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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, 48

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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. 49

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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 ~3

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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. ~4

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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. 59

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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. ~6

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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. 58

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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 _9

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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. ~ ~~~~^~~O ~rr~^ '~'^~v ^~^ 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. -rid r--~~~ ~~~~ 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 60

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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. 61

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~ 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.