are consistent with the diagnosis.
2. The temporal pattern of exposure and disease onset is coherent, that is,
exposure precedes disease onset or aggravation.
3. The exposure, if known, was sufficient to cause the disease.
· Biological monitoring for the assessment of exposure or specific end
organ effects, if available, is consistent with close-response characteristics.
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· Epidemiologic data, if available, support the effects at exposures com-
parable to those experienced by the individual.
4. No other condition or exposure more readily explains the disease.
Residents in internal medicine and family practice should be able to discuss
exposure risks with individuals. This will become increasingly important as
patients more frequently query their physicians about the potential effects of
low-level environmental exposures, or exposures that are established as adverse
only at higher occupational exposure levels, if at all. By using the tools of risk
assessment, the primary physician will be better able to allay unnecessary fears
about trivial risks and explain the relative importance of quantifiable health
risks. In this way, physicians can play an important role in explaining and
responding to inquiries about occupational and environmental hazards.
Internal medicine and family practice residency programs should teach the
specific skills related to care for patients with work-related diseases and injuries.
These skills include assessing impairment floss of bodily function) and disability
(impact of impairment on social or work function) and understanding the
physician's responsibility in disability programs, including state and federal
workers' compensation and Social Security disability.
Finally, as in other areas of clinical medicine, physicians need to learn to
appreciate their obligation to keep as informed as possible about occupational
and environmental hazards and to recognize when it is in the-patient's best
interest to seek consultation or referral elsewhere.
BARRIERS TO TEACHING OCCUPATIONTAE AND EN~RONMENTAL MEDICINE
Curricular change and innovation are difficult to achieve in medical educa-
tion (Abrahamson, 1978) and a variety of reasons have been cited for this (Ebert
1981~. These include institutional inertia, vested interests, and competition
among academic units. These generic barriers are all relevant to efforts to
improve the teaching of occupational and environmental health in medical
education. There are, however, several additional issues that are especially
problematic to preventive medicine in general, and occupational and environ-
mental medicine in particular. These are described in the following section.
Undergraduate Medical Education
The relative lack of teaching time for occupational and environmental health
in the undergraduate medical curriculum has been amply documented (Levy,
1985) . In order to address this problem, it is necessary to consider how curricular
time in medical schools is distributed. Briefly stated, the faculty determines
teaching hours and content, and the dean and department chairs determine
faculty composition. It is the availability of trained investigators who are capable
of attracting research funding support that is the primary determinant of who
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will be selected for the faculty, especially in the medical schools that are active
in research. In such schools, deans and department chairs are unlikely to select
faculty in disciplinary areas for which there is little likelihood of external
research funding. Without such funding, the faculty member is not likely to
achieve tenure. Further, faculty who are not productive researchers have little
likelihood of receiving sufficient respect from their peers to have an impact on
the highly competitive world of the medical school curriculum committee.
Thus, the lack of research funding contributes to a shortage of medical school
faculty, and this shortage is reflected in the meager curricular offerings in
occupational and environmental medicine. Where should such research funds
be obtained? At first glance, there would seem to be ample funding sources
among federal agencies, including the National Institutes of Health (NIH), the
National Institute of Environmental Health Sciences (NIEHS), the National
Center for Toxicology Research (NCTR), the Environmental Protection Agency
(EPA), and three Centers for Disease Control (CDC) organizations: the Na-
tional Institute for Occupational Safety and Health (NIOSH), the Center for
Environmental Health (CEIL, and the Agency for Toxic Substance and Disease
Registry (ATSDR). The total Public Health Service (PHS) extramural grants in
occupational and environmental health for recent years are shown in Table 5-1.
Unfortunately, only the NIEHS has a track record of supporting research at
medical schools. The NCTR is almost totally an intramural program. The CEH
and ATSDR have taken the traditional CDC view of focusing their efforts in-
house or at state health departments, with minimal interaction with academic
medical centers. The EPA has made some attempts to fund health-basecl
research in medical schools, primarily through cooperative agreements with
those located close to its North Carolina laboratory, and has a peer-reviewed
grants program that has been chronically underfunded. In 1986, the EPA
awarded $3.4 million in grants and cooperative agreements to medical schools
from its close to $200 million extramural research and development budget. The
NIOSH has made a specific attempt to fund academic medical centers through
its Educational Resource Centers (ERCs). The ERCs are intentionally spread
throughout the federal regions and are thus limited to a small percentage of all
medical schools. The NIOSH also has a grossly underfunded peer-reviewed
grants program now administered through the NTH. In 1986, it had a budget of
$6.2 million for extramural grants, of which $3.S million was received by medical
schools.
The NIEHS had an extramural budget of $71.S million in fiscal year 1986, of
which $31 million was received by medical school faculty. The NIEHS has
utilized a number of faculty development approaches, including the Research
Career Development Award, graduate training programs, and support of mid-
career switches, to provide a marked expansion in the full-time facula in
toxicology. Thus, there is a rapidly developing cadre of well-trained and sup-
ported academic toxicologists capable of teaching the basic science of toxicol
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TABLE ~1 Occupational and Environmental Health-Related Extramural Grants and Contracts
to Medical Schools by the U.S. Public Health Seance as a Percentage of the Total, 1977-1986
Amount to Percentage of
Year Total Amount($) Medical Schools($) Total Dollars
Occupational Health
198642,555,03814,043,422 33.0
198043,938,76217,324,868 39.4
198444,099,37015,421,644 35.0
198334,019,31913,016,781 38.3
198231,975,87912,156,301 38.0
198130,665,8489,927,295 32.4
198031,619,92410,610,248 33.6
197925,891,7367,011,543 27.1
197820,368,4808,395,987 41.2
197717,277,2658,158,765 47.2
TOTALS322,411,621116,071,854
Environmental Health
1986135,375,91560,019,307 44.3
1985139,369,63449,952,001 35.8
1984143,359,85656,403,239 39.3
1983125,605,00846,012,222 36.6
1982101,252,78735,640,434 35.2
198194,847,97732,116,504 33.9
198094,513,32932,597,079 34.5
197987,625,38135,626,627 40.7
197867,771,26027,470,957 40.5
197752,674,41922,056,769 41.9
TOTALS1,042,395,~66
397,900,139
SOURCE: National Institutes of Health. 1977-1986. CRISP Printout, Grants and Contracts.
Bethesda, Md.: National Institutes of Health.
Ogy to medical students. More recently, the NIEHS has been supporting similar
efforts In environmental epidemiology. Unfortunately, however, the public
health aspects of environmental health, including human exposure and health
effects assessment, have generally not been supported by the NIEHS. Other NTH
components, particularly the National Cancer Institute and the National Heart,
Lung, and Blood Institute, also have extramural research support in the area of
environmental or occupational health.
As a result of the direction of NIH activities, the departmental chair or dean
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who is interested in developing occupational and environmental health pro-
grams is naturally more inclined to recruit a basic science toxicologist than an
academic occupational or environmental health researcher. A well-chosen
toxicologist has a much clearer path to academically respectable research
funding and an obvious career ladder. This is much less true for even the
strongest recruit in occupational medicine. Furthermore, there are far fewer
candidates in occupational medicine who have had training specifically aimed
at an academic medical school career.
The situation of an inadequate funding base to support academic programs
mirrors the problem faced by medical school preventive medicine or public
health departments. Most other medical school departments or divisions have
a research mission represented at the NIH or a clinical mission considered
necessary for a tertiary care medical center. In contrast, there is only marginal
support for preventive medicine or public health from the NIH, the rationale
being in part the presence of the CDC, another agency of the Department of
Health and Human Services that has been given primal responsibility in this
area. Unfortunately, the CDC traditionally has spent the bulk of its funding intra-
murally and has not often turned to academic medical centers to provide the
basic information necessary for its mission. Obviously, this is a two-way process.
The CDC cannot be faulted for not supporting a preventive medicine public
health faculty at medical schools if medical schools do not recruit the faculty who
can be responsive to the CDC's needs. The CDC has a cooperative agreement
with the Association of Teachers of Preventive Medicine that provides a low level
of funding to a few academic preventive medicine departments, but that does
not provide basic support for the faculty.
This disparity in support for medical school research between the NIH and
the CDC may be more readily resolved for occupational and environmental
health than for other areas of preventive medicine. This is because of the exist-
ence of the NIEHS and three CDC~related agencies (CEH, NIOSH, and ATSDR),
all of which have mandates in the area of occupational or environmental health.
Relatively small changes in how these agencies function to achieve their missions
would provide the support patterns necessary to ensure the presence of medical
school faculty to teach environmental and occupational health. Without such a
faculty, no lasting impact on medical school teaching can be expected.
The availability of funds for clinical activities also affects faculty hiring
decisions at medical schools. This is particularly true for subspecialties that must
be covered for the academic medical center to fulfill its mission as a tertiary care
center, for example, in the area of pediatric neurology. Occupational and
environmental medicine, while potentially viable economically, are not ordinar-
ily considered a necessary part of the academic tertiary care complex. Further,
participating faculty who are in essence full-time clinicians may have less
academic impact and influence on curricular processes. Nevertheless, some
institutions have established exemplary academically oriented ambulatory clini
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cal operations in occupational and environmental medicine with important
service contributions, financial stability, and the offering of a base for both
undergraduate and graduate medical education. Examples are in New Haven
(Yale University), San Francisco (University of California at San Francisco and
the Pacific Medical Center), and Seattle (University of Washington) .
Correcting the current lack of academic activity in occupational and environ-
mental medicine will require at least two major policy changes. First, a clear
mandate for academic research support in this area must be given to the
appropriate federal agencies. Ideally, the NIEHS should broaden its mandate to
support a wider range of research. Additional efforts should be made by the EPA,
NTOSH, ATSDR, and CEH to look to medical schools for more of the research
findings central to their missions.
The second change is for the necessary funding to support the mandate.
Existing federal agency budgets cannot be stretched to cover additional respon-
sibilities. NIOSH in particular needs more support to enable it to undertake
successfully its mission to support research and faculty development at medical
schools. Such funding should primarily be in the form of competitive peer-
reviewed research support, which has been successful in providing the advances
that have characterized U.S. medicine in recent decades.
It would also be of value to diminish the artificial separation and fragmenta-
tion between occupational medicine and environmental medicine. Both occu-
pational medicine and environmental medicine are strongly oriented toward
prevention. As defined in Chapter 1, occupational medicine is a broadly based
specialty that primarily includes all aspects of the impact of work on health but
that also considers the impact of health on the ability of workers to perform their
tasks. Environmental medicine focuses predominantly on the effects of chemi-
cal and physical agents on human health. Identification and prevention of such
effects have become more and more a part of occupational health at the modern
workplace. The process of risk assessment, a central part of environmental
medicine, is also important for occupational medicine. Hazard identification
and dose-response estimation are necessary for exposures in the workplace or
the general environment; exposure assessment uses and expands on the tools of
classic industrial hygiene to determine exposure outside the work site. Risk
characterization and risk communication are important not only in environ-
mental and occupational medicine but also as important tools for the primary
care physician in the broader sense.
Workplace and community right-to-know laws are rapidly being promulgated
at the federal and state levels (Himmelstein and Frumkin, 19851. Queries from
concerned workers and residents will increasingly test the knowledge of physi-
cians. Often, it will be the same chemicals that cause concern both within and
beyond the workplace boundaries. The interrelatedness of these two specialties
is also apparent when one considers that a classic approach to protecting
workers, that of venting material to the outside, puts the community at risk.
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Wherever possible, students should learn about occupational and environ-
mental medicine at the same time. There is no need for separate educational
processes.
Graduate Medical Education
To a large degree, the same barriers identified above for undergraduate
medical education also create deficiencies in primary care and specialty gradu-
ate training, and the same solutions apply. Most importantly, the dearth of
faculty with specialty interests in occupational and environmental medicine and
the ir~adequate training in these areas of current faculty responsible for educat-
ing primary care physicians contribute to the omission of occupational and
environmental factors in etiologic investigations of disease. Even the best clinical
teachers in residency training programs are likely to omit occupational and
environmental conditions from the differential diagnoses of patients on the
wards and in the clinics. Role models of the generalist who is comfortable with
the medical, legal, ethical, and economic factors of work-related diseases are few
and far between. Similarly, there are few specialist teachers available to serve as
consultants, further limiting the exposure of residents to concepts necessary to
achieve minimal competencies in occupational and environmental health.
Compounding these deficiencies is the relative absence of specific clinical and
research experiences in occupational and environmental medicine in most
residency programs, experiences which could promote interest in pursuing
further training for academic or clinical specialty careers in the field. Faculty
with expertise in these areas have had no supportive home program, division, or
department. Institutional bases for these faculty have arisen on an ad hoc basis.
INCENTIVES FOR TEACHING OCCUPATIONAL AND ENVIRONMENTAL MEDICINE
.
Certain trends may provide incentives to increase graduate training in
occupational and environmental medicine. Both medical school and house staff
education are increasingly taking place in ambulatory settings. The growth of
family medicine departments and divisions of general internal medicine reflects
the change. Managed care systems provide incentives to hospital and medical
school administrators to broaden the patient care base of the academic medical
center. This could include facilities to provide care for people with possible
occupational or environmental illnesses. There may be an added incentive to
correctly identify health problems as being occupationally related, because
these are potentially reimbursable outside the prepaid system through workers'
compensation insurance. The increased interest of employers, insurance carri-
ers, and the public in health promotion and disease prevention further favors
attention, research, and clinical activities in the workplace, particularly as work-
site health promotion programs gain in popularity.
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ERVENTION STRATEGIES
The following section outlines specific intervention strategies designed to
achieve the educational objectives discussed above. Faculty training and support
for research are critical. Without a major effort to increase research support in
the field, an increase in faculty resources will not be likely.
Faculty Training
The number offaculty available to achieve the educational objectives outlined
above for undergraduate and graduate medical training is currently inadequate
(Association of Teachers of Preventive Medicine, 1986~. Interventions to over-
come this major barrier include the following:
1. Instituting career development awards to provide salary support and
resources to individuals committed to assuming leadership positions in occupa-
tional and environmental health in schools of medicine. Awardees could be
responsible for promoting and coordinating the education of the schools
students, other trainees, and faculty in the area of occupational and environ-
mental health. Awardees will also have the potential to develop associated
clinical and research activities in this field.
Several successful models in other disciplines now exist. These include career
development awards in preventive pulmonary medicine, preventive cardiology,
and alcohol and drug abuse. Any occupational and environmental medicine
awards should require the sponsoring academic institution to demonstrate
commitment to continue support for activities in the field beyond the award s
duration.
2. Providing opportunities for general internal medicine and family practice
medical school facula to receive additional training in occupational and
environmental health. By recognizing the fact that most primary care residency
programs will not be able to support full-time trained specialists in this field,
funding should also be made available to support individuals with demonstrated
clinical and teaching excellence in internal medicine and family practice who
seek additional training and experience in occupational and environmental
medicine. Such training should be obtained at academic centers with demon-
strated excellence in the field.
Guidotti (1984) has suggested that an excellent training program should be
able to provide:
· A broadly representative patient population with a heterogeneous mix of
work-related disorders, social classes, and occupations.
· Readily available academic support.
· Accessible specialty support for consultation, referral, and teaching.
· Extensive interaction with other occupational health professionals.
· Opportunity for research and scholarly activity.
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· A commitment to high~uality care at reasonable cost.
In addition, the committee believes that the academic training center should
rigorously adhere to a code of ethics that views the patient as the physician's
primary responsibility. The training center should provide ample opportunity
for trainees to gain experience in the nonclinical aspects of occupational and
environmental medicine.
3. Expanding residency and fellowship training in occupational and environ-
mental medicine. The anticipation of future needs for faculty and clinical
specialists in occupational and environmental medicine suggests expanded
support for specialty postgraduate training. Currently, this training is supported
predominantly through occupational medicine residency programs funded by
NIOSH. These positions are limited and are inadequate to meet future needs
and do not necessarily prepare individuals for faculty positions with educational
responsibilities for primacy care physicians. As with other preventive medicine
residencies, the lack of a hospital base makes the funding of resident stipends
particularly difficult. A number of mechanisms could meet these needs, includ-
ing the development offellowship programs for individuals who have completed
3 years of internal medicine or family practice training, as well as support for the
development of joint residency programs in internal medicine and family
practice with occupational medicine.
4. Exploring the possibility of offering certification of added competence to
diplomates in internal medicine and family practice who have advanced training
or experience in occupational and environmental medicine. The American
Board of Internal Medicine and the American Board of Family Practice, in
cooperation with the Arnencan Board of Preventive Medicine, should consider
this option.
Current specialty certification in occupational medicine is limited to satisfy-
ing board eligibility and certifying examination criteria established by the
American Board of Preventive Medicine (1982). A recent change in the eligibil-
ity requirements requires successful completion of a 2-year training program in
an accredited occupational medicine residency program for physicians who
graduated from medical school after January 1, 1984 (American Board of
Preventive Medicine, 19821. This new requirement further exacerbates the
current undersupply of certified specialists in occupational medicine. More-
over, even under former guidelines, the design, structure, and purpose of
certification by the American Board of Preventive Medicine do not necessarily
encompass the internist or family practitioner who has received additional
training or experience in occupational and environmental medicine. In order
to recognize such individuals appropriately, which would be useful for viability
in academic settings and an acknowledgment of special qualifications in clinical
practice, the committee believes that demonstrated expertise in the clinical
practice of occupational and environmental medicine and associated disciplines
i/
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should be recognized. This recognition could be similar to the recently adopted
practice of the American Board of Internal Medicine and the American Board
of Family Practice that identifies and recognizes added qualifications in the field
of geriatrics for diplomates in internal medicine and family practice who meet
eligibility criteria and pass the newly developed certifying examination (Institute
of Medicine, 1987) . Based on the experience of these efforts, other boards, such
as the American Board of Pediatrics, may wish to explore this approach.
Research Opportunities in Environmental and Occupational Medicine
The committee believes that research funding in environmental and occupa-
tional medicine is currently inadequate, particularly in support of investigations
studying the human health effects of occupational and environmental expo-
sures. Research opportunities are varied; they span the entire field of public
health and preventive medicine as well as clinical investigations into the
mechanisms, diagnosis, and natural history of resultant diseases. Specific mea-
sures to achieve a broadened research funding base include:
· Increasing the extramural budget of CDC and related agencies (ATSDR,
CEH, and NIOSH) to develop a substantial peer-reviewed extramural research
support program.
· Increasing the budget of NIEHS to allow it to emphasize and foster the
public health research aspects of its mission.
· Supporting and stabilizing EPA's extramural competitive research grants
program.
Intervention Strategies Specific to Undergraduate Medical Education
The need to enhance the teaching of occupational and environmental
medicine at the undergraduate level was described above. The committee rec-
ommends several strategies to meet this need:
1. Incorporating occupational and environmental health questions into the
National Boarcl of Medical Examiners and Federal Licensing Examination
certifying examinations. Board examinations play a major role in defining for
students and, to some extent, faculty the need for knowledge in a subject area
of medicine. More questions relevant to occupational and environmental
medicine should be included in National Board examinations. These questions
can and should be spread through a number of board examinations. Examples
include questions about lead poisoning in pediatrics, workplace impact on
reproductive functions in obstetrics and gynecology, occupational medicine
problems in internal medicine, and occupational health problems in preventive
medicine. Whenever possible, questions should probe for information about
the relationship of toxins to occupational or environmental exposures. For
example, for a question in hematology aimed at the causes of erythrocyte
basophilic stippling, rather than simply having lead as one of the answers, the
answer could be related to work in a battery factory.
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2. Modifying the curriculum to address educational objectives. As discussecl
above, curriculum modification requires the presence of a faculty that is capable
of achieving changes in time or content and the provision of high~uality
education to sustain the curriculum change. Approximately one-third of U.S.
medical schools do not have departments of public health or preventive or com-
munity medicine that might otherwise be expected to take the lead in teaching
occupational en c! environmental medicine using their own curriculum time.
Teaching efforts at such medical schools must therefore occur through other
departments. Among the possible targets for curriculum modifications are the
following:
· Basic science courses. These courses can easily include or emphasize concepts
important to occupational and environmental medicine. For example, the
pharmacology course can include basic principles of toxicology; the pathology
course can provide information about the effects of chemicals on the organ
system; and behavioral sciences courses, which often include information about
the stages of life, can discuss the impact of work on behavior and the psychologi-
cal aspects of working and unemployment on health. Curriculum development
efforts to provide and disseminate teaching modules in each of these areas would
be of value.
· Physical diagnosis course. This course can instruct students in obtaining
occupational and environmental histories, and this activity can be reinforced
throughout the curriculum.
· Clinical Ships. Learning during clinical clerkships depends to a large
extent on the availability of appropriate patients. The frequent location of U.S.
medical schools in inner city hospitals tends to act against the availability of
patients with readily cliscernible occupational factors in their disease process.
Often, in these patients substance abuse problems associated with poverty and
deprivation in inner city areas overwhelm other environmental factors. In such
situations, a concerted effort is needed to develop clinical programs that reach
out to employed groups of people in order to provide adequate teaching
opportunities. This requires faculty who are capable of optimizing available
opportunities to develop teaching efforts, despite a relatively limited number of
patients.
· Student clinical assignments. Introduction of occupational and environmental
clinical problems in the students' basic clerkships is desirable. The fourth year
in medical school is becoming increasingly structures} and could be utilized to
examine the special social, legal, ethical, and economic aspects of occupational
and environmental medicine. These topics would fit well into a new structure
that focuses on broad issues in medical practice such as ethics, health care
delivery systems, patient communication, and medical economics. Teaching the
venous aspects of environmental and occupational medicine could well fit into
this new structure.
Schools with departments or divisions of public health or preventive or
community medicine may approach curriculum change differently. The extent
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to which the teaching activities described above will be carried out in such
departments will depend on the presence of faculty with a specific interest and
expertise in occupational and environmental medicine, the number of teaching
hours available to the department, and the distribution of these teaching hours
within the curriculum. The importance of clinical instruction cannot be under-
estimated, however.
Intervention Strategies Specific to Graduate Education
Mona addition to the development of facula manpower, other interventions
should contribute to the accomplishment of the goals previously described
above. These include:
1. Expanding clinical training opportunities for residents in internal medi-
cine and family practice. Academically based occupational medicine clinics,
designed to provide multidisciplinary training in assessing the impact of occu-
pational and environmental factors on an individual's health problems, should
be supported and developed to provide sufficient training oDDortunit-ies for
internal medicine and family practice residents.
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2. Identifying occupational and environmental medicine as a component of
continuity training in primary care residency programs. Because occupational
and environmental medicine is considered a fundamental component of clini-
cal practice involving adult patients, the committee recommends that specialty
clinical experiences in occupational and environmental health be considered as
an experience for trainees in ambulatory care rotations. The Health Resources
and Services Administration (HRSA), which funds primary care training grants,
currently excludes ambulatory rotations in occupational medicine from meet-
ing its requirements for substantive time in continuity of care. Recognition of
ambulatory occupational medicine as a continuity of care experience in resi-
dency programs would help overcome this barrier to resident narucination chat
HRSA imposes.
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3. Expanding research opportunities in occupational and environmental
medicine for residents in internal medicine and family practice. Research
opportunities for internal medicines once family Trip rPci~Pntc ~1P~;~(r I
1 ~ ~ ~ --1 ret _v^~ ~ ,,,, ,,
. . .. . .
undertake directed activities In this area are limited. Support for and encourage-
ment of such opportunities in academic settings, industries, unions, and health
departments are seen as effective means of expanding these capabilities.
4. Expanding the current residency curricula to incorporate occupational
and environmental health issues. There are many ways to incorporate occupa-
tional and environmental health issues within internal medicine and family
practice training. If faculty are available, formal teaching events in occupational
and environmental medicine can be increased. Establishing inpatient consulta-
tion services with the active support of faculty with demonstrated expertise is
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another method. Finally, occupational and environmental medicine can be
identified as a "residency essential" in internal medicine. Essentials of an
accredited residency in graduate medical education have been described for
family practice and internal medicine. In family practice, both occupational and
environmental health are included as necessary components of instruction in
the section on community medicine. The committee recommends that the es-
sentials of internal medicine residency training be made explicit to include these
same areas, as current essentials now iclentif5r only those subspecialty areas tra-
ditionally considered part of internal medicine.
5. Expanding the content of occupational and environmental medicine in
certifying examinations of the American Board of Internal Medicine and the
American Board of Family Practice. Although both certifying board examina-
tions include questions in this area now, neither board reports the capability to
identify occupational and environmental questions or provides feedback to
examinees and institutions about performance in this area. The committee
encourages the expansion of questions in this field and the means to quantify
and provide feedback on performance on these questions.
6. Incorporating concepts of occupational health care delivery into those
programs teaching practice management. An increasing number of internal
medicine and family practice residency training programs include practice
management as part of training. Because occupational health care delivery
invokes special financial, legal, and ethical considerations, the committee
recommends that these aspects of providing occupational health services be ad-
dressed in such training.
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OCR for page 62
~ 771
T
_~
1 have often wondered
how so noxious a dust can come from the grain as
wholesome as wheat, and ~ began to suspect that in
that dust there must lurk minute worms imperceptible
tro our senses and that they are set in motion fly the
sifting and measuring of the grain and broadcast by
the air; then they readily adhere to the skin and excite
that great heat and itching all over the body.
Representative terms from entire chapter:
occupational medicine
